**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 8 (R50, R64, R65, R67, R70, R73, R78 and R235) of 9 residents reviewed for pressure injuries. * R78 developed a stage 4 pressure injury to the right posterior ankle despite the Facility knowing the resident was at risk for pressure injuries because the resident wore PRAFO boots. The Facility failed to perform checks each shift to monitor the skin under the boot to prevent skin issues from developing. The Facility failed to obtain written orders on length of time the PRAFO (contractor/LE (lower extremity) braces) boots should be worn. The resident's plan of care did not include interventions related to the PRAFO boots and was not updated for over a month regarding right posterior heel pressure wound after the discovery of the wound. A comprehensive assessment of the wound was not documented until the wound doctor saw R78 on 2/5/2024. This created a finding of Immediate Jeopardy (IJ) at a scope and severity of a J (immediate jeopardy/isolated) that began on 1/30/2024. On 04/24/24 at 09:37 AM the Surveyor notified the Director of Nursing (DON)-B, Nursing Home Administrator (NHA)-A and Facility Consultants about the immediate jeopardy. The immediate jeopardy was removed on 4/24/24 when the facility implemented their action plan. The deficient practice continues at a scope and severity of a G (actual harm/isolated) for the following examples regarding Residents R65, R235 and R64. * R65 was admitted to the facility from the hospital with an unstageable pressure injury on the coccyx. The pressure injury was not assessed on the day of admission. The pressure injury deteriorated to a stage 4 pressure injury with multiple courses of antibiotics after R65's admission. The resident developed multiple infections related to possible soiled dressing from stool that were not addressed in the treatment record to change dressings as needed. R65's air mattress was observed set to a higher weight load than what R65 weighed. Additionally, the wound physician indicated part of the issue with R65's wound involved offloading pressure. The facility did not establish a clear, individualized plan of care regarding repositioning for R65. * R50's air mattress was set to 550 pounds on several observations during the survey and R50's most recent weight is 185.9 pounds. * R235's guardian filed a grievance requesting R235 have an established repositioning schedule to prevent the development of a pressure injury. The facility did not establish an individualized repositioning schedule, and R235 developed a facility acquired, stage 3 pressure injury. * R70's air mattress was set to 550 pounds on several observations during the survey and R70's most recent weight is 152.2 pounds. * R64 was admitted to the facility with a sacral pressure injury and a chronic left heel pressure injury. The left heel was healed and then reopened on 11/11/23. The wound was not comprehensively assessed by a Registered Nurse (RN) until 11/13/23 when it was unstageable. On 2/7/24 through 2/13/24 R64 was hospitalized and underwent an incision to the bone with partial resection of left calcaneus and incision and drainage of left Achilles abscess. The resident was readmitted [DATE] and the wound was not comprehensively assessed by a RN until 2/19/24. During survey, R64 was observed on day 1 and day 2 without offloading interventions in place. *R67's air mattress was observed to be set to 210 pounds on multiple days of the survey despite R67 weighing 144 pounds. R67 is at risk for pressure injuries. *R73 was observed during multiple days of the survey to have their feet resting against the foot board of the bed and expressing discomfort from the pressure/position. R73 is at risk for pressure injuries. Findings include: The Facility Policy and Procedure titled Pressure Ulcers/Skin Integrity/Wound Management implemented 1/30/2023, revised 1/24/2024 documents (in part) . Policy: A system is in place for the prevention, identification, treatment and documentation of pressure and non-pressure wounds . Procedure . 2. Assessment and Treatment It is important that each existing pressure ulcer be identified, whether present on admission or developed after admission, and that factors that may have influenced its development, the potential for development of additional ulcers, or for the deterioration of the pressure ulcer(s) be recognized, assessed, and addressed as follows: a. Differentiate the type of ulcer (pressure-related versus non-pressure-related) because interventions may vary depending on the specific type of ulcer. b. Determine the ulcer's stage. c. Describe and monitor the ulcers characteristics. d. Monitor the progress toward healing and for potential complications. e. Determine if infection is present. f. Assess, treat, and monitor pain, if present; and g. Monitor dressings and treatments. 3. Treatment/Management a. Residents with risk for or who have a loss of skin integrity will receive the appropriate treatment/services, and residents who are determined to be at risk for or who have loss of skin integrity will receive appropriate treatment/services . 4. Documentation a. Assessment i. Assessment information should identify specific factors that might increase the risk of pressure ulcer development or affect healing of a pressure ulcer such as: 1. Decreased mobility . 4. Use of restraints . 6. Non-compliance or history of non-compliance. 7. Altered sensory perception . 10. History of pressure ulcers . ii. For a resident who was admitted with a pressure ulcer or who developed one may include the following documentation. 1. Ulcer site and characteristics at the time of admission or onset, including measurements . b. Care Planning . iii. The care plan should address prevention of any skin breakdown, including sheering or friction, repositioning or off-loading; pressure relief equipment; and the care and treatment to be provided to the resident for a pressure ulcer or non-pressure wound behaviors and preferences. iv. If a resident refuses or resists staff interventions, the care plan should reflect efforts to seek alternatives as well as education to resident and/or family regarding the risks. This education should be documented. v. Care plan interventions should be revised if there is recurring skin breakdown, a lack of progress toward healing, or if the resident acquires a new ulcer . 1.) R78 was admitted to the facility on [DATE] from (name of hospital in Illinois) where they had been since 11/9/2023. R78 has diagnoses that include acute cystitis without hematuria, fusion of spine-thoracic region, paraplegia, morbid (severe) obesity due to excessive calories, muscle weakness, need for assistance with personal care, depression, and anxiety disorder. Braden assessment on 12/1/24 indicates R78 is at mild risk for pressure injuries. Review of the discharge paperwork from the hospital R78 discharged from indicates R78 Occupational Therapy was working with R78 on the use of bilateral lower extremity PRAFO orthotics to prevent plantar flexion contractures. The orthosis wear schedule is noted to be 4 hours on/off with R78 being dependent in a supine position to don/doff orthotics. Precautions noted: If redness, swelling, numbness or tingling occurs, please remove splint, and notify OT. The documentation indicates orthotics were donned throughout session. The paperwork indicates R78 has a wound on their buttocks. There was no order for the PRAFO orthotics on admission on [DATE]. On 04/23/24 at 10:42 AM Surveyor spoke with DON-B and requested a physician order for the PRAFO orthotic and to talk to therapy about monitoring of the PRAFO orthotic for effectiveness. Surveyor was told will try to find if someone is still here from therapy to help with that. No order to the PRAFO orthotic was provided to Surveyor. On 04/23/24 at 03:32 PM DON-B told Surveyor there is no actual order for the PRAFO orthotics. On 12/1/23 the facility initiated a care plan with a focus area the resident is resistive to care AEB refusing scheduled medications, wound treatments and occasional therapy services r/t anxiety with new admission and debilitating comorbidities causing immobility and decreased independence. The Focus indicates it was revised on 12/18/23. Goals indicate: the resident will participate in care by performing/participating in self-care needs (ostomy care, med management, and therapy) w/less than 2-3 refusals by the next review date. Initiated 12/1/23, revised 1/2/24, target date 5/30/24. Interventions/Tasks include: - Allow the resident to make decisions about treatment regime, to provide sense of control, Date Initiated: 12/1/23. - Encourage as much participation/interaction by the resident as possible during care activities, Date Initiated: 12/1/23. - Give clear explanation of all care activities prior to an (sic) as they occur during each contact, Date Initiated: 12/1/23. - If possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed upon time, Date Initiated: 12/1/23. - Praise the resident when behavior is appropriate, Date Initiated: 12/1/23 - Provide resident with opportunities for choice during care revision, Date Initiated: 12/1/23. Surveyor noted this plan of care was not updated to address if R78 was refusing to remove the PRAFO orthotics or not allowing staff to check R78's skin under the PRAFO. There is no intervention on the care plan to discuss risks and benefits with R78 regarding decisions to refuse care. R78's skin was assessed on 12/4/23 (3 days after admission) by the facility. The skin impairment wound form dated 12/4/23 indicates R78 has a pressure injury on their sacrum that is an unstageable pressure injury. Measurements of wound indicate wound measured by (name of wound physician practice) wound MD. See note. The assessment for wound tissue bed, to indicate tissue percentages, is blank along with details regarding pain and treatment. R78 is noted to have a second wound on the right buttock that is a stage 3. The measurement of the wound also indicates wound measured by (name of wound physician practice) wound MD. See note. The assessment for wound tissue bed to indicate tissue percentages is blank along with details regarding pain and treatments. The skin evaluation indicates there is a stage 2 pressure injury to the left ankle that is documented as resolved. The notes indicate for skin ulcer/injury treatments: pressure reducing device for bed, turning/repositioning program, nutrition, or hydration to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressings (with or without topical medications) other than to feet, applications of ointments/medications other than to feet. Barriers to wound healing include paraplegia, HTN (hypertension), obesity. Current wound/skin integrity interventions indicate: Resident assessed by (name of wound physician practice) wound MD and wound team. Resident admitted to facility with preexisting pressure wounds to sacrum, R (right) buttock, and L (left) posterior ankle resolved. Resident wears bilateral ankle contractor braces, foam dressings continued for bilateral posterior ankles and R lateral foot where there is blanchable redness. Resident requires extensive assistance of two with repositioning in bed, off-loading positioning wedges are being used. Bilateral half side rails in place to allow resident to assist with repositioning. Air mattress in place. Currently eating 51-100% of meals. Wound physician (MD)-Q's wound evaluation dated 12/4/23 indicates wound present on back and buttock. Left and right lower extremity normal. The sacrum wound is unstageable measuring 2.5 x 2.2 x 0.7 40% necrotic tissue, 30% slough, 30% granulation tissue. Recommendations were to offload wound, reposition per facility protocol, group 2 mattress. This area was debrided by MD-Q. The right lower buttock, stage 3 measured 3.5 x 4.5 x 0.1. 