**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7.) R100's diagnoses include chronic respiratory failure, dependence on respirator (ventilator), Encephalopathy (general brain dysfunction characterized by alteration in brain function or structure), Quadriplegia (paralysis of all four limbs), and Guillain-Barre syndrome (rare neurological disorder where the body's immune system attacks the peripheral nervous system). R100's admission MDS (minimum data set) with an assessment reference date of [DATE] has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. Speech clarity is assessed as no speech. For functional limitation in range for motion R100 is assessed as having upper extremity and lower extremity impairments on both sides. Toileting hygiene & roll left, and right are assessed as being dependent and chair/bed to chair transfer was not attempted due to medical conditions or safety concerns. R100 is checked as receiving oxygen, suctioning, trach care and ventilator. R100's ADL (activities daily living) CAA (care area assessment) dated [DATE] under analysis of findings documents: This CAA triggers as resident is dependent for all activities of daily living. Resident somehow developed botulism and become paralyzed and is now on a vent with trach. She does not get up by choice as she says that she is too fatigued. Is working in OT/PT (occupational therapy/physical therapy) to gain strength and endurance. R100's ADLs (activities daily living) Functional Status/Rehabilitation Potential ADLS: I have impaired mobility related to quadriplegia care plan with a start date of [DATE] & last reviewed/revised on [DATE] documents an approach with a start date of [DATE] of Transfer status: full body mechanical lift with extensive assistance of 2. Surveyor noted this approach does not include the size of the sling to be used with the full body mechanical lift. On [DATE], at 10:16 a.m., Surveyor asked R100 if staff washed her up today. R100 shook her head no. Surveyor asked R100's permission to observe staff wash her up. R100 mouthed yes, please. On [DATE], at 11:37 a.m. Surveyor observed CNA/CC-P and CNA-CC place PPE (personal protective equipment) on and remove the bedding off R100. Surveyor then observed CNA/CC-P with the assistance from CNA-CC provide personal and incontinence cares to R100, change R100's gown apply lotion and place a full body mechanical lift sling under R100. At 12:15 p.m. CNA-CC brought the full body mechanical lift over by R100's bed and staff connected the full body mechanical sling to the lift. Surveyor noted the sling was blue with a yellow trim. CNA/CC-P raised the head of the bed up and staff attached the sling to the mechanical lift. CNA-CC placed the urinary collection bag into a fabric bag and R100 was raised off the bed. CNA/CC-P held onto the ventilator tubing while wheeling R100 over to the Broda chair while CNA-CC held onto R100's legs. R100 was positioned in the air over the Broda chair, CNA/CC-P stated to R100 okay [R100's first name] here we go, the battery alarm sounded, and CNA/CC-P stated the battery has gone dead. CNA/CC-P then went over to R100's door & looked out. CNA/CC-P removed her PPE, stated going to use hand sanitizer out here (referring to the hallway) because it's an emergency and left R100's room. At 12:20 p.m. CNA-CC stated this is sad and then asked R100 if she was okay. At 12:21 p.m. CNA/CC-P wearing a gown reentered R100's room with two batteries and placed gloves on. CNA-CC exchanged the full body mechanical lift battery and R100 was lowered into the Broda chair. CNA/CC-P stated [R100's first name] it didn't warn us this time, let me get her pillows. At 12:24 p.m. Surveyor asked CNA/CC-P how she knows when the lift batteries need to be changed. CNA/CC-P showed Surveyor the battery icon which showed the battery was green. CNA/CC-P informed Surveyor it shows the battery is charged but it's not. CNA/CC-P placed pillows under R100's lower legs and then stated to Surveyor they were trying to get new Hoyer's but got new batteries. On [DATE], at 12:33 p.m. Surveyor asked R100 when Surveyor observed her yesterday being transferred from the bed into the Broda chair and she was up in the air because the battery died has this happened before. R100 mouthed yes. R100 then wrote on the white board they need to pay attention to the patient we know how we feel. On [DATE], at 3:00 p.m. during the end of the day meeting Surveyor informed Previous Nursing Home Administrator (NHA)-C and Director of Nursing (DON)-B of the observation of the battery on the full body mechanical lift not working while R100 was suspended over the Broda chair. 8.} R51 diagnoses includes Chronic respiratory failure, Paranoid schizophrenia (outdated term for the condition schizophrenia which is a chronic mental disorder that affects how a person thinks, feels, & behaves), Atrial Fibrillation (irregular and rapid hear beat), and Seizures. R51's activities of Daily living (ADLs) Function/Rehabilitation Potential CAA (care area assessment) dated [DATE] under analysis of findings documents [R51's first name] is noted to have a significant change due to continued refusals of her vent. She remains trach dependent and often refuses medications. Reeducation provided by staff. Under care plan considerations documents Will proceed to care plan to prevent functional decline. R51's ADLs (activities daily living) Functional Status/Rehabilitation Potential [R51's first name] has impaired mobility related to stroke with left sided weakness care plan with a start date of [DATE] and reviewed/revised [DATE] has an approach with a start date of [DATE] of Bed mobility limited A (assist) transfers limited assist x (times) 1 with bathroom grab bar to toilet; Sara Steady was assist x 2 bed to/from wc (wheelchair); non ambulatory. R51's quarterly MDS (minimum data set) with an assessment reference date of [DATE] has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R51 is assessed as requiring substantial/maximal assistance for toileting hygiene, roll left & right is supervision or touching assistance, chair/bed to chair transfer & toilet transfer are assessed as partial/moderate assistance. R51 is always incontinent of urine and bowel and is assessed as not having any falls. R51 is checked as receiving oxygen, suctioning and tracheostomy care. R51's John Hopkins Fall Risk assessment dated [DATE] has a score of 16 which indicates a high fall risk. On [DATE], at 7:36 a.m. Surveyor observed CNA-CC & CNA-BB place PPE (personal protective equipment) on and enter R51's room. CNA-BB asked R51 if she was ready to go to the bathroom, removed the floor mat from the left side of R51's bed, raised the head of the bed, and assisted R51 with sitting up in bed. Surveyor noted as CNA-BB was assisting R51 with sitting up, R51 upper body tilted over towards the left and CNA-BB assisted R51 with sitting straight on the edge of the bed. CNA-CC placed shoes on R51 and then brought the Sara Steady in front of R51. CNA-CC & CNA-BB assisted R51 to stand up, the seat pads of the lift were placed under R51's buttocks and R51 sat down. The brakes of the Sara Steady were unlocked and R51 was wheeled into the bathroom & placed over the toilet. Surveyor noted the distance from R51's bed to the toilet is approximately 15 feet. R51 stood holding onto the grab bar on the wall and the raised toilet seat bar while the incontinence product was removed. R51 was then assisted with sitting on the toilet. CNA-BB wheeled the Sara Steady out of the bathroom and then made R51's bed while CNA-CC washed R51's legs, and placed socks & pants on R51. CNA-CC placed an incontinence product on R51. CNA-CC removed R51's gown. R51 washed her own face and then CNA-BB washed R51's upper body, placed deodorant and a shirt on R51. At 7:53 a.m. CNA-BB wheeled the Sara Steady into the bathroom placing the Sara Steady in front of R51. CNA-BB locked the brakes of the Sara Steady and told R51 not to stand up yet. At 7:55 a.m. R51 stood up, CNA-BB held onto R51 while CNA-CC washed & dried R51's buttocks. The seat pads were placed down & R51 sat down. R51 was then wheeled in the Sara Steady from the bathroom to the wheelchair in R51's room which was approximately 12 feet. R51 stood up, the seat pads were raised and R51 sat in the wheelchair. On [DATE], at 10:53 a.m. a Surveyor asked PT (Physical Therapist)-H about the Sara Steady. PT-H informed Surveyor the Sara Steady is used for transfers from surface to surface, it's not for long distance transfers. Surveyor inquired if a resident uses the bathroom how should they be transferred with the Sara Steady. PT-H indicated the resident should be transferred from the bed to the wheelchair with the Sara Steady, then wheelchair to toilet but no long distance travel with the resident in the Sara Steady. PT-H informed Surveyor if the resident if feeling weak the Sara Steady would not be the best option to use because the resident would have to lift themselves. The Sara Steady manual (Arjo) 12/2022 Intended use (page 6) documents: -Sara Steady is a mobile active lift with a safe working load of 400LB (pound). -Sara Steady is manufactured to a very high standard and has been designed to quickly and easily transport or transfer patients from one sitting position to another. it is not intended for long periods of sitting or transfer. -Sara Steady is intended to transfer a patient to/from a chair, wheelchair, a bed and a toilet -manual provides description of compatible slings to use for [NAME] steady. On [DATE] at 10:29 a.m. a Surveyor asked Director of Nursing (DON)-B if slings are used with the Sara Steady. DON-B indicated they have never used slings with the Sara Steady, their therapist use it without the slings and the slings are optional to use. On [DATE], at 9:05 a.m. Surveyor asked CNA-CC if anyone has told her she shouldn't use the Sara Steady to transfer a resident from the bed into the bathroom. CNA-CC replied no not from the bed into the bathroom. On [DATE], at 12:13 p.m. Surveyor asked Certified Nursing Assistant (CNA)/Care Coordinator (CC)-P how she knows what size sling to use for Residents. CNA/CC-P informed Surveyor the residents on the unit (vent unit) need the slings with the plastic hooks as they are more supportive. Surveyor asked how you know what size sling to use. CNA/CC-P replied go by their weight. If bariatric then use bariatric. If petite can't use bariatric. Surveyor asked CNA/CC-P if the care plan has the sling size on the care plan. CNA/CC-P replied no. On [DATE], at 1:57 p.m. Surveyor asked CNA-CC which residents on the vent unit are transferred out of bed and what lift is used. CNA-CC informed Surveyor the first names of R30, R34, & R100 are hoyer lifts, R51 is a Sara Steady and R88 is independent. Surveyor asked CNA-CC how she knows what size hoyer sling to use. CNA-CC informed Surveyor go by their weight. Surveyor asked CNA-CC how she finds out what a resident weighs. CNA-CC replied if I was a CNA that never worked here I could ask the nurse or can visualize and know what size to use. 9.) R38 was admitted to the facility on [DATE] with diagnosis that included Cerebral infarction and Quadriplegia. R38's Significant change Minimum Data Set, dated [DATE] assessed R38 to be totally dependent for transfers from bed to chair. R38 was assessed to have long and short term memory impairment and unable to participate in the Brief Interview for Mental Status. On [DATE] at 9:03 AM, R38 was observed to be transferred with a full mechanical lift by Certified Nursing Assistant (CNA)-V and CNA-GGGG. CNA-V and CNA-GGGG used a sling for the full mechanical lift that had a blue edging. CNA-V indicated it was a large sling. R38 was transferred safely from his bed to his Broda chair. On [DATE], R38's medical record was reviewed and nowhere did it indicate what size sling R38 should use for his transfers with the full mechanical lift. On [DATE], the sling size chart provided by the facility was reviewed and indicated an extra-large sling with blue edging was for residents that weigh 308 to 440 pounds. On [DATE] R38's weight was 188 pounds. R38's weight had been consistently in the 180's for the past year. On [DATE] at 9:35 AM, R38's sling that was used for the [DATE] transfer was observed in R38's closet. CNA-V indicated the sling was an extra-large. CNA-V was asked what R38 weighed, and CNA-V indicated she did not know. On [DATE], R38's current care plan last dated [DATE] was reviewed and indicated for falls use full body lift. No sling size in indicated on the care plan. On [DATE], R38's CNA Assignment Sheet was reviewed and documented: Transfers, full body mechanical lift with assist of 2. R38's CNA Assignment Sheet does not document what size sling R38 should use. On [DATE] at 9:40 AM, Former Administrator-C was interviewed in R38's room and indicated R38 had an extra-large sling in his closet and R38 should be using a large sling. Former Administrator-C left the sling in R38's room indicating the facility ordered the correct size but will use the extra-large until the new sling arrives. The above findings were shared with Former Administrator-C and Director of Nurses-B on [DATE] at 3:00 PM. Additional information was requested as to why R38 had the incorrect sling size, none was provided. Based on observation, interview, and record review, the facility did not ensure Residents received adequate supervision and assistive devices to prevent accidents for 11 (R49, R72, R83, R12, R315, R79, R100, R51, R38, R94, and R6) of 14 Residents reviewed for accidents. This has the potential to affect 64 residents who use a mechanical hoyer lift, a mechanical sit to stand, or a Sara Steady lift. Staff did not always use the correct lift or use it correctly. The facility does not have a process in place for staff to ensure residents that are transferred using a mechanical lift or sit to stand have the appropriate sling to use during the transfer. *On [DATE], R72 fell from a Sara Steady and suffered a displaced spiral fracture of the left femur. At the time, R72 was to be transferred with the use of a mechanical sit to stand. *R83, R12 and R315 were observed during a transfer with a mechanical hoyer lift to not have the correct size sling used. On [DATE], R49 slid off a mechanical lift sling left under R49 while in the wheelchair to the floor. The facility had not assessed the safety risks associated with leaving a sling under R49 including whether the presence of the sling could lead to an unsafe seating situation for R49 in their wheelchair. R49 suffered a right humerus fracture. The facility policy is to remove all slings once the Resident has been transferred. *R79 was observed to be sitting in a wheelchair with a sling left underneath. The facility policy is to remove all slings once the Resident has been transferred. *R100 was up in the air over R100's Broda chair when the mechanical lift battery stopped working. *R51 was observed being pushed a long distance in the Sara Steady to the bathroom., however, the Sara Steady is only designed for a simple very short distance transfer. *R38 was observed during a transfer with a mechanical lift to not have the correct size sling. *Upon interview, staff did not know what size sling to safely transfer R42. *Upon interview, staff did not know what size sling to safely transfer R6. *R94's care plan documented R94 was to transfer with the assistance of a 2 wheeled walker which was not available during the survey process. Facility failure to have a process in place for staff to ensure the safe transfer of residents created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA)-C, Director of Nursing (DON)-B, Chief Executive Officer (CEO)-A, and Director of Clinical Operations (DOC)-D of the immediate jeopardy on [DATE] at 2:07 PM. The Immediate Jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its removal plan. Findings include: The facility's Safe Resident Handling (Safe Lift/No Lift Transfers) Effective 10/09, Revised 3/19, Reviewed 3/24 documents: Guidelines: Therapy/Nursing will complete the following: 1. Therapy will determine the safest transfer technique for each Resident being assessed or followed by therapy. Therapy will communicate to nursing the best method of transfer in electronic health record (EHR). 2. If Resident is not on therapy caseload, nursing will consult with therapy as needed to update Resident transfer status. a. admission Screening -Therapy will determine Residents transfer status upon admission within 48 hours. 1. Therapy/Nursing will document transfer technique on the Resident care plan and Resident care guide in EHR. 2. Therapy/Nursing will provide training and education as needed to nursing staff regarding safest transfer technique for Resident being assessed. 3. Therapy/Nursing staff will monitor safety of current transfer technique and implement changes as appropriate. 4. Nursing staff will receive annual education and training on the safe transfer techniques by therapy/nursing. Criteria for determining transfer status of Resident: 3. Mechanical Stand (Sit to Stand) 1-2 people a. Resident is partially dependent and has some weight bearing ability and has sufficient upper body strength and usage. b. Residents that have difficulty following directions, panics during transfers or grabbing for a perceived safe surface. c. Compromised balance. d. Resident stands for less than 5 seconds or is unpredictable. 