**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to honor a resident's advanced directive of do not resuscitate for 1 (R1) of 4 residents reviewed for advanced directives and resident's rights. R1 has a State Do Not Resuscitate (DNR) form signed by R1's Power of Attorney (POA), and an active Medical Doctor (MD) order documenting DNR. On [DATE], R1 became unresponsive and was pulseless. Facility staff did not check R1's advanced directives before performing Cardiopulmonary Resuscitation (CPR) compressions on R1. R1's pulse returned. After receiving compressions, R1 complained of pain as high as 10 out of 10 and required an added MD order for Morphine to control R1's pain. The facility's failure to honor R1's DNR wishes led to facility staff completing chest compressions through the act of cardiopulmonary resuscitation (CPR) that caused R1 to be resuscitated, despite the formulation of an advanced directive to decline such measures and which led to R1 experiencing extreme pain post resuscitation. This situation created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Regional Nurse Consultant-C, and [NAME] President of Success (VP)-D were notified of the immediate jeopardy on [DATE] at 2:36 PM. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity (s/s) of an E (potential for harm/pattern) as the facility continues to implement their action plan. Findings include: The facility policy titled, Cardiopulmonary Resuscitation (CPR) with a review date of [DATE], documents, in part: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR) . The facility will follow current American Heart Association (AHA) guidelines regarding CPR. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order; and c. If the resident does not show obvious signs of clinical death . CPR certified staff will be available at all times. R1 was admitted to the facility on [DATE] with diagnoses that include Cerebrovascular disease, Dementia, Hypertension, Atrial Fibrillation, Pacemaker, and Type 2 Diabetes. R1's Significant change Minimum Data Set (MDS) assessment dated [DATE] documents that R1 is severely cognitively impaired and requires partial to moderate assist for toileting, mobility, and transfer. R1 has an activated Power of Attorney. Surveyor located multiple signed State DNR forms in R1's electronic medical record. The most recent State DNR form, signed by R1's POA, is dated [DATE]. R1's active MD order dated [DATE], documents: DNR. R1's Advanced Directive Care plan initiated [DATE] documents: Resident's advanced directive is: DNR. Goal: Resident's wishes will be honored. Pertinent Interventions include: Follow advanced directive per MD orders. Refer to MD orders for code status. Follow facility protocol for identification of code status . On [DATE] at 9:15 AM, R1's Physician Assistant (PA) documents in a progress note, in part: Updated by staff that patient was woken up early this morning to receive a shower. However following shower reported by staff that she has had significant increased fatigue and weakness from baseline including knocking over her utensils at breakfast and inability to feed herself, as well as slurred speech . Cares are discussed with POA regarding change in condition who is requesting no workup or ED evaluation, however request for hospice consult instead for comfort measures . goal of care remaining comfort only. R1's progress note dated [DATE] at 11:49 AM, documents in part: [R1] appeared to be weakened and coordination off. [R1] speech slightly slurred and not able to smile. [R1] able to move all extremities. Writer and PA . spoke with . POA who wants [R1] to be kept comfortable . POA agreed for hospice to evaluate for services. R1's Initial plan of care completed by the Hospice company, dated [DATE] documents, in part: Advanced Directives: Do Not Resuscitate . Surveyor noted R1 was started on hospice services on [DATE] with the goal of comfort measures. R1's Hospice Care plan dated [DATE], documents the following intervention: Honor advanced directives. R1's progress note dated [DATE] at 1:22 PM, documents in part: [R1] . coughing while eating and drinking. Appetite poor . Respiratory panel results are back and [R1 is] positive with Influenza A. Hospice nurse aware and new order to start Mucinex . R1's progress note dated [DATE] entered by R1's PA at 11:15 AM documents in part: [R1] has completed isolation precautions for recent influenza with resolution in symptoms noted. [R1] denies any further [upper respiratory symptoms], fevers/chills, shortness of breath or uncontrolled pain . On [DATE] at 11:40 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E. LPN-E stated that LPN-E worked on [DATE]. LPN-E stated that LPN-E was very familiar with R1. LPN-E stated that R1 had returned to R1's baseline after the diagnosis of Influenza A and LPN-E did not have any concerns regarding R1 on [DATE]. Surveyor asked what R1's advanced directive status was. LPN-E stated that R1 was a DNR. LPN-E stated that LPN-E knew all her residents' code status. LPN-E stated that R1 wore a DNR bracelet on R1's left wrist all the time. Surveyor asked where a staff member would look for advanced directives/code status. LPN-E stated that LPN-E would look in the electronic medical record. LPN-E stated that code status is seen when you open a resident's chart. On [DATE] at 1:14 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-I. CNA-I stated that CNA-I cared for R1 on [DATE] starting at 6 AM. CNA-I stated that R1 was acting normal and per R1's usual. R1 ate normally and followed R1's normal routine. R1's progress note entered by Registered Nurse (RN)-F, dated [DATE] at 6:45 PM documents in part: Nurse called to resident's room by CNA who stated, Resident is not responding. CNA reports that [R1] was providing [bedtime] care when the resident became unresponsive. Upon entering the room and assessment, resident is slumped and limp in the wheelchair; unresponsive to verbal stimulation. Skin noted as cold and pale. Lips are blue-tinged and labored mouth breathing is noted. A weak pulse of 40 is noted to the internal carotid artery. Breathing is labored at 8 per minute. Vigorous sternal chest rub applied; ineffective. Jaw-chin [lift] applied; ineffective. CNA sent to get oxygen line and tank. Resident's condition declining quickly. Chest rise and fall is absent. Intermittent shallow breaths noted. Resident assessed for pulse to radial and the carotid artery - pulse is absent. This nurse is unable to ascertain the resident's code status at this time and situation. Resident lowered to the floor. Upon assessment, pulse is still absent - CPR initiated. CPR effective. Oxygen at 2 [liters per minute] provided for support. [Vital signs] [temperature] 97.3, [pulse] 79, [blood pressure] 143/75, [respiratory rate] 20, [Oxygen saturation] 98%, [Blood sugar] 331 . The express decision of [R1's POA] as follows: The resident to remain in the facility and NOT be sent out [for] evaluation and treatment. [Hospice staff] to see the resident tonight. Surveyor noted, RN-F initiated CPR without checking for R1's code status. R1's Hospice nurse note with a visit date of [DATE], documents, in part: Call received through triage that patient had become unresponsive, become pulseless, and CPR was initiated despite DNR status . [Patient] was experiencing a significant change in [R1's] level of pain. [R1] was rating pain at 7 out of 10 to R1's chest wall and ribs. [R1] stated that it was painful to take a deep breath . Morphine (a narcotic pain medication) and Lorazepam (an anti-anxiety medication) orders obtained . Surveyor noted R1 had a pain rating of 7 out of 10 and is now requiring a narcotic pain medication to control pain. R1's MD orders entered on [DATE] include the following: -Morphine Sulfate oral solution 100 milligrams(mg)/5 milliliters(ml). Give 0.25 ml by mouth every 2 hours as needed for pain; pain-moderate; pain-severe. -Lorazepam oral tablet 0.5mg by mouth every 4 hours as needed for anxiety, agitation or restlessness. -Complete and document a skin assessment every shift for 3 days. Every shift check skin for bruising injury. R1's progress note dated [DATE] at 12:03 AM documents in part: . CPR was done to [R1] on prior shift, [R1] [complains of] pain to chest/ribs 10 [out of] 10. R1's progress note dated [DATE] at 1:50 AM documents in part: . The current status is resident [complains of] pain 10/10 to [R1's] chest. [As needed] Morphine . given . Surveyor noted R1 had two pain assessments completed after R1 received compressions and in both assessments, R1 rated pain 10 out of 10. R1's progress note dated [DATE] at 3:18 AM documents, in part: . Resident [complains of] pain to chest/ribs. R1's progress note dated [DATE] at 5:03 AM documents, in part: [R1] continues to [complain of] pain to [R1's] chest/ribs, sleeping with hands folded on her breasts. Noted increased pain with movement. [As needed medications] utilized and effective. R1's progress note dated [DATE] at 10:15 AM, R1's PA documents in part: . Updated by staff that . [R1] was found to be unresponsive with no pulse and deterioration in respirations. CPR was initiated and [R1] received 16 compressions, which [R1] was revived following . Code status confirmed as DNR and Director of Nursing reports education will be carried out to staff as well as continued close monitoring of [R1] ongoing. [R1] currently states that [R1] has a headache and [R1's] back is sore. [R1] is requesting medication for pain . R1's progress note dated [DATE] at 11:55 