10% slough, 60% granulation tissue, 30% skin. Recommendations to off load wound, reposition per facility protocol. There was no evaluation noted of R78's bilateral ankles. Surveyor noted orders for-Foam dressing to R lateral foot for protection. Every day shift every Mon, Wed, Fri - start 12/6/2023, d/c 2/23/2024. -Foam dressing to R/L posterior ankles for protection. Every day shift every Mon, Wed, Fri - start 12/6/2023, d/c 2/23/2024. On 04/24/24 at 08:38 AM Surveyor spoke with Director of Nursing (DON)-B to confirm where the order for Foam dressing to R/L posterior ankles for protection. Every day shift every Mon, Wed, Fri. came from. DON-B shared the wound doctor looked at the posterior heels after resident was admitted and during that initial assessment these recommendations were given verbally. The foam was an intervention, not an order from Wound Doctor-Q. -Check skin integrity under ankle contractor braces. Every, day shift - start 12/5/2023, d/c 2/23/2024. Review of R78's treatment administration record indicates the time for this treatment order is 6:15 AM. Facility documentation shows that staff monitored the skin only once daily from 12/5/23 to 2/23/24. On 12/8/24 a treatment order was added to complete nursing assessment skin observation tool every day shift every Friday for shower day skin monitoring. Surveyor noted there were no physician orders for R78 to wear the PRAFO orthotics or documentation the physician was consulted with regarding the wearing of the braces. Further, none of the recommendations that were noted in the discharge paperwork from occupational therapy regarding a donning and doffing schedule and signs and symptoms to monitor for with the use of the PRAFO orthotic for R78 were recorded. Review of the physical therapy evaluation dated 12/2/24 does not include reference or assessment of R78's PRAFO orthotics. On 12/4/24 the physical therapy summary of daily skilled services references passive stretches BLE (bilateral lower extremities) with PRAFO boot removal, ankle, knee, and hip ROM (range of motion) practiced with hold at the end of each movement to provide stretch, managed well. Repositioned in bed with roll side to side with max a (assist) x 2, placed PRAFO boots, wedges to deweight (sic) the sacral area and scooted up in bed with max a x2 with pts (patients) support with the headboard. On 12/8/23 R78 expressed concerns with positioning schedule. With physical therapy noting R78 is to be positioned Q (every) 2 hours for skin breakdown prevention. R78's interdisciplinary team conference was held on this date. Review of R78's physical therapy notes from 12/2/23-1/29/24 indicate occasional reference to R78 wearing the PRAFO orthotics however, the use of the orthotics do not appear to be documented as an ongoing part of the physical therapy evaluations. On 1/11/24 physical therapy notes: splint and brace program established/trained: PRAFO boot donning and doffing and skin check - nursing able to manage. The note also references a restorative program being established. On 04/24/24 at 12:07 PM Surveyor spoke to the Rehab Director-FF at the Facility about a discharge recommendation made by one of the physical therapists on 1/11/2024 that states splint and brace program established/trained: PRAFO boot donning and doffing and skin check-nursing able to manage. Rehab Director-FF shared they did not know what that means, will try to reach out to the Physical Therapist that made the note. Surveyor noted no additional information was provided and Surveyor was not able to speak to Therapist. On 1/25/24 physical therapy references R78 is taking the PRAFO boots off for a couple of hours when the wife visits and performs skin check. Review of the Skin impairment/Wound evaluation assessment completed on 1/29/2024 documents presence of a pressure injury to the sacrum. Surveyor notes there is no assessment of documentation on the skin impairment/wound evaluation of the bilateral areas on R78's ankles. only the one wound, no documentation of skin concerns to the bilateral lower extremities. A progress note written on 1/30/2024 at 9:03 pm indicates writer approached by pts spouse with skin concerns to bilateral Achilles. Upon assessment pressure injury noted to right Achilles and 2 small abrasions noted to left Achilles. NP (nurse practitioner) updated, NOR (new order) for medihoney daily to right Achilles and skin prep BID (twice daily) to left Achilles. txs (treatments) placed. pt tolerated well no complaints of pain or discomfort noted at this time. A Facility Skin Impairment/Wound Evaluation assessment was completed on 1/30/2024 that identifies a new stage 4 pressure injury to R78's right Achilles. The wound is measured as 1.5 by 2.0; no depth and no tissue description are included. On 04/23/24 at 11:32 AM Surveyor placed call to Licensed Practical Nurse (LPN)-U who was there when Family Member-V reported the skin change. LPN-U remembers Family Member-V telling them about it. They measured the area, and the other LPN updated the Nurse Practitioner. They got an order and let the supervisor know. Surveyor asked if LPN-U remembered what the wound looked like, LPN-U does not remember just knows they measured it and put a dressing on. On 04/23/24 at 11:34 AM Surveyor left a message for the other LPN who was there when Family Member-V reported the wound, a call back was not received. On 04/23/24 at 11:30 AM Surveyor called the charge nurse on duty when the skin change was reported on, 1/30/2024, no call back was received. The following orders were entered into the Treatment Administration Record (TAR) Cleanse Right Achilles with NS, pat dry apply medihoney and cover with dry gauze one time a day, start 1/31/2024, d/c (discontinue) 2/6/2024. Surveyor notes the treatment obtained from the Nurse Practitioner was entered and first signed out on 1/31/2024 the day after the Stage 4 pressure injury was identified. There is no description of the wound to identify the tissue type and if the tendon was visible at this time. On 04/23/24 at 12:34 PM Surveyor spoke with Family Member-V who would take the boots off. Family Member-V did not know how long the boots should be off daily, there was no order they knew of. When asked how often Family Member-V looked at R78's feet leading up to the discovery, Family Member-V stated being at facility five days a week Monday through Friday for a couple hours in the evening. The boots would be removed then and [NAME] lotion was put on R78's feet by Family Member-V. On 1/30/2024 when Family Member-V took the boots off, the dressing was 1/2 off and there was drainage on it, Family Member-V indicated they saw the wound and got the nurse. Surveyor asked Family Member-V about other opportunities when R78's feet could be observed. Family Member-V stated R78 should get a shower once a week and they should be cleaning R78 up other days. R78 was seen on 2/5/2024 by (name of wound physician practice) Wound Doctor-Q and the right posterior Achilles was added as a 3rd pressure wound. The wound was classified as a stage 4 of the right, posterior, Achilles tendon ankle. Etiology: pressure. Additional wound detail provided by Wound Doctor-Q states it is a medical instrument (boot) pressure sore. The wound size was (L x W x D): 2.6 x 3.1 x 0.6 cm. Exudate: Light Sero - sanguineous Thick adherent devitalized necrotic tissue: 40 % Slough: 20 % Other viable tissues: 40 % (Tendon) DRESSING TREATMENT PLAN Santyl apply once daily with Gauze island w/ bdr (border) over Recommendations: Off-Load Wound; Float Heels in Bed; Pressure Off-Loading Boot DEBRIDEMENT PROCEDURE completed. Review of R78's record indicates the intervention. On 2/5/24 the TAR was updated to include apply bilateral prevlon (sic) boots. Document refusals every shift. Surveyor noted this did not get added to R78's care plans until 3/1/24. On 04/23/24 at 11:00 AM Surveyor spoke with the (name of wound physician practice) Wound Doctor-Q via telephone and clarified that the tendon was visible before debridement procedure was completed on 2/5/2024. Wound Doctor-Q stated it was visible right away. R78 is then seen weekly by the (name of wound physician practice) Wound Doctor-Q. Notes each week 2/12/24 - 4/15/24 indicate that the wound decreased in size and continued to improve. The final note stated: Wound Size (L x W x D): 1.4 x 0.9 x 0.1 cm Granulation tissue: 100 % Wound progress: Improved evidenced by decreased surface area. Dressing(s) same Same recommendations No treatment needed by wound doctor, assessment only. On 4/22/24 at 11:49 AM Surveyor observed wound assessment provided by Wound Doctor-Q. Upon entering R78's room resident was wearing Prevalon boots on both feet, had a pressure relieving wedge under hip and another at upper back area. Wound Doctor-Q assessed right posterior ankle wound as smaller than last measurement, stated that no treatments needed, Facility should continue same dressing. Surveyor noted when the doctor asked if R78 needed lidocaine for pain management during wound evaluation R78 replied that resident does not feel pain from sternum down due to paralysis. On 04/22/24 at 12:44 PM Surveyor interviewed R78 about the orthotics R78 wore before developing the stage 4 pressure wound and those R78 is wearing now. R78 stated being admitted to Facility with a different type of boot meant to prevent drop foot, they had a hard sole with kick stands. R78 stated being in them for quite some time. R78 brought the boots which R78 got from (name of rehabilitation hospital program/lab) and continued to use them to prevent foot drop. R78 said that the boots had added padding where pressure wound started and thinks that the padding wore down and that was the problem. R78 states that Family Member-V pointed the skin change out to staff on 1/30/2024 in the evening. R78 stated that staff were not taking boots off and assessing feet daily. Family Member-V would take boots off in the evening and put lotion on feet. That is when the pressure wound was found on the back of the heel area. Per R78 they never refused any precautions, recommendations, or treatments. On 04/23/24 at 09:05 AM Surveyor spoke with Director of Nursing (DON)-B who confirmed R78 had the contractor boots (PRAFO orthotics) since admission and that two-nursing staff were in with R78 when Family Member-V informed them of the skin change. Surveyor asked DON-B for additional documentation or progress notes about the checking of skin integrity up to 1/30/2024. On 04/23/24 at 09:54 AM Surveyor spoke with Registered Nurse (RN)-W. RN-W signed the Treatment Administration Record (TAR) on 1/30/2024 for Check skin integrity under ankle contractor braces every, day shift. When RN-W was asked if staff checked under braces every day, RN-W replied yes, especially shower days. Surveyor noted 1/30/24 was not R78's Friday shower day. RN-W stated that if they signed it out on TAR then they did it and does not remember any skin impairment at that time. If a skin impairment was found, RN-W would complete a skin impairment eval and the unit manager is alerted. On 04/23/24 at 11:18 AM Surveyor followed up with R78 regarding the pressure wound. Per R78 Family Member-V was cleaning up feet and noticed that the callus on back of heel had turned to a wound. R78 states he was getting a shower once a week and made no refusals, actually wanted more showers that's why Family Member-V would give bed baths and clean up. When asked about daily skin checks, R78 shared he does not remember anyone from Facility taking boots off and looking at skin every day. R78 could not remove boots by himself, Family Member-V took them off nightly to give R78 a break from wearing them. On 04/23/24 at 01:59 PM Surveyor informed DON-B, Nursing Home Administrator (NHA)-A and the consultants that there was a very serious concern related to R78's facility acquired pressure injury. Surveyor shared concerns with R78 developing an avoidable, facility acquired stage 4 pressure injury when the facility did not get physician orders for R78's wearing of the PRAFO orthotics and assessed how long R78 should be wearing the orthotics daily to prevent possible skin breakdown. On 4/24/24 a progress note dated 4/23/2024 at 6:13 pm, signed by the facility therapy Physiatrist-GG was provided to the Surveyor stating