4. Full Mechanical lift-2 people a. Resident is non-weight bearing. b. Resident is weight bearing but won't bear weight. 5. Non-mechanical/One Person (Sara Steady): a. Suitable for who can partially weight-bear, but need an extra hand tasks like dressing or stabilizing during transfer b. Have some upper body strength and can follow basic transfer instructions c. May have compromised balance or difficulty following directions but can still participate in the transfer. 10. A minimum of two people must be present for mechanical lift transfers. 11. Caregivers may NEVER utilize less assistance with a transfer than the care plan states. If more assistance is required, the CNA must report change in status to the nurse. The nurse will determine safest transfer at time and inform therapy of change and document change in transfer in EHR. 12. Slings must be correctly matched to Residents (Small, Medium, Large, X-Large). 13. Slings must be matched to appropriate mechanical lift by manufacturer name. QIC 1. Regular observation of the staff CNA's transferring of Residents will take place on hire and/or annually with evaluation. Unit nurses, managers, supervisors, nurse educator and therapy should perform these evaluations in room observations. 2. Transfer incidents/injuries will be reported and thoroughly investigated per policy by interdisciplinary, as needed. Education and Training of Staff 1. All current nursing staff will be in serviced to the Safe Resident Handling Policy. 2. Nursing staff to complete demonstration for each device at training evaluation and annual evaluation. 3. All new staff to complete education and training within first orientation period. 4. Therapy and/or Nursing to re-evaluate Resident's current abilities to continue with current plan of care if a noted change in condition is identified (decline or improvement). 5. All Residents requiring physical assist and/or devices will be screened quarterly. Equipment Inspection and Maintenance 1. Daily visual by nursing staff prior to all transfers. 2. Preventative Maintenance Program by Buildings and Grounds. 3. Monthly form inspections with documentation for each type of lift device done by Buildings and Grounds . On [DATE], at 7:22 AM, Surveyor reviewed the manuals for the mechanical hoyer lifts and sit to stands that the facility provided. Medline MDS400SA and MDS600-Revised [DATE] .Warning! -Page 5 Together with the Resident's doctor, nurse, or medical attendant, select a Medline sling that is both practical and comfortable. The sling selected should be one that serves the needs of the Resident, while providing the Resident with optimal safety. .Warning! -Page 5 Medline slings are specially designed for use on Medline Lift equipment. For optimum performance use only, Medline stand assist slings. USE OF NON-MEDLINE SLINGS IS UNSAFE AND MAY RESULT IN INJURY TO THE RESIDENT OR CAREGIVER. Warning! Do not put anything between the Resident and the sling. This may cause the Resident to slide out of the sling and cause injury. .Page 12 Maintenance Schedule Slings-Check entire sling inventory for fraying, tearing, excessive wear of any kind and replace any worn or damaged slings with Medline slings. .Page 13 Do Not Operate Lift Unless All Maintenance Points Pass Inspection Warning: -Always carry out the daily checklist before using the lift -Do not use a sling unless it is recommended for use with the lift -Always check if the sling is suitable for the particular patient and is of the correct size and capacity -Never use a sling which is frayed or damaged -Always fit the sling according to the instructions provided -Always check the safe working load of the lift to be sure it is suitable for the weight of the patient -DO NOT use electric lifts in the shower -DO NOT charge an electric lift in a bathroom or shower room -CAUTION: Keep the batteries fully charged. Arjo Huntleigh [NAME] 300-11/2014 .Page 9 Preparation before transfer Before approaching the Resident, the caregiver shall always tell the Resident what they are going to do and have the correct size sling ready. .Using Standing Sling, and their different parts referred to in this manual Warning! An assessment must be made for each individual Resident being raised by the [NAME] 3000-by a medically qualified person-as to whether the Resident requires the lower leg straps when using the standing sling. The top of the sling can be recognized by the washing label which is placed on the outside top rim of the sling. .Pg 19 Caution:! It is recommended that equipment, accessories and slings supplied by ARJO Huntleigh are regularly cleaned and/or disinfected between each Resident use if necessary, or daily as a minimum. .Page 21 Care and Preventative Maintenance. The Arjo Huntleigh [NAME] 300 takes 2 different slings, a transfer and standing sling. .Providing the right sling for the individual patient type and need, is vital, to promote optimal safety and comfort. MAXI 500 4/2016 2 different models in the facility, 1 takes a straight bar, 1 does not. .Page 11 Sling Selection The spreader bar that is attached to the lift determines what slings can be used to transfer a patient Slings are color coded for size by having a different color edge binding or attachment strap coloring. Invacare Roze Stand Assist Patient Lift 2017 .Pg 15 Warning! Risk of Injury of Death Improperly attached, improperly adjusted or damaged slings can cause the Resident to fall -Use Invacare approved sling that is recommended by a health care professional for the comfort and safety of the individual being lifted -Invacare slings and Resident lift accessories are specifically designed to be used in conjunction with Invacare patient lifts -After each laundering (in accordance with instructions on the sling) inspect sling(s) for wear, tears, and loose stitching. Invacare Roze Stand Assist Patient Lift 2017 .Pg 15 Warning! Risk of Injury of Death Improperly attached, improperly adjusted or damaged slings can cause the Resident to fall -Use Invacare approved sling that is recommended by a health care professional for the comfort and safety of the individual being lifted -Invacare slings and Resident lift accessories are specifically designed to be used in conjunction with Invacare patient lifts -After each laundering (in accordance with instructions on the sling) inspect sling(s) for wear, tears, and loose stitching. Invacare Get-U-Up 2018 .Page 7 Invacare Stand Assist and Transfer slings are specifically designed to be used in conjunction with Invacare patient lifts. Slings and accessories are designed by other manufacturers are not to be utilized as a component of Invacare's patient lift system. Use the sling that is recommended by the individual's doctor, nurse or medical assistant for the comfort and safety of the individual that is being lifted. Surveyor notes all the models specify must use their sling for safety. On [DATE], at 10:38 AM, Surveyor was approached by the Occupational Therapist (OT)-E who has worked at the facility for about one year. OT-E shared that OT-E felt that there were significant safety concerns in regard to the Residents who required mechanical lifts, mechanical sit to stands, or a Sara Steady. OT-E explained to Surveyor that any Resident that is a minimal assist requires a Sara Steady. A Sara Steady is for only very short transfers, for instance from bed to wheelchair. It is not meant to be pushed to the bathroom with the Resident on it. OT-E informed Surveyor that physical therapy determines the safe transfer status of a Resident. OT-E stated that an outside therapy consultant (TC)-F came in and trained the therapy department about two weeks ago. OT-E stated that the therapy department was told by TC-F that something had happened to a Resident. A Resident had been left unattended on a Sara Steady. OT-E had no further details. OT-E explained to Surveyor that each Resident has to have the right sling for the right lift. OT-E informed Surveyor the facility has a hodge podge of slings. Certified Nursing Assistants (CNAs) take whatever sling is available, use the same sling from Resident to Resident, wiping the sling down between Residents. OT-E spends a lot of time searching for the right sling to match the machine. No one has been trained on what sling to use. CNAs don't know what sling to use or what loop to put it on. There is no care plan of what sling to use for each Resident. OT- E has sometimes seen a single CNA transfer a resident using a mechanical lift when it should have been two-person transfer. There is a major issue of the batteries not working. Looks green like it is charged, but then can't handle the load of the Resident so it stops working with the Resident up in the air. Because of short staff, the therapy department uses the Sara Steady by themselves, but it should be two to assist. On [DATE], starting at 11:17 AM, Surveyor took a tour with OT-E of all six units in the facility. Surveyor observed all mechanical lifts, and all areas that stored the slings. Some mechanical lifts in the hallways with slings draped over the lifts. Storage of mechanical lifts and sit to stands, and slings was very haphazard on each unit. ParkView 1 Multiple slings. Different colors, different brands, unable to determine what sizes on most. 1 hoyer and 1 mechanical sit to stand. TerraceView 1 2 mechanical sit to stands. 1 pump up sit to stand. Multiple different brands of slings-1 sling marked XL 650 pounds on the sit to stand. SunnyView 1 L sling marked 650 pounds on a sit to stand. On a mechanical lift a sling marked L 650 pounds was marked. ParkView 2 The end room has a wheelchair with a pile of multiple slings, multiple brands, multiple colors. OT-E stated, That's why they don't know what slings to use, that's why they use the same sling on all the Residents. TerraceView 2 3 different sit to stands in the closet, hoyer is a different brand other than maxi move from the other units. Certified Nursing Assistant (CNA)-I came into the room at this time. Surveyor interviewed CNA-I. CNA-I explained to Surveyor that CNA-I was checking on the midline sit to stand because it wasn't working in the morning. Surveyor asked if the Resident was still in bed. Surveyor notes it was about 11:10 AM. CNA-I stated, I just used another sit to stand. Per CNA-I, slings are piled up or hanging over the mechanical lift and CNA-I never knows what size to use. CNA-I informed Surveyor the mechanical lift is a Midline and the battery has not been charged and doesn't know what sling to use for that one. SunnyView 2 The shower room has 3 different mechanical lifts, 5 different slings, different brands, and colors. The netting is shredded on one sling. OT-E stated OT-E doesn't know what the colors mean. OT-E explained that 1 sling hanging is a sling from the hospital which is meant for a lift that is anchored to the ceiling. OT-E stated that if it was used on a facility lift it would act as like an accordion and fold in on the Resident. On [DATE], at 2:01 PM, Surveyor interviewed CNA-J about all the different slings. CNA-J stated, that you just look at the sling and decide if it fits the size of the Resident. There is no actual size to the sling, and they are not marked. On [DATE], at 2:20 PM, Surveyor made observations in the shower room. There were multiple different slings on hooks, multiple brands, no sizes on the slings. CNA Care Coordinator (CCC)-P came into the shower room and informed Surveyor that CCC-P was doing an audit of slings and mechanical lifts. CCC-P stated, She was doing an audit because state is here. The slings here are a waste of money. There are no actual sizes available in the shower room. Can't use any of these. Right now, there are 58 Hoyer's (sic) and 37 slings that I have counted. We have been telling the facility there is a problem for a couple of years. On [DATE] at the daily exit meeting with the facility, Surveyor requested a count of how many Residents require the assistance of mechanical lifts, mechanical sit to stands, and Sara Steady's. On [DATE], Surveyor notes that currently the facility states the facility has the following: 50 Residents require a mechanical hoyer lift 5 Residents require a mechanical sit to stand 9 Residents require a Sara Steady On [DATE], starting at 7:30 AM, Surveyor observed 3 mechanical lift transfers. On the mechanical lift, the color code read: XS burgundy Small red Medium yellow Large green LL light blue XL dark blue 1.) R83 was admitted to the facility on [DATE] with diagnoses that include Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease Affecting Left Dominant Side (complete paralysis on one side of body and partial/incomplete weakness on one side following stroke). R83 currently has an activated Health Care Power of Attorney (HCPOA). R83's Quarterly Minimum Data Set (MDS) completed [DATE] documents R83's Brief Interview for Mental Status (BIMS) score to be 11, indicating R83 demonstrates moderately impaired skills for daily decision making, requiring cues and supervision. R83 has range of motion (ROM) impairment on one side. R83 is dependent assistance for dressing, mobility, and transfers. R83 requires partial/moderate assistance for eating. R83's Assistance of Daily Living (ADL) care plan initiated [DATE] documents R83 has impaired mobility and requires a full body mechanical lift with assist of 2. On [DATE], R83 weighed 149 pounds. On [DATE], at 7:30 AM, Surveyor asked CNA-L where CNA-L obtained the sling that CNA-L was using for R83. CNA-L stated CNA-L found it in the shower room. Surveyor asked CNA-L what size it was. CNA-L stated, I do believe it's a large, no its a medium. Surveyor notes CNA-L was not wearing glasses when CNA-L shared the size. Surveyor obs[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility did not ensure a resident received treatment and care in accordance with professional standards of practice to include individual assessment and reporting when experiencing a medical change of condition, per standards of practice for respiratory therapists. This was discovered with 1 (R2) of 1 resident reviewed that had a medical change of condition while on a ventilator. On [DATE], at 11:12 PM, there was a progress note written by the Respiratory Therapist (RT)-T that indicated shortness of breath was present for R2 and that this was new, not chronic. RT-T raised R2's oxygen flow rate from 5 lpm (liters per minute) to 8 lpm. There is no evidence that any further assessment was completed indicating why to increase the flow rate or to help determine why R2 was newly short of breath. There is no evidence of further assessment to determine if increasing the oxygen flow rate improved the shortness of breath symptoms. There is no evidence this change of condition was communicated to the Registered Nurse working the same shift or to staff working the next shift. There is no evidence the change of condition was reported to R2's physician for consultation and treatment. R2 passed away in the Facility and was found deceased for several hours on [DATE] and pronounced dead at 8:40 AM by the Pulmonary Doctor. The Facility's failure to provide assessment and follow up created a finding of immediate jeopardy that began on [DATE]. Surveyor notified the Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A of the immediate jeopardy on [DATE], at 10:53 AM. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: The Facility Policy titled Notification of Changes last reviewed 12/24, documents (in part) . Policy: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate. The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident . Procedure: 1. The nurse will immediately notify the resident, resident's physician, and the resident representative(s) for the following (list not all inclusive): An SBAR (situation, background, assessment, recommendation) will be completed in the EMR (electronic medical record) to reflect pertinent info to notify the physician of . B. A significant change in the resident's physical, mental, or psychosocial status. C. A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. D. A need to alter treatment significantly . 2. The nurse will notify the resident, resident's physician, and the resident representative(s) for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician . The Facility Policy titled Respiratory Assessment last reviewed 7/24, documents (in part) . Policy: A Respiratory Assessment will be performed on the following residents to ensure proper respiratory treatments, equipment, and modalities are ordered to meet the resident's needs . 3. Any resident with a change of condition requiring respiratory treatments or oxygen therapy . General Information: The Respiratory assessment is performed one time for each of the above and charted in the EMR (Electronic Health Record). Procedure: 1. List Cardiopulmonary history. 2. Document heart rate; respiratory rate; O2 (oxygen) Saturation; FiO2/LPM (fraction of inspired oxygen/liters per minute); breath sounds, sputum color, consistency, and volume; expiratory time, breathing pattern; and ability to cough effectively. 