AM, documents in part: . [R1] complaining of pain and discomfort, given [as needed] Morphine . R1's progress note dated [DATE] at 3:11 PM, documents in part: The current status is [R1] complained of pain of back and chest . R1's progress note dated [DATE] at 1:40 AM, documents in part: . Denies pain at rest. Facial grimacing and moaning out present with repositioning. [As needed Morphine] given prior to cares . R1's progress note dated [DATE] at 9:27 AM, documents in part: Resident is on follow up for chest compressions performed causing some pain and discomfort. R1's progress note dated [DATE] at 11:09 AM, documents in part: Writer reached to [Nurse Practitioner] and hospice for new orders for STAT [chest x-ray] post injury per family request and possible scheduled pain meds for pain medication. Resident has received [as needed Morphine every 2] hours since 3/2. Resident in extreme pain and mobility has decreased . Surveyor noted the facility documented that R1 is in extreme pain. R1's progress note dated [DATE] at 4:12 PM documents in part: X-ray results negative for fracture. R1's progress note dated [DATE] at 5:58 AM documents: Pain to chest/ribs. R1's progress note dated [DATE] at 11:15 AM, R1's PA documents in part: . Updated by staff that family requested chest x-ray following recent compressions due to resulting pain. Chest x-ray results are reported as negative. Continues on hospice for comfort measures. R1's MD order entered on [DATE] documents: Morphine Sulfate oral solution 20mg/5ml. Give 0.5ml by mouth every 2 hours for pain. Surveyor noted that R1's Morphine was changed to a scheduled medication to be given every 2 hours instead of every 2 hours as needed. R1's progress note dated [DATE] at 1:42 AM documents in part: Resident is on follow up for monitoring [status post] CPR done on [DATE] PM shift. The current status is [vital signs stable]. Scheduled Morphine given as ordered. Noted [positive] pain indicators continue . Surveyor noted that R1's scheduled medications were discontinued on [DATE] at 9:38 PM. R1 continued to receive scheduled Morphine. Surveyor noted R1's health continued to decline. R1's progress note dated [DATE] at 8:18 AM documents: resident is actively dying. Surveyor reviewed R1's Resident Controlled Substance records for Morphine Sulfate (Concentrate) Oral Solution. On [DATE], Licensed Practical Nurse (LPN)-M documented: Date: [DATE], Time: 1600, Amount Given: 0.25 . On [DATE], LPN-M documented: Date: [DATE], Time: 1800, Amount Given: 0.25 . On [DATE], LPN-M documented: Date: [DATE], Time: 2000, Amount Given: 0.25 . On [DATE], LPN-M documented: Date: [DATE], Time: 2200, Amount Given: 0.25 . Surveyor noted on [DATE], on the evening shift, that R1 did not receive the correct dosage of scheduled morphine for 4 consecutive doses. Surveyor noted R1 was given 0.25ml instead of 0.5ml of Morphine for these 4 doses. Facility staff administered half of the prescribed dosage. (Cross-reference F760). On [DATE] at 12:00 PM, Surveyor requested to speak with LPN-M to conduct an interview. Director of Nursing (DON)-B informed Surveyor that LPN-M was no longer employed at facility. R1's progress note dated [DATE] at 6:40 documents in part: [R1] passed away at approximately 6:30 AM . On [DATE] at 12:32 PM, Surveyor interviewed RN-F who gave R1 compressions on [DATE]. RN-F stated that RN-F was alerted by a CNA that R1 was unresponsive. RN-F stated that when RN-F entered R1's room, RN-F noticed that R1 was in distress. RN-F stated that R1 had a pulse at that time. RN-F sent the CNA to retrieve oxygen. RN-F stated that RN-F did not have a phone or any other help, so RN-F had to determine if R1 was a DNR or not. RN-F stated in order to find that information, RN-F would need to leave the room and go to a computer. RN-F stated that R1 was experiencing a rapid decline and RN-F had to decide to follow protocol or stay with R1 and work with the information that RN-F had at hand. RN-F stated RN-F could not establish DNR status, so RN-F used RN-F's nursing judgement and decided to start CPR. RN-F stated that R1 was eased to the floor and R1 did not have a pulse. RN-F stated RN-F completed between 12 and 15 compressions with a good response. Surveyor asked if R1 was wearing a DNR bracelet. RN-F stated that RN-F did not notice a bracelet before administering compressions but was alerted to the bracelet after the fact. RN-F stated that it was unfortunate that RN-F did not see the bracelet prior to administering compressions. Surveyor asked if RN-F had received training on codes, CPR, or how to get help in determining code status. RN-F stated that RN-F is CPR certified but does not recall receiving training from the facility on codes. RN-F stated that there is not a process for calling a code. RN-F stated that there is not a portable phone that you can call other nurses. RN-F stated that the only way to determine code status is to leave the resident alone and RN-F did not feel comfortable leaving R1 since R1 was experiencing a rapid change of condition. Surveyor asked if R1 was in pain after the incident. RN-F stated that R1 complained of chest pain with movement after the compressions were given. On [DATE] at 1:14 PM, Surveyor interviewed CNA-I. CNA-I stated that CNA-I stated that CNA-I was doing rounds on [DATE] when CNA-I passed R1's room. CNA-I stated that CNA-I saw R1 on the floor and the nurse (RN-F) was assessing R1. CNA-I stated that RN-F told CNA-I to get a sling to help get R1 off the floor. CNA-I indicated that CNA-I did not see RN-F giving compressions to R1. CNA-I stated that R1 was responsive by the time CNA-I passed R1's room. Surveyor asked if R1 complained of any pain after the incident on [DATE]. CNA-I stated that R1 complained of chest pain. Surveyor asked how long the pain lasted. CNA-I stated that the pain lasted until R1 passed away. CNA-I stated that R1 would say that it hurts with any cares. On [DATE] at 1:25 PM, Surveyor interviewed Anonymous staff-G. Anonymous staff-G stated that Anonymous staff-G was working on a different unit the night of [DATE]. Anonymous staff-G stated that another staff member alerted Anonymous staff-G that a resident was unresponsive. Anonymous staff-G rushed to R1's room and noted that R1 was on the floor and RN-F was with R1. Anonymous staff-G stated that Anonymous staff-G saw R1's DNR bracelet on R1's wrist. Anonymous staff-G stated that Anonymous staff-G helped with whatever was needed and then returned to Anonymous staff-G's unit. Surveyor asked if R1 complained of pain. Anonymous staff-G stated that R1 was complaining of pain in R1's chest and back. Surveyor asked where a staff member would find code/DNR status. Anonymous staff-G stated that it is in the electronic medical record and R1 had it on R1's wrist. Anonymous staff stated R1 was only to have comfort measures in place and should not have received compressions. Anonymous staff-G stated, The whole thing was crazy. On [DATE] at 2:04 PM, Surveyor interviewed NHA-A and DON-B. NHA-A stated that the facility identified the concerns that RN-F gave compressions to R1 against R1's wishes. NHA-A stated the facility has educated current staff members on checking for code status before starting CPR, the CPR policy, and the Change of Condition policy. The facility completed audits on all residents' code status to ensure the correct documents are in place, the orders are in the medical record, and the code status appears in the ribbon within the electronic medical record. In addition, NHA-A stated that the facility did a care plan audit that was completed today to assure that advanced directives were correct in all residents' care plans. The facility has been completing Code drills because of this incident. DON-B stated that they are completing one minute management, where management will interview random staff to assure, they are aware of the process and retaining the education that is being completed. NHA-A stated that RN-F was pulled from the floor and suspended after the incident. Before returning to work RN-F will receive further education. Surveyor asked if wearing a DNR bracelet is part of a facility policy. DON-B stated that they do not require residents to wear a DNR bracelet. DON-B stated that a resident can choose to wear a bracelet, and the facility will add an intervention to the resident's care plan. Surveyor asked if R1 was wearing a DNR bracelet. DON-B stated that DON-B saw the DNR bracelet on R1 on [DATE]. Surveyor asked if the bracelet was an intervention on R1's care plan. DON-B stated that DON-B would look to see if the DNR bracelet was in R1's care plan. On [DATE] at 2:55 PM, NHA-A returned to Surveyor with a past non-compliance folder. NHA-A indicated again that the facility identified the concern of CPR being completed on a resident who is a DNR. NHA-A stated that the facility recognized that no resident would want CPR if it were not following their wishes. The facility wanted to focus on the concern so that it does not happen again. On [DATE] at 9:45 AM, Surveyor interviewed NHA-A and DON-B. Surveyor asked if RN-F received training on the code process. NHA-A and DON-B stated that RN-F is CPR certified. NHA-A stated that the topic is covered in new hire orientation and is briefly gone over during nurse-to-nurse training in orientation. NHA-A stated that the Maintenance Director will take new employees on a facility tour to ensure that new staff know where the code carts and AEDs are located. NHA-A confirmed that RN-F did complete new hire orientation. Surveyor