Every finding on record at Peninsula Health Center by Harborview

Based on observation, interview, and record review, the facility did not ensure the timeliness of reporting critical lab values for one (#67) out of eight residents sampled. Findings include: On 9/16/2024 at 11:10 a.m., an observation was made of Resident #67 in her room. Resident #67 was in bed, eyes closed with heavy breathing. Resident #67 did not wake up while interviewing her roommate. An unknown nursing staff member stated Resident #67 sleeps like that all the time. A review of Resident #67's medial record showed a critically low lab value dated 9/14/2024 for serum sodium of 127 millimoles per liter (mmol/L). A previous sodium level was from a lab drawn on 9/12/2024 with a sodium result of 132 mmol/L (normal 133-143 mmol/L). Photographic evidence obtained. On 9/17/2024 at 9:05 a.m., an interview was conducted with the Assistant Director of Nursing (ADON) regarding the low critical serum sodium level dated 9/14/2024. The ADON stated she would call the dialysis center to have them collect a specimen for a repeat lab for the resident's chemistry but stated the results might take a while. The ADON stated she would call the resident's physician to inform the physician of the results. On 9/17/2024 at 9:50 a.m., the ADON stated the physician was made aware of Resident #67's low serum sodium. The ADON stated she received orders from the physician for a STAT (Immediately) lab chemistry and a nephrology consult once the resident returned from dialysis today. On 09/19/24 at 10:13 a.m., an interview was conducted with Staff J, Licensed Practical Nurse (LPN /UM). Staff J stated she would take care of the labs ordered by physicians. Staff J stated the physicians were good about notifying her when labs were ordered. During the day, Staff J stated she would acknowledge orders from physicians but in the evening shift the nurse responsible for the resident would acknowledge the orders. Staff J stated the electronic chart would notify the nurse to confirm orders. Staff J stated the lab was connected to the facility's electronic medical record. The evening nurses would print the lab requisitions from the electronic chart to provide to the lab personnel to draw labs in the morning. Staff J stated results were available in the electronic medical records for all to see. Staff J stated the lab would call us for critical lab values and send us a fax. On 09/19/24 at 3:09 p.m., a telephone interview was conducted with Resident #67's physician. The resident's physician stated she received a call regarding the resident's low serum sodium two days ago but denied she received a call prior to the ADON's call. The physician stated she was aware of a low serum potassium of which the resident received an order for a potassium supplement. A review of the facility's policy and procedures titled Diagnostic Services revised 5/1/2024 shows an intent statement: it is the policy of the facility to provide diagnostic services in accordance with state and federal regulations. 1. The facility will provide or obtain laboratory services to meet the needs of its residents and will be responsible for the quality and timeliness of the services. 2. The facility will provide or obtain laboratory services only when ordered by the attending physician. 3. The facility will promptly notify the residents attending physician of laboratory results to assure that appropriate action may be taken if indicated for the resident's care.

Based on observation, interview, and record review, the facility failed to ensure enteral feedings were provided according to physician orders for one (#67) of two residents observed. Findings include: On 9/16/2024 at 11:10 a.m., an observation was made of Resident #67's enteral feeding pump of the total volume infused at 22,525 milliliters (ml). Photographic evidence obtained. On 9/17/2024 at 9:30 a.m., an observation was made of Resident #67 out of her room with the enteral feeding hanging, bottle half empty and pumped turned off. Staff H, Licensed Practical Nurse (LPN) assigned to Resident #67 stated resident was out to dialysis. Staff H stated the resident was scheduled early for dialysis and left the facility between 5:00 a.m. to 6:00 a.m. On 9/17/2024 at 11:37 a.m., an observation was made of Resident #67 returning from dialysis and wheeled into her room by a staff member. On 9/17/2024 at 12:35 p.m., an observation was made in Resident #67's room. The enteral tube feedings had not been connected to the resident for enteral nourishment. Photographic evidence obtained. On 9/17/2024 at 2:37 p.m., an observation was made of Resident #67's enteral feedings connected to the resident and infusing at 55 ml/hour and a total volume infused at 22 milliliters. On 9/17/2024 at 12:57 p.m., an interview was conducted with Registered Dietician (RD). The RD stated she was familiar with Resident #67 and the challenges she has had nutritionally. The RD stated at one point Resident #67 was eating, despite having a feeding tube and doing well. The RD stated since her last hospitalization , she had been fully dependent on tube feedings. The RD stated Resident #67 was originally on Glucerna but switched to Nepro on 8/17/2024. The RD stated she would follow the labs from dialysis and stated she had a good coordination and communication with the dietician from the dialysis center. The RD stated potassium had been an ongoing issue but she normally ran on the low side but recalled an incident when it was elevated which was unusual for her. The RD stated today she was made aware of a low sodium from a previous lab chemistry drawn on 9/14/2024. The RD stated she would change the enteral feedings back to Glucerna and reduce the amount of free water the resident was receiving. The RD was made aware of the findings from initial observation of Resident 67's total volume infused at 22, 252 ml and stated she would be changing the order for the tube feedings so it would not be so confusing for the staff. A record review of Resident #67's Admission Record showed an original admitted [DATE] with a readmitted [DATE]. Diagnoses includes but were not limited to end stage renal disease, type two diabetes mellitus with ketoacidosis without coma, dysphagia oropharyngeal phase and gastrostomy. A review of Resident #67's current physician orders showed a new order dated 9/17/2024 for enteral feed order: every shift for nutrition Glucerna 1.5 Cal at 80 ml/hour x 18 hours or until total volume 1440 ml infused in 24 hours. May turn off for care/services. Down at 8:00 a.m. Up at 2 p.m. Verify infusing every shift, clear pump when total volume has infused. A new physician order dated 9/17/2024 to flush gastrostomy tube with 60 ml of water every shift for hydration. On 9/18/2024 at 11:45 a.m., an interview was conducted with the Director of Nursing (DON). The DON provided a binder of the education for the nursing staff regarding competencies for providing resident care. Gastrostomy care was listed as a nursing competency where the nurse was checked off by demonstration. The DON was made aware of the initial observation for Resident 67's enteral feeding pump at 22, 252 total volumes infused. The DON stated education was needed. A review of the facility's policy and procedures titled, Appropriate Use of Feeding Tubes, revised 11/01/2022 shows the following policy statement: It is a policy of this facility to ensure that a resident maintains acceptable parameters of nutritional and hydration status. Feeding tubes will be used only as necessary to address malnutrition and dehydration, or when the resident's clinical condition deems this intervention medically necessary. . 5. c. Assessment of the resident's nutritional status, which may include usual food and fluid intake, pertinent laboratory values, appetite and usual weight and weight changes. Consideration of factors affecting appetite and intake, such as psychosocial factors or medications. 6. A resident who was fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal pharyngeal ulcers.

Based on observation, interview, and record review, the facility did not ensure services provided/arranged by an individual had the skills, experience, knowledge and licensure to perform tasks for one (#57) out of eight residents observed. Findings include: On 9/17/2024 at 8:15 a.m., an observation was made of an individual feeding Resident #57 in his high back wheelchair. An observation was made of the resident assisted by this individual to drink from a small plastic commercial bottle of apple juice without a straw. On 9/17/2024 at 10:14 a.m., an observation and interview were conducted in Resident#57's room with the individual sitting next to him. The individual sitting next to Resident #57 denied she was the resident's Certified Nursing Assistant (CNA) but a companion hired by the family. Resident #57's hired companion stated she would feed the resident in which the staff would provide the meal tray. The hired companion stated she would do incontinence care for the resident as well and stated the staff would bring her the supplies such as briefs and linen. The hired companion stated before she ended her shift, she would provide the resident with incontinence care by returning the resident to his bed. The hired companion stated the staff did not assist nor provide a lift to return the resident back to bed but she would lift the resident herself stating, he's light. The hired companion stated once the resident had been returned to his bed, she would provide incontinence care and reiterated the staff would bring briefs and linen. The hired companion denied CNA, feeding assistant or medical assistant licensure or status. On 9/17/2024 at 10:55 a.m., an observation and interview was conducted of Resident #57. Resident #57 was in bed covered in a blanket. The hired companion denied the staff returned the resident back to bed. The hired companion stated she got the resident back to bed. When asked if the hired companion lifted the resident back to his bed, she stated this time she was able to get the resident to stand stating, sometimes he can stand and take some steps with assistance. The hired companion stated the resident had a small bowel movement today but not enough to report to the staff. The hired companion stated she had at times talked to staff to inform them of events relevant during her stay with the resident. The hired companion stated she came every Tuesday, Friday and Sundays and had been doing this regularly for the past month. The hired companion stated she usually fed the resident breakfast once it was provided to her but would feed the resident lunch on Sundays because she started later every Sunday. On 9/17/2024 at 1:45 p.m., an interview was conducted with the hospice nurse assigned to Resident #57. The hospice nurse stated the resident was declining, and the family member had requested hospice to visit earlier than planned due to his decline. The hospice nurse stated an aide from hospice would come every Wednesday and Saturday to provide ADL care. On 9/17/2024 at 2:02 p.m., a request was made for the facility to provide an employee file for [hired companion.] On 9/17/2024 at 2:40 p.m., an interview was conducted with the Nursing Home Administrator (NHA), Director of Nursing (DON), the Assistant Director of Nursing (ADON), Regional Nursing Consultant, and Staff L, Licensed Practical Nurse (LPN)/ Supervisor for the east wing. The DON stated they were unable to locate an employee file for [hired companion] and the family had been contacted to verify the hiring of this companion. These individuals were not aware of the care provided by the hired companion related to feeding, transferring and providing incontinence care. Staff J, LPN/Supervisor for the north wing stated she knew of the companion but denied any observation of the hired companion transferring or providing incontinence care. Staff J stated she might see the hired companion feed the resident but nothing else. On 9/17/2024 at 2:55 p.m., an interview was conducted with Staff G, CNA and Staff I, CNA. Both stated they knew of the hired companion. Staff G, CNA stated prior to this current hired companion there was a man that would come be with Resident #57. Both stated the male hired companion would feed the resident as well. Staff G, CNA stated she transferred Resident #57 out of bed to his high-back wheelchair with two- person assist but could not state how the resident was returned to bed. A review of Resident #57's Admission Record showed an original admitted [DATE] with a readmitted [DATE]. Diagnoses include but were not limited to Parkinson's disease without dyskinesia, generalized anxiety disorder, unspecified dementia without behavioral, psychotic mood and anxiety disturbance, neurocognitive disorder with Lewy bodies, psychotic disorder with hallucinations due to known physiological condition, other seizures, dysphagia oropharyngeal phase, repeated falls, and cognitive communication deficit. A review of Resident #57's physician orders show an order dated 3/26/2024 for regular diet pureed texture, nectar consistency, fortified foods to all meals, NO STRAWS, scoop plate weighted utensils. An order for frozen nutritious treat two times a day for nutrition -document amount for lunch and dinner dated 01/09/2024. Hospice services for diagnosis of Parkinson's disease dated 9/06/2024. A review of Resident #57's current care plan showed a Focus area of potential nutritional risk related to diagnosis history of Parkinson's disease with a goal to consume food and fluids to his comfort level through review. Interventions include but not limited to monitor and report to physician as needed for signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusal to eat, appears concerned during meals and monitor intake, record meal percentage. Resident #57 shows a Focus area of at risk for possible falls with injuries related to deficits in his cognition, dementia, impairment of vision and needs assistance with ambulation, locomotion, mobility, transfers, toileting, and incontinent care needs. The goal will be to minimize risk of falls and fall related injuries. Resident #57 has a Focus area of recent reduction in prior levels of mobility and at risk for possible further changes declines in present levels of mobility due to the amount of assistance that is presently required with mobility and transfer needs related to diagnosis of Parkinson's disease, diabetes, dementia, repeated falls, seizures, peripheral vascular disease, chronic kidney disease. He requires assistance with his ambulation, locomotion, mobility, transfers, toileting, and incontinent care needs. Current interventions include but are not limited to sit to stand substantial /Maximal assistance; chair bed to chair transfer: substantial /Maximal assistance. Resident #57 has a Focus area of swallowing problem related to dysphagia with a goal to have minimal risk of injury related to aspiration. Interventions include but are not limited to all staff to be informed of resident special dietary and safety needs alternate small bites and sips use a teaspoon for eating do not use straws check mouth after meal for pocketed food and debris report to nurse provide oral care to remove debris instruct the resident to eat in an upright position, to eat slowly and to chew each bite thoroughly, monitor for shortness of breath, choking, labored respirations, lung congestion ,monitor, document and report as needed any signs and symptoms of dysphasia. A review of Resident #57's Minimum Data Set Section C -Cognitive Patterns dated 8/26/2024 showed a Brief Interview for Mental Status score of nine which indicated moderate cognitive impairment. Section GG- Functional Abilities and Goals GG0130 Self-Care showed substantial/maximal assistance for eating. GG0170 Mobility showed dependent, two or more persons assist with chair/bed-to -chair transfer. On 9/19/2024 at 10:15 a.m., an interview was conducted with Staff J, LPN/Supervisor. Staff J stated she was not familiar with the hired companion for Resident #57 and under no circumstances was the resident to be assisted with feeding, transferring, and toileting by the hired companion. On 9/19/2024 at 1:01 p.m., an interview was conducted with Staff I, CNA. She stated she noticed the hired companion in Resident 57's room a month ago and inquired who she was. The hired companion stated she was hired by the family. Staff I stated she had observed the hired companion feeding the resident once with apple juice. She stated Resident #57 was on a regular pureed diet with thickened liquids. She stated she believed the hired companion had thickened the liquid. Staff I stated Resident 57's room would be closed by the companion during her visits. Staff I stated the hired companion never asked her for supplies such as briefs or linen. She stated Resident #57 would be transferred by a two-person assist because he could be unsteady on his feet. Staff I stated the hired companion never would communicate if the resident had a bowel movement. Staff I stated prior to the hired companion, there was a male companion who would escort the resident to the bathroom and communicate if the resident had a bowel movement. Staff I stated the male resident would bring Resident #57 outside for walks in his wheelchair and assist the resident during meals. Staff I stated she had assumed a staff member was getting the resident back to bed for the past month. Staff I assumed the hired companion was a private CNA. On 9/19/2024 at 1:02 p.m., an interview was conducted with Staff G, CNA. Staff G stated she did not know the name of the hired companion but noticed her a month ago. Staff G stated prior to this hired companion there was a male companion who assisted the resident to the bathroom for a bowel movement; and would let the staff know. Staff G stated the male companion was good about taking the resident outside for fresh air and sun but never witnessed him in providing direct care to the resident. Staff G stated the new hired companion would shut the door and never witnessed her taking the resident out of his room. Staff G stated the hired companion did not ask her for supplies. Staff G stated Resident #57 was on a pureed thickened fluid diet and a two-person transfer because he could be unsteady on his feet. Staff G stated she thought both hired companions were CNAs. On 9/19/2024 at 1:15 p.m., an interview was conducted with Staff F, LPN. Staff F stated the hired companion never communicated with her. Staff F stated she thought the facility knew about this hired companion because the family had a male companion prior to the current companion. Staff F could not state when the hired companion started because she was on medical leave. Staff F stated Resident #57 had an order for honey thickened liquids but could not state why the resident was observed drinking apple juice with the hired companion. Staff F stated the kitchen would provide commercial thickened liquid such as apple juice or the staff would thicken the liquid. On 9/19/2024 at 1:30 p.m., an observation was conducted with Staff F, LPN in Resident #57's room. Resident #57 had a small refrigerator with twenty-one bottles of small twist top bottles of commercial made apple juice, two bottles of orange juice, one water bottle, apple sauce and pudding [photographic evidence obtained]. The Regional [NAME] President immediately removed the bottles of juice and stated the family would be informed and educated on the resident's order for honey thickened liquid. The Regional [NAME] President stated the staff was responsible for thickening the resident's liquids. One bottle of apple juice was opened and half full. The Regional [NAME] President stated the bottle of liquid had a thickened appearance. On 9/19/2024 at 2:01 p.m., a telephone conversation was conducted with [hired companion]. The hired companion confirmed the days she would visit Resident #57 as every Tuesday, Friday and Sundays. The hired companion stated she has had multiple conversations with staff members and gave an example of one of her last conversations. The hired companion stated the resident's family member had asked her to ask the nurses the last three documented weights. The hired companion stated the staff in the nurses' station told her the resident's weight was 125 pounds on three separate dates. The hired companion stated she put thickened mix in the resident's apple juice. The hired companion stated the family member provided the packets of thickener which could be located in the resident's dresser drawer. The hired companion stated she assumed the staff wanted her to provide incontinence care because they would provide the briefs and linen every time she showed up at the facility for her two to three-hour duty. A review of the facility's guest sign in sheet showed the hired companion signed in on 9/17, 9/15, 9/13, 9/10, 9/06, 9/04, 8/30, 8/23, and 8/21. On 9/12/2024 family member signed in the facility's guest sign in sheet. On 9/12/2024 a weight was entered for Resident #57 of 112 pounds. A review of the facilities policy titled: Private Duty Aides, revised March 2021, shows a policy statement: The use of private duty aide are permitted when approved by the resident's attending physician and the facility's director of nursing services. 1. Residents desiring the use of private duty aides must first obtain written approval of the attending physician and the director of nursing services. 2. The director of nursing services consults with the administrator when private duty aides are requested 3. Private duty aides follow the facilities established nursing care policies and procedures and instructions issued by the nurse supervisor charge nurse. Private aides do not administer direct care to the resident unless authorized in writing by the attending physician. 4. 5. Private duty aides report to the nurse supervisor charge nurse when coming on and off duty. 6. Private duty aides are directed to report changes in a residence condition to the nurse supervisor charge nurse immediately

Based on observation, interview, and record review, the facility failed to ensure a care plan was developed for the use of continuous oxygen therapy for one (#27) of twenty sampled residents who received oxygen therapy. Findings Included Review of the record for Resident # 27 revealed she was readmitted to the facility on [DATE] with diagnoses which included Acute and Chronic Respiratory Failure with Hypoxia. Review of a quarterly Minimum Data Set ( MDS ) assessment, dated July 7, 2024, revealed under Section J Health Conditions Shortness of Breath shortness of breath or trouble breathing with exertion and shortness of breath or trouble breathing when lying flat were both checked. An observation of Resident # 27 was conducted on 9/16/24 at 10: 28 a.m. She was observed seated in her wheelchair in her room wearing a nasal cannula in her nares. The nasal cannula and tubing was attached to an 02 concentrator set at 2 liters. Resident # 27 stated that she utilized her oxygen continuously and could not leave her room to go to activities without a portable oxygen tank. An observation of Resident # 27 was conducted on 9/18/24 at 10: 02 a.m. She was observed seated in her wheelchair in her room wearing a nasal cannula in her nares. The nasal cannula and tubing was attached to an 02 concentrator set at 2 liters. Review of comprehensive resident care plans for Resident # 27 revealed the mention of oxygen use in a care plan, initiated 4/9/24 and revised 79/24 with a focus of Has some reduction in prior levels of mobility Focus [Resident #27] has some reduction in prior levels of mobility she is at risk for possible further changes/ declines in present levels of mobility due to the amount of assistance that is presently required with mobility and transfers. She is oxygen dependent and does become short of breath upon exertion/ activity Review of interventions for this care plan revealed no specific intervention related to oxygen dependence. Review of all comprehensive care plans for Resident # 27 revealed no care plan specific to oxygen therapy.