Discussed with DON and leadership. Patient had arrived here in Dec from previous facility with rigid PRAFO boots, which (R78) had worn until developed some skin breakdown on back of distal leg/ankle. The use of these boots, which was well-tolerated at the previous facility, was reasonable to help prevent soft tissue injury and plantar flexion contracture for the patient. Surveyor noted that there are no details about how long to wear the boots or interventions to prevent skin breakdown and this was obtained by the Facility after they were informed of the serious concern. There is no documentation provided to the Surveyor to indicate Physiatrist-GG had assessed or consulted on R78's use of the PRAFO orthotics prior to R78 developing the stage 4 pressure injury to the right ankle. On 4/24/24 the Facility provided a late entry progress note to Surveyor stating LATE ENTRY FOR 1/31/24 Writer and (LPN-O) went to assess resident skin concerns to right achilleas (sic). Wound observed and assessed. Skin appears slightly open 0.2 cm x 0.2 x 0.1cm with slight purple hue periwound (sic). Total wound measured at approximately 1.5 cm x 2 cm. NP updated on wound. Orders to continue current treatment until seen by wound MD. Resident offered additional education on offloading and given offloading device options to try. At this time feels most comfortable offloading with pillows as (R78) directs staff to adjust, resident was urged to use device that would effectively float heels to relieve any pressure, and educated to ensure that heels are not touching surface because from what (R78) showed as preference pillows did not offer effective offloading. (R78) also decline to stop utilizing PRAFO boots despite education of prevelon (sic) boot benefits. We did confirm that (R78) had extra padding in the PRAFO boot. (R78) clarified wants them on at all times and Family Member-V will remove for a couple hours in the evening. On 04/24/24 at 09:58 AM Surveyor called LPN-U and asked about the PRAFO boots being worn after the pressure injury was discovered. LPN-U stated (R78) requested to continue to wear the PRAFO boots then switched on 2/5/2024 to the Prevalon boots after the wound doctor educated on the risks and benefits. Surveyor noted there is no indication facility staff discussed the risks and benefits of wearing the PRAFO with R78 at any time prior to Wound Doctor-Q's assessment of R78's right ankle, facility acquired pressure injury. On 04/24/24 at 10:05 AM Surveyor asked R78 when he started to wear the Prevalon boots and R78 can't remember, just knows switched to Prevalon boots at some point. Surveyor notes that Facility did not get physician orders on when or how long to wear the PRAFO boots only a recommendation for foam dressing to posterior ankles for protection every mon, wed, fri. R78's skin was only assessed daily not per shift. The Facility did not clarify with physicians' orders at admission for wearing the PRAFO orthotics. R78 continued to wear the orthotics after the pressure wound developed, Facility provided no evidence of risk analysis given to R78. There was no plan of care intervention for the PRAFO boots for Certified Nursing Aides (CNAs) even though the Facility recognizes resident wore from admission and had a pressure wound to the left posterior heel upon admission. On 4/25/24 the facility submitted additional documentation to review/consider regarding R78's Right Achilles Pressure Injury. Submitted was a pamphlet regarding a Pressure Relieving Ankle Foot Orthosis Instructions for wearing your Pressure Relieving Ankle Foot Orthosis (PRAFO) Surveyor noted this pamphlet is from a Prosthetic and Orthotic Department in a hospital in [NAME] Canada and it is not from the hospital or physician who originally ordered the PRAFO prior to admission. The facility highlighted the section asking When should the PRAFO be worn? A PRAFO should ideally be worn at all times, only being removed for wound care and showering, unless otherwise indicated by your doctor. Surveyor noted it is not even clear if the pictured PRAFO boot is the model R78 was using. Additionally, it is noted the facility did not give the doctor the opportunity to indicate otherwise when wearing the PRAFO as it was never assessed on discussed with a facility physician for orders for use. The facility also submitted an investigational summary indicating despite R78's many risks, the stage 4, facility acquired pressure injury should be considered unavoidable. The facility indicates in this information R78 had previously had a stage 4 pressure injury on this Achilles area necessitating the need to restage the area as a stage 4. There is no indication in R78's facility record R78 was admitted with a healed stage 4 pressure injury to the right Achilles and was assessed for the risk of redeveloping a stage 4 pressure injury to that ankle. The facility contends the occupational therapy notes included in the facility admission documents was not an order to be followed, was just a recommendation and the right of the resident to self-direct care and wear the braces continuously without specific wearing and removal orders relieves the facility of culpability. There is no indication the facility evaluated R78 for the wearing of the PRAFO orthotics, instituted ongoing evaluations of R78's tolerance of the devices post admission and present R78 with the risks and benefits of wearing such devices based upon an assessment of the devices for R78. The Facility's failure to provide care necessary to prevent the development and the deterioration of a pressure injury created a reasonable likelihood for serious harm, leading to a finding of immediate jeopardy. The Facility removed the immediate jeopardy on 4/24/24 when the Facility implemented the following: * R78 no longer uses his PRAFO boots. The pressure injury to his right Achilles is healing. His plan of care has been reviewed and is appropriate. * Any resident who wears a splint/brace has the potential for skin breakdown. Splint/brace orders will be obtained by Qualified Therapist or Physiatrist. * Orders for splint/brace and skin integrity checks will be reviewed by nursing and initiated. * Care plans have been reviewed and reflect the use of the splint/brace.? * Any new or worsening skin integrity issues will require a documented comprehensive RN assessment. This will include physician notification and care plan review. * Nursing staff to be educated on identifying a splint/brace along with the risk for skin breakdown related to the device. * Nursing staff to be educated on following the wearing schedule for splint/braces and completing skin integrity checks according to the plan of care. * Nursing staff will receive education on the need for an RN assessment when any new or worsening wound is found. * Education will begin April 24, 2024, for nursing staff and will continue and be provided prior to the start of their next shift for nursing staff. * Facility reviewed the policy for prevention of pressure injuries. * Medical Director is aware and involved in plan. * DON/designee will audit all brace/splint monitoring orders and wearing schedules three times per week to ensure completion. * DON/Nurse Managers will audit skin checks for braces/splints three times weekly to ensure compliance. * Results of audits will be reviewed through the QAPI process[TRUNCATED]

**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 (R87) with a significant change in condition had a comprehensive assessment performed. On [DATE] at approximately 5:30 a.m., R87's husband asked RN (Registered Nurse) T for assistance because R87 was not feeling well. RN T did not perform a comprehensive assessment into the change in condition. On [DATE] at approximately 6:00 a.m., R87 became unresponsive, 911 was called, and CPR (cardiopulmonary resuscitation) was initiated. On [DATE], R87 was transferred and admitted into the hospital with a diagnosis of cardiac arrest. R87 subsequently passed away 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 12:30 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for harm/ isolated) as the facility continues to implement its action plan. Findings include: R87 was admitted to the facility on [DATE] with diagnoses of internal prosthetic of right shoulder, type 2 diabetes, CHF (congestive heart failure,) and anxiety. The medical record indicates R87 had moderate cognitive impairment and R87's husband was the APOAHC (Activated Power of Attorney for Health Care.) The nurses note dated [DATE] at 5:42 a.m. documents Resident has been awake all shift calling several family members including her husband. Husband came in this morning around 5:30 am yelling at CNA (Certified Nursing Assistant) because resident is having what he has called anxiety attacks and was requesting anxiety medication for his wife. Writer went and spoke with husband in regard to resident and informed him that at this time there is nothing I can administer to resident. Writer also informed husband that we would request something during office hours of the dr. Husband then stated that wife was taking something at home for anxiety and didn't understand why writer couldn't just give her something because she is in distress. Writer assessed resident and saw no signs of distress. Resident was laying in bed not speaking. Writer again informed husband that I would pass it along in morning report to request something to assist resident with her anxiety. Husband then stated resident has more anxiety pills at home and he himself will bring them in and administer them to wife. Writer advised husband that he can bring in the medication but he could NOT administer the medication to the resident and the facility still needs to have an order to administer the medication. Husband then stated that he will bring it in and administer the medication and what you don't know won't hurt you. Writer informed husband that will be documented. The nurses note dated [DATE] at 8:08 a.m. indicates, Writer walked onto the rehab floor at 0600 (6:00 am) and was called down the hall by NOC (night) nurse to call 911 for a resident who did not have a pulse and was not breathing, writer called 911, and they (911) informed me that they had received a call for room [ROOM NUMBER], it was later clarified that the husband had made the call (to 911) from the room, RN confirmed resident's code status, writer hung up with 911 and took crash cart to the room. Chest compressions were in progress by RN when writer entered with crash cart, writer turned on AED and placed pads on patient, Another RN assisted with giving rescue breaths via ambu bag, no shock was advised for patient and AED (automated external defibrillator) gave instructions to continue CPR (Cardiopulmonary resuscitation), writer took over compressions until EMS arrived, EMS worked on resident in room for approximately another 10 minutes and transported resident to the hospital, directions were given to resident's spouse via EMS. The next nurses note dated [DATE] at 8:32 a.m. indicates, Writer was with resident at about 5:30am resident was alert, talking, moving, and watching TV. Writer was called back to room at 5:54am because husband called facility from room to have wife checked. Writer went back to room to check residents vital signs and assess resident. At that time writer applied blood pressure cuff and obtained glucometer. Writer noticed resident wasn't breathing and was unable to obtain a pulse. Writer began CPR. Writer called out for assistance. Other nurses came to assist. The other nurses took over so that I could print transfer documents, then EMS arrived and took over care. EMS then transferred resident to (name of hospital) ER. The nurses note dated [DATE] 11:33 am states, called ER for update, Resident admitted into ICU (Intensive Care Unit). The nursed note dated [DATE] 15:30 (3:30pm states, spoke to hospital ICU, admitting DX (diagnosis) cardiac arrest. The nurses note dated [DATE] 10:33 am states, reported to facility that resident passed away at the hospital. The hospital record