3. If a trach resident, document the trach size and type; insertion or change date; and stoma site integrity. 4. If a vent resident, document the ventilator settings including the mode, tidal volume, respiratory rate, peep, FiO2; the amount of pressure support; and any weaning plans. 5. Check the planned modalities of treatment for the resident. 6. List any pertinent comments vital to their treatment. According to the American Association for Respiratory Care, The practice of a respiratory therapist is directed by a licensed independent practitioner and is determined by state licensure laws where applicable. The practice typically focuses on: . o Direct and indirect patient observation and monitoring of signs, symptoms, reactions, general behavior and general physical response to respiratory care and diagnostic interventions. o Implementation of respiratory therapy procedures, medical technology, and diagnostic procedures necessary for disease prevention, treatment management, and pulmonary rehabilitation . The responsibilities of a respiratory therapist include, but are not limited to: 1. Performance and collection of diagnostic information . https://www.nbrc.org/wp-content/uploads/2019/09/AARC-Scope-of-Practice.pdf R2 was readmitted to the facility on [DATE]. R2's pertinent diagnoses include chronic respiratory failure with hypoxia, chronic kidney disease-stage 4, dependence respirator (ventilator) status, major depressive disorder, generalized anxiety disorder, insomnia, hypertensive chronic kidney disease, acute on chronic systolic (congestive) heart failure. R2's Quarterly Minimum Data Set (MDS) with an assessment reference date of [DATE] indicated R2 had a Brief Interview for Mental Status score of 14 (cognitively intact). R2 is responsible for self. R2 is listed as full code for resuscitation. R2's MDS showed that oxygen therapy, suctioning, tracheostomy care and invasive mechanical ventilator were used for respiratory treatment. R2 is assessed as having no impairment to upper or lower extremities and R2 uses a wheelchair for mobility. R2 is assessed as occasionally incontinent of bladder and frequently incontinent of bowel. R2 has a pulmonary care plan which documents R2 has potential for complications from COPD (chronic obstructive pulmonary disease), respiratory failure, CHF (chronic heart failure). Pertinent interventions include: Monitor for complications such as dyspnea, shortness of air, cyanosis or tachypnea. Start Date [DATE] Monitor Oxygen saturation and administer Oxygen per physician orders. Start Date [DATE] Provide treatment per physician's orders and monitor for response. Observe for side effects and inform physician. Start Date [DATE] Administer medications per orders and monitor for response. Observe for side effects and inform physician prn. Start Date [DATE] R2 has an alteration in respiratory status vent/trach care plan which reads R2 has alteration in respiratory status related to ventilator/trach use. Pertinent interventions include: Monitor and report signs of hypoxia (cyanosis, tachypnea, dyspnea, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse) Start date [DATE] Monitor O2 (oxygen) sats (saturation). Q (every) shift & PRN Start Date [DATE] Monitor for signs and symptoms of respiratory infection, shortness of breath. Start Date [DATE] RT (respiratory therapist) consult as needed Start Date [DATE] Monitor oxygen saturation via pulse oximetry Q shift and PRN when on continuous oxygen therapy. Start Date [DATE] Check O2 settings Q shift and PRN Start Date [DATE] Maintain patent airway Start Date [DATE] Suction PRN per MD (medical doctor) orders Start Date [DATE] Airway checks, q shift and PRN Start Date [DATE] FiO2 (fraction of inspired oxygen) to keep SpO2 (oxygen saturation) at/above 90% Start Date [DATE] Surveyor reviewed the electronic medical record (EMR) and found physician orders related to R2's ventilator (vent) and tracheostomy (trach) care which included: Vent Settings: PC (pressure control) 25/5 / RR (respiratory rate) 18 / FIO2 TO KEEP SPO2 AT / ABOVE 90%, Every Shift, effective [DATE] RT change trach Q12 weeks, Once A Day on Monday, effective [DATE] Surveyor notes a review of charting showed resident oxygen was kept at 5 liters leading up to the night of the incident. On [DATE], a respiratory progress note written by RT-T with time of 11:12 PM was entered with the notation of Recorded as Late Entry on [DATE] 03:15 AM. The progress note reads: Lung Sounds: diminished Respirations Rhythm/Pattern: Regular/Unlabored Cough present?: No Shortness of Breath present?: Yes (New or Chronic) New Fever present?: No Oxygen in use?: Yes (Liter Flow) 8 lpm Oxygen delivered by: Not Applicable Isolation Precautions in place?: Not Applicable Restlessness present?: No Anxiety present?: No Fatigue present?: No Comments: Vent settings: PC mode 25 PIP, 5 of PEEP, 18 RR, 5 lpm Actual PT: 25 PIP, 7.2 MVE, 386TV, 18 RR, Breath sounds: diminished Trach care: Gauze changed, and site cleaned Oral Care: mouth and gums brushed Secretions: PT (patient) didn't need suctioning Vital Signs: 84 HR (heart rate), RR (respiratory rate) 18, SPO2 97% Surveyor notes the progress note written by RT-T indicates R2 was having shortness of breath, which was new. The oxygen in use was recorded as 8 lpm. The vital signs were 84 for heart rate, 18 for respiratory rate, spo2 97%. There is no indication if these vitals were before or after the oxygen was increased. There is no subsequent follow up by RT-T. Based on interviews of staff working that shift (as shown below), there is no evidence RT-T communicated this change to other staff. No SBAR was completed and there was no communication with the physician. The next progress note was written by Registered Nurse (RN)-U on [DATE], at 05:10 AM. It documents writer went into room at 0500 to give resident her prn APAP (Tylenol) that she requests each morning. Resident was sleeping comfortably. Color was baseline and lips were pink. No complaints from either residents (sic) in that room all shift. Surveyor notes the last PRN dose of Tylenol recorded as administered on the MAR (Medication Administration Record) was at 12:27 AM, on [DATE], by RN-U. The next respiratory progress note was written on [DATE], by RT-S with time of 8:20 AM, which documents: Lung Sounds: N/A Respirations Rhythm/Pattern: Regular/Unlabored Comments: Vent Settings: Received on ACPC 25/5+ R 18 on 10L (liters) Vent Actuals: VT 80 MVE 1.9 PIP 24.3 PMAP 5.3 I/E 1:1.1 Vital Signs: HR POX RR unable to obtain Breath Sounds: Unable to obtain Secretions: N/A Trach Care: N/A Oral Care: N/A Tx: N/A Misco: N/A Resident unresponsive between approx. 0810-0820. RT bagged PT on 15L, nurse present, supervisor arrived. RT unable to obtain POX (pulse oximetry) and HR (heart rate) with POX device. BS (breath sounds) unable to be heard. Bilateral chest rise present from ventilation assistance. NP (nurse practitioner) present, nurse and nursing supervisor. Surveyor notes there is no documentation as to when oxygen was increased from 8 to 10 liters per minute. On [DATE], at 8:45 AM, a progress note was written by Nurse Practitioner (NP)-V that documents . evaluated at bedside this AM 0825, mottled/cyanotic/pupils fixed. No pulse/audible HR/ no BP/no respirations. Extremities stiff c/w (consistent with) rigor mortis. By estimation, pt likely expired at least several hours prior .reviewed with (Pulmonary Doctor) via phone, concurs, pronounced dead @ (at) 0840am. On [DATE], at 8:46 AM, Surveyor interviewed R8, the roommate of R2, and was told that R2 put the call light on that night and said something about breathing, roommate heard RT-T tell R2 that they turned up the oxygen. The Facility did an investigation after the incident and the statement Nursing Home Administrator (NHA)-A wrote as a statement from R8 indicates R8 reported that around 9pm she heard (R2) on the phone with her grandsons, playing a virtual game. Later, during the 3rd shift around 11pm, (R2) called the CNAs (Certified Nursing Assistants) to warm up her usual snack, hot pockets. (R8) stated that both she and (R2) received their breathing treatments close to midnight from the night (RT-T) and (R2) was fine at that time. (R8) also mentioned that she heard staff in the room about 3 times throughout the night . On [DATE], at 11:51 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-W who stated they were not her (R2's) nurse that day but NP-V went into R2's room and came out and said R2 was not breathing. During walk around between 6:30-7:00 AM, R2 and roommate were sleeping which was not unusual. Later when LPN-W went into the room with NP-V, R2 was ashen in color and looked like she was sleeping. On [DATE] at 1:50 PM, Surveyor interviewed CNA-Z who stated they rounded at around 7am and thought R2 was sleeping at that time. On [DATE], at 2:11 PM, Surveyor interviewed RT-AA who worked the next shift after the incident. RT-AA stated that the incident could be attributed to poor communication, there was a change in condition that was not reported or passed on. Surveyor asked what that change was and was told by RT-AA it was that the oxygen had been increased on the night shift. On [DATE], at 2:52 PM, Surveyor interviewed LPN-X via phone and was told at around 7am LPN-X went into the room as the roommate's vent lights were going off, LPN-X turned off the vent lights and looked over both patients and they were both in their sleeping positions. On [DATE], at 10:44 AM, Surveyor interviewed RT-T via telephone who was on the night shift and increased the oxygen level for R2. When asked if R2 was experiencing a change of condition RT-T stated the oxygen was at 5 liters and that they did raise it to 8 liters. RT-T stated this is common to do. R2's pulse ox was at 91% but R2 was not having trouble breathing. RT-T saw resident in no distress and R2 did not tell RT-T there was a problem. Surveyor notes this shows discrepancy from the progress note written the night of the incident that indicates R2 was experiencing a new change in condition of shortness of breath and does not follow physician order to raise SPO2 to keep saturation above 90%, R2 was above 90% according to RT-T's statement. The Facility investigation after the incident included a statement NHA-A wrote from their interview with RT-T. (RT-T) stated that (R2's) vital signs were normal throughout the night and that he was able to administer treatments as scheduled. He stated he performed (R2's) breathing treatment around 11 pm, closer to midnight. (RT-T) last checked on her around 445-5am, describing her as seemingly fine and possibly asleep. He stated that (R2) had not complained of any shortness of breath or distress during their interactions that night. (RT-T) noted that (R2) appeared stable and routine, with no indications of distress observed during their rounds. He expressed surprise at the news of her passing, stating that nothing seemed abnormal during the shift. Surveyor notes documentation of respiratory therapist administered treatments were requested starting with the night of [DATE] and Surveyor was provided the Medication Administration Record (MAR) for a nebulizer treatment done by nursing twice a day that was last done on the [DATE] second shift by Licensed Practical Nurse (LPN)-BB. Surveyor noted there was no documentation of a breathing treatment done by RT-T. Surveyor notes the discrepancy of RT-T's interview with Surveyor and statement of interview with RT-T from NHA-A. On [DATE], at 11:21 AM, Surveyor interviewed RN-U, via telephone, who was working on the night shift before R2 passed. RN-U stated that R2 was alert and oriented times 4, so would alert staff if there was an issue. RN-U stated she saw R2 at midnight, R2 was on her tablet and there were no complaints. When asked about the oxygen being increased RN-U stated that if there had been an issue RT-T would have let RN-U know and RN-U was not alerted of any change. On [DATE], at 1:43 PM, Surveyor interviewed LPN-BB, via telephone, who worked the PM shift before the oxygen level was increased. Surveyor asked if there was any indication of a change of condition for R2 to which LPN-BB responded no, R2 was vocal and would have been taken care of as needed, R2 was alert and oriented times 4 and would let RT, Nurse or aide know if there was any discomfort. On [DATE], at 8:23 AM Surveyor interviewed Pulmonary NP-V via telephone. NP-V could not remember the exact numbers but thought R2 was normally on 2-3 liters of oxygen and that the oxygen was increased to 8-10 liters. NP-V let Surveyor know that only the RT can increase the oxygen level, the resident cannot. NP-V stated that if the oxygen is increased that would suggest something is happening. NP-V remembers R2 looked like they were sleeping, NP-V checked on R2's roommate first, the room was dark. It was 8:15-8:30ish in the morning and the curtain was closed between the two residents. When NP-V went to R2 their eyes were closed and they did not respond to verbal stimuli. R2 had no pulse or blood pressure, pupils were fixed and dilated, R2's body was cold and stiff when found so best estimate was R2 had been gone a few hours. On [DATE], at 10:23 AM, Surveyor interviewed RT-S, via telephone, who was on the shift that R2 was found deceased . RT-S did not check on R2 between the start of shift and time R2 was found deceased , they started the shift and had multiple issues to deal with before this occurred. RT-S was told the nurse and Certified Nursing Assistant on the shift thought R2 was sleeping when they rounded. R2 did not have any medications due from RT-S until 9 am. RT-S stated that NP-V found R2 deceased and determined this had been for hours due to the condition of R2's body. RT-S stated there was wrongdoing on the part of the night shift (NOC) RT-T, R2 was not tended to properly when they complained they could not breathe, and RT-T increased the oxygen flow rate. The NOC RT (T) reported no changes even though the RT (T) had raised the oxygen flow rate. RT-S told Surveyor that the NOC RT (T) raised the oxygen flow per the roommate because R2 told RT-T that R2 could not breathe. When RT-S responded to the call for help R2's oxygen was at 10 liters and 5 liters is the norm for R2. RT-S stated the raising of the oxygen liters was a change of condition that should have been reported. RT-S stated that it is in the scope of practice for an RT to increase oxygen flow level but need to assess what is going on. If the pulse ox is low need to determine if resident needs to be suctioned, if the inner cannula has a mucus plug or if resident needs a PRN breathing treatment. The RT needs to figure out why a resident cannot breathe, not just turn up the oxygen. On [DATE], at 1:27 PM, Surveyor spoke to RN-U, via telephone, to clarify when Tylenol was brought to R2's room around 5am how RN-U could tell R2 was sleeping, per RN-U R2 was upright in bed, breathing and when RN-U touched R2's arm, R2 moved a bit and was warm. Surveyor asked RN-U if a pain assessment or any assessment had been done at this time as RN-U was bringing in a PRN medication. RN-U shared there was no assessment of R2 at this time. Surveyor noted there is no indication of a nursing assessment throughout the shift. On [DATE], at 1:49 PM, Surveyor interviewed RT-Y who works PRN for the Facility. When asked about increasing a resident's oxygen level Surveyor was told an assessment would be needed in addition to checking the pulse ox. RT-Y stated you need to look and touch resident. An increase in oxygen would be considered a change in condition because it is not the normal for the resident. Communication of the change would be expected and did not happen in this case. RT-Y felt this was a failure on RT-T's part. On [DATE], at 2:38 PM, Surveyor followed up with NP-V and asked what should be done before increasing oxygen on a resident and was told the RT should assess for suctioning and assess the situation. Surveyor then asked what should be done after the oxygen is increased and was told if the resident remains hypoxic it means they could need suction, do not have good profusion, and need to check for a fever. If the problem persists RT would need to again contact the provider and get an order for a chest x-ray. Overall, the RT needs to do an assessment to figure out why the resident needs more oxygen, need to troubleshoot. NP-V agreed with Surveyor that not reporting an increase in the oxygen needs of a resident is a problem as this is a change of condition all team members should be aware of. Surveyor notes 3 interviews with RT's that work with R2 (RT-S, RT-Y, RT-AA) stated a need to increase oxygen would be a change of condition that should be assessed and reported to the physician for consultation. RT-S stated that it is within the scope of practice for an RT to increase oxygen flow level but need to assess what is going on. On [DATE], at 3:21 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B regarding the NOC shift of [DATE] and R2's oxygen being increased from 5 to 8 liters. They stated that this would be part of the RT's job. Their assessment would include taking a pulse oximetry which would indicate the need for more oxygen. They also stated that there was a lack of checks