Based on observation, interview, and record review, the facility failed to ensure a base line care plan was developed for the use of continuous oxygen therapy for two (#206 and #360) of twenty sampled residents who received oxygen therapy. Findings included: 1. On 9/16/2024 at 10:00 a.m., an observation and interview was conducted with Resident #206. She was lying in bed, under the covers and with the head of her bed at approximately 45 degrees. An oxygen concentrator was on the left side of the bed. The concentrator was on and the flow rate read 4.5 (lpm) liters a minute. The resident said she needed oxygen all the time and did not know what the flow rate should be. She confirmed it felt a little rushed in through her nose. When she found out the oxygen flow rate on the concentrator was at 4.5 lpm, she said that was too high. She revealed she had just been readmitted from the hospital and had been utilizing the oxygen since her readmission. Resident #206 revealed she had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and that was the reason for her oxygen therapy, and nebulizer treatments. Resident #206 then remembered that when she was receiving oxygen therapy from the machine, it should be at 2 liters a minute. She did not know why the flow rate was so high and at 4.5 liters per minute. Resident #206 confirmed she had some slight discomfort in her nostrils and with some dryness. On 9/16/2024 at 1:20 p.m., Resident #206 was again observed in her room and lying upright in bed. She was still observed receiving oxygen therapy via the oxygen concentrator. The flow rate gauge on the concentrator read 4.2 - 4.5 lpm. On 9/17/2024 at 8:00 a.m., Resident #206 was observed in her room and seated upright in bed at 90 degrees. The resident was receiving oxygen therapy via the oxygen concentrator. The gauge on the concentrator revealed 4.2 - 4.5 lpm. Resident #206 again revealed she was not sure why the flow rate was so high, but she did need oxygen all the time due to her COPD. On 9/17/2024 at 12:10 p.m. Resident #206 was observed in her room and seated upright in bed. She was observed receiving oxygen therapy via the oxygen concentrator. The gauge on the concentrator revealed a flow rate of 4.2 - 4.5 lpm. On 9/18/2024 at 9:35 a.m., an interview with the Staff E, Registered Nurse, and who was assigned to the resident the past three days (9/18, 9/17, 9/16/2024), confirmed resident #206 had been a recent readmission from the hospital and also confirmed the resident needed continuous oxygen via the oxygen concentrator. Staff E was not sure why the resident was not ordered for oxygen use upon her admission and not until just this morning and was not sure why the resident was utilizing 4.5 lpm yesterday (9/17/2024), and the day before (9/16/2024). Staff E also confirmed Resident #206 had not been able, nor had the ability to adjust the oxygen flow rate on the oxygen concentrator. She confirmed there was no order for continuous oxygen use. Review of the medical record showed the Physician's Order Sheet dated 9/2024 did not indicate an order (routine or as need), related to oxygen use. A review of the Admission/Readmission Nursing evaluation dated 9/11/2024, Section K, Alerts revealed devices to include oxygen use at 2 liters a minute. Section M, Information notes revealed; Resident was alert and oriented, able to make needs known. A review of the physician's order sheet dated 9/18/2024 showed a new order for oxygen use. The order read may have O2 at 2 lpm continuous. A review of the hospital discharge record and hospital discharge medication list dated 9/9/2024 did not show the use of oxygen or oxygen therapy. A review of the current care plans with a next review date 12/11/2024 did not reveal any type of oxygen therapy to include the use of continuous oxygen, with problem area, goals and interventions. On 9/19/2024 at 9:00 a.m., an interview with the Care Plan Coordinator revealed she was not that familiar with the resident and wanted to look her up on the electronic medical record system. The Care Plan Coordinator revealed she was not aware the resident was admitted and receiving continuous oxygen therapy since her admission. She said she would have developed a care plan for oxygen use had she identified an order for it. The Care Plan Coordinator confirmed the resident was not formally ordered continuous oxygen use until just yesterday (9/18/2024), which was seven days after she was admitted . The Care Plan Coordinator revealed she typically would develop a care plan problem area after it was identified within the next business day. She further confirmed that if the resident used and had been using continuous Oxygen therapy since her admission, it should have been first ordered and then brought to her attention so she could develop the problem area with goals and interventions. On 9/19/2024 at 12:10 p.m., an interview with the Director of Nursing revealed she was made aware Resident #206 was receiving oxygen therapy since her readmission to the nursing facility on 9/11/2024 and there was no physician's order in place. She revealed as part of process of admission/readmission, it was the responsibility of the admitting nurse to assess and obtain orders from the physician. She further confirmed she was not sure who admitted Resident #206, but confirmed the nurse should have obtained an order for use of oxygen. The Director of Nursing said Resident #206 should not have had a flow rate of 4.2 - 4.5 lpm during the days she had it running between 9/11/2024 and 9/18/2024. The Director of Nursing confirmed though Resident #206 was not appropriately ordered for the oxygen use, there should have been a base line care plan with a problem area and interventions with related to oxygen therapy. 50732 2. Review of the Admission Record for Resident #360 showed the resident was admitted to the facility with diagnoses which included acute respiratory failure with hypercapnia, acute respiratory distress, pneumonia, altered mental status. Review of Resident #360's Minimum Data Set Assessment (MDS) dated [DATE] showed Section C-Cognitive Patterns showed the resident had a Brief Interview for Mental Status (BIMS) score of 0 which indicated severe cognitive impairment. On 09/18/2024 at 3:45 p.m., Resident #360 was observed in her room sitting by the bed sleeping in her wheelchair. The resident was observed wearing a soft cervical collar and a bandage on her forehead. Resident #360 was receiving oxygen via a nasal cannula and an oxygen tank was observed on the back of her wheelchair. On 09/19/2024 at 8:35 a.m., Resident #360 was observed in bed sleeping. The resident was receiving oxygen via oxygen concentrator at bedside via nasal cannula at 2 liters per minute. 09/19/2024 10:20 a.m., Resident #360 was observed in bed sleeping. The resident was receiving oxygen via oxygen concentrator at bedside via nasal cannula at 2 liters per minute. 09/19/24 1:08 p.m., Resident #360 was observed in her room sitting up in bed eating lunch. The resident said she was hungry and was quickly eating lunch. She said she was feeling good, just a little sleepy today. The resident was receiving oxygen via oxygen concentrator at bedside via nasal cannula at 2 liters per minute. Review of Resident #360's current physician orders showed the resident had an order for continuous oxygen via nasal cannula at 2 liters per minute. Review of Resident #360's Care Plan dated 09/05/2024 revealed the resident did not have a baseline care plan for continuous oxygen use. On 9/19/2024 the Nursing Home Administrator provided the Baseline Care Plan policy and procedure with a revision date of 3/1/2023, for review. The Policy stated: The facility will develop and implement a baseline care plan for each resident that includes the instruction needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. The Policy Explanation and Compliance Guideline revealed; 1.The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician's orders. iii. Dietary orders. iv. Therapy services. v. Social services. vi. PASRR recommendation, if applicable. 2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician's orders, and discussion with the resident representative, if applicable. a. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives. b. Interventions shall be initiated that address the resident's current needs including i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. iii .Any special needs such as for IV therapy, dialysis, or wound care. c. Once established, goals and interventions shall be documented in the designated format. 3. A supervising nurse shall within 48 hours that a baseline care plan has been developed. 4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: a. The initial goals of the resident. b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. 5. A supervising nurse or MDS nurse/designee is responsible for providing the written summary of the baseline care plan to the resident and representative. This will be provided by completion of the comprehensive care plan. 6. The person providing the written summary of the baseline care plan shall: a. Obtain a signature from the resident/representative to verify that the summary was provided. b. Make a copy of the summary for the medical record.

Based on observation, interview, and record review, the facility did not ensure one (#67) out of eight residents sampled had the proper paperwork for the resident's code status. Findings include: A record review of Resident #67's physician orders show an order dated [DATE] for Do Not Resuscitate (DNR). Resident #67's medical record did not have the [Do Not Resuscitate order form] signed by the physician in the electronic medical record. On [DATE] at 9:55 a.m., an interview was conducted with Staff F, Licensed Practical Nurse (LPN). Staff F was assigned to the North wing of the facility and stated there was a DNR binder in the nurses' station in which all the residents in the entire facility with a DNR order were in the binder. Staff F, LPN stated there was another binder in the East wing nurses' station. Staff F, LPN stated the North wing DNR binder rational for all the residents was to account for the residents from the other wing (east) who might be transporting either walking or self-propelling via wheelchair to their wing (north). Resident #67 room assignment was on the North wing. The DNR binder in the North wing did not have Resident #67's [Do Not Resuscitate order form] signed by the physician. Staff F, LPN, confirmed Resident #67's DNR paperwork was not in the DNR binder for the North wing. The Social Service Director (SSD) was in the nurses' station as well and stated he did weekly audits of residents' DNR paperwork but the nurses were responsible for residents transferred from hospitals with established DNR paperwork. On [DATE] at 10:07 a.m., an observation was made of the East wing's DNR binder. Resident #67's DNR paperwork was present. Resident #67 had a family member with the same last name as Resident #67 residing as a resident in the East wing. On [DATE] at 10:15 a.m., an interview was conducted with Staff F, LPN. Staff F, LPN stated when a newly admitted resident was received from a hospital, the nurses would review the resident's [transfer form] and make copies of the [DNR order form] on yellow paper and place it into the DNR binder. Staff F, LPN reviewed the last [transfer form] paperwork for Resident #67 and stated there was not a check on the form indicating code status. On [DATE] at 10:25 a.m., an interview was conducted with Staff F, LPN. Staff F stated in a potential code status situation she would go to the DNR binder to determine the resident's code status. On [DATE] at 10: 28 a.m., an interview was conducted with Staff H, LPN. Staff H stated she would go to the DNR binder first to determine a resident's code status. On [DATE] at 10:35 a.m., an interview was conducted with Staff E, Registered Nurse (RN). Staff E, RN stated she would go the DNR binder first to determine a resident's code status and stated if the paperwork was not in the binder, then the resident was a full code. On [DATE] at 10:39 a.m., an interview was conducted with Staff P, RN. Staff P, RN stated she would go to the medical records to determine the code status for the resident. Staff P demonstrated in the electronic chart where she would look to determine the resident's code status and added the physician orders could be reviewed as well to determine a code status. On [DATE] at 10:44 a.m., an interview was conducted with Staff M, RN. Staff M stated he would look in the resident's medical record and confirm with physician orders and added the DNR binder as an additional verification. On [DATE] at 10:45 a.m., an interview was conducted with Staff L, LPN/Supervisor. Staff L stated initially she would look in the DNR binder but stated she would confirm in the resident's medical record. Staff M and Staff L stated the SSD will update the binder. ON [DATE] at 11:00 a.m., interviews were conducted with Staff O, Certified Nurse Assistant (CNA). Staff O stated she would look at the DNR binder to determine a resident's code status. Staff Q, CNA stated she would go to the resident's medical records. Staff R, CNA stated she would go to the medical records under her [brand name for a file system that gives a brief overview of the resident] to view code status of a resident. Staff J, LPN/Supervisor stated she would go to the resident's medical record first. On [DATE] at 11:21 a.m., an interview was conducted with the SSD and the Director of Nursing (DON). The SSD stated code status audits were initially done monthly for their Quality Assessment and Performance meetings but with the transition to a new ownership, he discovered missing residents' code status; therefore, switched to weekly audits. The DON was aware of the different responses sampled staff answered when questioned on where they would go to determine a resident's code status during an actual code situation. A review of the facility's policy titled, Advance Directives revised [DATE] shows in their policy statement: The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. A review of the facility's policy titled, Emergency Procedure -Cardiopulmonary Resuscitation (CPR) revised ,d+[DATE] shows: 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Verify or instruct a staff member to verify the DNR or code status of the individual. c. Initiate the basic life support sequence of events.

Based on observation, interview, and record review, the facility did not ensure an assessment and physician orders were obtained for medication self-administration for one (#36) of eight residents sampled. Findings include: On 9/17/2024 at 9:41 a.m., an observation was made of Resident #36 in her room. A tracheostomy with a respiratory cap was visualized along with supplies for tracheostomy care. The resident stated she did most of her own tracheostomy care including her nebulizer treatments. Resident #36 stated her nebulizer medication was in her top left hand dresser drawer. Resident #36 gave permission to open drawer. An observation was made of two packets of Albuterol Sulfate Nebulization solution 0.63 mg/3 ml (milligram/milliliter) with one packet opened. Resident #36 stated she gave herself her own nebulizer treatment but the facility supplied her with the items and medication. A review of Resident #36's Admission Record showed she was admitted to the facility with diagnoses which included but not limited to acquired absence of larynx, tracheostomy status, anxiety disorder due to known physiological condition, and unspecified voice and resonance disorder. A review of Resident #36 current physician orders showed an order dated 9/09/2024 for albuterol sulfate nebulization solution 0.63mg/3 milliliters via trach every six hours as needed for shortness of breath. A review of Resident #36's Minimum Data Set, dated dated dated [DATE] under Section O -Special Treatments, Procedures, and Programs, showed Section E1 tracheostomy care A review of Resident 36's medical record did not show an assessment for resident self-administration or a physician's order. On 9/18/2024 at 9:50 a.m., an interview and observation was conducted with the Assistant Director of Nursing in Resident 36's room. Medication of albuterol remained in Resident #36's drawer and the resident confirmed she self-administered her nebulizer treatments herself as needed. On 9/18/2024 at 10:30 a.m., the Director of Nursing confirmed the missing assessment and orders for self- administration for Resident #36. A review of the facility's policy and procedures titled: Resident Self-Administration of Medication revised date of 3/01/2024 shows the following policy statement: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. 1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facilities interdisciplinary team. 2. Resident's preference will be documented on the appropriate form and placed in the medical record. 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and safe for self-administration. b. The resident's physical capacity to swallow without difficulty, open medication bottles, administer injections. c. The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for. d. The resident's capability to follow directions and tell time to know when medications need to be taken. e. The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff. f. The resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs. g. The resident's ability to ensure that medication is stored safely and securely.

Based on observation, interview, and record review, the facility failed to ensure two (#52 and #8) of eleven sampled residents , who dined in the main dining room, were provided and assisted with their meal until 30 and 40 minutes after all the others were served and ate their meal. Findings included: 1. On 9/16/2024 at 11:59 a.m., the main dining room was observed for lunch service. The room was observed with over twelve tables and many chairs. Prior to the meal observation, the room was used as a group activity, and there were many residents who were in attendance of that activity. After the activity was completed, there were nine residents who remained in the room to wait and be served their lunch. There were three staff members who were either talking/interacting with the residents in the room, or were providing them hydration. It was observed at this time, Residents #52 and #8 had been seated in the main dining room since the group activity ended. On 9/16/2024 at 12:08 p.m., a meal tray cart came out from the kitchen and the three staff members immediately began to serve and set up meal trays. They served two of eleven residents in the room. At 12:15 p.m. nine residents had been served and set up with their meals and were eating on their own. However, Residents #52, and #8, who were seated at tables by themselves and had not been served or assisted with their lunch meal. At that time, interviews with Staff B and C, who were Certified Nursing Assistants (CNA), revealed they were surprised Resident #52 and #8's meal had not been brought out. They said they had provided the kitchen with names of those who were eating in the dining room, about thirty minutes prior to the meal service. Staff B confirmed Residents #52 and #8 were on that list. On 9/16/2024 at 12:30 p.m., nine of the eleven residents were still eating their meals and Residents #52 and #8 still seated at their tables and had not been provided with their meal. Staff B and C walked up to both residents #52 and #8 and ensured them their meals were coming. An interview with Staff B revealed both residents #52 and #8 were to receive the primary meal so there should not have been any reason why their meal trays had not come out from the kitchen yet. It appeared resident #52 was getting irritated as to why everyone else was eating. He was overheard making loud noises and pointing at others who were eating. On 9/16/2024 at 12:35 p.m., Residents #52 and #8 had still not been provided and assisted with their meal. Both had called out twice and asked staff in the room where their meal was. Both were ready and wanting to eat. Staff B again tried to reassure both were going to receive their meal shortly. Staff C went to the kitchen door to ask why Residents #52 and #8's meals had not been made and brought out to them. Staff C was observed to not get an answer from the kitchen staff. On 9/16/2024 at 12:36 p.m., the Certified Dietary Manager (CDM) brought out a meal tray cart from the kitchen and said to staff; East, as if to say it needed to go to the East hall. During that time, Resident #52 was observed now banging on the table and yelling out non understandable words, and then said, food now, food now. On 9/16/2024 at 12:39 p.m., Resident #52 was now very upset and yelled out continually; food, where is it, where is it, [curse word] where is it. At this point, Resident #52 was being very disruptive to all others who were in the room eating. He was very upset because he did not receive his meal. Staff keep telling him they would get it for him. However, his meal had not come out from the kitchen as of yet. Resident #52 took off his glasses and started to cry out loud and staff sat down next to him to try and talk with him. He continued to cry aloud and kept yelling, where is it, where is it. On 9/16/2024 at 12:42 p.m., Staff B brought out a tray for resident #8, set it up, sat down, and began to assist her with eating. Resident #8 was not interviewable. Resident #8 sat at a table near others who were served and already eating from 12:08 p.m. through to 12:42 p.m., thirty-four minutes without being provided and assisted with her meal. On 9/16/2024 at 12:44 p.m., Staff sat with Resident #52 until his meal arrived. At that point, he had been the only resident who had not been served his meal. Staff provided him with a canned soda to drink. He accepted it but still wanted his meal and was still visibly upset. On 9/16/2024 at 12:45 p.m. four residents finished their meal and left the dining room. On 9/16/2024 at 12:48 p.m. Resident #52 was finally served his meal and he began to eat immediately on his own. Resident #52 was observed with cognitive and communication impairment, but was able to express he was now happy with getting food. Resident #52 sat at a table near others who were served and already eating from 12:08 p.m. through to 12:45 p.m., 37 minutes without being provided and assisted with his meal. On 9/16/2024 at 1:00 p.m., an interview with the CDM revealed he could not explain why Residents #52 and #8 had not received their meal tray for such a long time today. He explained he had a member of a county inspection agency in the kitchen during the time of meal service, and was not able to monitor the plating of meals. He confirmed Residents #52 and #8 should not have had to wait that long for their meals and that he would look into the situation. On 9/19/2024 at 10:00 a.m.,an interview with the Director of Nursing revealed all residents who dine in the main dining room for any meal service, should all be served roughly at the same time and should not have to wait long periods of time without a meal, as others have been served and who were already eating. She confirmed Residents #8 and #52 waiting over thirty minutes should not have happened. She also confirmed that it was not due to the lack of nursing staff in the dining room, but rather it was a problem in the kitchen on 9/16/2024. On 9/19/2024 at 2:00 p.m. the Nursing Home Administrator provided the Promoting/Maintaining Resident Dignity policy and procedure, with a implementation dated of 6/1/2024 for review. The policy stated: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. The Compliance Guidelines section of the policy stated the following but not limited to: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 6. Respond to requests for assistance in a timely manner. (5) The Self Determination section of the policy stated: (b) The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. 48441

Based on observation, interview, and record review, the facility failed to provide two (#206 and #54) of forty-four sampled residents with food items per their preference during one of three breakfast meal services observed. Findings included: 1. On 9/16/2024 at 10:00 a.m., Resident #206 was observed lying in bed, under the covers and with the head of the bed at approximately 45 degrees. She had an over the bed table placed in front of her with many personal items on it. During the visit, Resident #206 complained she was not receiving the correct diet and the food came to her cold, as well as she received things she did not like. On 9/17/2024 at 8:00 a.m., Resident #206 was observed in her room and seated upright in bed at 90 degrees. She was observed with her over the bed table placed in front of her with her breakfast tray on it, along with various other personal items. Her breakfast consisted of scrambled eggs, sausage, mashed potatoes, coffee, milk and water. The resident's meal ticket read she was to receive a Mechanical Soft CCHO [Controlled Carbohydrate] diet. Observation revealed she did receive the correct diet and texture. However, it was unknown why she received mashed potatoes. Photographic evidence obtained. The resident said she did not know why she received mashed potatoes and that she would eat them. She said she did not order them and she would in fact not eat mashed potatoes for breakfast, ever. She also revealed staff did not come in and go over her daily meal menu plan. She said she was sure she would receive tacos today and she did not like tacos. She revealed staff would have already gone over the menu choice today, but had not done so as of yet. On 9/17/2024 at 12:10 p.m., Resident #206 revealed she had not received her lunch tray. She confirmed that no staff members had come into her room today to ask her what she wanted for lunch, and she did not want what was on the menu as the primary meal. She said she did not eat tacos whether they were soft or hard. She said the spices did not agree with her. Resident #206 said she was not given the chance to change her order this morning and staff were not consistent with coming in the room every day to take meal service orders. On 9/17/2024 at 12:59 p.m., Resident #206 was served her lunch by Staff D, Certified Nursing Assistant (CNA). The meal consisted of a soft flour tortilla with ground meat and shredded cheese. A disposable cup was observed with a thick tomato chunky red salsa. Resident #206 revealed she would not be able to eat the tortilla as the texture would not agree with her. Staff D asked the resident if she wanted anything else and the resident could not decide. So, she had the aide take the soft taco back to the kitchen to chop up the meat and not bring a tortilla with it. However, Staff D brought back the same identical food items, only appeared to be reheated. Resident #206 stated again to the aide; I don't want tacos, I can't eat that, and I can't eat and swallow the tortilla. Review of the meal ticket revealed: Diet order: Mechanical Soft CCHO, 2000 ml fluid restriction, to receive ginger ale. Staff D confirmed she did not visit with the resident that morning to ask what she wanted for lunch. Staff D said whoever the resident was assigned to today, would have been the staff to ask her what she wanted for lunch. Staff D confirmed later in the day that Resident #206 did not eat the taco meat and tortilla, and revealed she did not want anything else. Review of the current Physician's Order Sheet for the month of 9/2024 revealed an order for a CCD (Consistent Carbohydrate) diet, Mechanical soft ground meats texture, Regular/thin consistency liquid and ground/chopped veggies, 2000 ml fluid restriction with a start date of 9/19/2024. Review of the current care plans with a next review date 12/11/2024 revealed the following problem areas, but not limited to: a. Has nutrition problem or potential nutrition r/t increased nutrient demand r/t skin impairment AEB (as evidenced by) need for healing of Pressure Ulcer. Nutritional risk r/t obesity, HF, diuretic therapy, on fluid restriction. Difficulties chewing and swallowing, with interventions in place to include: Administer medications as ordered. Observe and document for side effects and effectiveness, consult Speech Therapy as need, Fluid restriction, Observe signs and symptoms of dysphagia, pocketing and chocking, Provide supplements as ordered, Provide and serve diet as ordered, RD to evaluate and make diet change recommendations as need, Weigh per facility protocol. 2. On 9/17/2024 at 8:20 a.m. the 200 lounge/dining area was observed with Resident #54 seated at a table, while seated in her wheelchair and had her breakfast tray placed in front of her. She was finishing her meal and was able to eat without assistance. Resident #54 was interviewed and she revealed she was ok with the meal other than her untouched mashed potatoes. She was asked about her mashed potatoes and revealed she would not eat those for breakfast and did not order them. She was not sure why she received them and confirmed again she would not eat them, especially for breakfast. As Resident #54 was being interviewed, Staff D was observed to walk in the room to check on the resident. She sat down next to her and asked how she was doing. Resident said she was fine and thought she was done. Staff D was asked why Resident #206 had received mashed potatoes. She explained that when a resident was on a special diet CCHO, she was told that residents could not have hash browns so that seemed to be the replacement. Staff D said that residents who received mashed potatoes for breakfast, generally would not eat them. Review of the current Physician's Order Sheet dated for the month 9/2024 revealed orders for [nutritional shake] 2 times a day as a Supplement and a diet order for a Regular diet, pureed textured, regular thin consistency. On 9/17/2024 during the breakfast observation, from 8:10 am., through to 8:45 a.m., four additional random residents were observed who were all served mashed potatoes with their meal. Interviews with those four residents revealed they were interviewable and able to speak with relation to their daily care and services, and all who wished to remain as anonymous interviews. The four random and confidential resident interviews all revealed they had never had mashed potatoes for breakfast and would not eat them. They were not sure why they were served seasoned mashed potatoes for breakfast. It was observed when all four residents were finished with their meal, none ate the mashed potatoes. On 9/17/2024 at 11:00 a.m., an interview with the facility's Registered Dietitian revealed she reviewed the planned menu for each cycle and confirmed that today's (9/17/2024) primary breakfast meal was Cheesy Scrambled eggs, Cereal of choice, Hash browns, Milk, Coffee. She was asked if she knew mashed potatoes were served and if so, why did the kitchen served them to residents for breakfast. The Registered Dietitian revealed she was not aware of residents being served mashed potatoes but revealed there was hashbrowns. She revealed residents who were on a Mechanical Soft diet, would not be able to have the crunchy hashbrowns, and perhaps there was an alternate, but it should not have been mashed potatoes. She revealed she would follow up with the Dietary Manager. On 9/18/2024 at 8:45 a.m., the Registered Dietitian revealed she could not find out if the kitchen staff served mashed potatoes or not during the previous day's breakfast meal. She revealed it could have been hashbrowns that were processed to be more of a mechanical soft consistency. She was shown a photograph of what Residents #54 and #206 were served and she noted they did appear to look like mashed potatoes. On 9/18/2024 at 11:20 a.m., an interview with the Dietary Manager revealed he was not present on the line for breakfast meal service the day before on 9/17/2024, but overheard from the Registered Dietitian that possibly mashed potatoes were made and served. He could not be for certain if that happened or not as he had interviewed the previous day's cook and he could not get an answer if that happened or not. That cook was not present during this time on 9/18/2024 for interview. A review of the planned weekly menu revealed on 9/17/2024, breakfast consisted of Cheesy scrambled eggs, Cereal of choice, Hash browns and milk. There was no note of mashed potatoes to be served or offered. On 9/19/2024 the Nursing Home Administrator revealed the facility did not have a specific resident food preferences policy and procedure, but confirmed residents who did not want mashed potatoes for breakfast, should not have received them.