asked what the expectation is for staff who are alone, and a resident goes unresponsive. DON-B stated that staff should yell for help, if unable to get help, the staff member should go to computer to check for code status. DON-B stated that code status is also covered in nurse-to-nurse report at the beginning of the staff's shift. Surveyor asked if the DNR bracelet being worn by R1 was in R1's care plan. DON-B stated that it is not in the care plan. (Cross-reference F678). NHA-A provided a power point slide from the new hire orientation presentation. Surveyor reviewed the facility's new hire orientation slide titled, CPR. The slide contains the following bullet points: Licensed staff must maintain current CPR certification through CPR training that includes hands-on practice and in-person skills assessment . Center clinicians are certified in [Basic life support]-[CPR] through programs approved . Each center requires the placement and use of an [AED]. Discuss and show where AED is located. Center staff must participate in Code Drills throughout the year. Surveyor noted the specifics and step by step instructions of a code are not included on the CPR slide presented at new-hire orientation. Surveyor noted that where to find advanced directives/DNR status is not included on the CPR slide. On [DATE] at 10:09 AM, Surveyor informed NHA-A, DON-B, Regional Nurse Consultant-C, and VP-D of the following serious concerns: R1's wishes were not followed and despite multiple areas of DNR documentation, R1 was still administered CPR compressions. R1 complained of 10/10 pain and the facility documented R1's pain as extreme. R1 was wearing a DNR bracelet that was not included in R1's care plan. RN-F indicated that RN-F did not receive training for codes and stated that there is not a facility process for calling a code. According to Five Possible Side Effects of CPR, You Should Know, The methods used in Cardiopulmonary Resuscitation can have adverse effects such as the following: 1. Aspiration & Vomiting: The most frequent occurrence during CPR, vomiting can present a danger to the cardiac arrest victim. Since the cardiac arrest victim is unconscious, he cannot clear the vomit from his mouth. If not cleared, the victim is likely to aspirate (inhale) it into his lungs, blocking the airway and leading to possible infection. 2. Broken Ribs Bone: A rib fracture is the most common complication of CPR because the force of chest compressions is likely to break ribs. Other chest injury related to chest compressions are sternal fracture and other uncommon complication like lung contusion, pneumothorax, and haemothorax. In the elderly, this is significantly more common due to the brittleness and weakness of their bones. Broken ribs present danger because a broken rib could puncture or lacerate (cut) a lung, the spleen, or the liver. They are also very painful. The frequency of rib fractures associated with out of hospital cardiopulmonary resuscitation is underestimated by conventional chest x-ray. 3. Internal Brain Injuries: Since CPR leaves the brain receiving 5% less oxygen than normal, brain damage is possible. Brain damage occurs within 4 to 6 minutes from the time the brain is deprived of oxygen, and after 10 minutes, it definitely occurs. This can lead to long-term health complications. 4. Abdominal Distension: As a result of air being forced into the lungs, the abdomen of the cardiac arrest patient usually becomes distended (bloated) and full of air during CPR, leading to compression of the lungs (making ventilation more difficult) and an increased chance of vomiting. 5. Aspiration Pneumonia: The result of vomit and foreign objects (like a person's own teeth) being inhaled into the lungs can lead to aspiration pneumonia. This can be very dangerous to a victim's health and could complicate recovery, or even be fatal, even if the cardiac arrest victim does survive CPR. Overall, all of these side effects mean that if a person survives CPR, their long-term health could suffer and be alive. But their overall health and quality of life may be significantly affected. Additionally, the psychological ramifications of a near-death experience can substantially affect a survivor, leading to anxiety, stress, and depression, among other psychological conditions. https://www.mycprcertificationonline.com/blog/five-possible-cpr-side-effects-you-should-know/ The facility's failure to honor R1's DNR wishes which led to facility staff completing chest compressions that caused R1 extreme pain, created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on [DATE]. The immediate jeopardy was removed on [DATE] when the facility implemented the following action plan: Action Plan to prevent Recurrence: [Primary Care Physician], Hospice MD, and POA notified. Hospice in person visit. Skin eval. Pain eval. [Change of Condition] evaluation with [vital signs], Nursing evaluation. Morphine as needed ordered. Identification of other potentially affected residents and action: Current facility residents have the potential to be affected. Current residents will be reviewed for code status orders/documentation. Code status verified on PCC ribbon banner. CP plans are updated appropriately. Systemic measures to prevent reoccurrence: Reeducation to licensed nurses on need to verify code status prior to initiating CPR. If DNR-do not initiate CPR. If full code, initiate CPR and activate 911. Performance effectiveness and monitoring: DON/designee will conduct Code drills. Will be completed on each shift weekly for 4 weeks. Interviews of 5 nurses per week will be conducted x 4 weeks on various shift using case studies and what if scenarios to validate understanding and expectations required during a code situation. Scenarios will include situations where [resident] is a DNR, and others will be scenario where resident is a full code. Results of the above audits will be brought to the [Quality Assurance and Performance Improvement (QAPI)] . QAPI committee met on [DATE] to review above plan. Dated 3/2-Ongoing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not ensure that 1 out of 1 resident (R1) reviewed for abuse allegations was free from exploitation, abuse of power, and mental abuse. A facility Certified Nursing Assistant (CNA-C) and R1 exchanged phone numbers and began a friendship which included several text messages between the two individuals over several months. CNA-C and R1 continued with the relationship to the point that R1 believed CNA-C was his girlfriend and that he would eventually leave the facility and they would live together. CNA-C often visited R1 in his room while she was working and assigned to other units. CNA-C and R1 did become intimate, often talking sexually in text messages, sharing several kisses, laying under covers with one another, and touching in a sexual manner. CNA-C purchased gifts for R1 and would visit even when she was not working. Ultimately the relationship ended, and CNA-C became very adamant the relationship was never real and she wanted no further contact. CNA-C texted R1 comments that were humiliating, degrading, and ridiculing. R1 expressed experiencing disappointment, sadness, and loneliness because of the relationship ending. Facility staff were aware R1 and the alleged perpetrator had been texting and that she would often visit R1 in his room when not assigned to care for him. Facility staff knew R1 received gifts from CNA-C and staff even witnessed love notes being left in R1's room from CNA-C. When Administration became aware R1 and CNA-C had exchanged phone numbers, they did not further investigate the possibility that exploitation and/or possible sexual abuse may be occurring. The facility failed to prevent abuse and exploitation by staff failure to report the relationship between CNA-C and R1 to administration timely and by the failure of administration to intervene and complete a thorough investigation into the relationship, which allowed CNA-C ongoing access to R1. This created a finding of immediate jeopardy that began on 7/7/24. Surveyor notified Nursing Home Administrator-A, Director of Nursing-B, and VP of Success-G of the immediate jeopardy on 10/23/24 at 3:02 p.m. The immediate jeopardy was removed on 10/24/24, however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: Policy Review: Abuse, Neglect and Exploitation. Date implemented 3/2018. Date Reviewed/revised 7/15/2022. Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s). VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. F. Providing emotional support and counseling to the resident during and after the investigation, as needed. R1 was originally admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, chronic kidney disease Stage #3, retention of urine, speech and language deficits, depression, and alcohol use. R1 is responsible for himself in all decision making. A review of the most recent quarterly MDS (Minimum Data Set) dated 7/20/24 shows R1 has a BIMS (Brief Interview for Mental Status) score of 13 indicating intact cognition for daily decision making. Surveyor became aware R1 was in a relationship with Certified Nursing Assistant (CNA)-C was employed at the facility until 9/4/2024 and worked various shifts on various units throughout the facility. On 10/21/24, at 9:30 a.m., Surveyor began a review of the facility's self-reported incident which documents there was an allegation of an inappropriate relationship between a former staff member (CNA-C) and a resident (R1) with the staff member overstepping boundaries and the allegation may or may not involve exploitation (taking advantage of a resident for personal gain). The date discovered is documented as 10/2/24. Date occurred is 10/2/24, at 2:15 p.m. The occurred date and time are estimated. The timeline included in the facility's investigation stated on 10/1/24, an employee made Nursing Home Administrator-A aware of text messages between R1 and CNA-C. On 10/1/24, Nursing Home Administrator-A spoke to R1 and asked about R1's relationship with CNA-C and the employee using his (R1's) credit card. R1 denied the employee used his card. R1 stated the relationship was not an intimate relationship, they were just friends. R1 denied any text messages and did not want to be questioned about the incident. On 10/2/24, Nursing Home Administrator-A interviewed R1 again and asked if she could read their (CNA-C and R1) text messages. R1 allowed Nursing Home Administrator-A to read through the text messages on his (R1's) cell phone. The text messages date back to 7/6/24. Text messages include, I love you, I cant [sic] wait for us to be together, I miss you, I want to kiss you from head to toe, I cant [sic] wait to lay with you, lets be alone, I only belong to you. The text messages also included jealous statements about other caregivers and there were text messages that talked about R1's penis and being inappropriate. R1 stated to NHA-A that he always denied the relationship because he loved her (CNA-C) and did not want to get her in trouble. R1 thought they were going to be together. R1 apologized for not telling the truth earlier. Surveyor conducted a review of the actual text messages that were sent between R1 and CNA-C between 7/7/24 and 9/29/24. The messages establish a relationship building between R1 and CNA-C with each calling each other pet names like crush, love,. boyfriend, and girlfriend. The text messages reveal that R1 and CNA-C thought of each other throughout the day and night and sometimes in a sexually explicit manner. The text messages show CNA-C would visit R1 while at work and assigned to different units. The text messages show R1 was in belief that CNA-C was his girlfriend and hoped that the two of them would be together forever and he would be able to leave the nursing home. On 9/13/24 CNA-C texted R1 saying: What part of LEAVE ME ALONE do you not understand? YOU GOT MY ASS FIRED !!!! I am grateful to be working elsewhere the drama and bullshit at [name of facility] is crazy ! DO NOT CALL TEXT ME AGAIN WE WERE NEVER GOING TO BE ANYTHING YOU WILL BE STUCK IN A NURSING HOME THE REST OF YOUR LIFE! I DON'T WANT TO BE WITH SOMEONE WHO IS STUCK IN A WHEELCHAIR AT A NURSING HOME. [NAME] I GOOD! LEAVE ME ALONE IM NOT KIDDING OTHERWISE I WILL MAKE A PHONE CALL AND IT WONT TURN OUT SO GOOD FOR YOU . On 9/29/24 CNA-C texted R1 for the last time .I HOPE YOUR ASS GETS KICKED OUT! GO LIVE WITH YOUR [NAME]! DON'T THINK I WAS SERIOUS ABOUT YOU I WAS PLAYING YOU. YOU REALLY DON'T THINK SOMEONE LIKE ME WOULD WANT TO BE WITH A MAN WHO HAS TO PISS IN A BAG AND SIT IN A WHEELCHAIR AND SHITS HIMSELF. LOL . BEING NICE TO SOMEONE DOESN'T EQUAL ROMANCE LOL LATER GATOR. Surveyor continued to review the facility's investigation and noted on 10/2/24 the facility did notify the local Police Department. Surveyor was able to review the police report. The report includes details included in the text messages as well as R1 stating he touched CNA-C's breasts under her shirt and the two of them kissed on multiple occasions. The facility's investigation included statements from staff members. The following was noted: On 10/5/24, CNA-H answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-H wrote, No, I have not first person, but I have heard about it from several residents. Question #2-are you aware of staff giving residents gifts? CNA-H wrote yes. On 10/4/24, CNA-I answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-I wrote, I haven't witnessed any myself, but I did hear rumors about something from residents and a CNA about a month or two ago. On 10/4/24, CNA-J answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-J wrote, No I have not witnessed any inappropriate relationships between staff and residents, I've only heard about something of the sort through whispers. On 10/4/24, CNA-K answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-K wrote, I've heard about it threw staff and I have seen sweet/sexual notes from staff to resident. Question #2-are you aware of staff giving residents gifts? CNA-K wrote yes. On 10/7/24, CNA-L wrote a witness statement that documented the following: I witnessed an inappropriate relationship between a resident and a coworker. I am aware of the coworker giving the resident new clothes such as T-shirts. My resident showed me text messages between them. I then reported it to Social Services and Human Resources. My resident had confided in me and told me they were dating, which I reported. A note from the coworker was left pinned up to the resident's bulletin board. It was found in the morning after she was scheduled as a CNA for night shift on unit 200. On 10/21/24 at 12:50 p.m., Surveyor interviewed CNA-D regarding R1. CNA-D stated she was aware of the situation involving R1 and CNA-C and had heard other staff talk about inappropriate texts and letters and that the staff member bought things for R1. CNA-D stated she didn't report it because it was all hearsay. CNA-D stated that talk started bussing around April/May about R1 and CNA-C and then in July it was an everyday topic between staff. Staff would see CNA-C make her way around the facility and out of her way to go see R1. All the staff just wondered why. CNA-D stated she was aware several people reported it to their supervisors. CNA-D stated it wasn't until R1 brought it to upper management that an investigation was really done. On 10/22/24 at 8:10 a.m., Surveyor interviewed Registered Nurse (RN)-E regarding R1 and CNA-C. RN-E stated that sometime between August 5-9th 2024 a night CNA came to her and reported she felt there was some inappropriate contact between R1 and CNA-C. RN-E stated she reported it to the Director of Nursing (previous) and Administrator (previous). RN-E then stated that sometime between August 20-23rd, 2024, while at the 200 Unit nursing station, she heard a CNA talking about the relationship between R1 and CNA-C and that she had bought items for R1. RN-E stated that she then reported this to former Administrator/VP of Success-G and he said he would take it from there. RN-E stated that R1 would make comments about text messages and other staff would see CNA-C going into R1's room when she would be assigned to work on a different unit. RN-E stated that even R1's roommate would say that R1's girlfriend was here again last night. On 10/22/24 at 11:20 a.m., Surveyor interviewed Social Services Coordinator (SSC)-F. SSC-F stated that he was not aware of the relationship between R1 and CNA-C until he was asked to go interview R1 with the other Social Services Coordinator. SSC-F was unable to give a date of the interview, but it was about 2 months ago. R1 was asked about text messages between himself and a staff member. R1 stated why, am I going to get this person in trouble. R1 didn't want to answer questions so SSC-F stated they left the room and were not involved with R1 after that. SSC-F stated that he was told by VP of Success (VPS)-G to just leave it be and wait for further instructions. No follow-up was ever done by SSC-F after that. SSC-F stated he had never heard anything about R1 and a staff person in a relationship prior to that. SSC-F stated in the beginning of October 2024 he was asked to write a care plan for R1 regarding trauma informed care. Social Service progress note dated 10/3/24 at 12:29 p.m., documents; Late Entry: Writer spoke with R1 regarding incident that had happened. R1 stated he was fine and that he had no hard feelings. Writer asked if he felt it would be beneficial for him to see someone for talk therapy. R1 stated no he did not feel it was necessary and that he has a good friend who he visits with on a regular basis who he confides in without judgement. After our talk resident went back to spending time outside with peers. Surveyor reviewed R1's individual plan of care that documents R1 is at risk for retraumatization of past event or experience where reminders/triggers of event or experience may cause behavioral changes and/or emotional distress. Date initiated: 10/4/24. Interventions included to provide a safe environment, monitor for increased withdrawal, anger or depressive behaviors and explore opportunities to avoid. R1 was offered a referral to Psychology as an additional intervention but declined. On 10/22/24 at 12:50 p.m., Surveyor interviewed VPS-G regarding R1. VPS-G stated he was the interim Nursing Home Administrator from 8/9/24 to 9/23/24. VPS-G stated all he was initially aware of is that R1 and CNA-C had exchanged phone numbers. He stated that going forward a whole different picture has been painted. VPS-G stated staff had started to talk about CNA-C having R1's phone number and they were texting one another. VPS-G said he went to talk with R1 and R1 denied anything was going on. CNA-C was also asked about having R1's phone number and she denied it as well. CNA-C stated she felt bad for R1 and just wanted to be there for him. Other facility staff did not say anything moving forward and I just thought there was nothing out of the ordinary going on. VPS-G stated