on R2 because R2 was not a resident that needed to be checked for incontinence or needed to be changed on a schedule. They stated R2 was a highly functioning resident. Surveyor notes R2's care plan states R2 should be monitored for incontinence every 2-3 hours prn, staff should offer to assist with toileting with each encounter and whenever observed to be awake at night and supervision is required with transfer with a walker and gait belt. On [DATE], at 10:34 AM, Surveyor followed up with NHA-A and DON-B to find out what the rounding schedule should be on the unit, to which it was stated, for Certified Nursing Assistants and Nurses should be every 2 hours, there is not a set rounding requirement for RT's. NHA-A and DON-B went on to discuss RT-T's assessment the night of the oxygen increase showed R2's respiratory rate and rhythm were fine, and no treatment was needed, they stated that the documentation showed no physiological signs the patient was in distress. Surveyor asked DON-B if an assessment should be completed after a resident's oxygen is increased to which DON-B stated yes, that would be advised as best practice. They stated that because the charting says R2 was at 97% oxygen, R2 was not in distress. They stated that it must be factored in that R2 was a highly functioning resident, that R2 could suction themselves. When asked how oxygen got from 8 liters to 10 liters, NHA-A and DON-B did not have an answer. Surveyor again noted the vitals RT-T documented do not indicate if they were before or after R2's oxygen was increased and whether R2's shortness of breath had been resolved throughout the shift as no additional assessments or monitoring had been completed. Surveyor notes the physician orders state to increase the oxygen if below 90%. Surveyor has an interview with RT-T where RT-T stated R2 was at 91%, which was not within the parameter to increase the oxygen and that the 91% was never charted. Surveyor notes nowhere in the care plan is it stated R2 had been assessed and could suction themselves as indicated by NHA-A and DON-B. Surveyor notes there is no documentation on how the oxygen lpm got to 10. The conclusion to the Facility investigation includes Throughout the prior shift, staff were consistently attentive and frequently checked on (R2), as confirmed by interviews. (R2) was independent in most of her functional abilities and would call staff for any assistance. (R2) had a routine for most of her cares and typically requested assistance around 9am. During all staff visits to (R2's) room throughout the shift, nothing out of the ordinary was observed. (R2) had a recent hospitalization in November due to chronic heart failure (CHF) and it is likely that she experienced sudden cardiac arrest, a possibility supported by her medical history. It is important to note that the ventilator was set to assist control pressure support (ACPC) which means that while the machine was providing respiratory support, it would not have alarmed in the event of a sudden cardiac arrest . During this investigation, we identified areas for improvement and have since implemented walking rounds to exchange reports. Staff were educated on this new process to enhance communication and patient monitoring. The facility exercised due diligence in providing care for (R2) and responded appropriately to all her needs. Surveyor notes the care plan and assessments including the MDS do not support the statement that R2 was independent in functional abilities. Surveyor notes a new diagnosis of CHF would make R2 frailer and needing more assessment with a change of condition. It was also noted by Surveyor R2 had only been using a vent since late 2024. Surveyor notes that R2 had a change of condition that was not assessed appropriately or reported to other staff. R2's physician was not consulted with regarding the change in condition of shortness of breath leading to increasing R2's oxygen setting. R2 was not assessed/monitored during the shift by RT or nursing staff. R2 was found with their oxygen level raised to 10 lpm and deceased by the respiratory nurse practitioner-V. who indicated R2 had been deceased for a length of time based upon R2's physical condition at the time of finding R2 deceased . The Facility failed to take immediate action by not having follow up on the care provided to R2 following a change in condition the night before R2 passed. These actions created a reasonable likelihood for serious harm, thus leading to the finding of immediate jeopardy starting [DATE]. The facility removed the immediate jeopardy on [DATE] when the facility implemented the following: The Director of Nurses along with a consulting respiratory therapist will provide education to all nurses and RT's who will be delegated to the respiratory unit related to recognition of all respiratory changes of condition to include policies and procedures related to same and or other physiological changes of condition. Education included the following: Staffing expectations for all shifts related to the respiratory unit Change of condition policy and procedures titled: Physician Notification Respiratory policy and procedures which include: Mechanical Ventilation: Set up and Monitoring Oxygen Administration Pulse Oximetry Tracheostomy Care Notification and documentation expectations with change of condition Where to look for a comprehensive list of orders and treatment within the EHR Shift to shift report expectations and use of 24 hour report board Competency exercises - competency will include a return demonstration on care for a resident with a ventilator and or other open airway that includes verbal affirmation of what, when and whom to report any changes in condition. Nursing and respiratory staff will collaborate and communicate any change in condition as a team, implementing appropriate interventions as ordered by provider. Signs were posted at the clinical hub on the vent unit to inform clinical staff that if they have not received the competency, they are not permitted to work on the unit until they've received the training. All nurses and RT's will be required to view the in-service prior to their next working shift. Once present for their scheduled shift a competency will be provided by a DON or a verified competent facility designee. Education was started on [DATE] with PM shift. Education will continue on [DATE]. All nurses and RT's will be trained prior to their next working shift. Oxygen Administration Pulse Oximetry Tracheostomy Care Notification and documentation expectations with change of condition Where to look for a comprehensive list of orders and treatment within the EHR Shift to shift report expectations and use of 24 hour report board Competency exercises - competency will include a return demonstration on care for a resident with a ventilator and or other open airway that includes verbal affirmation of what, when and whom to report any changes in condition. Nursing and respiratory staff will collaborate and communicate any change in condition as a team, implementing appropriate interventions as ordered by provider. A competent RN will be designated to respond to all emergency situations for ventilator and tracheostomy residents at all times. The RN will be delegated and present and available to ensure timely and comprehensive assessments to any resident demonstrating a potential change in condition. This scheduling pattern will begin on [DATE] pm shift. The unit will be staffed with an RN who has demonstrated competency in caring for ventilator residents. CNAs will be scheduled to meet residents, and RT's scheduled as necessary. The Change of Condition policy, Physician Notification has been reviewed and modified to include; Examples of Change of Condition Notification expectations with change of condition Documentation of a change of condition Vital sign expectations All changes in condition will be listed on the 24-hour report board Facility standard of practice policies from [NAME] have all been reviewed, and implemented to include: Mechanical Ventilation: Set up and Monitoring, Oxygen Administration, Pulse Oximetry,Tracheostomy Care Shift to shift report expectations protocol has been developed to use with 24 hour report board Medical Director-EE consulted during the development of this corrective action plan. The DON and or designee will review progress notes and 24-hour report board daily for 1 month for any changes of condition to ensure all condition changes have been recognized and appropriate for the residents status. An audit tool has been developed to support identification of any condition change. Audits will continue daily for 1 month with ad hoc training provided as necessary for any missed opportunities. Audits will continue 3x per week for 2 months. The DON and or designee will observe the delivery of respiratory care assigned by nurse or RT 3x per week for two weeks and weekly observations for two months. All audits will be brought to the Quality Improvement Committee for review and recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure the necessary Respiratory Therapy services to provide respiratory care consistent with professional standards of practice to 2 (R7 and R1) of 3 residents reviewed for respiratory cares/ services. The facility did not ensure staff were trained, knowledgeable and competent to provide respiratory care to 9 residents who are ventilator dependent and 7 residents who are not ventilator dependent but have tracheostomies (trach). *On 01/25/2025, R7 was not put on R7's ventilator at night due to the Facility not having a Respiratory Therapist at the Facility. R7 did not have Respiratory orders relating to R7's ventilator. R7 did not have a documented Respiratory Assessment for every shift, between 01/06/2025 through 02/04/2025. *On 2/1/2025 R1's family member had to hook up R1's trach mask to oxygen due to scheduled facility staff not having the knowledge/competencies to hook R1's trach mask up to oxygen. R1's family provided suctioning to R1 due to staff not having the competency to provide suctioning for R1. *The facility does not ensure nursing staff have competencies to care for vulnerable residents requiring Respiratory Therapy Services when Respiratory therapists are not in the building or that licensed practical nurses (LPN's) scheduled to care for the residents with respiratory needs are not working outside their scope of practice and if delegated to, they are competent to carry out delegated tasks with supervision from competent registered nurses (RN). Facility failure to provide nursing staff with Respiratory Therapy Services competencies to vulnerable residents on the ventilator unit created a finding of immediate jeopardy that began on 1/25/2025. Surveyors notified the nursing home administrator (NHA)-A, Director of nursing (DON)-B of the immediate jeopardy on 2/6/2025 at 10:53 AM. On 2/13/25 Surveyors retuned to the facility to verify removal of the immediate jeopardy and complete the partial extended survey tasks. Based upon observation, interview and record review on 2/13/15 it was determined the immediate jeopardy was not removed upon exit from the facility. Findings include: The facility policy titled Respiratory Therapy Policy and Procedure: Respiratory Assessment reviewed on 7/2024 and applies to Nursing Services and Respiratory Therapy documents: POLICY: A respiratory assessment will be performed on the following residents to ensure proper respiratory treatments, equipment, and modalities are ordered to meet the resident's needs. 1. New admissions and re-admission to Respiratory Unit. 2. New admissions and re-admissions of resident's underlying pulmonary diagnosis, respiratory treatments, oxygen therapy, or a tracheostomy (Trach), by physician order. 3. Any resident with a change in condition requiring respiratory treatments or oxygen therapy, or with signs and symptoms of respiratory infection, by physician order. Procedure: 1. List cardiopulmonary history. 2. Document heart rate, respiratory rate, oxygen saturation, fraction of inspired oxygen/ liters per minute (FiO2/LPM, amount of oxygen in the air that a person inhales), breath sounds, sputum (saliva/mucus coughed up from the respiratory tract) color/ consistency/volume, expiratory time, breathing pattern, and ability to cough effectively. 3. If a trach resident, document the trach size and type, insertion or change date, and stoma site integrity. 4. If a ventilator (vent) resident, document the ventilator setting including the mode, tidal volume, respiratory rate, peep, FiO2, the amount of pressure support and any weaning plans. 5. Check the planned modalities of treatment for the resident. 6. List any pertinent comments vital to their (resident's) treatment. The facility policy entitled Respiratory Therapy Policy and Procedure: Ventilator Alarms and Call Lights Response reviewed on 7/2024 and applies to Nursing and Respiratory Therapy documents: Policy: Ventilator alarms will be responded to immediately by all staff. Alarms notify staff of life-threatening situations. Call lights will be responded to by all staff and care will be provided within the scope of the caregiver or reported to the caregiver needed to provide the care needed. The care provided will be documented appropriately. Procedure: 1. Determine if alarm is respiratory related. a) Respiratory related alarms include but not limited to: i. Patient needs suctioning. ii. Continual high pressure without cares. iii. Alarming after cares. iv. Patient disconnect. v. Unwitnessed alarms of unknow origin. vi. Call light from tracheostomy needing respiratory care. b) If the alarm is respiratory related provide emergency care as needed. c) Assess residents and provide needed care. d) Reassess residents and provide any care indicated. e) Document assessment and cares provided using respiratory assessment form in MatrixCare or on paper respiratory assessment form. f) Completed paper forms are to be placed in respiratory basked located near the Director's office. The facility policy entitled Respiratory Therapy Policy and Procedure: Suctioning (oral cavity) reviewed on 7/2024 and applies to Nursing Services and Respiratory Therapy documents: Policy: Oral suction will be performed according to proper practice standards. General Information: 1. Oral suctioning removes secretions from the oral cavity by means on a Yankauer inserted in the mouth. The procedure is used to: 1.1 Prevent aspiration 1.2 Decrease the potential for infection that may result from accumulated oral secretions. 2. Procedure to be performed by the respiratory therapist (RT), registered nurse (RN), licensed practical nurse (LPN), or certified nursing assistant (CNA). 3. Emergency suction machines are kept at kept on all nursing units. 4. For frequent suctioning, assign a machine to the resident and keep at bedside. The facility policy entitled Respiratory Therapy Policy and Procedure: Suctioning (oral/nasopharyngeal) reviewed on 7/2024 and applies to nursing services and respiratory therapy documents: Policy: Oral-Nasopharyngeal suction will be performed according to best practice. General information: 1. Oral-nasopharyngeal suction removes secretions from the pharynx by means of a suction catheter inserted through the mouth or nose. This procedure is used to: a) Maintain airway patency-prevent aspiration. b) Decrease the potential for infection that may result in accumulated secretions. c) Stimulate an effective cough and expectoration. 2. Procedure to be performed by RTs, RN, or LPN. The facility policy entitled Respiratory Therapy Policy and Procedure: Tracheostomy- Care and Maintenance reviewed on 6/2024 and applies to nursing and respiratory services documents: Policy: Tracheostomy care will be provided according to proper practice standards. General Information: . Safety: . 