dated [DATE] indicated R87 had a cardiac arrest and was intubated. The documentation indicated R87 may have anoxic brain injury and there was discussion with the family regarding aggressive life support. R87 was taken off life support on [DATE]. On [DATE] at 3:00 p.m., Surveyor asked NHA (nursing home administrator) A if there was an investigation into R87's unresponsive episode on [DATE]? NHA A stated she was not working at the facility during this time but would look for any information. On [DATE] at 9:30 am, NHA A gave Surveyor a statement from RN T. NHA A stated she had no other information for Surveyor other than RN T's statement. Additionally NHA A informed Surveyor RN T no longer works at the facility. On [DATE], Surveyor reviewed a statement dated [DATE], written by RN T, which indicates At about 5:30 a.m. I was called to Rehab for resident in (R87) husband. Her husband came in because resident was having what he called an anxiety attack. He said resident had been calling him all night. I spoke with husband in regards to resident not having anything for anxiety available for me to give and that we will be requesting something when the Drs office opens. Her husband informed me that she normally takes something at home and give them to her himself and what we don't know wont hurt us (conversation documented in progress note). I talked with resident's husband until roughly 5:40 a.m. While I was in the room speaking with the husband the resident was alert, talking, moving and breathing. She did not appear to be in any kind of distress or having any complications at that time. After this conversation I returned to [NAME] unit to complete my work on that hall. At 5:54 a.m. I received a call from the North hall CNA that the husband had called the facility from (R87 room) stating someone needed to come check his wife's vital signs because she didn't look good and if we didn't hurry up he was calling 911. At that time I went to rehab obtained the vital sign cart and proceeded to the room. As I approached the room I overheard the husband on the phone with 911. I approached the resident to start assessing her and her vital signs. At that time I noticed the resident was limp and wasn't responding. I attempted to call for help from my cell phone to the facility but didn't get an answer and attempted to overhead page from the room but was unsuccessful. I ran up the hall to get the code status, glucose machine and to overhead page for help. I returned to the room and resident and couldn't feel a pulse and resident wasn't breathing. I paused to look in the hall for help. I saw a day shift nurse who I called out for help. The day shift nurse from rehab and north came in the room to help. We continued with CPR and attached the AED to resident. Shortly after EMS arrived and took over. I called the on call manager to inform her of what happened. On [DATE] at 11:44 a.m., Surveyor interviewed R87's husband. R87's husband stated on [DATE], R87 called him around 4:00 a.m. and told him she doesn't feel good and he needed to come to the facility. R87's husband stated he told R87 to put her call light on and he would call the facility to get R87 assistance. R87's husband stated he hung up with R87 then called the facility and spoke to whoever picked up the phone and reported R87 needed assistance because she didn't feel well. R87's husband stated after a few minutes R87 called him again and stated no one showed up and she still doesn't feel well. R87's husband stated he told R87 that he was going to come in. R87's husband stated he called the facility before leaving his house and no one picked up the phone, it just rang and rang. R87's husband stated between leaving his house and getting to the facility, R87 called him at least ten times. R87's husband stated when he arrived at R87's room he found R87 gasping for breath and looking gray. R87's husband stated R87's call light was on. R87's husband stated he didn't see anyone in the hallway so he called the nurses station and asked for someone to come to R87's room. R87's husband stated a nurse did eventually showed up and he stated he thought R87 was having an anxiety attack and needed assistance. R87's husband stated he did have a conversation with RN T regarding him bringing in R87's medications from home. Surveyor asked R87's husband if RN T performed an assessment on R87, such as listening to her heart, obtaining vital signs, or touching her at any point. R87's husband stated RN T did not perform an assessment. R87's husband stated RN T came in and talked with him then looked at R87 and walked out. R87's husband stated R87 continued to not feel well so he called again to the nurses' desk asking for assistance. R87's husband stated after a few minutes, when they didn't show up to R87's room, he called 911. R87's husband stated after he called 911, RN T showed up and looked at R87 and went out and came back with a crash cart. Surveyor asked R87's husband at any point did R87 stop breathing? R87's husband stated he seems to remember R87 struggling to breath until the paramedics arrived. Surveyor asked R87's husband if RN T performed CPR on R87? R87's husband stated the paramedics arrived right when RN T was going to perform CPR. On [DATE] at 3:00 p.m., Surveyor discussed with NHA A the concern there is no comprehensive assessment of R87's change in condition. In addition, Surveyor shared concerns regarding lack of staff response to R87's husband's telephone call to the facility reporting R87 not feeling well, the facility not answering the phone after R87's husband tried calling the facility back several times prior to arriving at the facility, and the lack of timely response to R87's call light. Surveyor explained the concern R87's husband's view of the incident from [DATE] is different than RN T's statement. Surveyor explained the concern R87 had a change in condition that required CPR and there is no investigation into the incident. On [DATE], NHA A stated LPN P worked the north/south unit on [DATE] on NOC shift and still works at the facility. NHA A stated she talked with LPN P and wrote up a statement. LPN P's statement dated [DATE] indicates LPN P was working north/south unit on [DATE]. LPN P indicates she remembers R87's husband calling (unknown time) and stated he was trying to reach the rehab nurse because his wife was anxious and had her call light on. LPN P indicates she then went to rehab and found RN T and told her what R87's husband said. RN T told LPN P that RN T had been in and out of R87's room all night and that as soon as they leave the room R87 puts the call light on again. LPN P then states around 6:00 a.m. she heard a page that stated, all nurses to rehab. LPN P stated she went to rehab unit and saw RN T coming out of R87's room yelling call 911 because this lady is coding. LPN P stated she got the crash cart, a med tech (unknown name) called 911, and RN T initiated CPR until paramedics arrived and took over. Surveyor explained to NHA A the concern R87 was experiencing a change in condition and RN T did not perform a comprehensive assessment which then R87 became unresponsive and needing CPR. Surveyor also explained the nurses notes and RN T's statement along with LPN P's statement do not coordinate with each other. The facility's failure to perform a comprehensive assessment when R87 was experiencing a change in condition created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE], when the facility completed the following: - Nursing staff will receive re-education on detecting change in condition and conducting proper nursing assessments in the event of identifying a change of condition. - Nursing staff will receive re-education on physician notification policy. - Staff will receive re-education on call lights and responding to grievances (family concerns.) - Staff will receive re-education on resident adjustment post new admission including education on responding to reports of anxiety. - Education for licensed nurses will be done in person by NHA, DON (Director of Nursing,) or nurse managers. Education began on [DATE] with licensed nurses on the schedule. Education will continue and be provided prior to the start of next shift for those not in attendance on [DATE]. Education for staff began on [DATE] and was done by NHA, DON/nurse manager, or HR. Education will continue and will be provided prior to the start of the next shift for those not in attendance on [DATE]. - The Facility reviewed the policy and procedure on [DATE] for physician notification including the definition of a change of condition and timing of notification in conjunction with current standards of practice. - The Facility reviewed the policy on call lights. - The Facility reviewed the grievance policy (family concerns) - The Facility reviewed the policy for caring partners which outlines a process to address resident adjustment post admission and includes addressing mental health needs. - The Medical director has reviewed and provide input regarding the above policies. - Nursing managers / DON will conduct audits during morning clinical review to identify potential change of condition and ensure that an assessment has been completed, physician/family notified as needed and care plan updated as indicated. - Results of audits will be reviewed at QAPI (Quality Assurance Performance Improvement) meeting for further recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R68 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, diabetes, dementia with behavioral disturbance, depression, and anxiety. R68's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R68's Brief Interview for Mental Status (BIMS) score was 14 indicting R68 was cognitively intact. R68 was independent for transfers and used a wheelchair for mobility throughout the facility. R68 was not coded as wandering or having behaviors. On 3/7/2021 at 4:23 PM in the progress notes, nursing charted R68 went outside with the smoking residents and tried to open the gate. A wanderguard was placed on R68 at that time. On 3/8/2021, R68's Elopement Risk Care Plan was initiated with the following interventions: -Apply wander guard; monitor function and placement. -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. -Monitor exit seeking behavior. On 10/20/2021, R68's Elopement Risk Care Plan was revised with the intervention: R68 refused wander guard placement; now placed on the wheelchair to ensure patient safety while transferring in the wheelchair. On 3/8/2021, on the Treatment Administration Record (TAR,) an order was initiated to check the wander guard placement, location, and function daily with the wander guard being on the back bar on the left of the wheelchair. On 3/22/2021 at 2:24 PM, in the progress notes, nursing charted R68 eloped out of the west door that afternoon stating the door said to hold for 15 seconds and it will open. The wander guard was in place. R68 was redirected and will continue to be monitored. No further elopement attempts were documented. On 4/10/2022 at 7:31 PM, in the progress notes, nursing charted R68 received a shower that evening, and the wander guard was noted to be missing. A new wander guard was requested. On 4/11/2022 at 3:55 AM, in the progress notes, nursing charted the wander guard was unable to be located. The wander guard was last seen on 4/10/2022 to the left side of the wheelchair. R68 was sleeping. On 4/11/2022, an Elopement Risk Evaluation was completed and determined R68 was not at risk for elopement with a score of 1. (A score of 4 or more requires action unless resident is not ambulatory.) On 4/11/2022 at 11:21 AM in the progress notes, nursing charted R68 was re-evaluated and determined to not be at risk for elopement due to increased awareness. The Elopement Risk Care Plan was resolved. On 4/11/2022, R68's Elopement Risk Care Plan was resolved and the orders on the TAR regarding the wander guard were discontinued. On 7/11/2022, an Elopement Risk Evaluation was completed and determined R68 was not at risk for elopement with a score of 1. On 7/16/2022 