Based on record review and interviews with facility staff, family member, physicians, and review of facility policies and medical records, the facility failed to ensure freedom from neglect by not implementing the facility's policy and procedure for Resident Mistreatment, Neglect and Abuse Prohibition for one (Resident #1) of 3 sampled residents. The facility failed to recognize and report neglect for Resident #1, a physically impaired resident, who was dependent on staff for all care and services, required two-persons assistance, and received care from one (1) staff member. On [DATE], the resident fell from her bed while one staff person was providing care and hit her head on the wall. The resident was transferred out of the facility for acute care follow-up. The fall resulted in multiple fractures and injuries from which the resident succumbed to her death on [DATE]. A review of a quarterly Minimum Data Set (MDS) dated [DATE] Section G, Functional status showed the resident required extensive assistance, with two+ assistance for bed mobility. (Bed mobility indicates how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). An approach in Resident #1's care plan with a start date [DATE], showed 2 staff were required when rendering care. On [DATE], Resident #1 was provided incontinence care which required the resident to turn from side to side. The resident was physically impaired and was totally dependent on staff for care. The resident did not have the ability to prevent herself from falling off the bed. Staff A, Certified Nursing Assistant (CNA), who was performing the duty by herself, rolled the resident away from her during care. The resident, who was under the care of Hospice at the time, fell from the bed, landing on the floor, and hit her head on the wall, for which she required immediate transfer to a higher level of care. The facility did not immediately report the accident as possible neglect or abuse to the state agency, did not remove the staff member from care to protect other residents, and did not conduct an investigation that concluded neglect had occurred. These failures resulted in a finding of Immediate Jeopardy at a scope and severity of (J) due to the fatal injuries that resulted in the death for Resident #1, and the likelihood of similar accidents could occur with other residents. The facility administrator was notified of the Immediate Jeopardy on [DATE] at 2:45 p.m. It was determined that the Immediate Jeopardy was removed on [DATE] and F600 was reduced to a Scope and Severity of D after verification of removal of immediacy of harm. Findings included: Cross reference to F600, F609, and F689. A review of an emergency room hospital record for Resident #1 dated [DATE] showed the [AGE] year-old female . with multiple chronic conditions, bedbound status presents after a fall from her bed at the nursing home. The bed was elevated at a high height, and she rolled out of it falling today. The fall was unwitnessed she was found on the floor. Complaints of back pain, shortness of breath, left leg pain and right foot pain. She is on Eliquis [a blood thinner] 2.5 mg (milligram). She is also on chronic pain medications. She is not sure if she lost consciousness or hit her head. She denies neck pain. She states her back pain is mostly in her mid back. Patient presented hypoxic [levels of oxygen in the blood are lower than normal] on non rebreather. Initial oxygen saturation was reportedly 66%. The emergency room diagnosis as of [DATE] at 3:46 p.m. indicated: Fall, initial encounter, Traumatic intracranial hemorrhage [bleeding within the skull] with unknown loss of consciousness status, initial encounter Hierarchical condition categories (HCC), closed fracture of proximal end of left tibia [shin bone], unspecified fracture morphology initial encounter. The emergency plan of care showed the patient suffered multiple small head bleeds, T2 (spinal thoracic bone) compression fracture, likely pulmonary contusions. She also has a minimally displaced left proximal tibia and fibula (leg) fracture given she is non weight bearing likely non operative management does not want surgery and she does not walk. A knee immobilizer is ordered. She has a right great toe fracture. The resident was transferred to a trauma Hospital for further evaluation and treatment. A review of hospital records showed on [DATE] at 05:31 p.m., Resident #1 was admitted for trauma care having presented to [name of Hospital] from an outside hospital due to intracranial hemorrhage and multiple traumatic injuries after sustaining a fall at her nursing facility. Per prior notes, patient fell out of bed and onto the ground. Patient was a DNR (do not resuscitate) and brought form with her. Patient was noted to have a right great toe proximal phalanx fracture, left tibial plateau fracture, left proximal fibular fracture that was minimally displaced, right frontal ([NAME]) compression fractures . Neurosurgery was consulted after the patient and [family member] talked about the patient's goals of care. Orthopedic trauma surgery elected to treat patient's fractures non-operatively given the patient is non-ambulatory baseline status and under hospice care. Per prior medical records. The patient was transitioned to comfort measures only . The patient expired at 8.30 a.m. Review of ICU (intensive care unit) notes showed the resident was critically ill with organ failure and severe metabolic derangements. This patient's prognosis for recovery based on their response to treatment and therapy, extent of organ system function and/or reserve was considered moribund = very very poor. A Review of Nursing facility progress note dated [DATE] at 10:58 a.m., showed at approximately 10:30 a.m., Staff A CNA was providing care for patient when patient rolled out of bed onto the floor. Patient sustained skin tear to left lower leg and elbow which was cleansed and dressed with steri strips. The Advanced Practice Registered Nurse (APRN) was in the building when the event occurred and ordered the patient to be sent to the emergency room for evaluation/treatment due to patient complaining of hip and back pain. On [DATE] at approximately 10:50 a.m., the patient was transferred to [Hospital name] via stretcher/EMS [emergency medical service] The Medical Director (MD) and family member were notified via telephone. A review of Resident #1's electronic medical record (EMR) showed the resident was admitted to the facility on [DATE] with diagnoses to include Acute respiratory disease, pulmonary, unspecified systolic (congestive heart failure), acute myocardial infarction unspecified among other diagnoses. A care plan for Resident #1 with a start date [DATE], showed a category Health related complications indicating the resident is at risk for further reduction in prior levels of mobility. She is at risk for possible further changes/declines in present levels of mobility due to the amount of assistance that is required with mobility and transfer related needs related to: The resident requires extensive to total assistance of ,d+[DATE] with her locomotion/mobility/transfers, toileting, and incontinence care needs. She is non ambulatory and has expressed an extreme fear of falling. An approach with a start date [DATE] showed 2 staff when rendering care. On [DATE] at 01:59 p.m., Staff D, MDS Registered Nurse (RN) confirmed the care plan was not specific as it showed ,d+[DATE] staff assistance. Staff D said, I can see how that would be confusing for a CNA not to know the number of staff required to provide assistance. I could have done a better job. An occupational Therapy and plan of treatment for Resident #1 dated [DATE] showed under fall risk assessment, Root cause analysis completed: patient currently requires maximum assistance of 2 for safely rolling patient side to side in bed for sitting more upright in bed, and for repositioning, hygiene, peri care, cleaning as per the caregivers, due to patient's severe arthritis joint protection issues and decreased skin integrity . Patient is dependent for all mobility tasks. Review of an activities of daily living (ADL) Care plan with a start date [DATE], last revised [DATE]., showed the resident was at risk for further declines/changes in self-care functional capabilities. She is at possible risk for further declines/changes in present self-care functional; capabilities due to amount of assistance needed presently with self-care task set up, completion of task and thoroughness related to diagnosis; recovered covid-19/pneumonia/status post fracture left femur /CHF (Congestive Heart Failure), anemia, history of NSTEMI (Non-St-elevation Myocardial infarction) /GERD (Gastroesophageal reflux disease), hyperlipidemia, and depression. She is alert and oriented x2 (meaning, she required 2 staff to provide care). She is able to verbalize her wants and needs total assistance [,d+[DATE]] with her ADL care, dressing, personal hygiene, bathing needs. She has incontinent occurrences of the bladder and bowels with daily use of briefs. She requires extensive assistance with her incontinent and peri care needs. An approach to the care plan with a start date [DATE] showed 2 staff were required when rendering care. A review of Resident #1's progress notes revealed: On [DATE] a nursing note showed the resident is alert and communicative, reports generalized chronic pain especially with repositioning and personal care. On [DATE] a nursing note showed . reports of pain to both lower and upper extremities. Requires maximum assistance with all types of care. On [DATE] PT (Physical Therapy) screen was completed. Patient is currently at baseline for functional mobility with no need to change or decline in function recently. On [DATE], a quarterly observation note indicated transfer status/assist of assistive devices showed the resident is immobile. Has weakness in all extremities. Has contractures bilateral on hands. On [DATE], an MDS coordinator progress note showed the information was gathered to complete the quarterly MDS . Resident required extensive assist x2 (meaning, she required 2 staff to provide care) with bed mobility, toileting, and bathing. [Resident #1] is non-ambulatory and requires assistance. On [DATE] at 12:58 p.m., an interview was conducted with Staff B, Registered Nurse (RN) who responded to Resident #1 after her fall. Staff B said, I went to the room. I did not know the resident. I observed the resident on the floor. She was lying on the left side of the bed. Her head was up against the wall. I looked at her legs and noted she was bleeding on the leg and on the arm. I cannot remember if it was left or right. It was a significant tear on the lower extremity of the leg, about 6 inches, skin was pulled back a little bit. The skin was folded in, you could see the subcutaneous tissue. The tear on the arm was approximately an inch and a half. Her head was resting on the wall which made me think she had hit her head. I cleaned her up and steri stripped it as the paramedics came in. I did not move her, they said she had brittle bones. She was resting her head against the wall. It looked like she had propped her head on the wall, which to me meant she hit her head on the wall. It was apparent she had hit her head on the way down. She was not crying, but it was clear she was in pain. She did not express the pain to me. I figured anyone who suffered a fall like she did, would be in pain. She had an air mattress; I did not see the rails. I addressed the bleeding first. She was talking as I was applying the steri strips. She said to me, [I told them I was going to fall.] I stayed with the resident until the paramedics came. On [DATE] at 1:11 p.m., an interview was conducted with Staff A, CNA who was assigned to Resident #1 [DATE]. She said, On that day, [DATE] between 10 a.m. and 10:30 a.m., I went to her room to take care of her. I was changing her as she needed incontinent care. She had a problem with her leg. She could not bend or move her left leg. She had pain in her right side. When I got to the room, I stood by her bedside, on the side of the door. I did not have two people at that time. She had an air mattress. There were no grab rails on her bed. She did not have the ability to grab and hold on to the rails. She was on an air mattress. She had a drawsheet under her. She could not move herself in bed. I pulled the drawsheet towards me, and the resident came towards me too. I provided care and then I pulled the drawsheet again and as I pushed her over the other side, the leg came out of the sheet, she said, I fell , I fell . She was talking to me. She said to me don't worry, I'm okay. She hit the floor. There was no mat on the floor. She landed on her back. The CNA stated education was offered on how to roll the resident over. She said, they said I have to pull the drawsheet to me; the resident has to go towards me all the time and if anyone is on an air mattress, we need two people to assist. On [DATE] at 10:35 a.m., a telephone interview was conducted with Resident #1's family member/ Responsible party. She stated Resident #1 had been at this facility for a couple of years. She stated during her last visit, the resident was herself even though she had not been out of bed in 2 years. She could not call for help on her own. Her roommate would call for her. Staff liked her. She had limited ability to use her body due to not having been out of bed and not moving her limbs. She was stiff and had zero muscles left. Her legs would sometimes swell. They had her in an air mattress. Her legs had started to curl up. She had very limited use of her hands. She was wasting away getting thinner and thinner, she was not able to feed herself, she needed staff to assist her. She could not use a call light or use a phone. She would not be able to grasp anything. She could not pick herself up or move herself in bed at all. The family member said, I received a call from the facility on [DATE]. They reported she fell out of bed. They said a CNA was changing her while in her bed when she fell and that she was complaining of pain. They said they had to send her out to be evaluated at a local hospital. That Hospital called me and said she had contusions, and they were sending her to [name of Hospital] for trauma care. The next call I received was from that hospital. They said they were doing x-rays and the surgeon would call me if they were to do surgery. At about midnight she was in the ICU, and she was on oxygen. They said she was slipping away. They were trying to draw blood. The next morning, they took her out of ICU, and they said they had her settled in her room. Before I could fly out, the hospital called and said she was gone. The only call I received from the nursing home was from someone saying she had fallen, and it was an accident. I don't know the circumstances, but she could not have stopped herself from falling, especially if the person changing her was on the other side of the bed. She was helpless. She was fully dependent on staff. The family member who was noted crying on the phone stated, She wanted to go, and I supported her, what else could I do? On [DATE] at 12:28 p.m., during a telephone interview, the Facility's Medical Director (MD) said, It is very unfortunate that she died . She stated she was notified about the fall. The MD said, They called me and said it was an accident. The resident fell because the CNA was by herself while changing the resident. She stated she had participated in QAPI (Quality Assurance Performance Improvement) via phone call, and they had discussed the fall. The MD stated the plan was to have a workshop to educate the CNAs and nurses and provide education on preventing avoidable accidents. The MD said, I don't want this to ever happen again. The MD stated the main thing was to have two CNAs at bedside and not have one CNA perform any sort of care for repositioning and change of linens for dependent residents on air mattresses by themself. She stated the expectation should be to provide care per the resident's care plan. The MD said, If Therapy had assessed for two person to assist in her care, then that should have been followed. Incidents/accidents will happen when care plan is not followed. I spoke to the Nursing Home Administrator (NHA), there should have been two people in the room. If there had been two people, this could have been prevented. On [DATE] at 12:30 p.m., an interview was conducted with the Director of Rehabilitation, (DOR). She stated the most recent evaluation was conducted on [DATE]th, 2023, at which Resident #1 was assessed as dependent, meaning she required total assistance for ADLs. When they are dependent, we take into consideration multiple things. If a patient requires a max assist of 2 for repositioning, hygiene, or peri care, two staff should assist per patient's limitations, such as severe arthritis and need to protect skin integrity. This resident was dependent on staff for all mobility skills because she was non-ambulatory, bed-bound, had BLE (bilateral lower extremities) contraction and needed a lower pressure mattress for pressure release. The Resident was always a two - person assistance. That was her baseline. We did not need to address her level of assistance as that is what it has always been, and it had not changed. Going forward education for the CNAs would be important for the sake of staff providing care and the residents. Not having that level of communication puts the resident at risk. The DOR stated she knew the resident. She was alert and oriented, it was a sad surprise for a lot of people that she had died . She was able to communicate her needs. They said she fell . The facility did trainings and in services about patient care and the way or level of assistance and mobility is determined. The care plan should say 1 or 2. It should be clearly defined. It should be either or. That would be confusing. Therapists fill out section GG of the resident assessment. In the MDS section G, if the resident is coded as requiring 2 staff, that info should go into the care plan as is. Resident #1 should have received incontinence care with two aides, she received an assist of one aide. On [DATE] at 12:13 p.m., an interview was conducted with Staff C, Licensed Practical Nurse (LPN) who was assigned to the resident. She stated on [DATE] she did not see the event happen. Staff C said, I was on my lunch break between 10:30 a.m. and 11 a.m. another nurse was covering the floor during my break. I was outside when one of the CNAs came and asked for keys to the treatment cart to get steri strips because the resident had a skin tear. I came in and got the treatment cart and strips and went to the room. I found [Staff B, RN] and already cleaned the resident. The resident was still on the floor, she was on the left side of the bed by the door bed. I can't recall if there was a fall mat. The height of the bed when I walked in was about hip height. The resident had a few skin tears. She was lying flat on her back. She was oriented, presented normal affect. She stated her hip and leg hurt. Other than that, she was normal meaning, same as she usually is. Staff C stated at approximately 10:20 a.m. or so EMS (Emergency Medical Service) arrived and transported the resident to the Hospital. She stated training was conducted after the incident about abuse and neglect. Staff C stated for everyone who had an air mattress, they had put bolsters, and also specified two people must be present for any type of care. She said, We re-trained on turning patient towards you not away from you. Staff C said, It was very unfortunate, especially because of the end result. The patient died . The resident was pleasant, she liked her snacks and ginger ale. She was very content, liked TV (Television). She never got out of bed, but she made her needs known. She was alert and oriented. She had brittle bone disease. She was stiff. She did not go anywhere. She required full care for toileting. She had previously fractured her leg or hip and was not able to sit or get out of bed. She required the staff's total assistance, for everything. On [DATE] at 1:52 p.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN) Minimum Data Set (MDS) coordinator and Staff E, RN MDS coordinator. They stated they update care plans by gathering information from what the CNAs are charting, and what therapy had assessed. The CNAs receive information on care plan changes from charge nurse, and reports from CNA to CNA. Staff D said, In the IDT (Interdisciplinary Team) morning meetings, we follow -up on post fall reviews, we update care plans, and the unit manager sends the interventions back to the floor. The CNAs are educated to follow -up on interventions, these are carried over during shift-to-shift exchange. Staff D and E reviewed Resident #1's interventions post fall and confirmed there had been no changes. Staff D said, Her care plan is still the same. The approach dated [DATE] indicated 2 staff when rendering care, which meant there should have been two staff when providing toileting, incontinence care and bed mobility. Staff D stated the CNAs should follow interventions in the care plan. Staff D said, If an intervention is not implemented, it could result in failure to provide care as planned. If someone required two + assist, then they should have 2 staff providing care. Resident #1 required 2 staff. This is true and correct. Staff E said, Resident #1 did not do much for herself. She was dependent on staff for ADLs and safety. In a telephone interview on [DATE] at 3 p.m., the APRN stated, I was on my way out of the building, I saw people outside the resident's room. They said she fell , I went to the room, and saw the resident. She was on the floor. She said she had pain in her back. I asked her what happened, she said she fell , she said she was having pain in her back. She did not give a pain scale. She was transported to the hospital. The APRN stated she conducted a comprehensive assessment Resident #1 on [DATE]. The APRN said, She was a frail [AGE] year-old. She had issues with GI (Gastrointestinal) bleeding. She was a long-term patient with extensive medical history, a history of heart failure, she was considered in palliative care. She was small, she could not have been more than 90 pounds. She was not terminal, rather, failure to thrive due to heart failure which was chronic. She was not imminently ill. On [DATE] at 3:10 p.m. A telephone interview was conducted with Resident #1's primary care physician. (PCP). The PCP stated he saw her once, and when he came to see her a second time, he heard she was gone. The PCP said, I do not remember anything about her. Nothing that stands out .I see many patients. She was a long-term resident. An interview was conducted on [DATE] at 3:30 p.m. with the Staff Development Coordinator (SDC). She stated she had conducted in-services after Resident #1's fall. The SDC said, The training is 100% for direct care staff, Nurses, and CNAs. We trained on safely turning a patient over in bed. That means if you do not have two people, because we do not use side rails, you should pull the resident toward you. She stated while using a drawsheet, the staff should pull the resident towards them especially if they were on an air mattress. She stated they trained the CNAs on being aware that the resident may shift during care and that two people are required to change or move a resident on an air mattress. The SDC said, We have put bolsters on air mattresses and are monitoring to make sure the residents can remain safe when turned or repositioned in bed. The SDC stated rolling the resident away during care puts the resident at risk. The SDC said, I was familiar with the resident. She was able to talk, that is all she could do, she was bed fast. She was in constant pain. She used to have wounds and was on an air mattress for comfort. She had extremely limited use of her hands. She had a padded call light and used foam built up utensils. She could not grasp anything to pull herself up. She relied on staff to position her. The SDC stated the CNAs should follow care plan interventions. She stated if the care plan specified two person's assist, then they should follow that. The SDC said, If they do not follow the care plan, that would be careless, it puts everybody at risk. The SDC stated the CNAs learn from mentoring each other and that she did not conduct the CNA training herself. On [DATE] at 5:14 pm an interview was conducted with the Nursing Home Administrator (NHA)/Abuse Coordinator and Director of Nursing (DON)/Risk Manager. The NHA stated the event occurred on [DATE] at approximately 10:30 a.m. when a CNA [Staff A] was providing care. She was conducting a linen change; she had already completed the peri care. The NHA said, She [Staff A] was completing a linen change by herself. Immediately following the incident, I asked her if she knew how many people are needed to provide care. She said she always asks her nurse. The NHA stated the CNA said it could be 1 or 2 people. The NHA read part of the CNA's statement which reported, [sometimes the nurses get frustrated with me because I ask a lot of questions.] The NHA stated the CNA had completed care and was changing the resident's linens. She had started the process of turning the resident away from her when her left leg, which was stiff, got caught as she rolled to her right side. The NHA said, the bed was at the CNA's hip height. There were no fall mats. The resident hit the floor directly. The NHA stated they could not determine how she landed. She was noted on the floor, did not know if she hit her head. The NHA said, [Staff C], the nurse assigned was out for lunch break, and [Staff B] responded. [Staff B, RN] went into the room and assessed the resident. About the same time, the DON, and the Assistant Director of Nursing (ADON) came into the room. [Staff D] heard the CNA calling for help. She responded and saw the resident on the floor, and she called EMS. Resident #1 was sent to [Name of Hospital]. They then transferred her to [Name of Hospital] for trauma care. The NHA stated she was contacted by an investigator at the medical examiner's office for [name of county], on Saturday the 15th at approximately 4 p.m. and she was notified the resident had died . The NHA stated on Monday morning [DATE] they met with all department heads, reviewed care plans to determine bed mobility status and initiated education on how to disseminate information to staff with care plan changes. The NHA said, related to our investigation, we did not find that based on our policy the CNA had violated our policies. We determined it was an accident. Our findings revealed it was an accident. She provided care per the resident's care plan. The incident was not listed on the abuse / neglect log. We did not report to DCF (Department of Children and Families). We did not see it as abuse or neglect. We did not submit a five-day report. The resident was on an air mattress. In response we decided to add bolsters to all air mattresses. The NHA stated the nursing team assessed all the residents with air mattresses to see if it impeded their ability to rise. She stated they were trying to determine if the fall occurred because of the mattress to ensure other residents would not be affected. The NHA said, We do not have a policy/protocol for use of air mattresses. The standard would be for the CNAs to follow a resident's care plan. The DON stated they provided education on turning and repositioning of residents and how to roll the resident towards the CNA and not away from them. The DON stated when Staff A provided care, she turned the resident away from her. The DON said, We did not determine that she failed to follow procedure because our policy does not indicate the procedure of rolling a resident. She was alone when she was providing care. Nothing indicated she did anything wrong. She did everything correctly. The NHA said, Immediate and Five-day Federal reports were not reported because we did not feel there was abuse and neglect. That was the decision at the time, and it still is. Review of a facility document titled Facility Assessment, dated [DATE], showed under services and care offered based on the resident's needs, Mobility and prevention of falls/falls with injury. Specific care practices included: transfers, ambulation, restorative nursing, contracture prevention/care, supporting residents' independence in doing as much of these activities by himself/herself. A review of a facility policy titled, Abuse, Neglect and Misappropriation of property, dated [DATE], showed it is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property, and to assure that all alleged violations of federal or state laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property, are investigated, and reported immediately to the facility administrator, the state survey agency, and other appropriate state and local agencies in accordance with federal and state law. It is the organization's policy that the facility administrator or his or her designee, will direct a reasonable investigation of each such alleged violation, unless he or she has a conflict of interest or is implicated in the alleged violation. The facility administrator is responsible for reporting the results of all investigations to applicable state agencies as required by federal and state law. The facility administrator is the facilities designated abuse coordinator . and the implementation of this policy should be referred to him or her. Allegation of abuse means a report, complaint, grievance, statement incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring has occurred or plausibly might have occurred. An alleged violation involving abuse, neglect, exploitation, all mistreatment a reported immediately but no later than two hours after the allegation is made. Means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress. To the extent possible and applicable the following information may be pertinent when conducting a reasonable investigation: the date and time of the incident, the nature and circumstances of the incident, the location of the incident, the description of any injury, the condition of any injured person, the disposition of the injured person (for instance, transported to hospital), the names of witnesses and their accounts of the incident, the time and date of notification of the resident's physician and family, other pertinent information and the name and title of the person completing the documentation. Every stakeholder, contractor and volunteer immediately shall report any allegations of abuse, injury of unknown origin, all suspicion of crime . to the charge nurse on duty. Failure to report an allegation of abuse, injury of unknown origin or suspicion of crime may result in disciplinary action including termination of employment, and our further legal or criminal action against any person who is required to but fails to make such a report. A review of an undated facility document titled, Risk Manager, revealed the position is responsible for the development, implementation and facilitation of the Citadel-Florida's Risk Management and risk mitigation program. The responsibilities included assuming accountability for development, implementation, and assessment of Risk Management, Quality Assurance and Performance Improvement and Abuse prevention policies, procedures, and tools. The Risk Manager assumes accountability for development and implementation of a reporting, tracking and trending system for all incidents, adverse incidents and reportable events. Analyze root and contributing causes of events and trends, determine solutions, and provide preventative strategies. A review of a facility policy titled, Quality Assurance/Performance Improvement (QAPI)[TRUNCATED]