then there was a text that came through to R1 and CNA-C was breaking things off. It was then brought to our attention again and we asked R1 about their relationship. R1 then became cooperative and shared all of the text messages between himself and CNA-C. VPS- G stated once we started to ask CNA-C questions about her having R1's phone number she was educated on this not being appropriate. CNA-C then resigned 9/4/24. Surveyor asked why VPS-G didn't start an investigation when he was made aware that R1 and CNA-C were texting one another. VPS-G stated he didn't think anything was going on and no one else came forward with any information. VPS-G stated he did not go and ask staff if they knew anything about R1 and CNA-C and that he did not ask R1 to see the text messages. VPS-G stated he did not interview R1's roommate nor did he ask any other residents about relationships with staff. VPS-G stated he was not aware R1 received gifts from CNA-C and looking back he should have asked more about the situation. On 10/22/24 at 2:10 p.m., Surveyor interviewed Nursing Home Administrator-A regarding the facility's investigation into the relationship between R1 and CNA-C. Nursing Home Administrator-A stated that on 10/2/24, a staff member had come to her and had a concern about a text message she saw on R1's phone from CNA-C about calling the police on R1. Nursing Home Administrator-A stated she then went to talk with R1, and he denied it at first and said he was just friends with CNA-C. Nursing Home Administrator-A stated after talking with R1 a bit longer he agreed to share the text messages with her. Nursing Home Administrator-A stated she read through all of the messages, and they went back to July. R1 then let Nursing Home Administrator-A take pictures, with a facility cell phone, of the text messages. Nursing Home Administrator-A then said she had asked VPS-G if he had any knowledge of R1 and CNA-C being in a relationship. VPS-G stated he was aware they had exchanged phone numbers but they both stated they were just friends. Nursing Home Administrator-A stated on 9/4/24, she wanted to bring in CNA-C to talk about her about exchanging phone numbers with R1 and the purchase of t-shirts for him. CNA-C then resigned her position before we could get any further statement from her. Nursing Home Administrator-A stated there were a lot of rumors floating around about the relationship, but nobody actually said they saw anything. Nursing Home Administrator-A stated she would have expected staff to report rumors as suspected allegations. Nursing Home Administrator-A stated R1 initially denied anything was going on with CNA-C because he didn't want her to get into trouble. Nursing note dated 10/4/24 at 1:01 p.m., is documented by Nursing Home Administrator-A; Writer spoke to R1 about incident that occurred with former staff member. Writer encouraged resident to monitor his banking information. R1 stated he has had no discrepancies in his bank statements. He stated he will not be canceling his bank card. Writer educated R1 about proper relationships with staff members. R1 understands the expectations of relationships with staff members. On 10/23/24 at 9:05 a.m., Surveyor interviewed R1 in the privacy of his room. Surveyor explained that she had reviewed the facility's investigation regarding the relationship with CNA-C. Surveyor also stated that she was able to review the police report from the Police Department from when they came to speak with R1. Surveyor stated to R1 that she is aware that it must be a sensitive and difficult situation to talk about and that the purpose of the interview is to gain an understanding of how this situation affected R1. R1 stated CNA-C initially asked R1 for his phone number which he stated he gladly gave to her. R1 stated CNA-C was his caregiver and they had developed a friendship. R1 stated he was very comfortable with CNA-C. R1 said he really misses the relationship because he is just a lonely old guy. R1 said CNA-C would often visit him and he was always ok with that. R1 said he had given CNA-C a Visa debit card to purchase some items for him at Kwik Trip. CNA-C did accept it but didn't feel comfortable using it so she returned it to him. R1 said CNA-C did buy him t-shirts with her own money. R1 said CNA-C did want to stop the relationship and said that her job was more important. R1 said he always told CNA-C to not get in trouble because of him. R1 said then he felt like CNA-C knew something wasn't kosher and she told me I got her fired. R1 said CNA-C wouldn't talk to him after that. R1 said he felt really sad about this and asked Nursing Home Administrator-A if it was true that he got her fired. R1 said he never felt threatened by CNA-C only disappointed and sad. Surveyor asked R1 if he could talk a bit more about that. R1 said all I wanted to do is get out of this place and be with her. I don't want to be in a nursing home anymore. I thought we were going to be together forever. R1 said then CNA-C said that I was harassing her because I did text her a few times after she left. I was worried about her. R1 said CNA-C was going to call the police on him and that she and her husband would be filing the report. R1 said the whole situation has made him upset, the kind of upset you feel when you experience a bad break-up. R1 said some of the things CNA-C said to him in the end really broke his heart in two. R1 said he has been able to move on and has a few good friends at the facility he can talk to.R1 said he was offered to talk to a counselor, but he declined. R1 said he didn't think other staff members knew about him and CNA-C, but somehow things got around and there were a lot of rumors that they had sex. R1 said that was not true and, I always knew this place had ears. According to rightuseofpower.org, There is a power inequality whenever you take on a role that gives you authority over another or creates a perception that you have authority. Because of this inequality, residents can be manipulated, exploited, and/or abused by a caregiver who is allowed to begin a relationship with a resident. Therefore, the failure of facility staff to report the relationship between CNA-C and R1 to administration timely and the failure of administration to intervene and complete a thorough investigation into the relationship created a reasonable likelihood for serious harm, thus leading to a finding of Immediate Jeopardy. The facility removed the jeopardy on 10/23/24 when it completed the following: * Facility completed interviews of residents and staff on 10/9/24 by Executive Director or designee to determine any further concerns of actual or suspected abuse. * Facility staff reeducated by Executive Director or designee on Abuse, Neglect, and Exploitation policy starting 10/23/24 and will be completed prior to next scheduled shift. This reeducation included information on types of abuse, obligation to report abuse, abuse of power, and need to safeguard residents. This education included how abuse can affect a staff members licensure or ability to be employed in facility. * On 10/23/24 Director of Nursing Executive Director and [NAME] President of Success reviewed established Abuse, Neglect and Exploitation policy. No changes were necessary to this policy. * Executive Director or Designee will interview a sampling of no less than 3 staff and 3 residents daily including review of grievances to ensure proper recognition, reporting, and notification of suspected/potential or actual abuse. These audits will be completed daily for 2 weeks, then 5 days per week for 10 weeks or until substantial compliance is maintained. Results of these audits will be brought to QAPI (quality assurance performance improvement) for review and recommendation. * ADHOC QAPI review of this plan was completed 10/23/24 with Medical Director, VP (Vice President) of Success, Director of Nursing, and Executive Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 10/23/24 at 9:10 AM, Surveyor asked Director of Nursing (DON)-B for the faciliy's neuro-check policy. Nursing Home Administrator (NHA)-A returned to surveyor and informed surveyor that the incident involving the Hoyer lift bar hitting R5's head would be addressed in the fall policy under the neuro-checks section. NHA-A stated the facility does not have a separate neuro-check policy. The facility policy entitled, Fall Prevention and Management Guidelines with a review date of 7/18/24, documents, in part: . Neuro checks for any unwitnessed fall or witnessed fall, where resident hits their head: Initially, then hourly x 3, then continue neuro checks every 4 hours x 6, then continue neuro checks every 8 hours x 6 or as indicated by the physician. Alert MD (Medical Doctor) of any abnormal findings from neuro checks- do not wait until series is complete to notify MD of abnormal findings. In a document entitled, Post-Fall Assessments dated, August of 2021, The American Association of Post-Acute Care Nursing (AAPACN) documents the following about neuro checks : An assessment of neurological status, often called a neuro check, should be done when a resident hits his or her head or if it is unknown if they hit their head (unwitnessed fall). R5 was admitted to the facility on [DATE] with diagnosis that include Hemiplegia and hemiparesis following stroke, Contracture of left knee, Heart failure, Emphysema, Morbid obesity, Atrial-fibrillation, and Depression. R5's Annual Minimum Data Set Assessment (MDS) dated [DATE] documents R5 is cognitively intact. R5 