at 9:13 PM in the progress notes, Licensed Practical Nurse (LPN)-L charted R68 used the code to go out the door to the parking lot while LPN-L was on the phone. LPN-L and a Certified Nursing Assistant went to bring R68 back inside and R68 was swearing all the way into the building. A wander guard was replaced on R68 and R68 was continued to be monitored. On 7/16/2022 at 9:59 PM in the progress notes, nursing charted the wander guard was placed on R68's wheelchair due to R68 resisting when attempting to put the wander guard on the ankle. Surveyor did not find any documentation that the physician or emergency contact was notified of the elopement and the Elopement Risk Care Plan was not reinstated. On 7/16/2022 on the TAR, orders were initiated to check the wander guard every shift. On 8/14/2022 on the TAR, the order to check the wander guard was discontinued. On 8/23/2022 at 6:51 PM in the progress notes, LPN-L charted R68 went to the reception area, pushed through the door, and went across the street. LPN-N from rehab heard the overhead page from reception calling for a CNA first and then the receptionist called a manager STAT, so LPN-N went down to reception where the receptionist told LPN-N R68 went through the doors. LPN-N went out to find R68 and found him two blocks down the street. When R68 was returned, R68 was screaming that R68 was going to get out of the facility again. LPN-L charted R68 will continue to be monitored every 15 minutes. LPN-L charted Nursing Home Administrator and the Director of Nursing were called. LPN-L charted R68 had a wander guard on the wheelchair. Surveyor did not find any documentation that the physician or emergency contact were notified of the 8/23/22 elopement and the Elopement Risk Care Plan was not reinstated. No orders were in the TAR to check the wander guard for placement and function. On 8/24/2022 at 4:33 AM in the progress notes, nursing charted R68 was sleeping and continued to be on 15-minute checks. On 9/6/2022 at 6:46 PM in the progress notes, nursing charted the staff heard the door alarm going off on the [NAME] Unit; R68 was found wheeling self in the parking lot. When asked where R68 was going, R68 stated R68 was getting a tire for R68's bike. Staff redirected R68 back into the building without any complications. Surveyor did not find any documentation that the physician or emergency contact were notified of the elopement and the Elopement Risk Care Plan was not reinstated. No orders were in the TAR to check the wander guard for placement and function. On 9/30/2022, an Elopement Risk Evaluation was completed and determined R68 was at risk for elopement with a score of 5. (A score of 4 or more requires action unless resident is not ambulatory.) On 10/6/2022, R68's Elopement Risk Care Plan was reinitiated with the following interventions: -Monitor function of wander guard; place in rear pocket of the wheelchair due to R68 refusing to wear. -R68 will sign out prior to leaving building per policy due to BIMS revealing cognitively intact and own designated decision maker. On 10/11/2022 on the TAR, orders were initiated to check the wander guard placement (wheelchair rear pocket,) location, and function every shift. On 10/14/2022, the Elopement Risk Care Plan was resolved and the order to check the wander guard was discontinued. Surveyor noted no Elopement Risk Assessment was completed to determine if R68 was no longer a risk. On 1/1/2023, an Elopement Risk Evaluation was completed and determined R68 was at risk for elopement with a score of 5. (A score of 4 or more requires action unless resident is not ambulatory.) On 1/23/2023 at 9:33 AM, Surveyor observed R68 in the dining area across from the nurses' station. R68 was sitting in a wheelchair with an orange flag about five feet high attached to the back of the wheelchair. R68 was conversing with other residents at the table. On 1/23/2023, the Elopement Risk Care Plan was reinitiated. No interventions or goals were initiated at that time, just the focus statement. On 1/24/2023 in the morning, Surveyor requested from Nursing Home Administrator (NHA)-A any documentation of investigations for R68's elopements on 7/16/2022, 8/23/2022, and 9/6/2022. On 1/24/2023 at 3:24 PM, Surveyor met with NHA-A, Director of Nursing (DON)-B, Registered Nurse (RN) Consultant-C, and Corporate Consultant-D and requested any elopement investigations for R68. NHA-A stated they were unaware of R68 eloping. Surveyor stated R68 had eloped on 7/16/2022, 8/23/2022, and 9/6/2022 per the progress notes. NHA-A stated they would look into it and get back to Surveyor with any information. On 1/24/2023, the Elopement Risk Care Plan had the following interventions added: -Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. -Monitor exit seeking behavior. -The resident's triggers for wandering/eloping are wanting their personal belongings (motorcycle). The resident's behaviors is de-escalated by calling sister, remind resident motorcycle was sold, redirect by offering resident activity or snacks. -Wander guard to be kept in the wheelchair pocket due to refusal to wear. On 1/25/2023 on the TAR, an order to monitor the placement and function of the wander guard every shift was initiated. In an interview on 1/26/2023 at 3:21 PM, Corporate Consultant-D stated on 8/23/2022, R68 rolled over the receptionist's toe when R68 was trying to leave the building. Corporate Consultant-D stated staff never left eyes off of R68 during that time. In an interview on 1/26/2023 at 3:53 PM, LPN-I, who does the assessments for the MDS, stated R68's MDS was coming due and LPN-I saw the elopement Care Plan was not in place, so LPN-I called LPN UM-H to verify R68 had a wander guard on. LPN-I stated LPN UM-H told LPN-I that R68 had a wander guard on the left ankle; the wander guard had been on the wheelchair until recently and they put a sticker on it so R68 would accept it. Surveyor asked LPN-I if R68 had always had a wander guard on. LPN-I stated LPN-I did an assessment in 4/2022 and due to increased cognition, the wander guard was removed the Care Plan was resolved. Surveyor asked LPN-I if the wander guard was reinstated after 7/16/2022 when R68 got out of the building. LPN-I stated LPN-I was not sure because LPN-I was not covering R68 at that time. LPN-I stated they did a partial investigation and found out the nurse never took their eyes off of R68; they say R68 left and got R68 back into the building. LPN-I stated on 8/23/2022, R68 ran over the receptionist's foot to get out of the building; the receptionist called for help and the nurse came right away and ran after R68 to bring R68 back to the facility. LPN-I stated LPN-N was the nurse that ran after R68 at that time. LPN-I stated R68 went out of the rehab door, and LPN-I was not sure if the wander guard alarms with that door or not. LPN-I stated if someone was going out the door, the door would not automatically close if someone with a wander guard went through the door. LPN-I did not know anything about R68's elopement on 9/6/2022. Surveyor asked LPN-I why R68's Elopement Risk Care Plan was resolved on 10/14/2022? LPN-I stated neither LPN-I nor LPN UM-H resolved the Care Plan and did not know who did, so could not answer the question. LPN-I stated LPN-I reinstated the Elopement Risk Care Plan on 1/23/2023 but did not realize until the next day or so that no goals or interventions were reinstated so LPN-I put the interventions in at some time this week. LPN-I stated because R68 was under quarterly review for MDS, LPN-I noticed the Elopement Risk Care Plan was not in and it should not have been removed. Surveyor asked LPN-I if there is a book or binder showing which residents were at risk for elopement? LPN-I stated there are wander guard books in the staff lounge and maybe at every nurses' station, and one at reception. LPN-I stated it has the resident's name, picture, and face sheet so staff know who to be aware of. In an interview on 1/30/2023 at 9:18 AM, Surveyor asked NHA-A and Corporate Consultant-D if any investigations were done at the time of the elopements. Corporate Consultant-D stated no, they could not say that there were any investigations and could not recall that happening. Corporate Consultant-D stated staff were interviewed on 1/26/2023 and 1/27/2023 regarding R68's elopements. Those interviews were supplied to Surveyor. Corporate Consultant-D reviewed the staff statements with Surveyor. Corporate Consultant-D stated LPN-L was at the desk talking on the phone on 7/16/2022 when LPN-L heard the alarm go off from the wander guard; LPN-L got R68 from the parking lot. Corporate Consultant-D stated the wander guard alarm worked, notifying staff of R68 leaving the building. Surveyor shared with Corporate Consultant-D that the progress notes for that date indicate R68 punched in the code to get out of the door, so the interview with LPN-L did not match the events as recorded in R68's medical record. Corporate Consultant-D stated Receptionist-J, Admissions Coordinator-M, and LPN-L were interviewed regarding R68's elopement on 8/23/2022. Corporate Consultant-D stated Receptionist-J stated R68 wheeled past Receptionist-J, and R68 ran over Receptionist-J's foot. Corporate Consultant-D stated a code was needed to get in or out of the inner door at that time. Surveyor asked Corporate Consultant-D how R68 got out of the building so quickly if a code was needed to get out? Corporate Consultant-D was not sure. Corporate Consultant-D stated Receptionist-J ran to the phone to page for help; maybe one minute passed from the time of the page until LPN-N got to the reception area. Corporate Consultant-D stated Admissions Coordinator-M heard the exchange between Receptionist-J and R68 but did not get up. Corporate Consultant-D stated they had not been able to get in touch with the nurse involved with the elopement on 9/6/2022 so they do not have any information on that event. Surveyor shared with NHA-A and Corporate Consultant-D the concerns that none of the elopements were investigated at the time of the events to determine the root causes and then implement measures to keep R68 safe. Surveyor shared R68's Elopement Risk Care Plan was resolved on 4/11/2022 and not put back into place until 10/6/2022 and then resolved again on 10/14/2022 with no assessment to determine if R68 was at risk for elopement or not. Surveyor shared the intermittent orders to monitor the location and function of R68's wander guard and the concern there was no documentation the physician or emergency contacts were made aware of R68's elopements. NHA-A stated R68 was their own person so they can come and go as they please and the elopements were acted on immediately. Surveyor shared with NHA-A and Corporate Consultant-D that if R68 was their own person and not at risk for elopement, R68 would not have a wander guard on and would not have been escorted back to the facility. Surveyor reviewed the staff statements obtained by Corporate Consultant-D. -Elopement on 7/16/2022: LPN-L stated to Corporate Consultant-D on 1/27/2023 LPN-L was on the phone at the nurses' station and heard the west door alarm sounding. LPN-L placed the call on hold and immediately responded to the door in less than ten seconds. LPN-L saw R68 had exited to the parking lot where LPN-L immediately went and brought R68 back into the building. -Elopement on 8/23/2022: Receptionist-J stated to Corporate Consultant-D on 1/27/2023 that on 8/23/2022 R68 came zooming by the reception desk attempting to get out of the building at approximately 6:00 PM. Receptionist-J stated Receptionist-J immediately jumped up to stop R68. R68 pushed past Receptionist-J and ran over Receptionist-J's foot in the process. Receptionist-J paged for help and the nurses and CNAs came running. Receptionist-J told them R68 went outside, and they ran outside to catch R68, and they did. Receptionist-J stated the time from trying to stop R68 and the nurses running to get R68 was approximately one minute. -Elopement on 8/23/2022: Admissions Coordinator-M stated to Corporate