Based on record review and interviews with facility staff, family member, physicians, and review of facility policies and medical records, the facility failed to ensure supervision was provided to prevent a fall which resulted in the death of one (Resident #1) of 3 sampled residents. The facility failed to ensure Resident #1, a physically impaired resident, who was dependent on staff for all care and services received care as directed in her plan of care. The resident who required two-persons assistance received care from one (1) staff member resulting in a fall with fatal injuries. On [DATE], the resident fell from her bed while one staff person was providing care and hit her head on the wall. The resident was transferred out of the facility for acute care follow-up. The fall resulted in multiple fractures and injuries from which the resident succumbed to her death on [DATE]. The facility did not immediately report the accident as possible neglect or abuse to the state agency, did not remove the staff member from care to protect other residents, and did not conduct an investigation that concluded neglect had occurred. These failures resulted in a finding of Immediate Jeopardy at a scope and severity of (J) due to the fatal injuries that resulted in the death for Resident #1, and the likelihood of similar accidents could occur with other residents. The facility administrator was notified of the Immediate Jeopardy on [DATE] at 2:45 p.m. It was determined that the Immediate Jeopardy was removed on [DATE] and F689 was reduced to a Scope and Severity of D after verification of removal of immediacy of harm. Findings included: Cross reference to F600, F609, and F610. A review of an emergency room hospital record for Resident #1 dated [DATE] showed the [AGE] year-old female . with multiple chronic conditions, bedbound status presents after a fall from her bed at the nursing home. The bed was elevated at a high height, and she rolled out of it falling today. The fall was unwitnessed she was found on the floor. Complaints of back pain, shortness of breath, left leg pain and right foot pain. She is on Eliquis [a blood thinner] 2.5 mg (milligram). She is also on chronic pain medications. She is not sure if she lost consciousness or hit her head. She denies neck pain. She states her back pain is mostly in her mid back. Patient presented hypoxic [levels of oxygen in the blood are lower than normal] on non rebreather. Initial oxygen saturation was reportedly 66%. The emergency room diagnosis as of [DATE] at 3:46 p.m. indicated: Fall, initial encounter, Traumatic intracranial hemorrhage [bleeding within the skull] with unknown loss of consciousness status, initial encounter Hierarchical condition categories (HCC), closed fracture of proximal end of left tibia [shin bone], unspecified fracture morphology initial encounter. The emergency plan of care showed the patient suffered multiple small head bleeds, T2 (spinal thoracic bone) compression fracture, likely pulmonary contusions. She also has a minimally displaced left proximal tibia and fibula (leg) fracture given she is non weight bearing likely non operative management does not want surgery and she does not walk. A knee immobilizer is ordered. She has a right great toe fracture. The resident was transferred to a trauma Hospital for further evaluation and treatment. A review of hospital records showed on [DATE] at 05:31 p.m., Resident #1 was admitted for trauma care having presented to [name of Hospital] from an outside hospital due to intracranial hemorrhage and multiple traumatic injuries after sustaining a fall at her nursing facility. Per prior notes, patient fell out of bed and onto the ground. Patient was a DNR (do not resuscitate) and brought form with her. Patient was noted to have a right great toe proximal phalanx fracture, left tibial plateau fracture, left proximal fibular fracture that was minimally displaced, right frontal ([NAME]) compression fractures . Neurosurgery was consulted after the patient and [family member] talked about the patient's goals of care. Orthopedic trauma surgery elected to treat patient's fractures non-operatively given the patient is non-ambulatory baseline status and under hospice care per prior medical records. The patient was transitioned to comfort measures only . The patient expired at 8.30 a.m. Review of ICU (intensive care unit) notes showed the resident was critically ill with organ failure and severe metabolic derangements. This patient's prognosis for recovery based on their response to treatment and therapy, extent of organ system function and/or reserve was considered moribund = very very poor. A Review of Nursing facility progress note dated [DATE] at 10:58 a.m., showed at approximately 10:30 a.m., Staff A CNA was providing care for patient when patient rolled out of bed onto the floor. Patient sustained skin tear to left lower leg and elbow which was cleansed and dressed with steri strips. The Advanced Practice Registered Nurse (APRN) was in the building when the event occurred and ordered the patient to be sent to the emergency room for evaluation/treatment due to patient complaining of hip and back pain. On [DATE] at approximately 10:50 a.m., the patient was transferred to [Hospital name] via stretcher/EMS [emergency medical service] The Medical Director (MD) and family member were notified via telephone. A review of Resident #1's electronic medical record (EMR) showed the resident was admitted to the facility on [DATE] with diagnoses to include Acute respiratory disease, pulmonary, unspecified systolic (congestive heart failure), acute myocardial infarction (heart attack) unspecified among other diagnoses. A review of a quarterly Minimum Data Set (MDS) dated [DATE] Section G, Functional status showed the resident required extensive assistance, with two+ assistance for bed mobility. (Bed mobility indicates how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). An approach in Resident #1's care plan with a start date [DATE], showed 2 staff were required when rendering care. On [DATE], Resident #1 was provided incontinence care which required the resident to turn from side to side. The resident was physically impaired and was totally dependent on staff for care. The resident did not have the ability to prevent herself from falling off the bed. Staff A, Certified Nurse's Assistant (CNA), who was performing the duty by herself, rolled the resident away from her during care. The resident, who was under the care of Hospice at the time, fell from the bed, landing on the floor, and hit her head on the wall, for which she required immediate transfer to a higher level of care. A review of a care plan for Resident #1, Fall risk category with a start date [DATE], last revised [DATE], showed the resident was at risk for falls related to having suffered a fall within the last ,d+[DATE] months prior to admission. She has had a hip fracture within the past 6 months prior to admission. She is alert and oriented. She is able to verbalize all of her wants and needs and is understood by others. She required extensive assistance to basically total assistance [,d+[DATE]] with her locomotion, mobility, transfers, toileting, and incontinent care needs. She is non-ambulating at this point but is standing with walker. The treating therapist reported the resident had an extreme fear of falling which was impeding her ambulation. The resident used a wheelchair as primary mode of locomotion. She has daily use of psych medication. On [DATE] she suffered a fall with injury, laceration to bridge of nose which was noted healed . On [DATE] the resident suffered another fall with skin tears to her left leg and elbow. A goal in the care plan with a target date [DATE], showed will minimize risk of falls and fall related injuries. An approach with a start date [DATE] showed air mattress with bolsters to sides of bed. An approach with a start date [DATE] showed to keep bed in lowest position. A care plan for Resident #1 with a start date [DATE], showed a category Health related complications indicating the resident is at risk for further reduction in prior levels of mobility. She is at risk for possible further changes/declines in present levels of mobility due to the amount of assistance that is required with mobility and transfer related needs related to: The resident requires extensive to total assistance of ,d+[DATE] with her locomotion/mobility/transfers, toileting, and incontinence care needs. She is non ambulatory and has expressed an extreme fear of falling. An approach with a start date [DATE] showed 2 staff when rendering care. On [DATE] at 01:59 p.m., Staff D, MDS Registered Nurse (RN) confirmed the care plan was not specific as it showed ,d+[DATE] staff assistance. Staff D said, I can see how that would be confusing for a CNA not to know the number of staff required to provide assistance. I could have done a better job. An occupational Therapy and plan of treatment for Resident #1 dated [DATE] showed under fall risk assessment, Root cause analysis completed: patient currently requires maximum assistance of 2 for safely rolling patient side to side in bed for sitting more upright in bed, and for repositioning, hygiene, peri care, cleaning as per the caregivers, due to patient's severe arthritis joint protection issues and decreased skin integrity . Patient is dependent for all mobility tasks. Review of an activities of daily living (ADL) Care plan with a start date [DATE], last revised [DATE]., showed the resident was at risk for further declines/changes in self-care functional capabilities. She is at possible risk for further declines/changes in present self-care functional; capabilities due to amount of assistance needed presently with self-care task set up, completion of task and thoroughness related to diagnosis; recovered covid-19/pneumonia/status post fracture left femur /CHF (Congestive Heart Failure), anemia, history of NSTEMI (Non-St-elevation Myocardial infarction) /GERD (Gastroesophageal reflux disease), hyperlipidemia, and depression. She is alert and oriented x2 (meaning, she required 2 staff to provide care). She is able to verbalize her wants and needs total assistance [,d+[DATE]] with her ADL care, dressing, personal hygiene, bathing needs. She has incontinent occurrences of the bladder and bowels with daily use of briefs. She requires extensive assistance with her incontinent and peri care needs. An approach to the care plan with a start date [DATE] showed 2 staff were required when rendering care. A review of Resident #1's progress notes revealed: On [DATE] a nursing note showed the resident is alert and communicative, reports generalized chronic pain especially with repositioning and personal care. On [DATE] a nursing note showed . reports of pain to both lower and upper extremities. Requires maximum assistance with all types of care. On [DATE] PT (Physical Therapy) screen was completed. Patient is currently at baseline for functional mobility with no need to change or decline in function recently. On [DATE], a quarterly observation note indicated transfer status/assist of assistive devices showed the resident is immobile. Has weakness in all extremities. Has contractures bilateral on hands. On [DATE], an MDS coordinator progress note showed the information was gathered to complete the quarterly MDS . Resident required extensive assist x2 (meaning, she required 2 staff to provide care) with bed mobility, toileting, and bathing. [Resident #1] is non-ambulatory and requires assistance. On [DATE] at 12:58 p.m., an interview was conducted with Staff B, Registered Nurse (RN) who responded to Resident #1 after her fall. Staff B said, I went to the room. I did not know the resident. I observed the resident on the floor. She was lying on the left side of the bed. Her head was up against the wall. I looked at her legs and noted she was bleeding on the leg and on the arm. I cannot remember if it was left or right. It was a significant tear on the lower extremity of the leg, about 6 inches, skin was pulled back a little bit. The skin was folded in, you could see the subcutaneous tissue. The tear on the arm was approximately an inch and a half. Her head was resting on the wall which made me think she had hit her head. I cleaned her up and steri stripped it as the paramedics came in. I did not move her, they said she had brittle bones. She was resting her head against the wall. It looked like she had propped her head on the wall, which to me meant she hit her head on the wall. It was apparent she had hit her head on the way down. She was not crying, but it was clear she was in pain. She did not express the pain to me. I figured anyone who suffered a fall like she did, would be in pain. She had an air mattress; I did not see the rails. I addressed the bleeding first. She was talking as I was applying the steri strips. She said to me, [I told them I was going to fall.] I stayed with the resident until the paramedics came. On [DATE] at 1:11 p.m., an interview was conducted with Staff A, CNA who was assigned to Resident #1 [DATE]. She said, On that day, [DATE] between 10 a.m. and 10:30 a.m., I went to her room to take care of her. I was changing her as she needed incontinent care. She had a problem with her leg. She could not bend or move her left leg. She had pain in her right side. When I got to the room, I stood by her bedside, on the side of the door. I did not have two people at that time. She had an air mattress. There were no grab rails on her bed. She did not have the ability to grab and hold on to the rails. She was on an air mattress. She had a drawsheet under her. She could not move herself in bed. I pulled the drawsheet towards me, and the resident came towards me too. I provided care and then I pulled the drawsheet again and as I pushed her over the other side, the leg came out of the sheet, she said, I fell , I fell . She was talking to me. She said to me don't worry, I'm okay. She hit the floor. There was no mat on the floor. She landed on her back. The CNA stated education was offered on how to roll the resident over. She said, they said I have to pull the drawsheet to me; the resident has to go towards me all the time and if anyone is on an air mattress, we need two people to assist. On [DATE] at 10:35 a.m., a telephone interview was conducted with Resident #1's family member/ Responsible party. She stated Resident #1 had been at this facility for a couple of years. She stated during her last visit, the resident was herself even though she had not been out of bed in 2 years. She could not call for help on her own. Her roommate would call for her. Staff liked her. She had limited ability to use her body due to not having been out of bed and not moving her limbs. She was stiff and had zero muscles left. Her legs would sometimes swell. They had her in an air mattress. Her legs had started to curl up. She had very limited use of her hands. She was wasting away getting thinner and thinner, she was not able to feed herself, she needed staff to assist her. She could not use a call light or use a phone. She would not be able to grasp anything. She could not pick herself up or move herself in bed at all. The family member said, I received a call from the facility on [DATE]. They reported she fell out of bed. They said a CNA was changing her while in her bed when she fell and that she was complaining of pain. They said they had to send her out to be evaluated at a local hospital. That Hospital called me and said she had contusions, and they were sending her to [name of Hospital] for trauma care. The next call I received was from that hospital. They said they were doing x-rays and the surgeon would call me if they were to do surgery. At about midnight she was in the ICU, and she was on oxygen. They said she was slipping away. They were trying to draw blood. The next morning, they took her out of ICU, and they said they had her settled in her room. Before I could fly out, the hospital called and said she was gone. The only call I received from the nursing home was from someone saying she had fallen, and it was an accident. I don't know the circumstances, but she could not have stopped herself from falling, especially if the person changing her was on the other side of the bed. She was helpless. She was fully dependent on staff. The family member who was noted crying on the phone stated, She wanted to go, and I supported her, what else could I do? On [DATE] at 12:28 p.m., during a telephone interview, the Facility's Medical Director (MD) said, It is very unfortunate that she died . She stated she was notified about the fall. The MD said, They called me and said it was an accident. The resident fell because the CNA was by herself while changing the resident. She stated she had participated in QAPI (Quality Assurance Performance Improvement) via phone call, and they had discussed the fall. The MD stated the plan was to have a workshop to educate the CNAs and nurses and provide education on preventing avoidable accidents. The MD said, I don't want this to ever happen again. The MD stated the main thing was to have two CNAs at bedside and not have one CNA perform any sort of care for repositioning and change of linens for dependent residents on air mattresses by themself. She stated the expectation should be to provide care per the resident's care plan. The MD said, If Therapy had assessed for two person to assist in her care, then that should have been followed. Incidents/accidents will happen when care plan is not followed. I spoke to the Nursing Home Administrator (NHA), there should have been two people in the room. If there had been two people, this could have been prevented. On [DATE] at 12:30 p.m., an interview was conducted with the Director of Rehabilitation, (DOR). She stated the most recent evaluation was conducted on [DATE]th, 2023, at which Resident #1 was assessed as dependent, meaning she required total assistance for ADLs. When they are dependent, we take into consideration multiple things. If a patient requires a maximum assist of 2 for repositioning, hygiene, or peri care, two staff should assist per patient's limitations, such as severe arthritis and need to protect skin integrity. This resident was dependent on staff for all mobility skills because she was non-ambulatory, bed-bound, had BLE (bilateral lower extremities) contraction and needed a lower pressure mattress for pressure release. The Resident was always a two - person assistance. That was her baseline. We did not need to address her level of assistance as that is what it has always been, and it had not changed. Going forward education for the CNAs would be important for the sake of staff providing care and the residents. Not having that level of communication puts the resident at risk. The DOR stated she knew the resident. She was alert and oriented, it was a sad surprise for a lot of people that she had died . She was able to communicate her needs. They said she fell . The facility did trainings and in services about patient care and the way or level of assistance and mobility is determined. The care plan should say 1 or 2. It should be clearly defined. It should be either or. That would be confusing. Therapists fill out section GG of the resident assessment. In the MDS section G, if the resident is coded as requiring 2 staff, that info should go into the care plan as is. Resident #1 should have received incontinence care with two aides, she received an assist of one aide. On [DATE] at 12:13 p.m., an interview was conducted with Staff C, Licensed Practical Nurse (LPN) who was assigned to the resident. She stated on [DATE] she did not see the event happen. Staff C said, I was on my lunch break between 10:30 a.m. and 11 a.m. another nurse was covering the floor during my break. I was outside when one of the CNAs came and asked for keys to the treatment cart to get steri strips because the resident had a skin tear. I came in and got the treatment cart and strips and went to the room. I found [Staff B, RN] and already cleaned the resident. The resident was still on the floor, she was on the left side of the bed by the door bed. I can't recall if there was a fall mat. The height of the bed when I walked in was about hip height. The resident had a few skin tears. She was lying flat on her back. She was oriented, presented normal affect. She stated her hip and leg hurt. Other than that, she was normal meaning, same as she usually is. Staff C stated at approximately 10:20 a.m. or so EMS (Emergency Medical Service) arrived and transported the resident to the Hospital. She stated training was conducted after the incident about abuse and neglect. Staff C stated for everyone who had an air mattress, they had put bolsters, and also specified two people must be present for any type of care. She said, We re-trained on turning patient towards you not away from you. Staff C said, It was very unfortunate, especially because of the end result. The patient died . The resident was pleasant, she liked her snacks and ginger ale. She was very content, liked TV (Television). She never got out of bed, but she made her needs known. She was alert and oriented. She had brittle bone disease. She was stiff. She did not go anywhere. She required full care for toileting. She had previously fractured her leg or hip and was not able to sit or get out of bed. She required the staff's total assistance, for everything. On [DATE] at 1:52 p.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN) Minimum Data Set (MDS) coordinator and Staff E, RN MDS coordinator. They stated they update care plans by gathering information from what the CNAs are charting, and what therapy had assessed. The CNAs receive information on care plan changes from charge nurse, and reports from CNA to CNA. Staff D said, In the IDT (Interdisciplinary Team) morning meetings, we follow -up on post fall reviews, we update care plans, and the unit manager sends the interventions back to the floor. The CNAs are educated to follow -up on interventions, these are carried over during shift-to-shift exchange. Staff D and E reviewed Resident #1's interventions post fall and confirmed there had been no changes. Staff D said, Her care plan is still the same. The approach dated [DATE] indicated 2 staff when rendering care, which meant there should have been two staff when providing toileting, incontinence care and bed mobility. Staff D stated the CNAs should follow interventions in the care plan. Staff D said, If an intervention is not implemented, it could result in failure to provide care as planned. If someone required two + assist, then they should have 2 staff providing care. Resident #1 required 2 staff. This is true and correct. Staff E said, Resident #1 did not do much for herself. She was dependent on staff for ADLs and safety. In a telephone interview on [DATE] at 3 p.m., the APRN stated, I was on my way out of the building, I saw people outside the resident's room. They said she fell , I went to the room, and saw the resident. She was on the floor. She said she had pain in her back. I asked her what happened, she said she fell , she said she was having pain in her back. She did not give a pain scale. She was transported to the hospital. The APRN stated she conducted a comprehensive assessment Resident #1 on [DATE]. The APRN said, She was a frail [AGE] year-old. She had issues with GI (Gastrointestinal) bleeding. She was a long-term patient with extensive medical history, a history of heart failure, she was considered in palliative care. She was small, she could not have been more than 90 pounds. She was not terminal, rather, failure to thrive due to heart failure which was chronic. She was not imminently ill. On [DATE] at 3:10 p.m. A telephone interview was conducted with Resident #1's primary care physician. (PCP). The PCP stated he saw her once, and when he came to see her a second time, he heard she was gone. The PCP said, I do not remember anything about her. Nothing that stands out .I see many patients. She was a long-term resident. An interview was conducted on [DATE] at 3:30 p.m. with the Staff Development Coordinator (SDC). She stated she had conducted in-services after Resident #1's fall. The SDC said, The training is 100% for direct care staff, Nurses, and CNAs. We trained on safely turning a patient over in bed. That means if you do not have two people, because we do not use side rails, you should pull the resident toward you. She stated while using a drawsheet, the staff should pull the resident towards them especially if they were on an air mattress. She stated they trained the CNAs on being aware that the resident may shift during care and that two people are required to change or move a resident on an air mattress. The SDC said, We have put bolsters on air mattresses and are monitoring to make sure the residents can remain safe when turned or repositioned in bed. The SDC stated rolling the resident away during care puts the resident at risk. The SDC said, I was familiar with the resident. She was able to talk, that is all she could do, she was bed fast. She was in constant pain. She used to have wounds and was on an air mattress for comfort. She had extremely limited use of her hands. She had a padded call light and used foam built up utensils. She could not grasp anything to pull herself up. She relied on staff to position her. The SDC stated the CNAs should follow care plan interventions. She stated if the care plan specified two person's assist, then they should follow that. The SDC said, If they do not follow the care plan, that would be careless, it puts everybody at risk. The SDC stated the CNAs learn from mentoring each other and that she did not conduct the CNA training herself. On [DATE] at 5:14 pm an interview was conducted with the Nursing Home Administrator (NHA)/Abuse Coordinator and Director of Nursing (DON)/Risk Manager. The NHA stated the event occurred on [DATE] at approximately 10:30 a.m. when a CNA [Staff A] was providing care. She was conducting a linen change; she had already completed the peri care. The NHA said, She [Staff A] was completing a linen change by herself. Immediately following the incident, I asked her if she knew how many people are needed to provide care. She said she always asks her nurse. The NHA stated the CNA said it could be 1 or 2 people. The NHA read part of the CNA's statement which reported, [sometimes the nurses get frustrated with me because I ask a lot of questions.] The NHA stated the CNA had completed care and was changing the resident's linens. She had started the process of turning the resident away from her when her left leg, which was stiff, got caught as she rolled to her right side. The NHA said, the bed was at the CNA's hip height. There were no fall mats. The resident hit the floor directly. The NHA stated they could not determine how she landed. She was noted on the floor, did not know if she hit her head. The NHA said, [Staff C], the nurse assigned was out for lunch break, and [Staff B] responded. [Staff B, RN] went into the room and assessed the resident. About the same time, the DON, and the Assistant Director of Nursing (ADON) came into the room. [Staff D] heard the CNA calling for help. She responded and saw the resident on the floor, and she called EMS. Resident #1 was sent to [Name of Hospital]. They then transferred her to [Name of Hospital] for trauma care. The NHA stated she was contacted by an investigator at the medical examiner's office for [name of county], on Saturday the 15th at approximately 4 p.m. and she was notified the resident had died . The NHA stated on Monday morning [DATE] they met with all department heads, reviewed care plans to determine bed mobility status and initiated education on how to disseminate information to staff with care plan changes. The NHA said, related to our investigation, we did not find that based on our policy the CNA had violated our policies. We determined it was an accident. Our findings revealed it was an accident. She provided care per the resident's care plan. The incident was not listed on the abuse / neglect log. We did not report to DCF (Department of Children and Families). We did not see it as abuse or neglect. We did not submit a five-day report. The resident was on an air mattress. In response we decided to add bolsters to all air mattresses. The NHA stated the nursing team assessed all the residents with air mattresses to see if it impeded their ability to rise. She stated they were trying to determine if the fall occurred because of the mattress to ensure other residents would not be affected. The NHA said, We do not have a policy/protocol for use of air mattresses. The standard would be for the CNAs to follow a resident's care plan. The DON stated they provided education on turning and repositioning of residents and how to roll the resident towards the CNA and not away from them. The DON stated when Staff A provided care, she turned the resident away from her. The DON said, We did not determine that she failed to follow procedure because our policy does not indicate the procedure of rolling a resident. She was alone when she was providing care. Nothing indicated she did anything wrong. She did everything correctly. The NHA said, Immediate and Five-day Federal reports were not reported because we did not feel there was abuse and neglect. That was the decision at the time, and it still is. A review of a facility policy titled, Falls Policy, dated [DATE], showed the facility provides an environment that is free from accident hazards over which the facility has control to prevent avoidable falls. Guidelines showed: All residents will have a comprehensive fall risk assessment on admission/readmission, quarterly, annually and with significant change of condition. Appropriate care plan interventions will be implemented and evaluated as indicated by assessment. A comprehensive care plan will be implemented based on fall risk evaluation score with an individual goal and interventions specific to each resident. The care plan will be reviewed following each fall, quarterly, annually and with each significant change. Interventions are to be revised as indicated by the assessment. Interdisciplinary team (IDT)/ Director of Nursing (DON) or designee reviews during the risk meeting. Care plans will be reviewed and revised as appropriate and as needed. Falls will be reviewed at the facility Quality Assurance Performance Improvement(QAPI) committee. Responsible roles are the Director of nursing, licensed nurse, and interdisciplinary team. Review of a facility document titled Facility Assessment, dated [DATE], showed under services and care offered based on the resident's needs, Mobility and prevention of falls/falls with injury. Specific care practices included: transfers, ambulation, restorative nursing, contracture prevention/care, supporting residents' independence in doing as much of these activities by himself/herself. A review of a facility policy titled, Abuse, Neglect and Misappropriation of property, dated [DATE], showed it is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property, and to assure that all alleged violations of federal or state laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property, are investigated, and reported immediately to the facility administrator, the state survey agency, and other appropriate state and local agencies in accordance with federal and state law. It is the organization's policy that the facility administrator or his or her designee, will direct a reasonable investigation of each such alleged violation, unless he or she has a conflict of interest or is implicated in the alleged violation. The facility administrator is responsible for reporting the results of all investigations to applicable state agencies as required by federal and state law. The facility administrator is the facilities desig [TRUNCATED]