is dependent on staff for bathing, toileting, lower body dressing, mobility, and transfers. R5's Care Area Assessment (CAA) for Functional Abilities dated 8/3/24, documents, Resident requires assistance [with] most Activities of Daily Living (ADLs) d/t (due to) impaired mobility. Goal is to ensure resident is safe and needs are met. Nursing staff will continue to offer and assist [with] ADLs and ensure to meet resident's daily needs. On 10/21/24, at 10:03 AM, Surveyor interviewed R5. R5 informed Surveyor that during a Hoyer lift transfer a few weeks ago, R5 was hit on the top of the head. R5 stated 2 Certified Nursing Assistants (CNAs) were helping R5 get into her wheelchair. R5 stated one CNA was behind her and another one was in front of her. R5 stated the CNA's were talking back and forth to each other about the transfer. R5 stated R5 was lowered into the chair and the top bar of the Hoyer lift hit R5's head very hard. R5 stated she began to cry because the hit was hard and hurt a lot. R5 stated R5 was sent to the hospital for evaluation in the ER (Emergency Room). R5 stated the emergency room doctor told R5 that R5 had a mild concussion. R5 returned to the facility. R5 stated the pain lasted a few days and then resolved. R5's incident report entered by Licensed Practical Nurse (LPN)-Z, dated 9/6/24, at 11:35 AM, documents, [CNA-CC] informed writer that resident had a hit to the head from the Hoyer and is in pain. Upon entering room, writer observed resident holding her head crying in the wheelchair. [CNA-DD and CNA-CC] explained to writer how the bar fell onto resident's head with a good amount of blunt force. No bleeding or obvious bump noted upon immediate inspection. Resident stated the Hoyer lift bar hit her on top of her head and that it is throbbing. Immediate Action taken: neuro checks, vitals, NP (Nurse Practitioner) notified, DON (Director of Nursing) notified, family notified, 911 to hospital per NP. Surveyor reviewed R5's medical record and did not find an initial neurological evaluation documented for R5. R5's progress note dated 9/6/24, at 1:55 PM, documents, Resident came back from [Name of local hospital] ER with a closed head injury, mild concussion, and scalp contusion. Resident states it feels like she got hit in the head with a baseball bat and that her head is just pounding. Tylenol was given prior to her departure and will be given when needed. Surveyor reviewed R5's medical record and did not find a documented neuro-check upon R5's return from the hospital. R5's progress note entered by DON-B, dated 9/6/24, at 5:16 PM, documents, Writer assessed head and neuro status, called and spoke with [name of R5's emergency contact]. Assisted [R5] back to bed with CNA, monitored Hoyer, need to check square with weight distribution when going from bed to [wheelchair]. R5's progress note entered by DON-B, dated 9/6/24, at 5:17 PM, documents, [R5] returned with mild concussion . R5's Post Event Observation dated 9/6/24, at 8:35 PM, documents, Blood pressure 105/68, Temperature 97.1, Pulse 72. Respiration 18. Pain level 4. Pain location: top of the head. Resident is lying in bed resting. Tylenol given for pain. Surveyor noted a neuro-check was not documented at the time of the Post Event Observation evaluation. Surveyor reviewed R5's medical record for assessments completed the day after R5's head injury. Surveyor noted staff did not complete a Post Event Observation evaluation on 9/7/24. Staff did not document any neuro-checks on 9/7/24. Staff did not document any progress notes on 9/7/24. R5's progress note entered by DON-B, dated 9/8/24, at 6:28 PM, documents, . [R5] is not having a headache or any post effects of mild concussion . R5's Post Event Observation dated 9/8/24 at 6:29 PM documents, Blood pressure 118/72, Temperature 97.7. Pulse 72 (dated 9/6/24 at 8:35 pm). Respiration 18 (dated 9/6/24 at 8:35 pm). Pain level: 0. Stable, denies pain. Monitoring to ensure no headache. Surveyor noted the pulse and respiration documentation within the Post Event Observation were not updated and not a current assessment from 9/8/24. Surveyor reviewed R5's medical record and did not find a documented neuro-check at any time on 9/8/24. R5's Post Event Observation dated 9/9/24 at 3:08 AM documents, Blood pressure 118/72 (dated 9/8/24), Temperature 97.7 (dated 9/8/24). Pulse 72 (dated 9/6/24). Respiration 18 (dated 9/6/24). Pain level: 0. Resident resting quietly in bed tonight. No [complaints of] pain offered. Continue plan of care. Surveyor noted that all the vital sign documentation within the Post Event Observation were not updated and not a current assessment from 9/9/24. R5's progress note entered by Physician Assistant (PA)-AA dated 9/9/24 at 11:00 AM, documents, in part: . Updated by nursing staff that patient had a head injury late last week that occurred inadvertently during transfer with Hoyer. Due to significant resulting pain to head and being on Eliquis, [R5] was sent to ED for [evaluation]. [R5] returned to facility with workup notable for mild concussion and scalp contusion . Assessment and Plan . Head injury, closed with concussion- recent, along with scalp contusion. Status post ED [evaluation]. Recommendation to rest, ice and Tylenol as needed. Continue to monitor closely with neuro-checks per facility protocol. Pt denies any pain or further concerns today . Surveyor noted that PA-AA recommended that the facility staff continue neuro-checks per facility protocol. On 10/22/24 at 10:34 AM, Surveyor interviewed LPN-Z, who was caring for R5 when the injury occurred. Surveyor asked what staff should do if a resident has a head injury. LPN-Z stated that after caring for and assessing the resident the nurse will place the resident on the 24-hour board, so all shifts are aware of the increased monitoring. LPN-Z would complete an incident report in the residents' medical record and Neuro-checks would start to be completed. Surveyor asked if LPN-Z remembered the incident with R5 and the head injury. LPN-Z stated that LPN-Z was not in the room when the injury occurred but was called into the room by a CNA. LPN-Z stated that LPN-Z did vitals right away and assessed R5's head for any obvious injury. LPN-Z called the provider and was instructed to send R5 to the Emergency room. LPN-Z notified DON-B. Surveyor asked if R5 was placed on the 24-hour board or if neuro-checks were started on R5. LPN-Z stated that LPN-Z could not recall. On 10/22/24 at 1:44 PM, Surveyor interviewed DON-B. Surveyor asked if R5 was placed on the 24-hour board for increased monitoring after R5's head injury. DON-B indicated that DON-B would look into that and get back to Surveyor. Surveyor asked what monitoring was completed after R5's head injury. DON-B stated that post incident monitoring was completed to make sure R5 did not have any worsening symptoms. On 10/22/24 at 2:05 PM, NHA-A informed Surveyor that on 9/6/24, R5 was on the 24-hour board for a skin concern but there was no mention of monitoring the head injury on the 24-hour board. On 10/23/24 at 8:22 AM, Surveyor spoke to PA-AA regarding R5's head injury. PA-AA stated that she was made aware of the incident and knew that R5 was sent to the ER. A head scan was completed and R5 was diagnosed with a mild concussion. Surveyor asked what PA-AA would expect for monitoring after a mild concussion. PA-AA stated that the incident should be treated like a fall and facility staff would monitor neurological symptoms closely with neuro checks. Staff would watch for symptoms of fatigue, blurry vision, vital sign changes, neuro-check changes, etc. Surveyor informed PA-AA that Surveyor did not locate any documentation that neuro-checks were completed after R5's head injury. Surveyor asked if PA-AA would expect neuro-checks to be completed. PA-AA stated absolutely. On 10/23/24 at 8:57 AM, Surveyor interviewed DON-B. DON-B confirmed that R5 was not on the 24-hour board for increased monitoring of R5's head injury. Surveyor asked if neuro-checks should have been completed after R5's head injury. DON-B stated that nurses were completing the post incident assessment and DON-B thinks that nurses were completing the neuro-checks but not documenting them. Surveyor asked how other nurses would know if there were changes to the neuro-check assessment if the nurses were not documenting the assessment. DON-B stated the nurses should have been documenting neuro-checks. On 10/23/24 at 9:40 AM, Surveyor informed NHA-A of the concern that R5 had a head injury and was not placed on the 24-hour board for increased monitoring and neuro-checks were not completed. 2) R16 was admitted to the facility on [DATE] with diagnoses of Other Specified Diseases of Liver, Muscle Weakness, Hypertensive Heart Disease with Heart Failure, Unspecified Asthma, Arthropathic Psoriasis, Immunodeficiency, Type 2 Diabetes Mellitus, and Adjustment Disorder with Muscle Weakness. R16 discharged from the facility on 10/17/24. R16's admission Minimum Data Set (MDS) completed on 9/23/24 documents R16 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R16 was cognitively intact for daily decision making. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating, required substantial/maximum assistance for shower/bathing, lower dressing, personal hygiene, rolling left to right, and sit to lying. R16 required partial/moderate assistance for upper dressing. R16 was dependent for sit to stand, transferring from chair to bed, and toileting transfers. R16 was occasionally incontinent of bladder and always continent of bowel. R16 is at risk for developing pressure ulcers but has none currently. R16's MDS documents R16 desired to discharge to the community and required active discharge planning. R16's quarterly MDS completed on 10/9/24 documents R16's BIMS score to be 11, indicating R16 was demonstrating moderately impaired skills for daily decision making. R16's MDS also documents R16 is receiving ointments to areas other than feet. R16's Discharge MDS completed on 10/17/24 does not assess R16's cognitive skills. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating. R16 required substantial/maximum assistance for lower dressing, personal hygiene. Shower/bathing was not attempted due to medical condition. R16 required partial/moderate assistance for upper dressing, sit to lying and lying to sitting, sit to stand, chair to bed transfer, and toilet transfer. Transferring to to tub/shower was not attempted due to medical condition. R16 was supervision for rolling left to right. R16 was frequently incontinent of bladder and always incontinent of bowel. R16's Care Area Assessment (CAA) for Pressure Ulcer/Injury documents: .Care plan will be initiated or reviewed to improve or maintain current ADL (Activities of Daily Living) status and functional ability, maintain continence status, prevent pain, and decrease pressure ulcer/fluid deficit risk. Resident has increased risk for skin impairment related to increased need for help with ADL such as bed mobility which can decrease flood flow and increase pressure leading to wounds . Surveyor notes R16 was assessed to have shearing which was documented on R16's admission evaluation dated 10/17/24. R16 also had blisters on bilateral arms and legs that at times would be documented to be weeping. R16's skin focused care plan problem initiated 9/17/24 states the following: -Actual at (specify location) due to . -Administer treatment per MD (Medical Doctor) orders 9/17/24 -Encourage and assist as needed to turn and reposition; use assistive devices as needed 9/17/24 -Float heels as able 9/17/24 -Report evidence of infection such purulent drainage, [NAME], localized heat, increased pain, notify MD PRN 9/17/24 Surveyor notes R16's skin care plan was not revised to include person centered interventions to identify the potential for skin breakdown including pressure relieving mattress, pressure relieving cushion for wheelchair, and interventions to address R16's blisters on bilateral arms and legs. R16's Kardex documents R16 is receiving ointments for skin issues. R16's physician orders documents: -Weekly skin review every evening shift every Monday if new skin area is identified follow protocol for SBAR (Situation, Background, Assessment and Recommendation), MD update and risk management. -May have kerlix bedside for wound drainage from bilateral arms and legs as needed for drainage. -Clobetasol Pripionate External Cream 0.05%, apply to affect area topically as needed for psoriasis. -Triamcinolone Acetonide External Cream 0.1%, apply to buttock topically one time a day for dermatitis. R16's admission Evaluation dated 9/17/24 documents a score of 15-18 which means R16 is at risk for skin issues. It is documented by Registered Nurse (RN)-N that R16 has shearing on left buttock and a skin tear on right forearm with no other description for the areas. On 10/4/24, R16's Braden Scale for Predicting Pressure Sore Risk documents a score of 14, indicating R16 was at moderate risk. On 9/19/24, Physician (DR)-TT documented that R16 had fragile skin, scattered ecchymosis, weeping and blisters. Continues to have peripheral edema mostly 3rd spacing. Does have very fragile skin with multiple bruises and blistering lesions. 1 to 2 pretibial pitting bilateral lower extremity edema. Bilateral upper extremities puffy. Weeping. Surveyor notes R16's facility weekly head to toe skin checks does not document any of the skin areas identified by DR-TT including addressing interventions on R16's care plan. R16's EMR does not have documentation from nursing addressing areas that are identified as blisters and are weeping. On 10/22/24, at 2:14 PM, Surveyor interviewed Registered Nurse (RN)-N regarding R16's skin issues. RN-N stated R16 consistently scratched their arms. R16 also had an issue with edema. R16 would have areas that looked like they were open. RN-N stated R16 had multiple blisters with small holes with fluid that would come out. RN-N recalls the shearing area on R16's buttocks not being open but had new skin present. On 10/23/24, at 10:01 AM, Director of Nursing (DON)-B stated the expectation would licensed professionals should complete skin evaluations and assessments on any area that that has bruising, blisters, or is open. DON-B agreed R16's blisters would require additional assessments to be completed. On 10/23/24, at 3:22 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R16's skin issues were not further evaluated with comprehensive assessments and person-centered interventions identified and documented in R16's comprehensive care plan. No further information was provided by the facility at this time. Based on interview and record review, the facility did not ensure residents received treatment and care consistent with the N6 Wisconsin Nurse Practice Act for 3 (R2, R16, and R5) of 16 residents reviewed. During the night shift on 10/7/24, R2 was yelling help me, help me, and couldn't breathe. Certified Nursing Assistant (CNA)-QQ notified Registered Nurse (RN)-PP. RN-PP observed R2 sitting on the edge of the bed, leaning over the half side rail, and not responding. RN-PP laid R2 down in bed, placed the pulse ox on R2's finger but was unable to obtain a reading, checked the oxygen tubing, and observed R2 had agonal breathing. RN-PP noted R2 was a DNR (Do Not Resuscitate) and called R2's daughter who is the 2nd Power of Attorney (POA) to inquire what she would like the facility to do. RN-PP did not complete any further assessments, did not attempt to contact the doctor, and did not call 911. RN-PP contacted the nurse on the short term unit, 100 to 200 units, and asked RN-HH to come to R2's room. Upon RN-HH's assessment, R2 was pulseless and was not breathing. The facility's failure to comprehensively assess R2, contact R2's physician, or call 911 created a finding of Immediate Jeopardy (IJ) which began on 10/7/24. NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B, VP (Vice President) of Success-G, and VP of Clinical-GG were notified of the immediate jeopardy on 10/23/24 at 3:02 p.m. The immediate jeopardy was removed on 10/24/24. The deficient practice continues at a scope and severity of D (potential for harm/isolated) related to the examples involving R16 & R5 and as the facility continues to implement its action plan. * Weekly skin assessments did not address R16's weeping blisters on R16's arms. * R5 was transferred via a Hoyer lift on 9/6/24. A bar from the Hoyer lift hit R5's head causing pain. An initial neurological check (neuro-check) evaluation was not documented by the facility staff. R5 was sent to the emergency room (ER) for evaluation. R5 returned to the facility with a diagnosis of a mild concussion. R5 was not placed on the facility's 24-hour board for close monitoring. R5 did not have any documented neuro-checks completed after R5 returned from the ER. Findings include: The facility's policy titled, Change in Condition of the Resident and reviewed/revised 9/20/2022 under Policy documents: A facility should immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Policy Explanation and Compliance Guidelines documents: When a resident presents with a possible change of condition, after a fall or other possible injury, trauma, or noted changes in mental or physical functioning: 1. Assess the resident's need for immediate care/medical condition. Provide emergency care as needed. 2. Assess/evaluate the resident . 3. Notify resident's physician - Use INTERACT Change in Condition: when to report to the MD/NP/PA (Medical Doctor/Nurse Practitioner/Physician Assistant) as a guideline. a. Immediate notification: Immediate notification for any symptom, sign or apparent discomfort that is: 1. Acute or sudden in onset, and: ii. A marked change (i.e. more severe) in relation to usual symptoms and signs, or iii. Unrelieved by measures already prescribed requires a phone call to the provider. Do not fax for issues requiring immediate notification. If no response from provider and condition warrants, call the center medical director. If no response from the center medical director, contact the DON (Director of Nursing) for further guidance. According to the State of Wisconsin Nurse Practice Act: N 6.03 - Standards of practice for registered nurses. (1)? General nursing procedures. An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. 