2. Keep an ambu bag visible in room. Take ambu bag with resident when off unit. The facility policy entitled Respiratory Therapy Policy and Procedure: Treatments- Administration/ Documentation reviewed 7/2024 and applies to nursing services and respiratory services documents: Policy: To administer and the document all treatments on the Treatment Administration Request (TAR) or Respiratory Medication Administration Record (MAR) in the Electronic Medical Record (EMR). General Information: 1. Treatments and medications administration records are to be kept in the EMR. 2. All treatments including directions, sites, etc. will be transcribed in the EMR according to physician orders by . nurse, or RT and verification will be done by RN/LPN/RT. 3. All treatments performed by RN's, LPN's, RT's, and CNA's will be documented in the EMR. Surveyor notes that all the policies and procedures noted above are based on Lippincott Nursing procedures. Surveyor also notes that the above policies and procedures do not differentiate who does what. (Nursing services versus therapy services). There is no delegation of responsibilities for the specialized care on the ventilator/ tracheostomy unit. R1 RESPIRATORY SERVICES CONCERNS: * R1 was admitted to the facility on [DATE] and has diagnoses that include acute on chronic respiratory failure with hypoxia, ataxia following cerebral infarction, quadriplegia, legal blindness, anoxic brain injury, and epileptic seizures. R1 has a tracheostomy (non-ventilator dependent/requires trach mask hooked up to oxygen), gastrostomy and jejunostomy tube, R2 is non-verbal and not able to make needs known. On 1/27/2025, 1:46 PM, in the progress notes licensed practical nurse (LPN)-N documented . R1's family at bedside with concern that R1 has increased secretions and reports R1 had vomited. Per assessment R1 did not vomit and had normal amount of yellow tinged sputum and (sic) trach site. LPN-N provided oral care. R1's family member reports suctioning R1 themself without staff assistance or oversight. On 1/30/2025, at 10:25 AM, Surveyor observed R1's family at R1's bedside. Family member-J stated that the facility taught them how to suction R1 because R1 is getting ready to go home. Surveyor asked if family was allowed to suction R1 without staff present. R1's family member-J stated that there is never staff around or staff that know how to do it, so family member-J does it. Family member- J stated that on 1/27/2025 family member-J suctioned R1 because R1 had some emesis and there was not a respiratory therapist (RT) in the facility and R1's nurse did not know how to suction R1. On 2/3/2025, at 10:39 AM, Surveyor interviewed LPN-N who stated family member-J told LPN-N that family member-J was suctioning R1. LPN-N stated that R1's family member-J stated R1 has emesis and was suctioning R1's mouth out. LPN-N stated that R1 was not having emesis, and it was normal drainage. LPN-N stated that LPN-N normally does not work on the vent unit so got another nurse to help suction R1 because there was not a RT in the facility at that time. LPN-N stated LPN-N does not suction or do any trach cares for the residents on the vent unit, so LPN-N will call the nursing supervisor or get another staff member to do those tasks if they were needed. Surveyor asked LPN-N what LPN-N would do if there was an emergency with a resident that had a Trach. LPN-N stated LPN-N would call the supervisor, call the doctor/nurse practitioner (NP), or send the resident out to the hospital. On 2/3/2025, at 2:45 PM, Surveyor was called into R1's bedroom by R1's family member-J. Family member-J stated that R1 went to the hospital on 1/31/2025 and came back to the facility on 2/1/2025 early in the morning. When R1 and Family member-J arrived back at the facility around 5:00 AM on 2/1/2025 there was no RT in the building and the nurse on the unit did not know how to hook R1's trach mask up to the oxygen and asked family member-J to do it. Surveyor reviewed R1's progress notes and noted that there was no progress notes documented of R1 returning to the facility on 2/1/2025. Surveyor reviewed the schedule for 1/31/2025 night shift (10:00 PM- 6:30 AM 2/1/2025). Surveyor notes that there was not a RT assigned during the night shift and 1 registered nurse (RN) and 1 LPN nurse, both from an agency, were assigned to work the ventilator unit. On 2/3/2025, at 3:15 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R1's family member was suctioning R1 and hooked R1's trach up to oxygen because staff were not available that had competencies in completing those tasks/cares. DON-B stated it would get looked into. VENT UNIT NURSING COMPETENCY/ STAFFING CONCERNS: * The facility has a total of 59 beds available for residents requiring a ventilator. Currently the facility has 9 ventilator dependent and 7 non-ventilator dependent residents with tracheostomies with schedules of receiving oxygen via a trach mask requiring respiratory cares/ services. The Facility advertises on the facility website at https://www.vmpcares.com/healthcare/ventilator-care/ and through brochures that it has 24/7 respiratory therapists and ventilator certified nurses. On 1/30/2025, at 1:13 PM, Surveyor interviewed Scheduler-P who stated depending on facility census scheduler-P tries to schedule 2 respiratory therapists (RT's) on the ventilator unit for day (6:00 AM- 2:30 PM) and Evening (2:00 PM- 10:30 PM) shift; for night shift (10:00 PM- 6:30AM) 1 RT is to be scheduled. Surveyor asked what happens to the schedule if a RT is not available. Scheduler-P replied that requests to work go out to other facility RT's or ask for RTs to stay on shift for incentive. Scheduler-P stated that if an RT is not available then an agency RT is called in. Surveyor asked how it is determined when an RT is not available to work that nursing staff have the competencies to care for residents on the ventilator unit. Scheduler-P stated that all nursing is able to perform suctioning for residents. Surveyor asked about nursing competencies for the ventilator and tracheostomy cares. Scheduler-P stated that Director of Nursing (DON)-B has a list of nurses that have training with the ventilator and DON-B will communicate with Scheduler-P who to schedule if RT is not available. Scheduler-P stated that DON-B has that list. On 2/3/2025, at 3:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B who stated that the facility has experienced some changes recently with staffing RT's. DON-B stated RT staff have been leaving for other opportunities and administration noted that they had to do something. DON-B stated that on 1/9/2025 several nursing staff attended a ventilator certification course. DON-B stated that if an RT is not scheduled then they make sure to have one of the nursing staff that attended the course on the unit. DON-B stated that RT's used to make up their own schedules and primarily report to the pulmonologist but with the RT's leaving, the scheduling and reporting has changed to Scheduler-P and RT's now report to DON-B. NHA-A stated that there has been discussion on transferring all the residents with ventilators to the same unit and all the residents with tracheostomies will be on another unit. NHA-A stated that way they could have all the ventilators together and plan on having 1 RT, 1 nurse and 2 CNAs scheduled to that unit. NHA-A also stated that there is a plan to get all nurses to the ventilator certification course. On 1/30/2025, at 1:37 PM, Surveyor interviewed licensed practical nurse (LPN)-O who stated LPN-O received training on how to suction, perform trach cares, and trach ties when hired. LPN-O stated there was no ventilator training on hire and that LPN-O was not authorized to touch the ventilator or change settings. Surveyor asked LPN-O if a ventilator alarm went off and an RT was not available what would nursing do. LPN-O stated that if an alarm on the ventilator went off it could mean that the resident was in distress, so LPN-O would assess the situation and call the supervisor, on call doctor/ nurse practitioner (NP), or pulmonary on call. Surveyor asked what would happen in event of emergency and no one was available right away when called. LPN-O stated 911 would be called and send the resident out for further evaluation. On 2/3/2025, at 8:04 AM, Surveyor interviewed Anonymous staff-D who stated education was provided on how to suction, give treatments, and trach cares. Anonymous staff-D stated that if there was no RT on the unit and there was a concern that nursing would call the pulmonologist, and if there was concern or a resident was noted to be in distress, then nursing would send out to get further evaluation. Anonymous staff- D stated that nursing can touch the vent to a point, but does not touch settings or change anything, usually it is just to silence an alarm that may be going off. On 2/3/2025, at 10:45 AM, Surveyor interviewed RT-Q who stated RTs provide suctioning, trach cares, and oral cares to residents on the ventilator unit. RT-Q stated that not all of the residents have the pulmonary oversight like all the ventilator dependent residents do and technically nursing staff can do the suctioning and trach cares, but RT will do the cares if nursing staff ask them to because not all the nursing staff is sure on how to do suction or trach cares or has not done it for a long time. On 2/3/2025, at 11:02 AM, Surveyor interviewed RN supervisor-M. Surveyor asked RN-Supervisor-M how it is assured that the nurses scheduled on the vent unit have the competencies to care for the residents if RT is not in the building. RN supervisor-M stated he would need to get back to surveyor with that information since RN supervisor-M does not make up the schedule. Surveyor asked what the expectation of nursing staff is if a resident on a ventilator needed assistance, and no RT was available. RN supervisor-M stated that the doctor/NP, and pulmonary NP are on call 24/7 to get direction. RN supervisor-M stated that currently the facility is working on getting the nursing staff ventilator certified, but only a handful has been through the certification so far. On 2/4/2025, at 8:37 AM, Surveyor interviewed anonymous staff-C who stated that the RN supervisor is not directly assigned a unit but oversees the whole building. Anonymous staff-C stated that the RN supervisor is not always available for supervision of staff because they get pulled everywhere, whether it involves taking on a unit due to a call in, working with an admission, working on a discharge, or other tasks. The RN manager does not always have time to directly supervise someone. Surveyor asked what kind of cares nursing provides to the residents that are ventilator and non-ventilator dependent on the vent unit. Anonymous staff-C stated that the RT does most of the trach suctioning, trach cares, and vents. Anonymous staff-C stated they would be hesitant to hook up a resident to oxygen if they had a trach mask because they have never done it before and anonymous staff-C stated they do not touch or do anything with the ventilators and has never had any training on what to do. Surveyor asked anonymous staff-C what nursing staff would do in the event of an emergency or someone on a ventilator needed assistance. Anonymous staff- C stated that they would call the on-call doctor or send the resident out but would not be comfortable doing anything with the ventilators. Surveyor requested to look at what competencies nursing (LPN and RN) are expected to be able to perform at the facility. The following competencies were documented that pertain to the ventilator/trach unit: - Oral Hygiene - Oxygen - Trach care/ inline suctioning. Surveyor notes that there are no ventilator competencies. On 2/4/2024, at 3:23 PM, Surveyor interviewed NHA-A and DON-B. Surveyor asked how it is determined that the ventilator unit has staff that are competent and how do they ensure agency staff have the competencies to a care for the vulnerable residents that require ventilator/trach cares. DON-B stated that when an RT is not scheduled, they always make sure a nurse that went to the vent certification course is scheduled to the unit. Surveyor asked how are the LPN's that were certified supervised and delegated on the unit with such vulnerable residents. DON-B stated that there is a nursing supervisor on the schedule, 24/7 on call doctor/NP, and pulmonary doctor/NP are always available by phone 24/7. DON-B stated that DON-B is always available by phone as well. Surveyor asked what if there was a situation that required emergent care for the resident, and no one was available. DON-B stated that staff would call 911 and send the resident out to be further evaluated. Surveyor requested to review the education provided in the ventilator certification class and what staff attended the class and the check off competencies for trach care/ in line suctioning provided to nursing staff upon hire. DON-B stated that there is not a check off competency and the DON-B will go over it with staff. Surveyor requested to see what DON-B goes over with nursing staff. DON-B stated she will write something up. On 2/5/2025, at 9:18 AM, Surveyor was provided the Ventilator Certification course material and DON-B stated that the facility staff that attended the course on 1/9/2025 included: DON-B, Staff development Coordinator, and 5 LPN's. DON-B stated the next class offered will be in March 2025. Surveyor asked if any of the RN supervisors were educated on the ventilator. DON-B stated that no RN supervisors attended the course, but RT gave some education to nursing staff. Surveyor requested to see what the RT went over with staff, and who RT went over it with. Please note, Surveyor has not received a list of staff or education RT went over with facility staff on the ventilator unit or what DON-B goes over with staff regarding suctioning, and trach cares at time of write up. Surveyor reviewed the course material for the ventilator certification course. The Adult Ventilator Care Certification course was provided through [Hospital] and the instructors were Respiratory care practitioners employed at [Hospital]. The class was eight hours and included handouts, lecture, return demonstrations and a 50 question exam. The class objectives included: 1. Verbalize the components of routine pulmonary assessment including: a. Ventilatory pattern. b. Breath sounds. c. Sputum characteristics. d. Oxygenation. 2. Ability to discuss the components of oxygenation systems and auxiliary oxygen delivery devices. 3. Demonstrate tracheostomy tube change, site care, and suctioning. 4. Ability to recognize and react to tracheostomy emergency situations. 5. Ability to adjust ventilator settings according to physician orders. 6. Ability to troubleshoot ventilator settings and alarms. Surveyor notes that 2 staff members that attended the ventilator certification course (LPN-O and Anonymous staff-D) stated that the nursing staff do not touch the ventilator and just verify settings and would call the on-call supervisor, doctor/ NP, pulmonary doctor, and call 911 in event of an emergency. That does not match up with what was taught in the ventilator certification course on 1/9/2025 for staff to complete. During interviews, there were staff, (despite possibly attending the 1/9/25 training) that still do not feel comfortable providing respiratory cares. Surveyor reviewed the staff schedules for January 2025, the following dates/ shifts had the following staff scheduled without a RT scheduled: (note shift hours - Day shift: 6:00 AM - 2:30PM, Evening shift: 2:00 PM- 10:30 PM, Night shift 10:00 PM - 6:30 AM). 1/5/2025: Day shift- no RT scheduled; 2 LPNs scheduled both vent certified Evening shift- RT scheduled for 6:30 PM - 10:30 PM, 2 LPNs scheduled both vent certified Night shift- no RT scheduled, 1 agency LPN, 1 LPN vent certified. 1/6/2025: Evening shift- RT scheduled for 6:30 PM- 10:30 PM, 1 agency LPN, 1 LPN vent certified. 1/7/2025: Evening shift- no RT scheduled, 1 LPN scheduled 2:00PM - 6:30PM, 1 LPN scheduled 6:30PM- 10:30PM, 1 LPN vent certified. Night shift- no RT scheduled, 1 agency RN, 1 LPN vent certified. 1/8/2025: Evening shift- RT scheduled from 6:30PM- 10:30PM, 1 LPN schedule for 2:30PM - 6:30PM, 1 LPN, 1 LPN vent certified. 1/10/2025: Evening shift- RT scheduled until 7:00PM, 1 LPN, 1 agency LPN Night shift- no RT scheduled, 1 agency LPN, 1 LPN vent certified. 