Based on record review and interviews with facility staff, family member, physicians, and review of facility policies and medical records, the facility failed to protect the resident's right to be free from neglect by not providing the services to prevent necessary to avoid physical harm, pain, and mental anguish for one resident (#1) of 3 sampled residents. Resident #1, who was a physically impaired resident, and was dependent on staff for all care and services, required two persons assistance for bed mobility, and received care from one staff member. On [DATE], the resident fell from her bed while one staff person was providing care and hit her head on the wall. The resident was transferred out of the facility for acute care follow-up. The fall resulted in multiple fractures and injuries from which the resident succumbed to her death on [DATE]. The facility failed to recognize neglect and did not immediately report the accident as possible neglect or abuse to the state survey agency and to the state abuse investigation agency, did not remove the staff member from care to protect other residents, and did not conduct an investigation that concluded neglect had occurred. The facility also failed to implement their Resident Mistreatment, Neglect and Abuse Prohibition policies and procedures. These failures resulted in a finding of Immediate Jeopardy at a scope and severity of (J) due to the fatal injuries that resulted in the death of Resident #1, and the likelihood of similar accidents could occur with other residents. The facility administrator was notified of the Immediate Jeopardy on [DATE] at 2:45 p.m. It was determined that the Immediate Jeopardy was removed on [DATE] and F600 was reduced to a Scope and Severity of D after verification of removal of immediacy of harm. Findings included: Cross reference to F609, F610, and F689. A review of an emergency room hospital record for Resident #1 dated [DATE] showed the [AGE] year-old female . with multiple chronic conditions, bedbound status presents after a fall from her bed at the nursing home. The bed was elevated at a high height, and she rolled out of it falling today. The fall was unwitnessed she was found on the floor. Complaints of back pain, shortness of breath, left leg pain and right foot pain. She is on Eliquis [a blood thinner] 2.5 mg (milligram). She is also on chronic pain medications. She is not sure if she lost consciousness or hit her head. She denies neck pain. She states her back pain is mostly in her mid back. Patient presented hypoxic [levels of oxygen in the blood are lower than normal] on non rebreather. Initial oxygen saturation was reportedly 66%. The emergency room diagnosis as of [DATE] at 3:46 p.m. indicated: Fall, initial encounter, Traumatic intracranial hemorrhage [bleeding within the skull] with unknown loss of consciousness status, initial encounter Hierarchical condition categories (HCC),closed fracture of proximal end of left tibia [shin bone], unspecified fracture morphology initial encounter. The emergency plan of care showed the patient suffered multiple small head bleeds, T2 (spinal thoracic bone) compression fracture, likely pulmonary contusions. She also has a minimally displaced left proximal tibia and fibula (leg) fracture given she is non weight bearing likely non operative management does not want surgery and she does not walk. A knee immobilizer is ordered. She has a right great toe fracture. The resident was transferred to a trauma Hospital for further evaluation and treatment. A review of hospital records showed on [DATE] at 05:31 p.m., Resident #1 was admitted for trauma care having presented to [name of Hospital] from an outside hospital due to intracranial hemorrhage and multiple traumatic injuries after sustaining a fall at her nursing facility. Per prior notes, patient fell out of bed and onto the ground. Patient was a DNR (do not resuscitate) and brought form with her. Patient was noted to have a right great toe proximal phalanx fracture, left tibial plateau fracture, left proximal fibular fracture that was minimally displaced, right frontal ([NAME]) compression fractures . Neurosurgery was consulted after the patient and [family member] talked about the patient's goals of care. Orthopedic trauma surgery elected to treat patient's fractures non-operatively given the patient is non-ambulatory baseline status and under hospice care per prior medical records. The patient was transitioned to comfort measures only . The patient expired at 8.30 a.m. Review of ICU (intensive care unit) notes showed the resident was critically ill with organ failure and severe metabolic derangements. This patient's prognosis for recovery based on their response to treatment and therapy, extent of organ system function and/or reserve was considered moribund = very very poor. A Review of Nursing facility progress note dated [DATE] at 10:58 a.m., showed at approximately 10:30 a.m., Staff A Certified Nursing Assistant (CNA) was providing care for patient when patient rolled out of bed onto the floor. Patient sustained skin tear to left lower leg and elbow which was cleansed and dressed with steri strips. The Advanced Practice Registered Nurse (APRN) was in the building when the event occurred and ordered the patient to be sent to the emergency room for evaluation/treatment due to patient complaining of hip and back pain. On [DATE] at approximately 10:50 a.m., the patient was transferred to [Hospital name] via stretcher/EMS [emergency medical service] The Medical Director (MD) and family member were notified via telephone. A review of Resident #1's electronic medical record (EMR) showed the resident was admitted to the facility on [DATE] with diagnoses to include Acute respiratory disease, pulmonary, unspecified systolic (congestive heart failure), acute myocardial infarction unspecified among other diagnoses. A care plan for Resident #1 with a start date [DATE], showed a category Health related complications indicating the resident is at risk for further reduction in prior levels of mobility. She is at risk for possible further changes/declines in present levels of mobility due to the amount of assistance that is required with mobility and transfer related needs related to: The resident requires extensive to total assistance of ,d+[DATE] with her locomotion/mobility/transfers, toileting, and incontinence care needs. She is non ambulatory and has expressed an extreme fear of falling. An approach with a start date [DATE] showed 2 staff required when rendering care. On [DATE], Resident #1 was provided incontinence care which required the resident to turn from side to side. The resident was physically impaired and was totally dependent on staff for care. The resident did not have the ability to prevent herself from falling off the bed. Staff A, CNA, who was performing the duty by herself, rolled the resident away from her during care. The resident, who was under the care of Hospice at the time, fell from the bed, landing on the floor, and hit her head on the wall, for which she required immediate transfer to a higher level of care. On [DATE] at 01:59 p.m., Staff D, MDS Registered Nurse (RN) confirmed the care plan was not specific as it showed ,d+[DATE] staff assistance. Staff D said, I can see how that would be confusing for a CNA not to know the number of staff required to provide assistance. I could have done a better job. An occupational Therapy and plan of treatment for Resident #1 dated [DATE] showed under fall risk assessment, Root cause analysis completed: patient currently requires maximum assistance of 2 for safely rolling patient side to side in bed for sitting more upright in bed, and for repositioning, hygiene, peri care, cleaning as per the caregivers, due to patient's severe arthritis joint protection issues and decreased skin integrity . Patient is dependent for all mobility tasks. Review of an activities of daily living (ADL) Care plan with a start date [DATE], last revised [DATE]., showed the resident was at risk for further declines/changes in self-care functional capabilities. She is at possible risk for further declines/changes in present self-care functional; capabilities due to amount of assistance needed presently with self-care task set up, completion of task and thoroughness related to diagnosis; recovered covid-19/pneumonia/status post fracture left femur /CHF (Congestive Heart Failure), anemia, history of NSTEMI (Non-ST-elevation Myocardial infarction) /GERD (Gastroesophageal reflux disease), hyperlipidemia, and depression. She is alert and oriented, is able to verbalize her wants, and needs total assistance [,d+[DATE]] with her ADL care, dressing, personal hygiene, bathing needs. She has incontinent occurrences of the bladder and bowels with daily use of briefs. She requires extensive assistance with her incontinent and peri care needs. An approach to the care plan with a start date [DATE] showed 2 staff were required when rendering care. A review of Resident #1's progress notes revealed: On [DATE] a nursing note showed the resident is alert and communicative, reports generalized chronic pain especially with repositioning and personal care. On [DATE] a nursing note showed . reports of pain to both lower and upper extremities. Requires maximum assistance with all types of care. On [DATE] PT (Physical Therapy) screen was completed. Patient is currently at baseline for functional mobility with no need to change or decline in function recently. On [DATE], a quarterly observation note indicated transfer status/assist of assistive devices showed the resident is immobile. Has weakness in all extremities. Has contractures bilateral on hands. On [DATE], an MDS coordinator progress note showed the information was gathered to complete the quarterly MDS . Resident required extensive assist x2 (meaning, she required 2 staff to provide care) with bed mobility, toileting, and bathing. [Resident #1] is non-ambulatory and requires assistance. On [DATE] at 12:58 p.m., an interview was conducted with Staff B, Registered Nurse (RN) who responded to Resident #1 after her fall. Staff B, RN said, I went to the room. I did not know the resident. I observed the resident on the floor. She was lying on the left side of the bed. Her head was up against the wall. I looked at her legs and noted she was bleeding on the leg and on the arm. I cannot remember if it was left or right. It was a significant tear on the lower extremity of the leg, about 6 inches, skin was pulled back a little bit. The skin was folded in, you could see the subcutaneous tissue. The tear on the arm was approximately an inch and a half. Her head was resting on the wall which made me think she had hit her head. I cleaned her up and steri stripped it as the paramedics came in. I did not move her, they said she had brittle bones. She was resting her head against the wall. It looked like she had propped her head on the wall, which to me meant she hit her head on the wall. It was apparent she had hit her head on the way down. She was not crying, but it was clear she was in pain. She did not express the pain to me. I figured anyone who suffered a fall like she did, would be in pain. She had an air mattress; I did not see the rails. I addressed the bleeding first. She was talking as I was applying the steri strips. She said to me, [I told them I was going to fall.] I stayed with the resident until the paramedics came. On [DATE] at 1:11 p.m., an interview was conducted with Staff A, CNA who was assigned to Resident #1 [DATE]. She said, On that day, [DATE] between 10 a.m. and 10:30 a.m., I went to her room to take care of her. I was changing her as she needed incontinent care. She had a problem with her leg. She could not bend or move her left leg. She had pain in her right side. When I got to the room, I stood by her bedside, on the side of the door. I did not have two people at that time. She had an air mattress. There were no grab rails on her bed. She did not have the ability to grab and hold on to the rails. She was on an air mattress. She had a drawsheet under her. She could not move herself in bed. I pulled the drawsheet towards me, and the resident came towards me too. I provided care and then I pulled the drawsheet again and as I pushed her over the other side, the leg came out of the sheet, she said, I fell , I fell . She was talking to me. She said to me don't worry, I'm okay. She hit the floor. There was no mat on the floor. She landed on her back. The CNA stated education was offered on how to roll the resident over. She said, they said I have to pull the drawsheet to me; the resident has to go towards me all the time and if anyone is on an air mattress, we need two people to assist. On [DATE] at 10:35 a.m., a telephone interview was conducted with Resident #1's family member/ Responsible party. She stated Resident #1 had been at this facility for a couple of years. She stated during her last visit, the resident was herself even though she had not been out of bed in 2 years. She could not call for help on her own. Her roommate would call for her. Staff liked her. She had limited ability to use her body due to not having been out of bed and not moving her limbs. She was stiff and had zero muscles left. Her legs would sometimes swell. They had her in an air mattress. Her legs had started to curl up. She had very limited use of her hands. She was wasting away getting thinner and thinner, she was not able to feed herself, she needed staff to assist her. She could not use a call light or use a phone. She would not be able to grasp anything. She could not pick herself up or move herself in bed at all. The family member said, I received a call from the facility on [DATE]. They reported she fell out of bed. They said a CNA was changing her while in her bed when she fell and that she was complaining of pain. They said they had to send her out to be evaluated at a local hospital. That Hospital called me and said she had contusions, and they were sending her to [name of Hospital] for trauma care. The next call I received was from that hospital. They said they were doing x-rays and the surgeon would call me if they were to do surgery. At about midnight she was in the ICU, and she was on oxygen. They said she was slipping away. They were trying to draw blood. The next morning, they took her out of ICU, and they said they had her settled in her room. Before I could fly out, the hospital called and said she was gone. The only call I received from the nursing home was from someone saying she had fallen, and it was an accident. I don't know the circumstances, but she could not have stopped herself from falling, especially if the person changing her was on the other side of the bed. She was helpless. She was fully dependent on staff. The family member who was noted crying on the phone stated, She wanted to go, and I supported her, what else could I do? On [DATE] at 12:28 p.m., during a telephone interview, the Facility's Medical Director (MD) said, It is very unfortunate that she died . She stated she was notified about the fall. The MD said, They called me and said it was an accident. The resident fell because the CNA was by herself while changing the resident. She stated she had participated in QAPI (Quality Assurance Performance Improvement) via phone call, and they had discussed the fall. The MD stated the plan was to have a workshop to educate the CNAs and nurses and provide education on preventing avoidable accidents. The MD said, I don't want this to ever happen again. The MD stated the main thing was to have two CNAs at bedside and not have one CNA perform any sort of care for repositioning and change of linens for dependent residents on air mattresses by themself. She stated the expectation should be to provide care per the resident's care plan. The MD said, If Therapy had assessed for two person to assist in her care, then that should have been followed. Incidents/accidents will happen when care plan is not followed. I spoke to the Nursing Home Administrator (NHA), there should have been two people in the room. If there had been two people, this could have been prevented. On [DATE] at 12:30 p.m., an interview was conducted with the Director of Rehabilitation, (DOR). She stated the most recent evaluation was conducted on [DATE]th, 2023, at which Resident #1 was assessed as dependent, meaning she required total assistance for ADLs. When they are dependent, we take into consideration multiple things. If a patient requires a max assist of 2 for repositioning, hygiene, or peri care, two staff should assist per patient's limitations, such as severe arthritis and need to protect skin integrity. This resident was dependent on staff for all mobility skills because she was non-ambulatory, bed-bound, had BLE (bilateral lower extremities) contraction and needed a lower pressure mattress for pressure release. The Resident was always a two - person assistance. That was her baseline. We did not need to address her level of assistance as that is what it has always been, and it had not changed. Going forward education for the CNAs would be important for the sake of staff providing care and the residents. Not having that level of communication puts the resident at risk. The DOR stated she knew the resident. She was alert and oriented, it was a sad surprise for a lot of people that she had died . She was able to communicate her needs. They said she fell . The facility did trainings and in services about patient care and the way or level of assistance and mobility is determined. The care plan should say 1 or 2. It should be clearly defined. It should be either or. That would be confusing. Therapists fill out section GG of the resident assessment. In the MDS section G, if the resident is coded as requiring 2 staff, that info should go into the care plan as is. Resident #1 should have received incontinence care with two aides, she received an assist of one aide. On [DATE] at 12:13 p.m., an interview was conducted with Staff C, Licensed Practical Nurse (LPN) who was assigned to the resident. She stated on [DATE] she did not see the event happen. Staff C said, I was on my lunch break between 10:30 a.m. and 11 a.m. another nurse was covering the floor during my break. I was outside when one of the CNAs came and asked for keys to the treatment cart to get steri strips because the resident had a skin tear. I came in and got the treatment cart and strips and went to the room. I found [Staff B, RN] and already cleaned the resident. The resident was still on the floor, she was on the left side of the bed by the door bed. I can't recall if there was a fall mat. The height of the bed when I walked in was about hip height. The resident had a few skin tears. She was lying flat on her back. She was oriented, presented normal affect. She stated her hip and leg hurt. Other than that, she was normal meaning, same as she usually is. Staff C stated at approximately 10:20 a.m. or so EMS (Emergency Medical Service) arrived and transported the resident to the Hospital. She stated training was conducted after the incident about abuse and neglect. Staff C stated for everyone who had an air mattress, they had put bolsters, and also specified two people must be present for any type of care. She said, We re-trained on turning patient towards you not away from you. Staff C said, It was very unfortunate, especially because of the end result. The patient died . The resident was pleasant, she liked her snacks and ginger ale. She was very content, liked TV (Television). She never got out of bed, but she made her needs known. She was alert and oriented. She had brittle bone disease. She was stiff. She did not go anywhere. She required full care for toileting. She had previously fractured her leg or hip and was not able to sit or get out of bed. She required the staff's total assistance, for everything. On [DATE] at 1:52 p.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN) Minimum Data Set (MDS) coordinator and Staff E, RN MDS coordinator. They stated they update care plans by gathering information from what the CNAs are charting, and what therapy had assessed. The CNAs receive information on care plan changes from charge nurse, and reports from CNA to CNA. Staff D said, In the IDT (Interdisciplinary Team) morning meetings, we follow -up on post fall reviews, we update care plans, and the unit manager sends the interventions back to the floor. The CNAs are educated to follow -up on interventions, these are carried over during shift-to-shift exchange. Staff D and E reviewed Resident #1's interventions post fall and confirmed there had been no changes. Staff D said, Her care plan is still the same. The approach dated [DATE] indicated 2 staff when rendering care, which meant there should have been two staff when providing toileting, incontinence care and bed mobility. Staff D stated the CNAs should follow interventions in the care plan. Staff D said, If an intervention is not implemented, it could result in failure to provide care as planned. If someone required two + assist, then they should have 2 staff providing care. Resident #1 required 2 staff. This is true and correct. Staff E said, Resident #1 did not do much for herself. She was dependent on staff for ADLs and safety. In a telephone interview on [DATE] at 3 p.m., the APRN stated, I was on my way out of the building, I saw people outside the resident's room. They said she fell , I went to the room, and saw the resident. She was on the floor. She said she had pain in her back. I asked her what happened, she said she fell , she said she was having pain in her back. She did not give a pain scale. She was transported to the hospital. The APRN stated she conducted a comprehensive assessment Resident #1 on [DATE]. The APRN said, She was a frail [AGE] year-old. She had issues with GI (Gastrointestinal) bleeding. She was a long-term patient with extensive medical history, a history of heart failure, she was considered in palliative care. She was small, she could not have been more than 90 pounds. She was not terminal, rather, failure to thrive due to heart failure which was chronic. She was not imminently ill. On [DATE] at 3:10 p.m. A telephone interview was conducted with Resident #1's primary care physician. (PCP). The PCP stated he saw her once, and when he came to see her a second time, he heard she was gone. The PCP said, I do not remember anything about her. Nothing that stands out .I see many patients. She was a long-term resident. An interview was conducted on [DATE] at 3:30 p.m. with the Staff Development Coordinator (SDC). She stated she had conducted in-services after Resident #1's fall. The SDC said, The training is 100% for direct care staff, Nurses, and CNAs. We trained on safely turning a patient over in bed. That means if you do not have two people, because we do not use side rails, you should pull the resident toward you. She stated while using a drawsheet, the staff should pull the resident towards them especially if they were on an air mattress. She stated they trained the CNAs on being aware that the resident may shift during care and that two people are required to change or move a resident on an air mattress. The SDC said, We have put bolsters on air mattresses and are monitoring to make sure the residents can remain safe when turned or repositioned in bed. The SDC stated rolling the resident away during care puts the resident at risk. The SDC said, I was familiar with the resident. She was able to talk, that is all she could do, she was bed fast. She was in constant pain. She used to have wounds and was on an air mattress for comfort. She had extremely limited use of her hands. She had a padded call light and used foam built up utensils. She could not grasp anything to pull herself up. She relied on staff to position her. The SDC stated the CNAs should follow care plan interventions. She stated if the care plan specified two person's assist, then they should follow that. The SDC said, If they do not follow the care plan, that would be careless, it puts everybody at risk. The SDC stated the CNAs learn from mentoring each other and that she did not conduct the CNA training herself. On [DATE] at 5:14 pm an interview was conducted with the Nursing Home Administrator (NHA)/Abuse Coordinator and Director of Nursing (DON)/Risk Manager. The NHA stated the event occurred on [DATE] at approximately 10:30 a.m. when a CNA [Staff A] was providing care. She was conducting a linen change; she had already completed the peri care. The NHA said, She [Staff A] was completing a linen change by herself. Immediately following the incident, I asked her if she knew how many people are needed to provide care. She said she always asks her nurse. The NHA stated the CNA said it could be 1 or 2 people. The NHA read part of the CNA's statement which reported, [sometimes the nurses get frustrated with me because I ask a lot of questions.] The NHA stated the CNA had completed care and was changing the resident's linens. She had started the process of turning the resident away from her when her left leg, which was stiff, got caught as she rolled to her right side. The NHA said, the bed was at the CNA's hip height. There were no fall mats. The resident hit the floor directly. The NHA stated they could not determine how she landed. She was noted on the floor, did not know if she hit her head. The NHA said, [Staff C], the nurse assigned was out for lunch break, and [Staff B] responded. [Staff B, RN] went into the room and assessed the resident. About the same time, the DON, and the Assistant Director of Nursing (ADON) came into the room. [Staff D] heard the CNA calling for help. She responded and saw the resident on the floor, and she called EMS. Resident #1 was sent to [Name of Hospital]. They then transferred her to [Name of Hospital] for trauma care. The NHA stated she was contacted by an investigator at the medical examiner's office for [name of county], on Saturday the 15th at approximately 4 p.m. and she was notified the resident had died . The NHA stated on Monday morning [DATE] they met with all department heads, reviewed care plans to determine bed mobility status and initiated education on how to disseminate information to staff with care plan changes. The NHA said, related to our investigation, we did not find that based on our policy the CNA had violated our policies. We determined it was an accident. Our findings revealed it was an accident. She provided care per the resident's care plan. The incident was not listed on the abuse / neglect log. We did not report to DCF (Department of Children and Families: the Florida state agency responsible for investigating abuse and neglect). We did not see it as abuse or neglect. We did not submit a five-day report. The resident was on an air mattress. In response we decided to add bolsters to all air mattresses. The NHA stated the nursing team assessed all the residents with air mattresses to see if it impeded their ability to rise. She stated they were trying to determine if the fall occurred because of the mattress to ensure other residents would not be affected. The NHA said, We do not have a policy/protocol for use of air mattresses. The standard would be for the CNAs to follow a resident's care plan. The DON stated they provided education on turning and repositioning of residents and how to roll the resident towards the CNA and not away from them. The DON stated when Staff A provided care, she turned the resident away from her. The DON said, We did not determine that she failed to follow procedure because our policy does not indicate the procedure of rolling a resident. She was alone when she was providing care. Nothing indicated she did anything wrong. She did everything correctly. The NHA said, Immediate and Five-day Federal reports were not reported because we did not feel there was abuse and neglect. That was the decision at the time, and it still is. Review of a facility document titled Facility Assessment, dated [DATE], showed under services and care offered based on the resident's needs, Mobility and prevention of falls/falls with injury. Specific care practices included: transfers, ambulation, restorative nursing, contracture prevention/care, supporting residents' independence in doing as much of these activities by himself/herself. A review of a facility policy titled, Abuse, Neglect and Misappropriation of Property, dated [DATE], showed it is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property, and to assure that all alleged violations of federal or state laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property, are investigated, and reported immediately to the facility administrator, the state survey agency, and other appropriate state and local agencies in accordance with federal and state law. It is the organization's policy that the facility administrator or his or her designee, will direct a reasonable investigation of each such alleged violation, unless he or she has a conflict of interest or is implicated in the alleged violation. The facility administrator is responsible for reporting the results of all investigations to applicable state agencies as required by federal and state law. The facility administrator is the facilities designated abuse coordinator . and the implementation of this policy should be referred to him or her. Allegation of abuse means a report, complaint, grievance, statement incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring has occurred or plausibly might have occurred. An alleged violation involving abuse, neglect, exploitation, all mistreatment a reported immediately but no later than two hours after the allegation is made. Means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress. To the extent possible and applicable the following information may be pertinent when conducting a reasonable investigation: the date and time of the incident, the nature and circumstances of the incident, the location of the incident, the description of any injury, the condition of any injured person, the disposition of the injured person (for instance, transported to hospital), the names of witnesses and their accounts of the incident, the time and date of notification of the resident's physician and family, other pertinent information and the name and title of the person completing the documentation. Every stakeholder, contractor and volunteer immediately shall report any allegations of abuse, injury of unknown origin, all suspicion of crime . to the charge nurse on duty. Failure to report an allegation of abuse, injury of unknown origin or suspicion of crime may result in disciplinary action including termination of employment, and our further legal or criminal action against any person who is required to but fails to make such a report. A review of an undated facility document titled, Risk Manager, revealed the position is responsible for the development, implementation and facilitation of the Citadel-Florida's Risk Management and risk mitigation program. The responsibilities included assuming accountability for development, implementation, and assessment of Risk Management, Quality Assurance and Performance Improvement and Abuse prevention policies, procedures, and tools. The Risk Manager assumes accountability for development and implementation of a reporting, tracking and trending system for all incidents, adverse incidents and reportable events. Analyze root and contributing causes of events and trends, determine solutions, and provide preventative strategies. A review of a facility policy titled, Quality Assurance/Performance Improvement (QAPI), dated [DATE], showed the purpose was to provide a process that will enhance the care and experience for all residents, improve the work environment for stakeholders, and quality of all services provided by the facility. The int [TRUNCATED]