Consultant-D on 1/27/2023 that on 8/23/2022 at about 6:00 PM, Admissions Coordinator-M was in their office next to the reception area. Admissions Coordinator-M had their door open halfway and heard the commotion. Admissions Coordinator-M heard Receptionist-J say no to R68 followed by Ow and then heard Receptionist-J yelling for help. Receptionist-J overhead paged for the nurse and staff to help. Admissions Coordinator-M could not see as the door was blocking the view. Admissions Coordinator-M ran out where Receptionist-J was and Receptionist-J stated R68 ran over Receptionist-J's foot when Receptionist-J tried to stop R68, but R68 pushed past Receptionist-J and got out of the building. Admissions Coordinator-M stated LPN-N and two CNAs came quickly and went outside and got R68. -Elopement on 8/23/2022: LPN-N stated to Corporate Consultant-D on 1/26/2023 that the receptionist overhead paged for the west wing nurse to come to the receptionist at 6:51 PM on 8/23/2022. LPN-N stated LPN-N went to the receptionist and the receptionist stated a resident had left the building. LPN-N stated from the first page to when LPN-N went to the receptionist was one minute. LPN-N yelled to page a CNA and LPN-N ran outside and looked around. LPN-N went to the sidewalk and looked across the street. R68 was in the wheelchair across the street and going forward. LPN-N crossed the street and hollered for R68 to stop. R68 started to roll faster. LPN-N ran and caught up to R68 and brought R68 back to the facility. In an interview on 1/30/2023 at 11:46 AM, Surveyor asked Receptionist-J if a wander guard would set an alarm off at that door. Receptionist-J stated yes, the alarm would sound. Surveyor asked Receptionist-J to state what happened on 8/23/2022. Receptionist-J stated R68 was going out of the building and ran over Receptionist-J's foot. Receptionist-J stated the alarm sounded and Receptionist-J yelled for help. Surveyor asked if Receptionist-J called on the overhead page to get help? Receptionist-J stated no, staff heard the alarm and Receptionist-J yelled down the hallway for help. Receptionist-J stated a nurse and a couple of CNAs ran to the area and Receptionist-J told them R68 had gotten out, so they ran after R68. Surveyor asked Receptionist-J if there was a binder with residents at risk for elopement? Receptionist-J stated yes and provided the binder. Surveyor noted there were eight residents in the binder including R68. Receptionist-J stated the Activities Director updates the binder but was not sure how often. Surveyor noted the written statement provided by Corporate Coordinator-D of the interview with Receptionist-J and the in-person interview with Receptionist-J did not have the same facts and differed from the progress notes in R68's medical record of the events of 8/23/2022. No investigations of the elopements were completed on 7/16/2022, 8/23/2022, and 9/6/2022 and therefore no root cause analyses were completed to determine appropriate interventions to keep R68 safe. The elopement on 8/23/2022 had R68 crossing the street the facility is located on; the street is a four-lane divided road with a large, elevated median including turn lanes with extensive traffic. R68 went across the parking lot, across this heavily trafficked road and down two blocks in a wheelchair before being reached by facility staff. No Elopement Risk Care Plan was in place at the time of the elopements and no Care Plan was initiated after the elopements. The Elopement Risk Care Plan was initiated on 1/23/2023 after the survey team had entered the building for the recertification survey. No further information was provided to Surveyor. The facility's failure to not evaluate and analyze residents' falls and elopement attempts to determine a root cause analysis, the failure to implement resident centered care plan interventions to reduce future risk of falls and elopements, the failure to monitor interventions for effectiveness and modify interventions to provide additional supervision to mitigate the risk of another accident occurring, and the failure to provide the supervision necessary to prevent falls and elopement for both R29 and R68 created a finding of immediate jeopardy that began on 8/17/22. The facility removed the immediate jeopardy on 1/31/23, when it had completed the following: - Licensed nurses received re-education on completing a thorough risk management entry following a fall or exit seeking event that could result in an elopement. Entries may include witnessed statements, contributing factors and post-fall investigation. Education was done in person by NHA, DON, or nurse managers with an interactive problem solving exercise. Education began on 1/31/23 with licensed nurses on the schedule. Education will continue and be provided prior to the start of next shift for those not in attendance on 1/31/23. - Staff was re-educated on policy and procedure for falls and elopements/potential elopements. - The IDT has been re-educated on conducting a comprehensive assessment and root cause analysis following a fall or an event/behavior pattern that indicates a resident might be at risk for elopement. The root cause analysis is also the process by which the IDT will determine specific level of supervision that would be required to maintain resident safety. Any determined interventions are care planned. IDT education is being provided by Corporate consultant team in person with interactive group problem solving session. IDT has been re-educated on updating care plans utilizing information gathered through the root cause analysis process as well as ensuring physician has been notified when applicable. IDT education was provided by Corporate consultant team in person with interactive group problem solving session. - The Fall policy and procedure was reviewed and revised to reflect current facility practice which includes a root cause analysis process for updating the care plan to reflect individual resident needs including level of supervision. The IDT will be responsible to ensure the level of supervision is care planned and revised as necessary based on resident assessment. - Elopement policy and procedure was reviewed and revised to reflect current facility practice that includes an assessment process to develop care plans that are resident centered. This policy reflects the need to update the physician in the event a resident is determined to be at risk for elopement or has actually eloped. The IDT will be responsible to ensure the level of supervision is care planned and revised as necessary based on resident assessment. Elopement policy will reflect the need to change the door alarm code in the event a resident becomes aware of the code. Elopement and Fall policy were reviewed with opportunity for input by the medical director on 1/31/2023. - All falls will be audited during clinical IDT meeting to include a root cause analysis and IDT summary of facility actions. - Behaviors that could indicate risk for elopement will be reviewed during clinical IDT to include a root cause analysis and care plan updates as identified. - Door alarms will be audited daily for proper functioning x 4 weeks then weekly ongoing. Wanderguard bracelets will be audited daily for function. - Results of fall and elopement investigations will be reviewed during QAPI to identify patterns or trends. The deficient practice continues at a scope/severity of D potential for harm/isolated based on the following example: 3. R72 was admitted to the facility on [DATE] with diagnoses of diabetes, peripheral vascular disease, anxiety, depression, and a right below the knee amputation. R72's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R72 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and coded R72 needing extensive assist with bed mobility and totally dependent for toileting and was always incontinent of bowel and bladder. R72 had multiple falls when admitted to the facility due to the newly right below the knee amputation. R72 had poor balance and was forgetful to the fact that there was not a right leg to stand on. Each fall was not comprehensively assessed, and the Falls Care Plan was not revised with an appropriate intervention to prevent future falls in similar circumstances. R72's At Risk for Falls Care Plan was initiated on 1/31/2022 and the following interventions were in place on 8/29/2022: -Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed. -Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. -Ensure that the resident is wearing appropriate footwear. -Physical Therapy evaluate and treat as ordered or as needed. -Resident needs re-education on safety and asking for staff assistance and using reacher related to impulsive behaviors. -Resident to be provided a reacher and longer charger with staff assistance to encourage phone, pen pouch, and paper along with water at bedside table within reach. -Resident to have a night light in room to improve visual function in the evening. -Resident to have a psych consult related to increased behaviors. -Resident to have all commonly used items within reach, i.e., reacher, remote, phone, etc. to increase patient safety and independence. -Resident to have Dycem placed in wheelchair to increase safety while in the wheelchair. -Resident to have medication review related to increased falls with attention seeking behaviors. -Resident to have scoop mattress to increase safety while in bed related to rolling out of bed. -Review information on past falls and attempt to determine cause of falls; record possible root causes, alter/remove any potential causes if possible; educate resident/family/caregivers/interdisciplinary team as to causes. -The resident needs a safe environment with the bed in low position at night. R72's Activities of Daily Living Care Plan was initiated on 1/31/2022 and had the following interventions in place on 8/29/2022: -Bed Mobility: the resident requires limited assist by one staff to turn and reposition in bed every shift and as necessary; two-person extensive assist to boost. -Toilet Use: The resident requires moderate to extensive assist by one staff for toileting. Fall #1: On 8/29/2022 at 4:04 PM in the progress notes, nursing charted R72 fell out of bed when R72 was being rolled to be changed. R72 stated they were rolled too far and fell over the side of the bed. On 8/29/2022 at 4:14 PM in the progress notes, nursing charted R72 had a witnessed fall. R72 was being changed and rolled to the right side and R72 continued to roll off the bed. R72 caught themselves between the bed and the nightstand and was eased to the floor. R72 complained of pain 3 out of 10 to bilateral knees but the pain subsided once back in bed. The Nurse Practitioner and emergency contact was notified. R72's At Risk for Falls Care Plan was revised on 8/29/2022 with the following interventions: -Resident to have bilateral bed rails to increase safety and independence with bed mobility. -Staff re-education on proper bed mobility and safety with transfers. On 8/30/2022 at 9:16 AM, the Interdisciplinary Team (IDT) met to review the fall. R72 was rolled too far when the brief was being changed and rolled off the bed, catching themselves on the nightstand and staff assisted R72 to the floor. R72 had a single left side partial bedrail in place. The IDT determined the intervention of a right side bedrail to assist with bed mobility and education of staff to ask for additional staff if resident is not assisting would be added to the care plan. R72's Activities of Daily Living Care Plan was revised on 8/30/2022 with the following intervention: Side Rails: Bilateral half rails up as per doctor's order for safety during care provision to assist with bed mobility; observe for injury or entrapment related to side rail use; reposition every shift and as necessary to avoid injury. R72's Activities of Daily Living Care Plan was revised on 9/1/2022 with the following intervention: Toilet Use: the resident requires extensive to dependent assist by one staff for toileting. Fall #2: On 9/10/2022 at 3:44 PM in