1/13/2025: Evening shift- No RT scheduled until 6:30PM, 2 LPN both vent certified 1/23/2025: Night shift- no RT scheduled, 1 LPN, 1 LPN vent certified 1/25/2025: Evening shift- No RT scheduled for 6:30 PM- 10:30PM, 1 LPN, 1 agency LPN 1/27/2025: Day shift- no RT scheduled, 1 agency LPN, 2 LPN vent certified 1/31/2025: Night shift- no RT scheduled, 1 agency RN, 1 agency LPN, no RN supervisor listed 2/1/2025: Night shift- no RT scheduled, 1 agency RN, 1 LPN vent certified, no RN supervisor listed Surveyor notes that according to chapter N6: Standards of Practice for Registered Nurses and Licensed Practical Nurses documents the following: N 6.04 Standards of practice for licensed practical nurses: (1) PERFORMANCE OF ACTS IN BASIC PATIENT SITUATIONS. In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider: (a) Accept only patient care assignments which the L.P.N. is competent to perform. (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient. (d) Consult with a provider in cases where an L.P.N. knows or should know a delegated act may harm a patient. (e) Perform the following other acts when applicable: 1. Assist with the collection of data. (2) PERFORMANCE OF ACTS IN COMPLEX PATIENT SITUATIONS. In the performance of acts in complex patient situations the L.P.N. shall do all of the following: (a) Meet standards under sub. (1) under the general supervision of an R.N., physician, podiatrist, dentist or optometrist. (b) Perform delegated acts beyond basic nursing care under the direct supervision of an R.N. or provider. An L.P.N. shall, upon request of the board, provide documentation of his or her nursing education, training or experience which prepares the L.P.N. to competently perform these assignments. On 2/5/2025, at 10:35 AM, Surveyors shared concerns with NHA-A and DON-B of the oversight of the vulnerable residents residing on the ventilator unit and staff having the ability to assess and treat residents when necessary. Surveyor shared concern with NHA-A and DON-B that the ventilator unit is specialized, and the RT's have their tasks and expertise, however RT's do not have the ability to delegate tasks to LPN's. Surveyor shared concerns that there is no direct oversight of an RN over the LPNs on the unit and that no RN's are vent certified that would oversee the LPN's. Surveyor asked how the tasks are delegated to the LPN if there is no RN supervision over the LPN staff that is scheduled especially if the RN did not have ventilator training. DON-B stated that there is always an RN supervisor on each shift and they can contact DON-B if not in the building, doctor/NP on call, or the pulmonary on call. Surveyor asked to clarify the RN supervisor role. DON-B stated that the RN Supervisor oversees the whole facility. On day and evening shift there is 1 RN supervisor for 2nd floor, 1 RN supervisor for 1st floor, and night shift there is 1 RN supervisor for the whole building. Surveyor asked if a RN supervisor is directly assigned only for the ventilator unit. DON-B stated there is not an RN supervisor assigned only to the ventilator unit. Surveyor shared concern that facility staff do not have all the competencies or direct oversight to care for residents that are ventilator and non-ventilator dependent residing on the ventilator unit when a RT is not in the building. Surveyor shared concerns with DON-B that not all RN supervisor staff have the competencies or feel confident about caring for residents on the ventilator unit. * R7 was admitted to the facility on [DATE] with diagnoses that include Acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood stream), dependence on respirator (ventilator, Pneumonitis due to inhalation of food and vomit, and Chronic obstructive pulmonary disease with exacerbation. R7's admission Minimum Data Set (MDS), dated [DATE], documents in part that R7 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R7 is cognitively intact. R7's MDS documents R7 has Respiratory treatments documented as: continuous oxygen therapy, suctioning as needed, tracheostomy care, invasive mechanical ventilator, and had 7 days of respiratory therapy for at least 15 minutes a day in the last 7 days. On 02/04/2025, at 10:18 AM, Surveyor interviewed R7, who indicated having no concerns. Surveyor reviewed R7's Facility provided document, titled Care Plan for R7. Surveyor noted, R7's care plan documents the following problem category, Pulmonary and documents R7 has alteration in respiratory status related to ventilator/trach use. Surveyor noted R7's care plan documents in part the following: . Change trach Q (every) 6 weeks & as needed (PRN) . Change tubing, masks, cannula & other equipment, per protocol . Check O2 (oxygen) settings Q4H (every 4 hours) & PRN . Elevate HOB (head of bed) to 30 degrees . Encourage pursed lip breathing . Humidifier, per MD order . Lab/Diagnostic work, per MD orders . Maintain patent airway . Maxorb 2 Ag+ Alginate wound Dressing with silver placed under Tracheostomy dressing TID (three times daily) for wound . Mechanical Vent Support, per MD orders . Monitor and report signs of hypoxia (cyanosis (blue skin), tachypnea (fast breathing), dyspnea (shortness of breath), confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse) . Monitor for S/Sx (signs/symptoms) of respiratory infection, shortness of breath . Monitor O2 sats, Q4H & PRN . Monitor oxygen saturation via pulse oximetry Q4 hours & PRN when on continuous oxygen therapy . Monitor Respiratory status, per MD orders or PRN . Oral Hygiene Q Shift & PRN . Provide calm environment free of stimuli to reduce /prevent anxiety . Resident will require a minimum of 7 hours each night of ventilator support chronic respiratory failure with hypercarbia. This will be continuous. Resident to be on ventilatory support each night and PRN during the day. Sip/puff call light . Stonghold device to be placed to prevent accidental ventilator disconnection. Suction PRN per MD orders . Trach care Q Day & PRN . Vent Settings: ACVC 450/18/5+ FiO2 to keep SpO2 at or above 92% . R7's respiratory care plan with a problem start date of 11/23/2024 includes an intervention with an approach Start Date of 12/19/2024. Respiratory therapy: ___ (specify plan -nebulizers, inhalers, etc.). Surveyor noted this was not individualized or complete for R7. On 02/04/2025, Surveyor reviewed R7's document titled, Physician Order dated 02/04/2025, and noted orders related to R7's medications, treatments, and enhanced barrier precautions and no orders related to ventilator care and/or management is documented. Surveyor reviewed the Facility provided document titled, Physician Order Report, dated 01/01/2025-01/31/2025, which documents R7 had documented Respiratory orders with a start date of 11/21/2024 and discontinued on 01/06/2025. Surveyor reviewed the Facility provided document titled, Physician Order Report, dated 12/18/2024-12/31/2024, which documents R7 had Respiratory orders documented with a start date of 11/21/2024 and discontinued on 01/06/2025. ORDER INTERVIEWS On 02/04/2025, at 10:25 AM, Surveyor asked Respiratory Therapist (RT)-R to show Surveyor what R7 has for Respiratory Therapy while in R7's room. RT-R indicated R7 is on a ventilator at night and switched to an aerosol, T-piece valve (a specialized adaptor used to safely deliver aerosolized medications to an individual who is on a ventilator) during the day, which R7 currently had on. RT-R indicated that nurses are responsible for ensuring R7 is on the ventilator at night and taken off the ventilator in the morning when RT is not at the Facility. Surveyor asked RT-R how nursing staff or agency staff would know of R7's ventilator orders, RT-R indicated that RT orders are separate from the nursing orders and was not sure if nursing staff could see the RT orders for R7. RT-R indicated that report would be given to the next shift from RT or RN supervisor. RT-R indicated that RT[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement interventions when 1 of 6 residents (R5) reviewed for elopement out of a total sample of 11 was assessed as being at risk for elopement. R5, who was described as extremely confused, was assessed as being high risk for elopement on 12/14/23 and should have had a departure alert bracelet in place at that time. R5 was last seen on 12/16/23 between 4:00 PM and 4:15 PM. Staff identified that R5 was not in the building at 4:30 PM. R5 crossed a heavily traveled 4 lane street and was found by a neighbor in their yard at 4:50 PM. The resident was outside unsupervised and without the staff's knowledge of the resident's whereabouts for approximately 20 minutes. R5 did not have a wanderguard placed until after the elopement. Failure to implement interventions for a person who was at high risk for elopement created a finding of immediate jeopardy, which began on 12/16/23. NHA A (Nursing Home Administrator) DON B (Director of Nursing) CCO (Chief Clinical Officer) and COO (Chief Operating Officer) were notified of the immediate jeopardy on 01/10/2024 at 4:23 PM. The immediate jeopardy was removed on 12/18/23; however, the noncompliance continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. Findings include: A review of a facility policy titled Wanderer Care, revised in January 2023, revealed, Policy: Measures will be taken to make every effort to be aware of the location of all residents and to provide safety for the identified wanderers . 2. Residents who are identified at risk to wander and high risk to wander must have an individualized plan of care completed by Social Services. 3. Wandering Risk Scale Directions and Use specified, d) Assess Resident in the following areas: i. Mental status, ii. Mobility, iii. Speech patterns, iv. History of wandering, v. Diagnosis of dementia e) Check the most appropriate box in each section. f) The score will total on the bottom right-hand side of the assessment. Scores of: 0-8 Low Risk to Wander; 9-10 At Risk to Wander; and 11 and above High Risk to Wander . b) If the resident is identified as At Risk to Wander. Initiate interdisciplinary care plan accordingly and follow plan of care. c) If the resident is identified as High Risk to Wander, the following actions must be taken: i. Initiate interdisciplinary care plan including specific approaches/interventions and time-measured goals. Review and update as needed, but no less than quarterly. ii. Inform patient representative of the identification methods being taken. iii. Apply [departure alert bracelet], provide name band, and label all clothing. iv. Once determined resident is a wanderer this information will be communicated to other departments via email. a. Resident's name and room number will be added to the wander list. b. Wander list will be updated by Social Services ongoing and reviewed weekly. c. Changes and updates as they occur will be forwarded to all departments by Social Services. v. The list of wanderers will be kept in a purple binder in all departments along with a picture and room number of each resident identified as a wanderer. R5 was admitted on [DATE] with diagnoses that included cerebral infarction (stroke), cerebrovascular disease, paroxysmal atrial fibrillation, and aphasia (a language disorder that affects a person's ability to communicate). R5's Wandering Risk Scale assessment, dated 12/12/23 completed by LPN Q (Licensed Practical Nurse) revealed as assessment score of 9. This indicates R5 is at risk to wander. R5's Wandering Risk Scale assessment, dated 12/14/23 recompleted by RN T (Registered Nurse)revealed a score of 11. This indicated R5 was at high risk to wander. R5's Care Plan revealed a Category initiated on 12/12/2023 that indicated R5 had impaired decision-making. Interventions directed staff to provide daily orientation to the facility routines and activity schedules, use environmental cues to stimulate memory and promote appropriate behavior, and provide a consistent physical environment and daily routine. The care plan did not address R5's elopement/wandering risk. Based on the facility's policy and procedure, staff should have developed and implemented a care plan and placed a departure alert bracelet on R5 among other interventions. There is no evidence this was completed. R5's Interdisciplinary Notes included the following entries: ~Documented by LPN Q and dated 12/16/2023 at 6:15 PM, R5 was noted to be missing from the unit at 4:30 PM. The note revealed the supervisor was notified, and staff searched all units' rooms, including the assisted living area. According to the note, staff also searched the outside facility perimeters. The note revealed that at 4:50 PM, the supervisor received a call from a staff member who lived across the street, who stated that the resident was found outside their house. Per the note, the resident was taken to the hospital for a medical evaluation. ~Documented by RN V and dated 12/16/2023 at 6:48 PM, RN V was notified at 4:35 PM that staff could not find R5. According to the note, the last known time the resident was seen was at 4:30 PM. The note revealed staff searched all the rooms on the unit, around the hallways, the front entrance area, the assisted living area, and the area outside the facility but could not locate the resident. Per the note, RN V immediately called DON B, who instructed the RN to call a code. The note revealed after RN V got off the phone with DON B, they received a phone call from someone who lived across the street from the facility, who stated that they found a resident who was extremely confused. The note revealed the caller reported they asked the person's name, but the person could not answer. According to the caller, it appeared that the resident had sustained a fall due to a skin tear on their hand. The note indicated they were able to confirm the person was, in fact, R5 after the caller described the individual's clothing. The police and ambulance were called to the scene. The note further indicated the resident would be evaluated at the emergency room (ER), and upon return to the facility, a departure alert bracelet would be placed. During an interview on 01/09/2024 at 2:29 PM, RN V stated they were notified by LPN Q at 4:35 PM that R5 was missing and was last seen between 4:00 PM and 4:15 PM. RN V indicated they called DON B and were told to call a missing persons code. RN V said that immediately after the call with DON B, a therapy employee who lived across the street from the facility called to see if the facility had a missing resident because an individual was found between the caller's garage and their neighbor's garage. RN V said the caller described what the person was wearing, and at that time, it was confirmed the person they found was R5. RN V said that the caller reported R5 appeared to have fallen because they had a skin tear on their hand, and the caller had already contacted emergency medical services (911) because they did not recognize the individual as a resident of the facility. RN V said on the day of the incident, R5 was wearing brown pants, a flannel shirt, socks, and shoes and indicated the resident could walk unassisted around their room. RN V stated R5 was not at risk for wandering according to their information in their electronic health record (EHR) and had not exhibited any exit-seeking behaviors prior to the event. RN V said they did not know R5's wander risk score but indicated if a resident was identified as a wander risk, this should be documented in their EHR and listed on the 24-hour board kept at the nurses' station on each unit (a method used to communicate information from shift to shift). RN V denied knowledge of a book with information about residents identified as at risk for wandering and stated the care plan should be updated for any resident identified as at risk for wandering. During an interview on 01/09/2024 at 3:15 PM, LPN Q said that during the medication pass on 12/16/23 at 4:30 PM, she noticed R5 was not in their room. LPN Q indicated that the resident was last seen at 4:15 PM. LPN Q said after she realized R5 was missing, she alerted staff and the RN supervisor, who called a missing person code. LPN Q stated they looked on the first, second, and basement floors and outside the facility but were unable to find the resident. LPN Q stated RN V then received a call from a therapy employee who lived across the street from the facility, who said she had found an individual and she was unsure if they were one of the facility's residents but had already contacted 911 and the resident was sent to the ER. LPN Q stated that R5 had a skin tear on their left hand and forearm before they went missing. LPN Q said the resident must have left the facility through the front door. LPN Q explained that based on the location of the resident's room, R5 would have turned left out of their room and then left at the lobby and out the front door. LPN Q said she felt the resident was able to leave out the front door because there was no receptionist at the time the resident left, and the door only alarmed if a resident wearing a departure alert bracelet approached the door. LPN Q said there was usually a receptionist until 8:00 PM each day. LPN Q stated she had conducted the resident's wandering risk scale on 12/12/2023 and determined the resident had a score of 1 or 2, which would indicate not at risk for wandering, but she was later told by the Quality and Clinical Support nurse she did it incorrectly and to correct it. LPN Q indicated that after she corrected the assessment, R5 scored a 9, which indicated the resident was at risk for wandering; however, she did not correct the assessment and identify the resident was at risk for wandering until after the resident eloped. LPN Q said once a resident was identified as at risk for wandering, the care plan was updated, and the 24-hour report board would list the resident as a wanderer. LPN Q said if these things had been done, it was possible R5's elopement could have been prevented. During an interview on 01/09/2024 at 3:30 PM, the Director of Admissions, who oversaw the receptionist, said the receptionist usually manned the front desk at the facility entrance from Monday through Friday from 8:00 AM to 8:00 PM and on Saturdays and Sundays from 9:00 AM to 5:00 PM. She said the doors automatically locked at 8:00 PM on Monday through Fridays and at 5:00 PM on the weekends but were only locked for entry from outside, not for exiting from the inside. The Director of Admissions indicated that on the day of R5's elopement, there was no receptionist on duty due to an emergency call-in, which left the front entrance unmanned. During an interview on 01/10/24 at 9:48 AM, RT W (Rehabilitation Technician), who found R5 at their house on 12/16/23, said that they lived less than a mile from the facility across a 4-lane busy street with a median in between the lanes. RT W indicated that crossing that street would be dangerous for someone with R5's mental status. RT W stated she found R5 in an alley between their garage and their neighbor's garage. RT W said at first, she did not recognize the individual they found as a resident of the facility, so she called 911. She said once the ambulance arrived, they asked if she knew who the individual was, and at that time, she noticed a bandage on the individual hand that looked to be a bandage typically used at the facility. RT W said the ambulance transported the individual to the ER, and she called the facility and spoke to an RN supervisor, who confirmed they had a missing resident. RT W recalled R5 was wearing a red plaid flannel shirt with a long-sleeved shirt under the flannel one, blue jeans, socks, and shoes. RT W stated they did not remember what the temperature was that day, but it was kind of misty outside. According to Weather Underground, the weather in [NAME] on 12/16/23 at 4:40 PM was 44 degrees Fahrenheit, winds out of the south/southeast at 16 miles per hour, and there was light rain. During an interview on 01/10/24 at 10:10 AM, the QCSN (Quality and Clinical Support Nurse) stated that the wander risk assessment done on admission for R5 was scored incorrectly with a score of 2 because the nurse initially checked the resident as being able to move without assistance in a wheelchair, was able to follow instructions, and could communicate. The QCSN stated R5 was ambulatory, could not follow instructions, and could not communicate. The QCSN said if the assessment had been accurate, R5 would have scored a 9 and a care plan addressing wandering would have been developed, and interventions would have been implemented. The QCSN stated the risk assessment conducted on 12/14/23 was inaccurate because it had both no history of wandering and history of wandering marked and stated the resident should have had a departure alert bracelet placed as an intervention with detailed, appropriate interventions regarding their wandering risk. During an interview on 1/13/2024 at 12:58 PM, NHA A stated they expected residents who were deemed as at risk for wandering/elopement were safeguarded by implementing increased observation, listing the resident on the 24-hour board, and staff on the unit conducting huddles to ensure all staff were aware of the potential for wandering and/or elopement. NHA A said if a resident was at risk for wandering, they were to place a departure alert bracelet on the resident, and/or staff were to provide one-to-one supervision as the very highest safeguard. NHA A said they had updated their policy and it now specified that any resident that scored a nine or above for their wander risk score would have a departure alert bracelet implemented. The immediate jeopardy that began on 12/16/23 was removed om 12/18/23 when the facility implemented the following actions: 1. R5 was sent to the ER and did not return 2. Wander Risk assessments were completed and behavior care plans were reviewed and updated as needed. 