Based on record review and interviews with facility staff, family member, physicians, and review of facility policies and medical records, the facility failed to ensure freedom from neglect by not implementing the facility's policy and procedure for Resident Mistreatment, Neglect and Abuse Prohibition for one (Resident #1) of 3 sampled residents. The facility failed to recognize and report neglect for Resident #1, a physically impaired resident, who was dependent on staff for all care and services, required two-persons assistance, and received care from one (1) staff member. On [DATE], the resident fell from her bed while one staff person was providing care and hit her head on the wall. The resident was transferred out of the facility for acute care follow-up. The fall resulted in multiple fractures and injuries from which the resident succumbed to her death on [DATE]. A review of a quarterly Minimum Data Set (MDS) dated [DATE] Section G, Functional status showed the resident required extensive assistance, with two+ assistance for bed mobility. (Bed mobility indicates how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). An approach in Resident #1's care plan with a start date [DATE], showed 2 staff were required when rendering care. On [DATE], Resident #1 was provided incontinence care which required the resident to turn from side to side. The resident was physically impaired and was totally dependent on staff for care. The resident did not have the ability to prevent herself from falling off the bed. Staff A, Certified Nursing Assistant (CNA), who was performing the duty by herself, rolled the resident away from her during care. The resident, who was under the care of Hospice at the time, fell from the bed, landing on the floor, and hit her head on the wall, for which she required immediate transfer to a higher level of care. The facility did not immediately report the accident as possible neglect or abuse to the state agency, did not remove the staff member from care to protect other residents, and did not conduct an investigation that concluded neglect had occurred. These failures resulted in a finding of Immediate Jeopardy at a scope and severity of (J) due to the fatal injuries that resulted in the death for Resident #1, and the likelihood of similar accidents could occur with other residents. The facility administrator was notified of the Immediate Jeopardy on [DATE] at 2:45 p.m. It was determined that the Immediate Jeopardy was removed on [DATE] and F600 was reduced to a Scope and Severity of D after verification of removal of immediacy of harm. Findings included: Cross Reference to citations F600, F610, and F689. A review of an emergency room hospital record for Resident #1 dated [DATE] showed the [AGE] year-old female . with multiple chronic conditions, bedbound status presents after a fall from her bed at the nursing home. The bed was elevated at a high height, and she rolled out of it falling today. The fall was unwitnessed she was found on the floor. Complaints of back pain, shortness of breath, left leg pain and right foot pain. She is on Eliquis [a blood thinner] 2.5 mg (milligram). She is also on chronic pain medications. She is not sure if she lost consciousness or hit her head. She denies neck pain. She states her back pain is mostly in her mid back. Patient presented hypoxic [levels of oxygen in the blood are lower than normal] on non rebreather. Initial oxygen saturation was reportedly 66%. The emergency room diagnosis as of [DATE] at 3:46 p.m. indicated: Fall, initial encounter, Traumatic intracranial hemorrhage [bleeding within the skull] with unknown loss of consciousness status, initial encounter Hierarchical condition categories (HCC), closed fracture of proximal end of left tibia [shin bone], unspecified fracture morphology initial encounter. The emergency plan of care showed the patient suffered multiple small head bleeds, T2 (spinal thoracic bone) compression fracture, likely pulmonary contusions. She also has a minimally displaced left proximal tibia and fibula (leg) fracture given she is non weight bearing likely non operative management does not want surgery and she does not walk. A knee immobilizer is ordered. She has a right great toe fracture. The resident was transferred to a trauma Hospital for further evaluation and treatment. A review of hospital records showed on [DATE] at 05:31 p.m., Resident #1 was admitted for trauma care having presented to [name of Hospital] from an outside hospital due to intracranial hemorrhage and multiple traumatic injuries after sustaining a fall at her nursing facility. Per prior notes, patient fell out of bed and onto the ground. Patient was a DNR (do not resuscitate) and brought form with her. Patient was noted to have a right great toe proximal phalanx fracture, left tibial plateau fracture, left proximal fibular fracture that was minimally displaced, right frontal ([NAME]) compression fractures . Neurosurgery was consulted after the patient and [family member] talked about the patient's goals of care. Orthopedic trauma surgery elected to treat patient's fractures non-operatively given the patient is non-ambulatory baseline status and under hospice care. Per prior medical records. The patient was transitioned to comfort measures only . The patient expired at 8.30 a.m. Review of ICU (intensive care unit) notes showed the resident was critically ill with organ failure and severe metabolic derangements. This patient's prognosis for recovery based on their response to treatment and therapy, extent of organ system function and/or reserve was considered moribund = very very poor. A Review of Nursing facility progress note dated [DATE] at 10:58 a.m., showed at approximately 10:30 a.m., Staff A CNA was providing care for patient when patient rolled out of bed onto the floor. Patient sustained skin tear to left lower leg and elbow which was cleansed and dressed with steri strips. The Advanced Practice Registered Nurse (APRN) was in the building when the event occurred and ordered the patient to be sent to the emergency room for evaluation/treatment due to patient complaining of hip and back pain. On [DATE] at approximately 10:50 a.m., the patient was transferred to [Hospital name] via stretcher/EMS [emergency medical service] The Medical Director (MD) and family member were notified via telephone. A review of Resident #1's electronic medical record (EMR) showed the resident was admitted to the facility on [DATE] with diagnoses to include Acute respiratory disease, pulmonary, unspecified systolic (congestive heart failure), acute myocardial infarction unspecified among other diagnoses. A care plan for Resident #1 with a start date [DATE], showed a category Health related complications indicating the resident is at risk for further reduction in prior levels of mobility. She is at risk for possible further changes/declines in present levels of mobility due to the amount of assistance that is required with mobility and transfer related needs related to: The resident requires extensive to total assistance of ,d+[DATE] with her locomotion/mobility/transfers, toileting, and incontinence care needs. She is non ambulatory and has expressed an extreme fear of falling. An approach with a start date [DATE] showed 2 staff when rendering care. On [DATE] at 01:59 p.m., Staff D, MDS Registered Nurse (RN) confirmed the care plan was not specific as it showed ,d+[DATE] staff assistance. Staff D, RN said, I can see how that would be confusing for a CNA not to know the number of staff required to provide assistance. I could have done a better job. An occupational Therapy and plan of treatment for Resident #1 dated [DATE] showed under fall risk assessment, Root cause analysis completed: patient currently requires maximum assistance of 2 for safely rolling patient side to side in bed for sitting more upright in bed, and for repositioning, hygiene, peri care, cleaning as per the caregivers, due to patient's severe arthritis joint protection issues and decreased skin integrity . Patient is dependent for all mobility tasks. Review of an activities of daily living (ADL) Care plan with a start date [DATE], last revised [DATE]., showed the resident was at risk for further declines/changes in self-care functional capabilities. She is at possible risk for further declines/changes in present self-care functional; capabilities due to amount of assistance needed presently with self-care task set up, completion of task and thoroughness related to diagnosis; recovered covid-19/pneumonia/status post fracture left femur /CHF (Congestive Heart Failure), anemia, history of NSTEMI (Non-St-elevation Myocardial infarction) /GERD (Gastroesophageal reflux disease), hyperlipidemia, and depression. She is alert and oriented x2 (meaning, she required 2 staff to provide care). She is able to verbalize her wants and needs total assistance [,d+[DATE]] with her ADL care, dressing, personal hygiene, bathing needs. She has incontinent occurrences of the bladder and bowels with daily use of briefs. She requires extensive assistance with her incontinent and peri care needs. An approach to the care plan with a start date [DATE] showed 2 staff were required when rendering care. A review of Resident #1's progress notes revealed: On [DATE] a nursing note showed the resident is alert and communicative, reports generalized chronic pain especially with repositioning and personal care. On [DATE] a nursing note showed . reports of pain to both lower and upper extremities. Requires maximum assistance with all types of care. On [DATE] PT (Physical Therapy) screen was completed. Patient is currently at baseline for functional mobility with no need to change or decline in function recently. On [DATE], a quarterly observation note indicated transfer status/assist of assistive devices showed the resident is immobile. Has weakness in all extremities. Has contractures bilateral on hands. On [DATE], an MDS coordinator progress note showed the information was gathered to complete the quarterly MDS . Resident required extensive assist x2 (meaning, she required 2 staff to provide care) with bed mobility, toileting, and bathing. [Resident #1] is non-ambulatory and requires assistance. On [DATE] at 12:58 p.m., an interview was conducted with Staff B, Registered Nurse (RN) who responded to Resident #1 after her fall. Staff B said, I went to the room. I did not know the resident. I observed the resident on the floor. She was lying on the left side of the bed. Her head was up against the wall. I looked at her legs and noted she was bleeding on the leg and on the arm. I cannot remember if it was left or right. It was a significant tear on the lower extremity of the leg, about 6 inches, skin was pulled back a little bit. The skin was folded in, you could see the subcutaneous tissue. The tear on the arm was approximately an inch and a half. Her head was resting on the wall which made me think she had hit her head. I cleaned her up and steri stripped it as the paramedics came in. I did not move her, they said she had brittle bones. She was resting her head against the wall. It looked like she had propped her head on the wall, which to me meant she hit her head on the wall. It was apparent she had hit her head on the way down. She was not crying, but it was clear she was in pain. She did not express the pain to me. I figured anyone who suffered a fall like she did, would be in pain. She had an air mattress; I did not see the rails. I addressed the bleeding first. She was talking as I was applying the steri strips. She said to me, [I told them I was going to fall.] I stayed with the resident until the paramedics came. On [DATE] at 1:11 p.m., an interview was conducted with Staff A, CNA who was assigned to Resident #1 [DATE]. She said, On that day, [DATE] between 10 a.m. and 10:30 a.m., I went to her room to take care of her. I was changing her as she needed incontinent care. She had a problem with her leg. She could not bend or move her left leg. She had pain in her right side. When I got to the room, I stood by her bedside, on the side of the door. I did not have two people at that time. She had an air mattress. There were no grab rails on her bed. She did not have the ability to grab and hold on to the rails. She was on an air mattress. She had a drawsheet under her. She could not move herself in bed. I pulled the drawsheet towards me, and the resident came towards me too. I provided care and then I pulled the drawsheet again and as I pushed her over the other side, the leg came out of the sheet, she said, I fell , I fell . She was talking to me. She said to me don't worry, I'm okay. She hit the floor. There was no mat on the floor. She landed on her back. The CNA stated education was offered on how to roll the resident over. She said, they said I have to pull the drawsheet to me; the resident has to go towards me all the time and if anyone is on an air mattress, we need two people to assist. On [DATE] at 10:35 a.m., a telephone interview was conducted with Resident #1's family member/ Responsible party. She stated Resident #1 had been at this facility for a couple of years. She stated during her last visit, the resident was herself even though she had not been out of bed in 2 years. She could not call for help on her own. Her roommate would call for her. Staff liked her. She had limited ability to use her body due to not having been out of bed and not moving her limbs. She was stiff and had zero muscles left. Her legs would sometimes swell. They had her in an air mattress. Her legs had started to curl up. She had very limited use of her hands. She was wasting away getting thinner and thinner, she was not able to feed herself, she needed staff to assist her. She could not use a call light or use a phone. She would not be able to grasp anything. She could not pick herself up or move herself in bed at all. The family member said, I received a call from the facility on [DATE]. They reported she fell out of bed. They said a CNA was changing her while in her bed when she fell and that she was complaining of pain. They said they had to send her out to be evaluated at a local hospital. That Hospital called me and said she had contusions, and they were sending her to [name of Hospital] for trauma care. The next call I received was from that hospital. They said they were doing x-rays and the surgeon would call me if they were to do surgery. At about midnight she was in the ICU, and she was on oxygen. They said she was slipping away. They were trying to draw blood. The next morning, they took her out of ICU, and they said they had her settled in her room. Before I could fly out, the hospital called and said she was gone. The only call I received from the nursing home was from someone saying she had fallen, and it was an accident. I don't know the circumstances, but she could not have stopped herself from falling, especially if the person changing her was on the other side of the bed. She was helpless. She was fully dependent on staff. The family member who was noted crying on the phone stated, She wanted to go, and I supported her, what else could I do? On [DATE] at 12:28 p.m., during a telephone interview, the Facility's Medical Director (MD) said, It is very unfortunate that she died . She stated she was notified about the fall. The MD said, They called me and said it was an accident. The resident fell because the CNA was by herself while changing the resident. She stated she had participated in QAPI (Quality Assurance Performance Improvement) via phone call, and they had discussed the fall. The MD stated the plan was to have a workshop to educate the CNAs and nurses and provide education on preventing avoidable accidents. The MD said, I don't want this to ever happen again. The MD stated the main thing was to have two CNAs at bedside and not have one CNA perform any sort of care for repositioning and change of linens for dependent residents on air mattresses by themself. She stated the expectation should be to provide care per the resident's care plan. The MD said, If Therapy had assessed for two person to assist in her care, then that should have been followed. Incidents/accidents will happen when care plan is not followed. I spoke to the Nursing Home Administrator (NHA), there should have been two people in the room. If there had been two people, this could have been prevented. On [DATE] at 12:30 p.m., an interview was conducted with the Director of Rehabilitation, (DOR). She stated the most recent evaluation was conducted on [DATE]th, 2023, at which Resident #1 was assessed as dependent, meaning she required total assistance for ADLs. When they are dependent, we take into consideration multiple things. If a patient requires a max assist of 2 for repositioning, hygiene, or peri care, two staff should assist per patient's limitations, such as severe arthritis and need to protect skin integrity. This resident was dependent on staff for all mobility skills because she was non-ambulatory, bed-bound, had BLE (bilateral lower extremities) contraction and needed a lower pressure mattress for pressure release. The Resident was always a two - person assistance. That was her baseline. We did not need to address her level of assistance as that is what it has always been, and it had not changed. Going forward education for the CNAs would be important for the sake of staff providing care and the residents. Not having that level of communication puts the resident at risk. The DOR stated she knew the resident. She was alert and oriented, it was a sad surprise for a lot of people that she had died . She was able to communicate her needs. They said she fell . The facility did trainings and in services about patient care and the way or level of assistance and mobility is determined. The care plan should say 1 or 2. It should be clearly defined. It should be either or. That would be confusing. Therapists fill out section GG of the resident assessment. In the MDS section G, if the resident is coded as requiring 2 staff, that info should go into the care plan as is. Resident #1 should have received incontinence care with two aides, she received an assist of one aide. On [DATE] at 12:13 p.m., an interview was conducted with Staff C, Licensed Practical Nurse (LPN) who was assigned to the resident. She stated on [DATE] she did not see the event happen. Staff C said, I was on my lunch break between 10:30 a.m. and 11 a.m. another nurse was covering the floor during my break. I was outside when one of the CNAs came and asked for keys to the treatment cart to get steri strips because the resident had a skin tear. I came in and got the treatment cart and strips and went to the room. I found [Staff B, RN] and already cleaned the resident. The resident was still on the floor, she was on the left side of the bed by the door bed. I can't recall if there was a fall mat. The height of the bed when I walked in was about hip height. The resident had a few skin tears. She was lying flat on her back. She was oriented, presented normal affect. She stated her hip and leg hurt. Other than that, she was normal meaning, same as she usually is. Staff C stated at approximately 10:20 a.m. or so EMS (Emergency Medical Service) arrived and transported the resident to the Hospital. She stated training was conducted after the incident about abuse and neglect. Staff C stated for everyone who had an air mattress, they had put bolsters, and also specified two people must be present for any type of care. She said, We re-trained on turning patient towards you not away from you. Staff C said, It was very unfortunate, especially because of the end result. The patient died . The resident was pleasant, she liked her snacks and ginger ale. She was very content, liked TV (Television). She never got out of bed, but she made her needs known. She was alert and oriented. She had brittle bone disease. She was stiff. She did not go anywhere. She required full care for toileting. She had previously fractured her leg or hip and was not able to sit or get out of bed. She required the staff's total assistance, for everything. On [DATE] at 1:52 p.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN) Minimum Data Set (MDS) coordinator and Staff E, RN MDS coordinator. They stated they update care plans by gathering information from what the CNAs are charting, and what therapy had assessed. The CNAs receive information on care plan changes from charge nurse, and reports from CNA to CNA. Staff D said, In the IDT (Interdisciplinary Team) morning meetings, we follow -up on post fall reviews, we update care plans, and the unit manager sends the interventions back to the floor. The CNAs are educated to follow -up on interventions, these are carried over during shift-to-shift exchange. Staff D and E reviewed Resident #1's interventions post fall and confirmed there had been no changes. Staff D said, Her care plan is still the same. The approach dated [DATE] indicated 2 staff when rendering care, which meant there should have been two staff when providing toileting, incontinence care and bed mobility. Staff D stated the CNAs should follow interventions in the care plan. Staff D said, If an intervention is not implemented, it could result in failure to provide care as planned. If someone required two + assist, then they should have 2 staff providing care. Resident #1 required 2 staff. This is true and correct. Staff E said, Resident #1 did not do much for herself. She was dependent on staff for ADLs and safety. In a telephone interview on [DATE] at 3 p.m., the APRN stated, I was on my way out of the building, I saw people outside the resident's room. They said she fell , I went to the room, and saw the resident. She was on the floor. She said she had pain in her back. I asked her what happened, she said she fell , she said she was having pain in her back. She did not give a pain scale. She was transported to the hospital. The APRN stated she conducted a comprehensive assessment Resident #1 on [DATE]. The APRN said, She was a frail [AGE] year-old. She had issues with GI (Gastrointestinal) bleeding. She was a long-term patient with extensive medical history, a history of heart failure, she was considered in palliative care. She was small, she could not have been more than 90 pounds. She was not terminal, rather, failure to thrive due to heart failure which was chronic. She was not imminently ill. On [DATE] at 3:10 p.m. A telephone interview was conducted with Resident #1's primary care physician. (PCP). The PCP stated he saw her once, and when he came to see her a second time, he heard she was gone. The PCP said, I do not remember anything about her. Nothing that stands out .I see many patients. She was a long-term resident. An interview was conducted on [DATE] at 3:30 p.m. with the Staff Development Coordinator (SDC). She stated she had conducted in-services after Resident #1's fall. The SDC said, The training is 100% for direct care staff, Nurses, and CNAs. We trained on safely turning a patient over in bed. That means if you do not have two people, because we do not use side rails, you should pull the resident toward you. She stated while using a drawsheet, the staff should pull the resident towards them especially if they were on an air mattress. She stated they trained the CNAs on being aware that the resident may shift during care and that two people are required to change or move a resident on an air mattress. The SDC said, We have put bolsters on air mattresses and are monitoring to make sure the residents can remain safe when turned or repositioned in bed. The SDC stated rolling the resident away during care puts the resident at risk. The SDC said, I was familiar with the resident. She was able to talk, that is all she could do, she was bed fast. She was in constant pain. She used to have wounds and was on an air mattress for comfort. She had extremely limited use of her hands. She had a padded call light and used foam built up utensils. She could not grasp anything to pull herself up. She relied on staff to position her. The SDC stated the CNAs should follow care plan interventions. She stated if the care plan specified two person's assist, then they should follow that. The SDC said, If they do not follow the care plan, that would be careless, it puts everybody at risk. The SDC stated the CNAs learn from mentoring each other and that she did not conduct the CNA training herself. On [DATE] at 5:14 pm an interview was conducted with the Nursing Home Administrator (NHA)/Abuse Coordinator and Director of Nursing (DON)/Risk Manager. The NHA stated the event occurred on [DATE] at approximately 10:30 a.m. when a CNA [Staff A] was providing care. She was conducting a linen change; she had already completed the peri care. The NHA said, She [Staff A] was completing a linen change by herself. Immediately following the incident, I asked her if she knew how many people are needed to provide care. She said she always asks her nurse. The NHA stated the CNA said it could be 1 or 2 people. The NHA read part of the CNA's statement which reported, [sometimes the nurses get frustrated with me because I ask a lot of questions.] The NHA stated the CNA had completed care and was changing the resident's linens. She had started the process of turning the resident away from her when her left leg, which was stiff, got caught as she rolled to her right side. The NHA said, the bed was at the CNA's hip height. There were no fall mats. The resident hit the floor directly. The NHA stated they could not determine how she landed. She was noted on the floor, did not know if she hit her head. The NHA said, [Staff C], the nurse assigned was out for lunch break, and [Staff B] responded. [Staff B, RN] went into the room and assessed the resident. About the same time, the DON, and the Assistant Director of Nursing (ADON) came into the room. [Staff D] heard the CNA calling for help. She responded and saw the resident on the floor, and she called EMS. Resident #1 was sent to [Name of Hospital]. They then transferred her to [Name of Hospital] for trauma care. The NHA stated she was contacted by an investigator at the medical examiner's office for [name of county], on Saturday the 15th at approximately 4 p.m. and she was notified the resident had died . The NHA stated on Monday morning [DATE] they met with all department heads, reviewed care plans to determine bed mobility status and initiated education on how to disseminate information to staff with care plan changes. The NHA said, related to our investigation, we did not find that based on our policy the CNA had violated our policies. We determined it was an accident. Our findings revealed it was an accident. She provided care per the resident's care plan. The incident was not listed on the abuse / neglect log. We did not report to DCF (Department of Children and Families). We did not see it as abuse or neglect. We did not submit a five-day report. The resident was on an air mattress. In response we decided to add bolsters to all air mattresses. The NHA stated the nursing team assessed all the residents with air mattresses to see if it impeded their ability to rise. She stated they were trying to determine if the fall occurred because of the mattress to ensure other residents would not be affected. The NHA said, We do not have a policy/protocol for use of air mattresses. The standard would be for the CNAs to follow a resident's care plan. The DON stated they provided education on turning and repositioning of residents and how to roll the resident towards the CNA and not away from them. The DON stated when Staff A provided care, she turned the resident away from her. The DON said, We did not determine that she failed to follow procedure because our policy does not indicate the procedure of rolling a resident. She was alone when she was providing care. Nothing indicated she did anything wrong. She did everything correctly. The NHA said, Immediate and Five-day Federal reports were not reported because we did not feel there was abuse and neglect. That was the decision at the time, and it still is. Review of a facility document titled Facility Assessment, dated [DATE], showed under services and care offered based on the resident's needs, Mobility and prevention of falls/falls with injury. Specific care practices included: transfers, ambulation, restorative nursing, contracture prevention/care, supporting residents' independence in doing as much of these activities by himself/herself. A review of a facility policy titled, Abuse, Neglect and Misappropriation of property, dated [DATE], showed it is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property, and to assure that all alleged violations of federal or state laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property, are investigated, and reported immediately to the facility administrator, the state survey agency, and other appropriate state and local agencies in accordance with federal and state law. It is the organization's policy that the facility administrator or his or her designee, will direct a reasonable investigation of each such alleged violation, unless he or she has a conflict of interest or is implicated in the alleged violation. The facility administrator is responsible for reporting the results of all investigations to applicable state agencies as required by federal and state law. The facility administrator is the facilities designated abuse coordinator . and the implementation of this policy should be referred to him or her. Allegation of abuse means a report, complaint, grievance, statement incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring has occurred or plausibly might have occurred. An alleged violation involving abuse, neglect, exploitation, all mistreatment a reported immediately but no later than two hours after the allegation is made. Means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress. To the extent possible and applicable the following information may be pertinent when conducting a reasonable investigation: the date and time of the incident, the nature and circumstances of the incident, the location of the incident, the description of any injury, the condition of any injured person, the disposition of the injured person (for instance, transported to hospital), the names of witnesses and their accounts of the incident, the time and date of notification of the resident's physician and family, other pertinent information and the name and title of the person completing the documentation. Every stakeholder, contractor and volunteer immediately shall report any allegations of abuse, injury of unknown origin, all suspicion of crime . to the charge nurse on duty. Failure to report an allegation of abuse, injury of unknown origin or suspicion of crime may result in disciplinary action including termination of employment, and our further legal or criminal action against any person who is required to but fails to make such a report. A review of an undated facility document titled, Risk Manager, revealed the position is responsible for the development, implementation and facilitation of the Citadel-Florida's Risk Management and risk mitigation program. The responsibilities included assuming accountability for development, implementation, and assessment of Risk Management, Quality Assurance and Performance Improvement and Abuse prevention policies, procedures, and tools. The Risk Manager assumes accountability for development and implementation of a reporting, tracking and trending system for all incidents, adverse incidents and reportable events. Analyze root and contributing causes of events and trends, determine solutions, and provide preventative strategies. A review of a facility policy titled, Quality Assurance/Performan[TRUNCATED]