the progress notes, nursing charted R72 rolled to the floor and complained of pain to the head. 911 was called and R72 was transferred to the hospital. On 9/10/2022 at 10:10 PM in the progress notes, nursing charted when the nurse was walking down the hall, R72 was not in bed. The nurse entered the room and found R72 in a prone position. R72 denied hitting the head but said the foot was hurting. R72 was given Tylenol and vital signs were within normal range. The nurse assisted R72 back into bed per care plan. The nurse again asked R72 if R72 had any pain. R72 replied that the middle of the head was hurting. R72 sounded confused with the replies and the nurse sent R72 to the hospital for evaluation. R72 was admitted to the hospital for medical reasons not associated with the fall. The physician and emergency contact were made aware. Surveyor did not find any IDT notes of the review of the fall. The At Risk for Falls Care Plan was not revised. Fall #3: On 10/29/2022 at 10:09 AM in the progress notes, nursing charted R72 was found lying on the floor in R72's room on the left side. R72 was slightly confused per usual. R72 was responding, speaking well, and pupils and hand grasps were equal. Surveyor did not find any IDT notes of the review of the fall. The At Risk for Falls Care Plan was not revised. On 1/23/2023 at 9:52 AM, Surveyor observed R72 sleeping in bed. The bed had a scoop mattress and bilateral partial siderails in place. On 1/23/2023 at 12:13 PM, Surveyor asked R72 if R72 had any falls while at the facility. R72 could not recall ever falling at the facility. In an interview on 1/26/2023 at 8:58 AM, Licensed Practical Nurse (LPN)-H stated when a resident has a fall, a fall packet is completed by the nurse on the floor. LPN-H stated the nurse tells the IDT what they saw and if the resident cannot tell them what happened, the nurse summarizes what they see. LPN-H stated in the morning meeting with the clinical managers, the falls are reviewed, and they investigate a little more to come up with the Care Plan interventions to prevent future falls. LPN-H stated MDS nurses are a part of the meeting, and they update the Care Plan after the meeting. Surveyor asked LPN-H if staff statements are obtained, such as when the last time the resident was toileted or what the resident was doing the last time they were seen. LPN-H stated LPN-H had not seen staff statements in a long time. LPN-H stated they used to be part of the packet, but now the packet is down to one sheet. LPN-H stated the resident is interviewed the next day if they are interviewable to find out what happened. In an interview on 1/26/2023 at 4:08 PM, Surveyor reviewed R72's falls with Licensed Practical Nurse (LPN)-I. LPN-I was the Unit Manager prior to their current position in MDS. Surveyor asked LPN-I how R72 fell out of bed on 8/29/2022. LPN-I stated the CNA probably used too much force when rolling R72 to change the brief. LPN-I stated R72 was on an air mattress and sometimes it does not take much to roll off an air mattress. Surveyor shared with LPN-I that R72 did not have an air mattress at that time; the air mattress was put on the bed on 9/9/2022. LPN-I stated R72 should have been rolled toward the CNA and not away. Surveyor shared with LPN-I that no IDT notes or Care Plan revisions were found after R72's falls on 9/10/2022 or 10/29/2022. LPN-I recalled R72 refusing to have the bed on the rehab unit moved to the long-term care unit and the rehab bed had a scoop mattress. LPN-I did not know when the scoop mattress was replaced on R72's bed, but Surveyor had observed a scoop mattress on R72's bed. LPN-I stated LPN-I was on vacation on 10/29/2022 so another unit manager would have covered any of the falls at that time so could not speak as to why there were no IDT notes or Care Plan revisions. LPN-I stated either the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) run the IDT meetings and the MDS nurse would revise the Care Plan after the meeting. In an interview on 1/30/2023 at 1:17 PM, Surveyor reviewed with DON-B and Registered Nurse (RN) Consultant-C R72's falls on 8/29/2022, 9/10/2022, and 10/29/2022. DON-B stated R72 was on an air mattress on 8/29/2022 when the CNA rolled R72 off the bed. Surveyor shared the air mattress was not added to the Care Plan until 9/9/2022. Surveyor shared one of the interventions to prevent future falls after the fall on 8/29/2022 was to educate staff on how to turn residents when providing cares. No education documentation was provided. RN Consultant-C stated a CNA sometimes has to roll the resident away from them to get the resident clean. Surveyor shared with RN Consultant-C that R72's Care Plan stated R72 was a two person assist if needed. DON-B and RN Consultant-C did not have any explanation as to why there were no IDT meetin

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure staff provided basic life support to 1 (R37) of 1 Residents who required Cardiopulmonary Resuscitation (CPR.) The facility currently has 50 out of 92 residents who desire CPR (Full Code.) The failure of staff to immediately call a code for R37 on the overhead page system, failure to call 911, the failure to not start CPR immediately, the failure to bring the crash cart & AED (Automated External Defibrillator) into R37's room during the code, and RN-NN instructing LPN-MM to stop CPR created a finding of immediate jeopardy that began on [DATE]. Administrator-A, DON (Director of Nursing)-B, Corporate Consultant-C, & Regional Clinical of Operations-D were notified of the immediate jeopardy on [DATE] at 12:18 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement and monitor their action plan. Findings include: The Cardiopulmonary Resuscitation-CPR policy & procedure with an effective date of [DATE] documents under guidelines: This facility will provide basic life support including CPR - Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order and resident choice indicated in the resident's advanced directives. Under CPR Procedure it is documented: 1. Employee to verify safety of the scene/environment. 2. Check for resident response. Tap or shake shoulder of resident asking, Are you okay? 3. Simultaneously assess the resident for breathing and pulse for 10 seconds. If necessary, open the airway: Head-tilt/chin-lift technique. If a head, neck, or spinal injury is suspected, utilize the modified jaw-thrust maneuver. 4. Shout for nearby help or pull the call light for assistance. Activate emergency response System by announcing overhead, 3 times CODE BLUE and LOCATION. 5. Staff immediately instructed to retrieve emergency cart/equipment. If collapse was witnessed and staff member alone, leave resident to activate the emergency response system and retrieve emergency cart (unless another staff member is able to retrieve device) before beginning CPR. 5. Identify code status/advance directive preferences. If the resident has a valid advance directive, indicating Do Not Resuscitate, DO NOT PERFORM CPR: ILLINOIS - a POLST (Physician Orders for Life-Sustaining Treatment Form that indicates that resuscitation is not desired.) WISCONSIN - a POST (Physician Orders for Scope of Treatment form that indicates that resuscitation is not desired). 6. If a DNR order/Advanced Directive does NOT exist or if Advance Directive does not indicate DO Not Resuscitate, begin resuscitation efforts. 7. If Resident does not exhibit normal breathing and has a pulse, begin rescue breathing. 1 breath every 5-6 seconds (10-12 per minute) using face mask or Resuscitator Bag. If resident is presenting with agnal breaths, continue as if resident is not breathing. 8. Check pulse approximately every 2 minutes. 9. If no pulse, begin CPR. Place backboard under resident in bed or assist resident to a firm, flat surface if possible. Compress chest compressions at a rate of 100-200 per minute (place 2 hands on the lower half of the sternum). Compress to a depth of at least 2 (inches). Ensure full recoil following each compression. Minimize any pauses in compressions. Ventilate 2 breaths after 30 compressions, each breath to be delivered over 1 second, causing chest to rise (30:2 Ration for both 1 or 2 rescuers). Use face mask or resuscitator bag. 10. Continue resuscitation efforts until one of the following occurs: Resident presents with effective, spontaneous circulation. Care is transferred to emergency responders to provide advanced life support. The rescuer is not able to continue due to exhaustion, dangerous environmental hazards or efforts to resuscitate places others in danger. Reliable and valid criteria that indicates irreversible death are met, criteria of obvious death are identified or criteria for termination of resuscitation is met. 11. Turn CPR over to emergency personnel upon arrival and prepared to take over. The Automated External Defibrillator (AED) Policy dated [DATE] documents Purpose: The purpose of this policy is to provide information regarding the use of the AED. The use of the AED: The AED is to be applied to a victim if indicated, during a code blue response. R37 was readmitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, COPD (chronic obstructive pulmonary disease,) panlobular emphysema, diabetes mellitus, hypertension, depression, aphasia, and anxiety disorder. R37 was his own person. Resident's care plan notes Resident has advanced directive CPR - Full Code which was initiated [DATE]. Interventions are: * Code status will be reviewed on a quarterly basis and PRN (as needed) initiated [DATE]. * Resident has decided to remain a full code initiated [DATE]. The physician order dated [DATE] documents Full Code - (Provide CPR.) The orders administration note dated [DATE] at 3:54 p.m. documents Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 4 hours as needed for SOB (shortness of breath)/Wheezing Audible wheezing noted. The orders administration note dated [DATE] at 5:51 p.m. documents Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 4 hours as needed for SOB/Wheezing PRN (as needed) Administration was: Effective. The next nurses note is dated [DATE] at 4:59 a.m. and documents The Resident passed away at 04:50 am. The CPR initiated. Doctor was notified. [Name] called and notified via voice mail. Then author called his daughter [name] and notified the time of death. The Resident was unresponsive to the treatment. No pulse, BP (blood pressure)/heart rate were absent. The only vital signs documented on [DATE] were at 12:53 a.m. for 94% oxygen via nasal cannula. The nurses note dated [DATE] at 5:11 a.m. documents Nurses note Time of Death Resident observed with no pulse, respirations or audible heart tones. Time of death: The Resident passed away at 04:50 am. The CPR initiated. Doctor was notified. The Resident was unresponsive to the treatment. No pulse, BP/heart rate were absent. Second nurse confirming death. (If needed): The charge nurse evaluated ETD (estimated time of death) announced. Family Notification: Then author called his daughter [name] and notified the time of death. Physician Notification: The physician [name] notified. Coroner Notification: Other Notification (Describe): The Resident was unresponsive to the treatment. No pulse, BP/heart rate were absent. CPR performed. Authorization received to release body to funeral home. Post mortem care performed.: Notification that death is a coroner case, post mortem care deferred.: Funeral home notification: Requested documents faxed to coroner office: Time of transport to funeral home/coroner office: Belongings transported with body: Disposition of belongings to family. (Be specific): Eligible medications returned to pharmacy. Others to be destroyed.: Other notes: The Resident passed away at 04:50 am. The CPR initiated. Doctor was notified. [name] called and notified via voice mail. Then author called his daughter [name] and notified the time of death. The Resident was unresponsive to the treatment. No pulse, BP/heart rate were absent. On [DATE] at 1:51 p.m., Surveyor asked RN (Registered Nurse)-BB if there are AED machines in the