1.) R2 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease (receives hemodialysis three times a week), COPD (chronic obstructive pulmonary disease), DM (diabetes mellitus), dementia, anxiety disorder, and obstructive sleep apnea. R2 has an order for CPAP (Continuous Positive Airway Pressure) with 2 liters of oxygen. R2 has an activated Power of Attorney for Health Care (POAHC) and advance directives for DNR (do not resuscitate). R2 was not receiving hospice services. The annual MDS (minimum data set) with an assessment reference date of 7/29/24 shows R2 has a BIMS (Brief Interview for Mental Status) score of 8 which indicates moderate cognitive impairment. R2 is assessed as having verbal behaviors 1 to 3 days during the assessment period and is not assessed as refusing care. R2 is independent in eating, roll left & right, sit to stand, chair/bed to chair transfers, and toilet transfers. R2 is occasionally incontinent of urine and continent of bowel. R2 was transferred to the hospital on two occasions, 9/15/24 and 9/25/24, prior to R2's change of condition. R2 was not hospitalized during either of these transfers. The nurses note dated 9/15/24 at 12:15 p.m. documents: Resident c/o (complained of) feeling lightheaded and upon standing she vomited. She also stated that she felt her heart beating very fast and felt like she was going to die. Writer took vitals and pulse was 101. Resident stated she still did not feel well. Writer called on call provider which [Name] NP indicated to have her sent out to be checked over. This nurses note was written by LPN (Licensed Practical Nurse)-FF. The nurses note dated 9/15/24 at 1625 (4:25 p.m.) documents: Resident has come back from ER (emergency room) via stretcher. She was helped into her wheelchair and is eating dinner now. She came back with new order for Zofran 4 mg (milligram) Q (every) 8 hours PRN (as needed) for nausea. At the ER they did a cardiac monitor along with other labs which showed nothing concerning. Writer updated POA on resident before and after resident was sent out and returned. This nurses note was written by LPN (Licensed Practical Nurse)-FF. The nurses note dated 9/15/24 at 1751 (5:51 p.m.) documents: Writer received a call from [Name] RN (Registered Nurse) from [hospital] ER that urine test results came back post d/c (discharge) and resident has a UTI (urinary tract infection). New orders received Keflex BID (twice daily) 500 mg for 7 days. This nurses note was written by LPN (Licensed Practical Nurse)-FF. The nurses note dated 9/25/24 at 2123 (9:23 p.m.) documents: Resident was sent to ER from dialysis to have a new port inserted. Resident had some minor bleeding from site after returning. Call ER to report bleed per summary instructions. An order to place a compression dressing to site. If bleeding does not stop resident is to go to ER. After several minutes bleed has stopped and compression dressing is still intact. Resident is to be woke at 0500 (5:00 a.m.) on 9/26/24 to return to dialysis for a 0600 (6:00 a.m.) chair time. Family arranged transportation to arrive at 0540 (5:40 a.m.). This nurses note was written by LPN-Z. The progress note dated 9/30/24 at 11:45 a.m. under Subjective documents: Patient is seen in her room during visit currently resting in bed. She has now completed antibiotics for UTI (urinary tract infection) without any further urinary concerns reported. Recently updated by nursing staff that patient had worsening behaviors with confusion that had been noted upon starting Dilaudid. Pain clinic was updated and gave order to discontinue Dilaudid and start Norco instead, which patient has been tolerating without adverse effect. She does note ongoing back pain at baseline and is reminded to let nursing staff know when she has pain, with goal to optimize her pain control. Patient has no other complaints today. No shortness of breath or chest pain. Mentation appears at baseline currently. Nursing staff to continue to monitor pain control as well with no other new concerns reported today. The nurses note dated 10/6/24 at 03:26 (3:26 a.m.) documents: Resident summary: Resident A/O (alert/orientated) x (times) 2-3, able to make needs know, Denies pain and discomfort other than her base line. Resident has dialysis appoint three times a week. Resident independently hydrates and nourishes adequately. Resident independently propels her wheelchair in the facility. Needs assistance with ADL (activities of daily living). On a breathing treatment and pain meds (medication). Resident is continent of bowel and bladder. This nurses note was written by RN-OO. The nurses note dated 10/7/24 at 05:42 (5:42 a.m.) documents: Pt (patient) put call light on and informed staff she could not breathe. Pt sat at edge of bed. CPAP on. CNA (Certified Nursing Assistant) notified writer and writer went to room. Pt sitting at edge of bed and leaning over the side rail. Lips are blue. Pt is not responding verbally. Writer unable to get pulse ox. Fingers are cyanotic. Agonal breathing present. Pt is a DNR. Writer placed call to daughter [Name] and informed of information. [Name] stated she wanted to call her brother to see if they wanted her to go to the ER. [Name] will call facility back. This nurses note was written by RN-PP. The nurses note dated 10/7/24 at 05:47 (5:47 a.m.) documents: Pt has no pulse or respirations. Writer placed call to daughter [Name] and updated on death. [Name] is still trying to call her brother. [Name] unsure when they will be coming to the facility. Writer did ask [Name] about funeral home (burial or cremation). [Name] states she has the information and will update facility on funeral home information when they get her [sic] (here). This nurses note was written by RN-PP. The nurses note dated 10/7/24 at 05:52 (5:52 a.m.) documents: Call placed to [Name] Medical answering service and informed of death with need for call back. This nurses note was written by RN-PP. The nurses note dated 10/7/24 at 05:55 (5:55 a.m.) documents: Call received from [Name] Medical; [Name] NP informed of death. Permission given to release body to funeral home. This nurses note was written by RN-PP. On 10/23/24 at 9:34 a.m., Surveyor asked LPN-FF how R2 was during the evening shift on 10/6/24. LPN-FF informed Surveyor R2 was completely normal, there were no concerns, nothing with R2's vital signs, behavior or anything. Surveyor asked LPN-FF if R2 complained of not feeling well. LPN-FF informed Surveyor she was stating she was not feeling good for two weeks and they did send her out. LPN-FF informed Surveyor R2 was not admitted and they did not find anything. (See nurses note dated 9/15/24 On 10/22/24 at 4:18 p.m., Surveyor spoke with CNA-RR who worked the evening shift on 10/6/24 and night shift into 10/7/24. CNA-RR informed Surveyor she was in training and got to the facility about 6:00 p.m. Surveyor asked CNA-RR if she was in R2's room between 6:00 p.m. & 10:00 p.m. (evening shift). CNA-RR informed Surveyor she went into R2's room one time with the CNA she was training with and R2's call light went off she thought sometime between 8:00 p.m. & 9:00 p.m. CNA-RR explained R2 was on the toilet getting ready for bed and needed her hair put up in a bun. CNA-RR informed Surveyor she did exactly what R2 wanted. The next time R2's call light went off was around shift change and she wanted ice. CNA-RR informed Surveyor she worked the 300 unit during the night shift. CNA-RR informed Surveyor the last time she heard about R2 was between 5:00 a.m. & 6:00 a.m. when RN-PP told her you have to give me a second I have a code & took off running, want to say she passed away. On 10/22/24 at 11:17 a.m., Surveyor spoke with CNA-QQ on the telephone. Surveyor asked CNA-QQ to explain what occurred on 10/7/24 with R2. CNA-QQ informed Surveyor it was an average night. R2 got up at 4:00 a.m. and asked for water & ice for a flavor packet she had and then laid back down. CNA-QQ informed Surveyor an hour or hour and a half later R2 was yelling help me help me and she couldn't breathe. CNA-QQ informed Surveyor R2 had a mask on her face. CNA-QQ informed Surveyor she was on the 400 hall with R2 and the nurse was on the 300 hall. CNA-QQ informed Surveyor she yelled for the nurse, who was not a regular nurse, that R2 couldn't breathe. CNA-QQ informed Surveyor the nurse came in then said she needs to see if R2 is a DNR as doesn't look good. CNA-QQ informed Surveyor she went back in a few minutes later and the nurse and another nurse were in the room. She, (referring to RN-PP,) must have called the charge nurse. CNA-QQ informed Surveyor she was told to get another aide as R2 had passed. On 10/22/24 at 6:35 a.m., Surveyor interviewed RN-PP regarding R2. Surveyor asked RN-PP if she was the nurse assigned to R2. RN-PP informed Surveyor she was the nurse on the 300 & 400 wings. Surveyor asked RN-PP if she had taken care of R2 prior to R2 having a change of condition and expiring. RN-PP informed Surveyor this was the first night with R2 alone explaining she had taken care of her one time prior when she was training with [first name], LPN. Surveyor asked RN-PP if she received report of any concerns involving R2. RN-PP informed Surveyor there were no concerns voiced to her from the PM (evening) shift. RN-PP informed Surveyor since there was COVID in the facility she had checked R2's temperature & oxygen sats and changed the nebulizer equipment. RN-PP indicated R2 was alert & verbal and aroused easily. Surveyor asked RN-PP if she remembers what time R2's change of condition was. RN-PP replied no, it's in the charting. RN-PP informed Surveyor she also administered R2 her morning medication. Surveyor asked what time these medications were given. RN-PP informed Surveyor she can give morning medication any time after 3:00 a.m. and couldn't tell Surveyor what time. RN-PP informed Surveyor she thinks there was an agency CNA working this night and the CNA sits at the 400 nurses' station and she was at the 300 nurses' station. RN-PP informed Surveyor she doesn't know what interactions the CNA had with R2 and Surveyor would have to ask the CNA what her interactions with R2 were. RN-PP informed Surveyor the CNA shouted she's not able to breathe and then s[TRUNCATED]