Based on observation, record review and interview, the facility failed to ensure the accuracy of medical record documentation for one (Resident #2) of three sampled residents. Resident #2 had a fall on 04/02/2023 and was subsequently transferred to the hospital. The facility documented Neurological monitoring for Resident #2 after she had left the facility. In addition, the facility documented the time of the fall on 04/02/2023 inaccurately. Findings include: An observation was conducted of Resident #2 on 05/03/2023 at 1:20 p.m., resident was in her room, in her bed. Bed was in a low position. She had a floor mat on one side of her bed, the left side, between the bed and the door side. Resident stated she was comfortable, but she did not feel so well. An interview conducted on 05/03/2023 at 10:58 a.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), regarding the fall events for Resident #2. The DON and ADON indicated Resident #2 had a fall on 04/01/2023 at 16:03 in the day room, the fall was not witnessed. They indicated neuro-checks were initiated for the fall because it was not witnessed. The DON and ADON indicated Resident #2 had a fall on 04/02/2023 at 13:24 (1:24 p.m.) in the resident's bedroom, the fall was not witnessed, and she was found on the floor. The DON indicated she was not able to answer when the resident was last seen, but she could find out who was assigned to the resident. The DON stated the resident was transferred to the emergency room at approximately 12:45 p.m. The ADON stated the staff may not have charted correctly about the time. The ADON stated, the resident did not return to the facility until 04/05/2023. On 05/03/2023 at 1:37 p.m., the DON provided the Neurological Flow sheet for Resident #2's 03/30/2023 fall and the 04/01/2023 fall. The form indicated: Vital Signs and Neuro Checks: Q 15 mins. X (for) (1) hour Q 30 mins. X (1) hour Q 1 hour x (4) hours, then Q 4 hours x (24) hours. A review of the instructions indicated monitoring would be completed for 30 hours. At this time, the forms were reviewed with the DON and she indicated the forms were completed appropriately. A review of the 04/01/2023 Neurological Flow sheet, located in the Electronic Medical Record (EMR), documented the following monitoring for Resident #2. 04/01/2023, time of monitoring, 1626. 04/01/2023, time of monitoring, 1645. 04/01/2023, time of monitoring, 1700. 04/01/2023, time of monitoring, 1715. 04/01/2023, time of monitoring, 1745. 04/01/2023, time of monitoring, 1815. 04/01/2023, time of monitoring, 1915. 04/01/2023, time of monitoring, 2015. 04/02/2023, time of monitoring, 2115. 04/02/2023, time of monitoring, 0115. 04/02/2023, time of monitoring, 0500. (hard to read time entry) 04/02/2023, time of monitoring, 0915. 04/02/2023, time of monitoring, 1315. 04/02/2023, time of monitoring, 1715. Noted, if the monitoring had been completed as the instructions indicated, from the 04/01/2023 time of 2015, the nurse should have had monitoring documented at the following time entries: 04/01/2023, 2115 04/01/2023, 2215 04/02/2023, (now every 4 hours), 0215. 04/02/2023, 0615. 04/02/2023, 1015. 04/02/2023, (resident's fall had occurred prior to 12:10 p.m.) A review of the EMS (Emergency Medical Service) run report, dated 04/02/2023, reflected a phone call to the dispatch call center was received on 04/02/2023 at 12:10 p.m. and the paramedics were at the patient (Resident #2) at 12:28 p.m. The EMS narrative documented: Patient was found supine in facility bed. Patient was alert to verbal .pt has a small hematoma to her eyebrow and a small laceration to the middle of her forehead. Pt was found to have low BGL (blood glucose level) and is known diabetic. A review of Resident #2's hospital records, dated 04/02/2023, indicated a hospital course: Patient is a (geriatric) age female presents from (nursing home) for hypoxemia. Patient takes metformin and sulfonylurea [medications to lowwer blood glucose]. EMS found her sugar to be 49 mg/dl (milliograms/deciliter) [below normal range].

Based on observations, interviews, and record review, the facility did not ensure post [CONDITION(S)] care was provided for two (Resident #30 and #7) of two residents reviewed for [CONDITION(S)] Findings included: During a facility tour on 07/06/22 10:14 AM, Resident #30 was observed in his room being assisted by a staff member. Resident #30 was preparing to leave for [CONDITION(S)]. An attempt to interview the resident was not successful. Resident #30 was not easily understood but responded to yes and no questions. When asked if he had a snack or lunch packed for later, Resident #30 stated he did. Review of Resident #30's electronic medical record (EMR) showed the resident is [AGE] years old and was admitted to the facility on an 04/14/22 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders for Resident #30 dated 04/14/22 - 07/07/22 showed: Medications administered prior to [CONDITION(S)] as ordered by physician. Receives [CONDITION(S)] at [name of facility] on Monday, Wednesday, and Friday at 11:15 a.m. No B/P (blood pressure) / blood draws or IV's (intravenous) to access arm. Vital signs prior to [CONDITION(S)], once a day on Monday, Wednesday, Friday 07:00-15:00. Diet: meal consumption, add fluid consumption to task at Breakfast, Lunch and Dinner Renal diet. One can of Nepro daily. Weigh resident monthly, once a day on second Wednesday of the month. Review of resident # 30's weight record showed the resident was last weighed on 4/27/22 and a weight noted at 158.2. No other weights were documented. The physician orders did not show orders to provide post [CONDITION(S)] care. A Care plan for Resident #30 dated 04/14/22 showed a problem category: Resident requires [CONDITION(S)] due to Dx (Diagnosis): of end stage renal disease. Resident goes to [CONDITION(S)] M-W-F at 11:30 a.m. Catheter to left upper chest. The goal indicated resident will be free from complications such infection / altered skin integrity/ significant weight loss or gain due to receiving [CONDITION(S)]. An approach included to monitor weight and report excessive weight loss or gain to physician. Review of the [CONDITION(S)] book for Resident #30 showed only three [CONDITION(S)] communication forms: 4/25/22: an incomplete form without information from the facility was noted. 4/27/22 an incomplete form without information from the facility was noted. 7/1/22: a completed form was noted. Review of the Residents vitals log showed Resident #30 did not have vitals logged consistently before [CONDITION(S)] and no monitoring was documented for after [CONDITION(S)] care. The three post [CONDITION(S)] forms did not show documentation related to post [CONDITION(S)] care, weights, vitals, bruit / thrill monitoring. On 07/07/22 at 03:10 PM, an interview was conducted with the Director of Nursing (DON) The DON stated the [CONDITION(S)] office had not been sending the forms back, they (nursing staff) had to call and get them. When asked when she last called or obtained the copies, the DON stated she did not know and would follow up with the Unit Manager. The DON stated the nurses were expected to do vitals. The DON could not confirm if post [CONDITION(S)] care was being provided. The DON stated for Resident #30, the nurse who received the orders did not push through the orders for post [CONDITION(S)] monitoring. The DON stated they did not transcribe orders as ordered. Review of the record for Resident #7 showed the resident is [AGE] years old and was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #7's physician orders dated 09/01/21 - 07/07/21 showed: [CONDITION(S)] on Tuesday and Saturday, chair time 11 a.m. at [name of facility], pick up time 9:30 a.m. Medications administered prior to [CONDITION(S)] as ordered by physician. Monitor for bleeding from CVC (central venous catheter) site after [CONDITION(S)] once a day Review of the record did not show post [CONDITION(S)] care was provided. A care plan for Resident #7 with a start date of 10/07/21, showed resident #7 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Has [CONDITION(S)] on Tuesday and Saturday. An interview was conducted on 07/08/22 at 09:53 AM, with Staff A, LPN (licensed practical nurse). Staff A stated Resident #7 went to [CONDITION(S)] twice a week. Staff A stated for pre [CONDITION(S)] prep, the CNA's (certified nurse's aides) assisted the resident to get ready, dressed, and made sure they had a snack or meal to go. The nurse took vitals and administered medications. Staff A stated post [CONDITION(S)] was supposed to be the same, check vitals and monitor bruit and thrill. Staff A stated she did not know if this resident's bruit and thrill were being monitored. On 07/08/22 at 10:10 AM, an interview was conducted with Staff B, LPN. Staff B stated he had one resident who was on [CONDITION(S)]. He stated the CNA's helped the resident get ready in the morning. He said he made sure the resident brought his folder along to [CONDITION(S)]. Staff B did not know if vitals should be checked but he would find out from the DON. He did not know about post [CONDITION(S)] care because he was not normally in the building when the resident returned. On 07/08/22 at 10:15 AM, an interview was conducted with Staff C, RN / MDS (registered nurse / minimum data set). Staff C stated she was working on updating the care plans and orders for the residents on [CONDITION(S)]. Staff C stated she was notified yesterday the orders did not include pre and post [CONDITION(S)] care. She stated the orders should include monitoring the resident's site for bleeding, check bruit and thrill, and take vitals. Staff C stated they would update orders, care plans, and educate the nurses on the expectation. On 07/07/22 at 04:50 PM, an interview was conducted with the DON. The DON stated the orders to monitor the resident post [CONDITION(S)] were missed. The DON stated they should have been entered. The DON stated she would expect to see active orders which should include to check bruit and thrill and shunt every shift and to monitor site for bleeding after [CONDITION(S)]. The DON stated she would review the orders for both residents and make sure they were in place. 07/08/22 at 11:58 AM, a follow -up was conducted with the DON. The DON stated Resident #30 should have been weighed, monthly per orders. The DON stated they missed it. The DON stated the plan was to start weighing the residents per orders. The DON said, we just did not do a good job with that. We did not weigh him as required. The plan is to review the [CONDITION(S)] communication forms to make sure they capture all the orders with post care expectations. The DON stated she would educate all the nurses on the expectations. Review of a facility policy titled, care of residents receiving [CONDITION(S)], last revised 8/7/19, showed guideline steps 2. Observe for hemorrhage secondary to [MEDICATION(S)] therapy during [CONDITION(S)]. 3. Observe for infection or clotting of the access area. 4. Observe that dressing remains intact. 5. Observe catheter limb clamps are secure Review of a facility policy titled, review of physician orders, last revised 11/6/19, showed it is the standard of this facility that physician orders are reviewed daily to ensure delivery of applicable care, tracking of change of condition, and updating care plans are consistently provided. Review of a job description titled, charge nurse (LPN or RN) dated 03/2021, showed an expectation to: provide direct nursing care to the residents. Cooperate with other resident services when coordinating nursing services and be certain that the resident's total regimen is maintained. Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices. Review the resident's chart for specific treatments . as necessary.