facility. RN-BB replied we do. Surveyor inquired where they are located. RN-BB stated on the crash cart and he will show Surveyor. RN-BB then showed Surveyor the crash cart with an AED on top of the cart and stated if someone is unresponsive you should bring it with you. On [DATE] at 1:58 p.m., Surveyor asked RN-O if each unit has a crash cart. RN-O replied yes. Surveyor then asked if there are AEDs in the Facility. RN-O replied yes. On [DATE] at 3:19 p.m., Surveyor asked Administrator-A what time night shift staff leave. Administrator-A informed Surveyor they are here until 6:00 a.m. unless schedule says they are leaving early. Surveyor informed Administrator-A Surveyor needs to speak with two night shift staff, LPN (Licensed Practical Nurse)-MM and CNA (Certified Nursing Assistant)-LL. Administrator-A informed Surveyor LPN-MM was here today for a CPR class as he could not come back to work until he completed the CPR class. On [DATE] at 5:45 a.m., Surveyor met with CNA-LL. Surveyor asked CNA-LL to explain what occurred on [DATE] with R37. CNA-LL explained he walked into R37's room for routine change, R37 was coughing a little, he asked R37 if he needed a break and R37 could speak. After CNA-LL got the brief on, R37 started having a major coughing fit, seemed pretty bad. CNA-LL stated he then went to get LPN-MM. Surveyor asked if LPN-MM went to R37's room. CNA-LL replied yes. CNA-LL informed Surveyor he assumed R37 was like this because his oxygen was not on. CNA-LL informed Surveyor LPN-MM placed R37's oxygen back on, R37 seemed to be doing okay, LPN-MM told him to continue with his rounds and check R37 frequently. CNA-LL informed Surveyor he would take care of a resident and when finished would go back and check R37. CNA-LL stated during the third time of checking R37, R37 was not responsive. CNA-LL informed Surveyor he called R37's name & rubbed his chest to try to wake him. CNA-LL informed Surveyor he went to get LPN-MM. LPN-MM came in, looked at R37 & checked his vital signs. CNA-LL informed Surveyor he stayed with R37 while LPN-MM went to get the other nurse. CNA-LL indicated while he was in R37's room he continued to try to wake R37 up by calling his name, rubbing his chest, and trying to get his attention. CNA-LL informed Surveyor the two nurses came in and LPN-MM started CPR. Surveyor asked CNA-LL if the nurses had the AED with them. CNA-LL replied no, and stated they didn't get the crash cart either. CNA-LL informed Surveyor the two nurses took turns doing CPR and after a couple rounds of doing CPR they pronounced him dead and called the family. Surveyor asked if a code was announced on the overhead page. CNA-LL informed Surveyor he doesn't remember. Surveyor asked if 911 was called. CNA-LL replied no. Surveyor asked CNA-LL how R37 was at the start of his shift. CNA-LL replied he was fine, nothing wrong with him. CNA-LL informed Surveyor R37 always had respiratory issues but not that bad. Surveyor asked what R37's respiratory issues were. CNA-LL informed Surveyor R37 frequently coughed and always wore oxygen. Surveyor asked CNA-LL if R37 could tell him what was wrong with him. CNA-LL replied R37 was coughing too much to tell him what was wrong. Surveyor asked CNA-LL if he has received any recent in-services. CNA-LL replied yes, this past Friday on what to do during a code blue. On [DATE] at 6:01 a.m., Surveyor met with LPN-MM. Surveyor asked LPN-MM to explain to Surveyor what occurred on [DATE] with R37. LPN-MM informed Surveyor he was working on the north & south units that night. CNA-LL came and told him R37 was uncomfortable, went there, R37 did not have the nasal cannula on and was having difficulty breathing. LPN-MM informed Surveyor he put R37's nasal cannula on, checked his pulse & breathing. Surveyor asked when CNA-LL came to get him was he on R37's unit? LPN-MM explained he was on the South unit, the other unit. LPN-MM indicated this was not the way R37 used to look and went to get the charge nurse RN-NN. LPN-MM indicated he told RN-NN there was something wrong with R37, was still breathing. Surveyor asked if RN-NN came back with him to R37's room. LPN-MM replied yes, saw R37 was a little more uncomfortable and started CPR. Surveyor asked LPN-MM if CNA-LL informed him R37 was coughing. LPN-MM replied no he didn't tell me that got the charge nurse and started CPR. Surveyor informed LPN-MM, CNA-LL had informed Surveyor CNA-LL went to get him when R37 was coughing bad, you went in placed R37's oxygen back on and told CNA-LL to check R37 frequently. CNA-LL indicated after the third time of checking R37, he went and got you and this is when you went to get RN-NN. LPN-MM informed Surveyor he doesn't remember the time line. LPN-MM informed Surveyor R37 couldn't be revived. LPN-MM informed Surveyor he asked if he should call a code and RN-NN told him no, he's dead, she's in charge so I went with her. LPN-MM informed Surveyor he called the Kenosha police as he didn't have the coroner's phone number, called the POA (power of attorney) sister in law, the daughter, & director when charge nurse pronounced R37 dead. Surveyor asked LPN-MM if he took R37's vital signs would this be documented? LPN-MM replied he didn't know how many times he went in R37's room. Surveyor asked LPN-MM if he brought the crash cart or AED in R37's room? LPN-MM replied no. Surveyor asked why not? LPN-MM replied because I was doing CPR, she told me to give CPR. Surveyor asked LPN-MM how he was doing CPR? LPN-MM replied chest compressions. Surveyor asked LPN-MM if he is CPR certified? LPN-MM replied yes and went through the CPR class yesterday. Surveyor asked if 911 was called? LPN-MM replied no and that he asked the charge nurse and she said no need. Surveyor asked LPN-MM who pronounced R37? LPN-MM replied the charge nurse. Surveyor asked who was doing CPR? LPN-MM replied I was. Surveyor asked if RN-NN also did CPR? LPN-MM replied no. LPN-MM informed Surveyor while he was performing CPR he asked RN-NN to call 911 and she said no need. Surveyor asked LPN-MM why he stopped CPR? LPN-MM said R37 was not responding so declared him dead. Surveyor asked how many rounds of CPR were performed? LPN-MM replied 3, 3 to 4. Surveyor asked LPN-MM if he had an ambu bag? LPN-MM replied no, did CPR for 15 to 20 minutes. Surveyor asked LPN-MM to explain how he did CPR. LPN-MM stated he did 30 compressions then checked for respirations and RN-NN stated carry on, carry on. Surveyor asked LPN-MM if a code was called on the overhead paging? LPN-MM replied No, I asked her and she said no. Surveyor asked LPN-MM where he would find a Resident's code status? LPN-MM informed Surveyor in the patient's chart & PCC (pointclickcare.) Surveyor asked how he knew R37 was a full code? LPN-MM informed Surveyor when he gives medication it's there. Surveyor asked LPN-MM on the night of [DATE] did he check R37's code status? LPN-MM replied no, then stated he rechecked the code status. Surveyor asked LPN-MM if there was anything else he wanted to tell Surveyor? LPN-MM informed Surveyor it was a very particular situation, never came up with this situation, what he was told was strange. Surveyor asked LPN-MM what he meant by what he was told was strange? LPN-MM informed Surveyor not to call the code, 911, and declaring dead by the charge nurse. LPN-MM informed Surveyor he asked RN-NN what needs to be documented and she was not able to give him information on what to document. Surveyor asked LPN-MM when he called the doctor did he speak with the doctor? LPN-MM replied yes. Surveyor asked LPN-MM what he told the doctor? LPN-MM said R37 was not responding and he's dead. Surveyor asked LPN-MM if he informed the doctor R37 had been coughing and CPR was performed? LPN-MM replied no, it was a short conversation and put the phone down. On [DATE] at 9:35 a.m., Surveyor spoke to RN-NN on the telephone. Surveyor asked RN-NN to explain to Surveyor what occurred on [DATE] with R37. RN-NN informed Surveyor she was working on another unit and first name of LPN-MM came up to her at 4:40 a.m. and told her R37 didn't have a pulse. RN-NN informed Surveyor she went to the room, the patient was cold to touch, didn't have a pulse, and began CPR. Surveyor inquired who started CPR. RN-NN replied first name of LPN-MM. Surveyor inquired if CPR was on the bed or floor. RN-NN replied left R37 on the bed. RN-NN informed Surveyor we did another round of CPR, there was still no pulse and called the doctor that R37 passed away and did CPR. Surveyor asked who made the decision to stop CPR? RN-NN stated there were no pulses present and I said to stop it. Surveyor asked RN-NN if she called a code or called 911? RN-NN replied no. Surveyor asked RN-NN why didn't she call a code or call 911? RN-NN replied I was thinking he was a DNR (do not resuscitate.) Surveyor asked RN-NN if they brought the crash cart & AED into R37's room? RN-NN replied no, and stated the patient was new to me, didn't know the patient. The facility's failure to provide R37 with CPR in accordance with current standards of practice and the facility's policies, the failure to call an overhead code blue 3 times and to immediately start CPR, the failure to call 911, the failure to retrieve the emergency cart/equipment such as the crash cart, AED, Ambu bag in order to provide CPR, and the failure to continue resuscitation efforts until care is transferred to emergency responders to provide advanced life support created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when it had completed the following: * All departments received reeducation on basic life support including the CPR policy in the form of verbal education with verification of competency. Training was provided by the NHA, DON, and Nurse Managers. Training was initiated on [DATE] and was completed on [DATE]. The training occurred both individually and in small groups. Staff received reeducation prior to beginning of their next shift. * This training has been incorporated into the orientation process for all new hires. Education includes: Facility policy on CPR and how to respond in the event someone is found unresponsive. Location of the crash carts. Use of AED. Activation of Emergency Response Calling 911. Identification of code status. Once you initiate CPR you cannot stop until 911 arrives and assumes responsibility for the code. * CPR drills have been conducted on each shift and will be ongoing. * Review of CPR Policy on [DATE] by NHA, DON, Medical Director, and Corporate Nurse Consultant. * The CPR Policy was revised on [DATE] to reflect the use of an advanced directive form that indicates full code or DNR status. * Crash Cart Inventory audit in place [DATE] to be completed daily. * Facility has developed a process for internal review of code status events to be completed by IDT team following a Code Event. * Process in place to ensure CPR certification is current. * The facility has established a system to ensure that staff provide care and treatment related to code status based upon resident wishes, standards of practice, and policy and procedures. * Facility has established a system to ensure that advanced directives/code preferences are reflected accurately and timely in the resident's medical record in conjunction with physician consultation. * Hospice providers have been informed of facility policy for obtaining code status. In the event there is a request for a change in code status for a hospice patient, the hospice providers have been instructed to inform the Nurse manager assigned to the unit. If it is outside of normal business hours, the staff nurse will contact the nurse manager on call to facilitate the request immediately. * Facility has developed a process for internal review of code status events to be completed by IDT following a code. IDT team will Audit Post Code Forms following each code event. This will be ongoing. * Crash Cart Inventory Form will be audited by Unit Managers Weekly and following a code event. This is ongoing. Review of audits will be part of the ongoing QAPI (quality assurance performance improvement) process.