2. Changes were communicated by supervisors or at bottom of 24 hour board 3. Review and monitoring of residents upon admission and with change of environment or medical status for risk of change in behavior 4. Re-education of nursing staff on the following: - Difficult Behaviors, Management - Elopement precautions, Management - Monitoring of change of conditions and subtle behaviors that may precipitate behavior changes - Documentation and Care Planning 5. Mock Missing Resident Search to be scheduled next quarter 6. Audits will be completed weekly for 8 weeks to ensure the following: - Residents with change of conditions are on 24-hour board and discussed at clinical meeting. - Bi-monthly Behavior Meeting 7. Results will be analyzed and reported to QAPI (quality assurance and performance improvement) monthly for further recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that 1 (R32) of 12 residents at high risk for elopement were not provided with safety measures, interventions and assessments to prevent elopement; 1 (R329) of 5 residents with falls followed Care Plan to prevent falls; 12 (R80 and R11) of 24 residents reviewed for environment were provided with a safe environment; and 1 (R40) of 1 resident who smoked was assessed to be a safe smoker. 1. R32 was assessed as a high elopement risk and demonstrated active wandering behavior and desire to leave facility starting on 10/2/22. Facility placed a Wanderguard on and initiated a Care Plan. Facility stated they initiated 1:1 monitoring but that was not put in place until 11/6/22. R32 continued to have wandering behaviors. On 10/20/22 R32 was moved to the 1st floor more secure unit but R32 continued to wander and eloped on 10/24/22 and was found in the Aurora Clinic in basement of complex. R32 was not assessed and the Care Plan was not updated with any added interventions. R32 had ongoing documentation of trying to leave. On 11/5/22, R32 exits the facility after she pulled the fire alarm and exited the posterior exit door on the unit. R32 had fallen and sustained facial fracture. R32 continued to pull fire alarm, attempt to leave unit and wander. Care Plan was updated with interventions that were already in place or not effective. Facility indicated 1:1 initiated 11/6 however is not consistently implement particularly on third shift where 1:1 monitoring was left to discretion of nursing. 2. R329's care plan stated resident was to be a 2 person assist with cares. Resident was being assisted with cares in bed by 1 CNA and suffered a fall out of bed and sustained a hematoma, bruising and skin tear. A root cause analysis was not done and not following the Care Plan was not identified as the cause of the fall. 3. R80 utilizes an air mattress which should be set according to R80's weight. The facility did not ensure R80's air mattress was set correctly which posed a safety/hazard risk for R80. 4. R11 utilizes an air mattress which should be set according to R11's weight. The facility did not ensure R11's air mattress was set correctly which posed a safety/hazard risk for R11. 5. R40 was a smoker and was not assessed for safe smoking status or if they were able to independently smoke or needed supervision. The facility's failure to properly monitor, assess and intervene on previous elopements of R32 created a finding of Immediate Jeopardy (IJ) that began on 10/3/22. Surveyor notified Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Director of Clinical Operations (DCO)-C of the IJ on 12/21/22 at 12:51 PM. The IJ was removed on 12/21/22, however; the deficient practice continues at a scope/severity level of E (No Actual Harm/Pattern). Findings include: Surveyor reviewed facility's Wanderer Care policy with a reviewed date of 7/18. Documented was: POLICY: Measures will be taken to make every effort to be aware of the location of all residents and to provide safety for the identified wanderers. GENERAL INFORMATION: 1. Wandering most likely results from a combination of factors including organic brain changes, but also can be predisposed by psychosocial and cultural patterned or determinants based on occupation, interests, living arrangements, marital status and social habits. 2. Factors in the facility that may promote wandering are confusion from noise, people gathering or disorganization. 3. Wandering may increase at certain times of the day. Late afternoon or early evening is prime time for increased wandering. 4. Wandering may also happen when there is an unmet need i.e. hungry, tired, pain, thirsty, needing to use the bathroom. PROCEDURE: 1. As part of the admission assessments, all newly admitted residents' clinical status will be assessed by nursing to determine their risk for wandering using the Wandering Risk Scale Form (see attached). 1.1 Reassessment as follows: A. After 72 hours by Social Services B. Whenever there is change in condition and/or Quarterly review, to be completed by Social Services . Scores of: 0-8 Low Risk to Wander 9-10 At Risk to Wander 11-above High Risk to Wander 5. Action required bases on Wandering Risk Scale Score: 4.1 If the resident is identified as Low Risk to Wander, no intervention to prevent wandering is needed. 4.2 If the resident is identified as At Risk to Wander. Initiate interdisciplinary care plan accordingly and follow plan of care. 4.3. If the resident is identified as High Risk to Wander, the following actions must be taken: A. Initiate interdisciplinary care plan. A.1 Including specific approaches/interventions and time-measured goals. Review and update as needed but no less than quarterly. B. Inform patient representative of the identification methods being taken. C. Apply wander guard bracelet, provide name band, and label all clothing. D. Once determined resident is a wanderer, this information will be communicated to other departments via email. D.1 Resident's name and room number will be added to the wander list. D.2 This list will be updated by Social Services ongoing and reviewed weekly. D.3 Changes and updates as they occur will be forwarded to all departments by Social Services. E. The list of wanderers will be kept in a purple binder in all departments along with a picture and room number of each resident identified as a wanderer. E.1 The binders will be updated by each department as the changes and updates are communicated by Social Services. 6. Encourage participation in unit activities, both physical and social. 7. Initiation of Code Purple when applicable. Refer to EMERGENCY CODE-PROCEDURE Policy. Surveyor reviewed facility's FALLS - PREVENTION/ FALLING STAR policy with a revision date of 7/20. Documented was: POLICY: MP maintains the responsibility to assess each resident as to the risks of injury from falling, implement an individualized interdisciplinary care plan that addresses those risks in a proactive manner and evaluates the effectiveness on a routine basis. In addition to addressing the issue of individual fall incidents, VMP takes seriously its responsibility to be at the forefront in fall prevention efforts by tracking and trending of fall incidents to identify extrinsic as well as intrinsic causes and implementing fall prevention interventions. Fall Prevention (Falling Star Program) Incidence of falls and falls resulting in injury increase with age, use of certain Medications or if balance or gait problems exist. The goal of this protocol is to include the Interdisciplinary Team (Resident, Resident representative, Nursing, Social Services, PT/OT, Physician, Activities, Dietary, Pharmacy and Speech Therapy) in fall prevention by: 1. Identifying specific fall risk factors for each resident; 2. Increasing the team's awareness of these residents and their risk factors; 3. Discussing and documenting strategies initialized for each resident and eliciting the team's cooperation in attempting to minimize the risk factors identified, without compromising mobility and functional independence, whenever possible; 4. Reporting and recording falls and near falls so that new risk factors or residents that are high risk can be identified; 5. Ultimately, decreasing risks and preventing falls to the degree possible. 6. Trending and tracking of extrinsic as well as intrinsic causes of fall occurrences. 7. Falling stars criteria: 2 falls in 30 days; 3 falls in 90 days. 8. A falling star list will be maintained and updated for all units/departments, to identify residents at high risk for falls and heighten awareness of all staff. 9. A resident will be removed from the Falling Star program after three consecutive months of no falls, unless the IDT decides that a high risk safety concern remains. GENERAL INFORMATION: Fall Definition: A fall is a sudden unexplained change in position to a next lower surface, (i.e. chair to floor, bed to mat, etc.). A fall is also an episode where a resident loses his or her balance and would have fallen were it not for staff intervention. In other words, an intercepted fall is still a fall. PROCEDURES: I. Proactive: To prevent the first fall: 1. All residents are assumed to have some risk of falls and staff is aware of the potential for a fall of any resident at any time and takes precautions when transferring/ambulating all residents. 1.1 At admission a discussion is conducted with each resident. It includes call light usage and the procedure for obtaining assistance for transfer or ambulation. 2. All residents will have a Fall Risk Assessment completed upon admission, quarterly with a significant change per Resident Assessment Instrument (RAI) process and immediately following the fall incident. 3. Care Plan will be updated to reflect changes in- interventions that are necessary to maintain resident's safety. Residents that have a Score of 18 or higher on Fall Risk Assessment, or residents that experience a fall incident, will have one or more interventions implemented immediately following each fall incident/ admission. The decision as to which if any measure to use will be based on history/observation and/or nurse's judgement. Refer to the following list of potential interventions that may be implemented. Il. Assessing Risk Potential 1. The Fall Risk Assessment will be completed by nursing personnel upon admission, annually quarterly, with a significant change and with any fall. Included in the assessment are risk factors and a health history as they relate to falls. Assessment care planning and monitoring of residents related to fall issues will be initiated by the primary nursing staff along with input from Team Meetings, observation and/or staff report. 3. A review of resident's medications should be completed for possible effects/side effects relating to falls, with a focus on medications which could predispose to falls (i.e. diuretics, cardiovascular, antihypertensive, antipsychotic agents, hypnotics, antidepressants, sedatives, analgesics, and laxatives. Consider not only the class of drugs, but the number of drugs (polypharmacy), and the potential for addictive effects when the accumulate in the body that also increases risk. Nursing Policy & Procedure Falls - Prevention and Intervention 4. Assess adaptive equipment walker, w/c, hearing aids, glasses etc. 5. Assess for vision/hearing problems. 6. Assess and encourage the use of proper footwear. 7. Assess for orthostatic hypotension, if able. 8. Assess the environment in which the fall occurred. IV. Interventions to Prevent Falls (The following is not meant to be all inclusive) Interdisciplinary team members will discuss and initiate appropriate interventions for identified risk factors. Interventions will be designed in relation to diagnosis and need: 1. Impaired Mobility - assess potential for PT/OT or Restorative Nursing Program - consider need for assistance with ambulation and/or transfer - consider need for assistive devices (cane, walker, etc.) - encourage use of call light to request assistance and ask resident to wait until assistance arrives. - contact housekeeping if room clutter/floor condition is a concern and consider reorganizing room. - evaluate adequate lighting, need for night light. - evaluate supportive equipment W/C and/or walker fit, bed height, etc. - consider bedside commode. 2. General Debility - encourage mid day nap or rest period, if appropriate. - avoid complete bed rest, unless absolutely necessary and remove bed rest orders as soon as possible. - consider increasing the frequency of observation or keeping in public area when up. - assess need for attention to decrease pain, anxiety or agitation. - assess adequacy of nutrition and hydration. - assist with activity at regular intervals to increase stamina and balance. - encourage participation in exercise program, if possible. - assess need for assistance with ADL's, ambulation or toileting. 3. Incontinence - assess need for regular toileting schedule. - assess need for incontinence under padding/under garments. - consider a urological consultation with a specialist. 4. Visual/Auditory Impairment - check hearing aid for proper function and battery, if applicable. - complete a preliminary vision screening and/or refer to Optometrist if need for glasses is assessed. Nursing Policy & Procedure Falls - Prevention and Intervention 5. Improper Shoe Fit - Assess footwear including shoes and slippers. - request purchase of proper shoes/slippers, if necessary. 6. Restraints/Alternatives - consider motion detectors - Monitor all interventions to be sure the least restrictive intervention is being used. 7. Consultation - consult with MD, Pharmacist or Psychiatrist, as needed, for repeat falls - Resident/resident representative/staff education will be done by Social Service and/or Nursing to increase their awareness and cooperation with proposed interventions, as needed. V. Documentation 1. All fall interventions will be care planned and recorded on Care Plan and on CNA Care Card as appropriate. 2. All risks and benefits will be provided to the resident/resident representative/POA-HC/Guardian. 3. Interdisciplinary review of fall incident will be completed in EHR. VI. Post Fall Incident: After caring for the immediate physical/psychological needs of the resident the Nurse will: 1. Complete Incident Report, Fall Evaluation, Fall Risk, ID Note and any other necessary documentation in EMR. 2. Complete Notes of interview 3. Send appropriate paperwork to DON/Designee. 4. Determine and implement an immediate intervention to prevent another fall with guidance from Fall program Coordinator or designee. 5. Update POA-HC/Resident/ Resident Representative/Guardian after each fall. 6. Call Fall Program Coordinator with fall details. VII. Nurse Manager to review fall incident within 24 hours of fall (Next business day). The following shall occur: 1. Resident incident will be reviewed with Interdisciplinary Team (IDT)/ Fall Program Coordinator. 2. Fall intervention recommendations from the meeting will be added to the Resident Care Plan and CNA Care Card (as appropriate, this is the responsibility of the Nurse Manager or designee.) 3. The Care Plan will be reviewed and modified as needed. * Note: Upon reviewing the resident fall at the Falls Review meeting, the Interdisciplinary Team will complete the Investigation Section of the Incident Tracking form in AOD. All interventions and modifications to the Resident Care Plan and CNA Care Card will be recorded in the EHR. 1. R32 was admitted to the facility on [DATE] with diagnoses that included stenosis of other cardiac prosthetic device, syncope, heart valve replacement, diastolic heart failure, aortic valve stenosis, unspecified dementia without behaviors/psychosis/mood/anxiety, anxiety and urinary tract infection (UTI). R32's room was on the second floor in an unlocked, unsecured unit. Surveyor reviewed Wandering Risk Scale assessment for R32 with assessment dates of 9/21/22 and 9/26/22 with assessments of Low Risk of Wandering. Surveyor reviewed R32's Progress Notes and documented on 10/2/22 8:20 PM was Resident was yelling out of window. Help, Help. I have been kidnaped. Gave resident a cup of tea, tried to calm resident down. Documented on 10/2/22 at 9:17 PM was Wandergaurd put on right ankle. Resident stated she was going to leave. Has been walking out in the hall, walking towards door. Documented on 10/2/22 at 10:32 PM was Exit seeking: [patient (Pt)] attempt to leave unit via elevators [times (X)] 2, made to lower floor on 2nd attempt. Staff safely [returned] to proper unit [with] incident. When asked states, I am leaving just waiting for my ride. Staff re/oriented to [room]/unit. Update to On-call provider/family. Wandergaurd apply to [right (R)] ankle, 24hr [continuous] monitoring initiated. Surveyor reviewed Wandering Risk Scale assessment for R32 with assessment dates of 10/2/22. Documented was: Mental Status - cannot follow instructions Mobility - can move [without (w/o)] assistance in [wheelchair (w/c)] Hx of Wandering - with [history (hx)] of wandering (hx of res/family or noted on hospital paperwork) [Diagnoses (Dx)] - with dx dementia . SCORE: 11. Score of 11 indicated a High Risk for Wandering. Surveyor reviewed R32's Comprehensive Care Plan with an initiation date of 10/3/22. Documented was: [R32] will maintain safety though review date. Wanderguard in place with monitoring per facility protocol. Intervene as necessary to ensure safety of resident. Stay with resident if they leave unit in a wandering episode. Watch for these signs: pacing, packing belongings, talking about leaving, putting on a coat. Redirect resident from stimulus with activity of their choice. When resident is exit seeking, offer toileting, food and drink. Utilize [one to one supervision (1:1)] [as needed (PRN)]. Do not argue with [R32] about the correctness of their beliefs. Surveyor reviewed schedules for Certified Nursing Assistant (CNA) staff who would be assigned 1:1 monitoring for R32. There was no 1:1 aide scheduled from 10/3/22 through 11/5/22. Surveyor reviewed R32's Progress Notes and documented on 10/6/22 at 1:38 AM was Resident attempted to wander from unit twice, she stated I heard a loud crash, I have to find out where its coming from. Resident was redirected and brought back to unit, writer reorientated resident on date, time, and place. Although confused resident was pleasant and nonconfrontational, 1:1 sitter initiated until resident fell back to sleep, and q15 minute checks thereafter. There was no 1:1 sitter initiated, no added interventions put in place and no assessment of elopement risk. On 10/6/22 a psych referral was completed for R32 and on 10/10/22 R32 was seen by psych services and medication changes were made. On 10/7/22 R32 was moved from room [ROOM NUMBER] to 2410 on the second floor to be closer to the nurses' station for monitoring although R32 was supposed to be on 1:1 monitoring. Surveyor reviewed R32's Progress Notes and documented by Music Therapy on 10/12/22 was .distressed phone calls from [R32], saying she wanted to call police as she was being held here against her will . [R32] accepted visit, presenting as grumpy and anxious to leave, with bags packed next to her on the bed, looking through book to find numbers for a ride . took opportunity to remove [R32] to go for a walk, quickly moving bagged belongings to the closet . Surveyor reviewed R32's Progress Notes and documented on 10/15/22 at 6:11 AM was Resident did wander once on shift, she stated I am going to the bathroom on the second floor. Resident was assisted to her room where she was toileted and went back to bed. Documented on 10/17/22 at 6:05 AM was Resident out wandering in hall. Reports I heard my son knocking on my door. Reassured resident that she is safe and her son is not here. Easily redirected to room. On 10/7/22 R32 was moved from room [ROOM NUMBER] to 1315A on the first floor. Documented in Progress Notes on 10/20/22 at 9:57 AM was [R32] will - transfer from 2404 to 1315A on this date. Both [R32] and her [daughter in-law] are in agreement with transfer. [Daughter-in-law] agrees that [R32] needs a more secure unit due to her wandering. [R32] will also benefit from the structured activities on the unit and keep her busy. Surveyor noted that first floor unit has no locked doors and was not secure as the units' doors were closed with signs to Keep Doors Closed but not locked. Wanderguard alarms on the posterior exit door at the end of the hallway, the elevators and in the front lobby. The posterior exit door was also alarmed as a fire door. Surveyor reviewed MD orders for R32. Documented with a start date of 10/23/22 was Record number of episodes of wandering behaviors such as pacing, packing belongings, talking about leaving, putting on a coat. If 1 or more, document incident and interventions in EMR. Notify supervisor as indicated. Surveyor reviewed R32's Progress Notes and documented on 10/24/22 at 11:42 PM was [7:15 PM] Staff respond to unit posterior door alarm, noted pt left out of unit. Elopement protocol activated, Pt found in Aurora facility basement w/ clinic staff. 3 women's hand bags seen to R shoulder w/ pt belongings, when asked, states I am leaving. Staff escorted safely back to proper unit s/ incident. Post elopement assessments completed, no findings noted. Pt calm, [vital signs stable (VSS)], in no acute distress, Wandergaurd in place R ankle/activated. Update to provider & family, voice msg left for pt contact to call facility for pt update. 24hr f/u monitoring initiated. There was no 1:1 aide scheduled for 24 hour monitoring. There was no update to the care plan or added interventions after elopement and no post elopement assessments completed. On 10/28/22 R32 was moved from room [ROOM NUMBER]A to 1312B on the first floor after an altercation with her roommate. Surveyor reviewed R32's Progress Notes and documented on 10/28/22 at 12:25 PM was Resident reports to staff and MD that her son is being chased and in danger. MD contacted daughter, who states that resident son is not in danger and is safe. Staff to closely monitor resident for behavior and wandering behaviors. Documented on 10/30/22 at 10:31 PM was At [10:30 PM] yelling -screaming about son trying to leave Unit. Documented on 10/31/22 at 6:18 AM was Around [10:30 PM] the resident was staying by exit doors on [R32's unit (SV1)] stating she wants to go home next door. She was difficult to redirect. It took several staff members to redirect. She asked for phone to call her [son], and it was provided. Also tried go to the door to leave, and again was redirected X3 . Documented on 10/31/22 at 10:56 AM was Resident found wandering in hallway X3, attempted to exit unit X1. Not easily redirected. Daughter-in-law in this unit, redirected resident, focused on crafts. Documented on 11/02/22 at 4:36 AM was Resident attempted to leave unit X2. Said that she will be killed if she does not leave. When attempting to redirect, resident became combative, pushing and hitting staff. Resident eventually settled and is currently sleeping. Will continue monitoring. Documented on 11/02/22 at 9:42 AM was Later in shift kept trying to leave unit Needed help, from all to keep on floor. Documented on 11/03/22 at 2:13 AM was [2:00 AM] While staff assisting in a room, resident exited the [posterior exit fire door]. She saw there was stairs going up and down, so did not attempt to go further. Staff heard door alarm go off and immediately got her back onto unit. She was walking around as staff assisted other residents and went towards [another unit] around [2:15 AM]. Will watch at nursing office for closer monitoring. Documented on 11/05/22 at 5:27 AM was Resident noted to be wandering X1, no behaviors this shift. R32 eloped from the facility at 4:16 PM on 11/5/22. Documented at 4:59 PM was 16:16 Fire Code called to SV1 unit, several responded to scene, no fire findings. Staff [instructed] to initiate Res head count, immediately found pt missing from unit. Code purple activated, all on different unit complete. Documented on 11/5/22 at 7:54 PM was To add to previous note, resident was noted to not be in her room or in common areas on unit around [4:15 PM]. Code purple was called for resident and a dozen staff from multiple departments responded to search for resident. Search was initiated on SV1 while we waited for responders and resident was not found in any bedroom, utility area, or bathroom on unit. Back stairwell was searched and resident was not found. Staff searched both floors of Maplewood and the basement including clinic hall. Within 10 minutes it was determined that she was not likely inside the building or in the parking lots so search was expanded to include sidewalks around campus. Resident was then located on Oklahoma about 40 feet west of driveway to Maplewood. She had with her a purse and two cloth bags containing picture frames and other belongings. She was wearing a blouse with a sweater over it, 3/4 length pants and shoes. She was being attended to by a good samaritan who noticed her in distress. She had fallen outside apparently hitting her head on the curb. Fire Dept responded to a call from the good samaritan. Resident noted to have facial bleeding and swelling including damage to her forehead, nose, left cheek as well as abrasions to both knuckles. Resident was upset but seemed to be comforted and calmed by the fire dept staff. First aid was provided by the fire dept on the scene and she was taken by ambulance to the ER. Family updated by Supervisor. Awaiting update as to what hospital resident is being evaluated at and possible readmit. Anticipating the need for 1:1 supervision until safety can be established if resident re-admits this weekend. On 11/6/22 at 1:35 AM R32 returned to the facility from the hospital. R32 had sustained a facial fracture. Documented at 11/6/22 at 1:42 AM was Around [11:00 PM] on 11/05/2022 received a call from ED nurse regarding the resident's returning to the facility with hairline facial [fracture (Fx)]. She was given analgesics, and will be returning to [facility] . She was given call light and put to bed with staff to monitor. Documented on 11/6/22 at 6:27 AM was Resident returned from hospital pleasant and cooperative . Slept for a few hours then was found wandering the halls X2, asking where her sons were. Resident was brought out to common area for close monitoring. There was no 1:1 monitoring put in place when R32 returned from the hospital. On 11/7/22 at 4:45 PM, R32 rang the fire alarm again. Documented at 5:03 PM was [4:45 PM] resident who had been in room rang the fire alarm Did not leave unit on 15min checks 1;1 tonight. There was no documentation stating whether R32 was on 1:1 or 15 minute checks. Surveyor reviewed R32's Comprehensive Care Plan with a revision date of 11/7/22. Added to the Wandering Care Plan was: Psych consult made. Referral to pastoral care. Q15 min checks. Encourage family involvement/visits. Surveyor noted that Psych had already consulted and had seen R32 on 10/10/22. Surveyor also noted that R32 was supposed to be on 1:1 monitoring and was unsure why 15 minute checks were added to the care plan. Surveyor reviewed R32's CNA Kardex to direct cares for CNA's. Documented with a start date of 11/6/22 was: Provide 1:1 visits PRN. Especially when wandering and anxious, provide validation and engage [R32] in the moment (i.e. constructive discussions about what you can do now to help, refer her to daily routine schedule binder, invite to activity, meet basic needs as able, remind her and engage her in independent leisure, talk about her likes and interests and fond memories of her youth). Documented under Progress Notes on 11/10/22 at 2:21 AM was Resident made multiple attempts to leave the unit. Took multiple staff to redirect as resident became combative, scratching and pinching staff. Once in bed resident began to punch the walls and snatch down blinds on window next to bed. 1:1 monitoring initiated and resident continued to yell out help, I'm being held hostage. This lasted for about 2 hours before resident eventually settled down. 1:1 monitoring was not in place on this shift. Documented under Progress Notes on 11/13/22 at 11:22 PM was The resident tried multiple times to leave the unit stating there is someone in the car is waiting for her. She was going to the exit door, and setting alarms out tried get through the doors going outside. It took several staff members to be able to redirect the resident. Also the resident was combative and hitting the staff. Documented on 11/14/22 at 7:48 AM was Resident awake and wandering hallway since beginning of shift, has two bags packed and attached to walker. Resident states she has to go home and take care of her house, asked this writer which door leads out . Documented on 11/14/22 at 8:57 PM was Resident pulled fire alarm near door trying to get out door. Documented on 11/16 at 3:32 AM was No 1:1 supervision available overnight . Documented on 11/23/22 at 2:12 PM was Attempted to elope off unit X1 . Documented on 11/26/22 at 11:14 AM was .3 attempts to elope this shift . Documented on 11/30/22 at 1:45 PM was [6:50 PM] Exit seeking: Pt disruptive, calling staff names, demand to leave unit. Re/directing unsuccessful, able to walk out of unit double doors out in hallway w/ staff stand by assist. Staff walked w/ pt to [another unit] before pulling fire alarm. Staff provided guidance until pt safely ret to proper unit. Assistance w/ phone call to family provided, offered snack/fluids, helpful. During survey on 12/19/22 at 10:12 AM, 1:04 PM and 3:52 PM, Surveyor observed R32 in room alone with no 1:1 supervision. On 12/20/22 at 8:14 AM, Surveyor observed R32's door closed and knocked. Surveyor entered room and noted R32 was sitting on bed alone, in robe and gown, gripper socks on, drinking coffee. R32 had a duffle bag in hand and a Wanderguard on ankle. Surveyor found the 1:1 aide (CNA-L) in the hallway who entered R32's room at 8:21 AM. On 12/20/22 at 8:23 AM and 11:15 AM Surveyor interviewed CNA-L. Surveyor asked how much of the shift she is the 1:1 for R32. CNA-L stated the whole time. NA-L stated R32 kicks her out which happens every 2-3 minutes. Surveyor asked if CNA-L had other residents that you care for? CNA-L stated she is my only assignment but I answer call lights sometimes to help out. Surveyor asked if she is the only 1:1 aide. CNA-L stated no, there is a 1:1 aide on all 3 shifts. Surveyor asked how long this 1:1 has been in place. CNA-L stated it had been about a month to a month and a half. Surveyor asked how she knows how to take care of R32. CNA-L showed Surveyor a piece of paper with a note that documented 1:1 supervision AT ALL TIMES. On 12/20/22 at 11:22 AM Surveyor interviewed Unit Manager (UM)-M Surveyor asked on what shifts R32 has a 1:1. UM-M stated R32 always had a 1:1 and Scheduler-O schedules them and the Nurses will cover if needed. Surveyor asked when the 1:1 was put in place, UM-M stated it started when she fell outside referring to the 11/5/22 incident. Surveyor asked what the 1:1 would do throughout a shift. UM-M stated just keeping an eye on her. UM-M stated she was not sure what specifically and she I would have to look in her chart. CNA care card binder - no [NAME] card. On 12/21/22 at 8:51 AM Surveyor interviewed Registered Nurse (RN)-N. Surveyor asked when R32 usually wanders or tries to leave the unit. RN-N stated really early in the morning, more on Night shift. RN-N stated she is usually fine on First shift and that is the only shift she works. Surveyor asked if she has had any training or In-services on elopement at the facility. RN-N stated no, she did in prior jobs at other facilities that had locked units. RN-N stated this is not a locked unit but has Wanderguard alarms on the side dining room, the front door and the elevators. On 12/21/22 at 9:15 AM Surveyor interviewed Scheduler-O. Surveyor asked when she schedules 1:1 aides for R32. Scheduler-O stated for the AM and PM shifts. Surveyor asked about Night shift. Scheduler-O stated she does not schedule Night shift 1:1. Scheduler-O stated the RN Supervisor assigns a 1:1 from the staff that is scheduled. Surveyor asked if there are eve