Based on observations, record review, and interviews, the facility failed to ensure one (Resident #97) of four residents reviewed for nutrition services was monitored for weight change and intake at meals. Resident #97 was noted to have lost 37 lbs., a 14% weight loss, over a two-month period, even though he was not on a physician ordered weight loss program. Findings included: A review of Resident #97's electronic medical record revealed the resident weighed 256 pounds (lbs.) on 4/4/2022 and 219 lbs. on 6/9/22. This was a weight loss of 37 lbs., calculated to be a 14.45% weight loss in 2 months, which the facility's policy identified as severe. According to the facility's policy titled Weighting and Measuring Height Policy Resident, dated 3/22/22, a loss of 7.5% or greater is described as a severe weight loss. A review of admission records indicated Resident #97 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of orders indicated a diet order, dated 6/28/22, for regular, nectar thickened liquids, dysphagia (dys) puree diet. Food served in bowls, no salt packet, no straws, frozen treat with lunch and dinner, and 1200 milliliter (ml) fluid restrictions as well as an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #97's vital sign log indicated the resident weighed 258.6 lbs. upon admission (3/9/22) with a body mass index (BMI) of 40.5. On 4/4/22 the resident weighed 256 lbs. with a BMI of 40.09. There was no weight recorded in May. On 6/7/22 the resident weighed 219 lbs. The resident was reweighed on 6/9/22 with a confirmed weight of 219 lbs. with a BMI of 34.3. There had been no weights recorded since 6/9/22. A review of the resident's meal consumption logs from the previous 10 days (6/27/22 to 7/6/22) was completed. The log indicated the resident had eaten less than 50% of eight of ten breakfast meals, less than 50% of the last nine lunches, and 51% - 75% of dinner on one of ten meals reviewed. No dinner intake was documented for nine of the ten meals reviewed. Resident #97's Minimum Data Set (MDS) admission assessment, dated 3/14/22, was reviewed. Section K, Swallowing/Nutritional Status, indicated the resident had coughing or choking during meals or when swallowing medications and had complaints of difficulty or pain with swallowing. Section K stated the resident was 67 inches in height with a weight of 255 lbs. and he had no weight gain or loss in the last month of 5% or more or 10% or more in the last six months. The quarterly MDS, dated [DATE], was also reviewed. Section C, Cognition, indicated Resident #97 had a brief interview for mental status (BIMS) score of 7, indicating severely impaired cognition. Section K, Swallowing/Nutritional Status, indicated the resident had coughing or choking during meals or when swallowing medications. It stated the resident was 67 in height with a weight of 219 lbs. Section K also stated there had been no weight loss or gain of 5% or more in the last month or 10% or more in the last six months. A review of medication orders since admission was conducted. Resident #97 was taking [MEDICATION(S)], a diuretic on and off since admission, as well as receiving IV fluids. His orders included: 2.0 Cal supplement 120 cc with meals from 3/18/22 to 4/6/22 [MEDICATION(S)] 1 mg twice a day for [CONDITION(S)] from 3/29/22 to 6/10/22 and from 6/15/22 to 6/24/22. [MEDICATION(S)] 1 mg once a day for [CONDITION(S)] from 6/24/22 to 6/28/22 D 5% and 0.9% sodium chloride 1 Liter Intravenous (IV) at 75 ml/hour(hr.) x 1. 5/31/22 one time at 1730 and one time at 2200 Sodium Chloride 0.45% [MEDICATION(S)] solution 50 ml/hr. IV 100 ml/hr. now then discharge. Stat labs after IV therapy. 6/9/22 5% dextrose injection 100 ml/hr. IV x 1 hour until new orders. 6/21/22 [MEDICATION(S)] [MEDICATION(S)] solution 1 Liter IV at 100 ml/hr. one time. 6/30/22 Dextrose 5% in water (D5W) [MEDICATION(S)] solution 100 ml/hr. IV. Start 7/1/22 and continue through 7/4/22 A review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . He was treated and returned. He was also sent the hospital on 7/1/22 for penile bleeding. He returned to the facility on an antibiotic, [MEDICATION(S)], for a [CONDITION(S)]. A review of Speech Therapy notes indicated Resident #97 was receiving therapy from 3/8/22 to 3/28/22, from 5/23/22 to 6/10/22 and again from 6/16/22 to 6/29/22. The therapy was all geared toward swallowing function. The discharge summary dated 3/28/22 noted: CNAs required consistent education and training with decreased follow through with recommended swallowing guidelines. Max encouragement and redirection throughout P.O. (oral intake) Patient overwhelms easily and increased anxiety with visual of P.O and required one food item and drink item presented at a time. A speech therapy encounter note, dated 6/29/22, stated Speech Language Pathologist (SLP) re-educated patient and staff on swallowing guidelines; positioning, recommended diet and liquids, compensatory strategies, signs/symptoms of aspiration, and precautions. Patient and staff verbalized understanding and agreement. Patient has cognitive-communicative barriers to comprehension and recall. Nectar liquids tolerated status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment modifications to overcome barriers: collaborate with nursing, discussion with interdisciplinary team, eliminate distractions, implement multi-modality grading and cueing, quiet location for treatment and use low stimulation environment for treatment. A review of the nutrition assessments and notes did not reveal that the RD followed through with any of the SLP's recommendations, such as smaller, more frequent presentations of his meal components as snacks. The SLP who worked with the resident was unavailable for interview. The resident had swallow studies completed on 5/26/22 and 6/29/22 with the following results: An x-ray of the esophagus on 06/29/2022 for dysphagia, oropharyngeal phase indicated gastroesophageal reflux was present. A video swallow test was conducted on 05/26/2022 which showed no cough or other evidence of aspiration or penetration (into the lungs). An observation was made of Resident #97 on 7/5/22 at 8:07 p.m. A bag of D5W IV solution was noted hanging next to the bed, not currently running. Resident was sleeping covered up. A midline on his right arm was visible. A second observation was made on 7/7/22 at 9:44 a.m. The resident was in bed with the head of the bed elevated, watching TV. Resident had a midline in his right arm. His body was completely covered with the exemption of his head and arms. Attempts were made to speak with the resident, but he only grunted. An interview with the Director of Nursing (DON) was conducted on 7/7/22 at 11:56 a.m. The DON reviewed the resident's electronic medical record and stated the only note from the Registered Dietician (RD) was a diet clarification on 6/9/22. She stated the RD reviews each resident upon admission and would send recommendations for the resident's weight loss, weight gain, food preferences, or diet changes. The DON reviewed the dietician recommendations book and found two recommendations from the RD regarding Resident #97. The first recommendation was from 6/9/22, a change in diet from hospital diet of 2 gm Na+ to No salt packet continue dys (dysphagia) pureed, NTL, food in bowls, no straws was recommended. The second was dated 6/17/22. This recommendation was again to discharge the 2 gm Na+ diet. Pureed, No salt pack, HTL, food in bowls, frozen treat lunch and dinner. The DON confirmed the RD is not actively following this resident. An interview was conducted with the Registered Dietician on 7/7/22 at 12:08 p.m. She stated she did an initial assessment when Resident #97 was admitted to the facility. The RD stated she was not currently following the resident for weights. She stated residents have weekly weights for 4 weeks then go to monthly weights unless they need to continue with weekly. She said she did not know why the resident was not weighed in May and she could not explain why the resident did not trigger for her to track him for weight loss. She stated, the way the reports come in, it may not have tracked. The RD reviewed the Nutrition Evaluation completed at Resident #97's admission. She stated in her initial plan she wanted the resident to have a gradual weight loss to ideal body weight of 193 pounds, but she typically did not want them to lose weight initially until they were done with their initial problem (what they were admitted for ). She stated she would not recommend losing weight from the get-go and that was why she did not have a weight loss plan in place to track him. She stated 14.45% weight loss in two months would not be considered gradual weight loss, but there could be some allowance in that. She stated she would have been following him for weights if it would have triggered on her report. She confirmed she did review the percent of breakfast, lunch and dinner consumed. She stated it was a team effort and she would expect the team to communicate to her something was happening so she could put him back on weekly weights. The RD stated she initially had him on a supplement, Med Pass, due to his intake not meeting his current needs. She stated the Med Pass was later discontinued. She also stated she did not know why the resident was on IV fluids and fluid restrictions. A request was made for the staff to get a current weight on Resident #97. The RD provided a requested copy of the Nutrition Evaluation completed upon admission. The evaluation was dated 3/15/22 with a completion date of 7/7/22. The evaluation stated the resident showed poor intake related to complaint of pain/discomfort swallowing, even with pureed foods. It stated he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The initial plan of care was listed as the following: Obese resident (BMI>30) shows chewing, swallowing, and self-feeding issues, altered labs, with inadequate oral intake and risk of malnutrition indicated per MNA (Mini Nutritional Assessment) score. Goal: Resident will safely consume adequate nutrition/hydration, without excess, as evidenced by resolution of infection with no s/s of dehydration, choking, aspiration or further complaints of discomfort or pain while swallowing; improved labs; with grad weight loss advised closer to adjusted ideal body weight of </= 193# once medically stable. Plan: Monitor and document intake of food and fluids, offering assistance as needed and offering alternative at meals as needed Monitor weights per facility protocol (weekly x 4 weeks upon admission then monthly when stable), referring to MD/RD for further intervention as indicated. An interview was conducted with the Nursing Home Administrator (NHA) on 7/7/22 at 1:15 p.m. He stated he would have expected the RD to have a plan for weight loss in place to achieve the goal she put in place at admission. He stated he would also expect the RD to be following Resident #97 due to his weight loss and other health concerns. He stated the amount of weight loss the resident had should have triggered for her and she should have been following. The NHA stated it is the job of the RD to ensure those things happen. An interview was conducted with the DON on 7/7/22 at 1:50 p.m. The DON stated the RD should have had an initial weight loss plan related to her goal, if the plan was for him to lose weight. She stated she would have expected the RD to have been aware of the Resident's weight loss and be following him. At 1:17 p.m. on 7/7/22 a current weight for Resident #97 was entered into the electronic medical record. The resident's current weight was 181 lbs. with a BMI of 28.35. This calculated to be a -17.35% weight loss from 6/9/22 to 7/7/22 and a -29.3% weight loss from 4/4/22 to 7/7/22. An interview was conducted with Staff E, Certified Nursing Assistant (CNA) on 7/7/22 at 1:46 p.m. Staff E stated she assisted Resident #97 with eating his lunch. She stated she must feed him, and he ate about 30% of his meal. She stated he did not eat much and would begin to cough/choke. She stated when he began to cough/choke, they (CNAs) took the tray out and end the meal. An interview was conducted on 7/12/22 at 1:17 p.m. with the facility medical director. She stated she was unaware Resident #97 had such a large weight loss. She confirmed diuresis alone would not cause the resident to lose 29.3% of his body weight in 3 months. She stated sometimes weight loss could be higher if food intake was not great or a different method of weighing was used, but either way she would expect the registered dietician to be following the resident. The doctor stated if the resident had been on a weight loss plan for obesity, a gradual weight loss would be 1-2 lbs. a week or approximately 8 lbs. a month. She said going from 219 lbs. to 181 lbs. in a month is not gradual. It is definitely too quick. She said based on his medical issues and initial nutrition evaluation (upon admission), she would have expected the RD to be following the resident and for his weights to be tracked. The doctor stated when the resident was being fed and began coughing/choking the meal should not be taken away and ended. She said that absolutely shouldn't happen. She stated the resident should be given a break and then attempt to eat more food. She stated if the problem continued the team needed to know so they could work on different methods or different diets/meals. The doctor stated she did try to speak with the resident last month about how he was eating, but he did not want to talk about it. She stated she did often base things on how the resident felt and appeared versus just numbers. She stated she did not feel like he had been negatively affected by the weight loss, but now that she was aware of how severe the loss was, she was going to do a malignancy work up to ensure nothing else was causing the weight loss. The medical director said she would expect Resident #97's weight loss to have been brought to her attention. A facility policy titled Weighting and Measuring Height Policy Resident, dated 3/22/22, reviewed. Policy stated: the organization will strive to maintain residents' usual body weight or desirable body weight range, to the extent possible, to ensure each resident is able to maintain the highest practicable level of well-being. To help monitor and/or identify residents at nutritional risk, the organization will establish a baseline weight and a schedule for weighting residents thereafter, per current professional standards of practice. Severe weight loss is described as greater than 5% in 1 month, greater than 7.5% in 3 months, or greater than 10% in 6 months. Responsible roles included registered dietician, director of nursing, licensed nurse, certified nursing assistant.

Based on observations, interviews, and record review, the facility did not ensure one (Resident #99) of 32 residents reviewed, received treatment and care in accordance with professional standards of practice related to a change in condition, assessment, and following physician orders. Findings included: An observation of Resident #99 was made on 7/6/22 at 2:44 p.m. The resident was lying in bed with her eyes closed. She had steri-strips on her left hand and a scabbed over wound on the right side of her nose. A review of admission records indicated Resident #99 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #99's orders indicated an order dated 3/5/22 for head-to-toe skin checks weekly with special instructions to complete non-pressure observations or wound management form if appropriate. A review of Resident #99's Minimum Data Set (MDS) dated [DATE] was conducted. Section C, Cognitive Patterns, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3, meaning she had severe cognitive impairment. Section F, Functional Status, indicated the resident needed a two+ person physical assist for transferring, bed mobility, and personal hygiene. Section F also indicated walking did not occur during the seven day assessment period. A review of Resident #99's electronic medical record did not show any skin checks being completed since 4/11/22. The medical record also did not note any accidents occurring recently or any wound/treatment orders for the resident's left hand. An interview was conducted with Staff H, Licensed Practical Nurse (LPN) on 7/8/22 at 9:57 a.m. Staff H stated the scabbed area on the right side of the resident's nose was from a cancerous spot that was removed. She stated she was unaware the resident had steri-strips on her hand. Staff H was observed entering the resident's room, uncovering the resident's arm, and assessing the steri-strips. She stated she did not know what happened. Staff H, LPN proceeded to go to the computer to review Resident #99's medical records. She indicated she did not see any information in the computer about the steri-strips or an accident. An interview was conducted with the Director of Nursing (DON) on 7/8/22 at 10:06 a.m. She stated she was not aware of the steri-strips on Resident #99's hand. She stated she didn't know they were there until Staff H called her a few minutes prior. The DON reviewed Resident #99's electronic medical record and stated, I don't see anything in here. The DON confirmed the scabbed wound on the resident's nose was due to a previous cancer removal. An interview was conducted with Staff D, LPN, Unit Manager (UM) on 7/8/22 at 10:24 a.m. Staff D stated she had no idea what happened to Resident #99, nothing had been reported to her. Staff D stated the accident should have been documented and reported to her. She stated even if she was not there at the time, she should have seen it in her morning report. She also stated the doctor should have been notified to receive treatment orders. An additional interview was conducted with the DON on 7/8/22 at 12:20 p.m. The DON stated after speaking to a few staff members, she feels the injury to Resident #99's left hand could have occurred by hitting her hand when she was being transferred between the bed and her chair. The DON stated she did not know which staff member applied steri-strips to the resident. She stated the nurse should have assessed the resident and called the doctor for treatment orders. She confirmed steri-strips should not have been applied until orders from the doctor were obtained for cleaning and/or treatment. She also stated an additional order should have been entered for monitoring for signs and symptoms of infection. The DON stated an event should have been entered to capture the who, what, when and where of what happened and what orders were received from the doctor. She stated she had no idea if the wound was cleaned or treated properly. She stated she did assess the area herself today, and did not see any current signs and symptoms of infection. Staff D, LPN, UM entered a progress note on 7/8/22 at 1:04 p.m. The note stated the resident had a skin tear on her left hand. The doctor was notified, and orders were received to cleanse daily and keep steri-strips on until they fell off. Staff should monitor every shift. On 7/8/22 at 2:06 p.m., the DON indicated the resident's last skin check was completed in April. She confirmed there was a current order for weekly skin checks and those had not been completed as ordered. The Nursing Home Administrator (NHA) stated for some reason the order did not cross over to the treatment administration record. He stated Certified Nursing Assistants (CNA) look at the resident's skin when they were showering them and filled out a sheet for the nurses to review. He confirmed nurses should be completing a full skin assessment weekly according to the doctor's order. A facility policy titled Skin Integrity Policy, dated 6/9/22, was reviewed. The policy stated the facility will ensure that based on the comprehensive assessment of a resident: 1. A resident received care, consistent with professional standards of practice, to prevent avoidable skin integrity issues and does not develop avoidable skin integrity issues unless the individual's clinical condition demonstrates that they were unavoidable; and 2. A resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent avoidable skin integrity issues from developing. Procedures: 4. The licensed nurse shall initiate applicable Skin Integrity documentation if a new area of impairment is identified. A facility policy titled Change of Condition, dated 11/6/19, was reviewed. The policy stated the facility will evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay evaluation information to physician and to document actions to include but not limited to the following: -Accident which results in injury and/or has the potential for requiring physician intervention. A job description for registered nurse and licensed practical nurse was provided by the NHA. The job description included: -Complete accident/incident reports, as necessary -Transcribe physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care. -Notify the resident's attending physician when the resident is involved in an accident or incident. -Notify the resident's attending physician and responsible party when there is a change in the resident's condition.

Based on record review and interviews, the facility did not ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for one (Resident #97) of 32 sampled residents. Findings Included: A review of Resident #97's medical records revealed a Level I screen for Serious Mental Illness and/or Intellectual Disability or Related Conditions for Medicaid Certified Nursing Facility only. The Level I screen indicated Resident #97 had anxiety disorder, depressive disorder, and [CONDITION(S)] disorder. It also indicated the resident had recent treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . With these indications a Level II PASRR evaluation must be completed prior to admission, unless the individual meets the definition of hospital discharge exemption. Resident #97 was admitted to the facility under the 30-day hospital discharge exemption. The exemption stated, if the individual's stay is anticipated to exceed 30 days, the NF (Nursing Facility) must notify the Level 1 screener on the 25th day of the stay and the Level II evaluation must be completed no later than the 40th day of admission. No Level II screening was found in the resident's medical record. A review of admission records indicated Resident #97 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #97's orders indicated MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Staff G, Social Services Director on 7/7/22 at 3:43 p.m. Staff G reviewed Resident #97's electronic medical record and confirmed there was no Level II PASRR. After reviewing Resident #97's Level I screening, Staff G confirmed the resident did need a Level II PASRR. She stated she does not have a masters or RN and wasn't clear how the hospital discharge exemption worked on the PASRR II. An interview was conducted with the Nursing Home Administrator (NHA) on 7/7/22 at 4:00 p.m. He stated Resident #97 was not originally going to be here longer than 30 days, but he is now a permanent resident. He reviewed Resident #97's Level I screening and stated this was during a time when the facility was changing social service directors and it fell through the cracks. The NHA stated he would contact the Level I screener. The NHA also noted the physician's signature was missing from the Level I screen for the 30-day hospital discharge exemption. A facility policy titled Pre-Admission Screening and Resident Review (PASRR,) dated 8/1/18, was reviewed. The policy stated PASRR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Guideline: 2. Those individuals who test positive at Level I are then evaluated in depth, called Level II PASRR. The results of this evaluation result in determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care. 4. If an individual who enters a nursing facility as an exempted hospital discharge is later found to require more than 30 days of care, the State mental health or mental [CONDITION(S)] authority must conduct an annual review within 40 calendar days of admission.

Based on observations, staff interview, and facility record review, the facility failed to ensure resident medications were stored and supervised in a manner that was free from access to other residents during one (3/11/2021) of four days observed, and on one (East wing) of two units. It was observed that loose pills and capsules were placed visibly in the space between the wall and the back of the handrail on a main hallway. Findings included: On 3/11/2021 at 1:00 p.m., the 200 East hallway was observed during the lunch meal service. While standing in the main hallway, between resident rooms [ROOM NUMBERS], the space between the wall and the back of the handrail was observed with loose pills and capsules. Further observations revealed one orange round tablet, one white round tablet, and one large white capsule. The medications were easily visible from the hallway and could easily be accessed by anyone who walked by. This area was observed with high traffic of both residents and staff members. There were three residents who were observed using the wall handrail to self propel up and down the hallway and had access to the loose medications. The surveyor stood in the area until 1:57 p.m. and during that period, no staff observed the loose medications. At 1:57 p.m., Staff C, Housekeeper was observed at the end of the hall and was wiping down the wall handrails. At 1:58 p.m., an interview with the East wing Unit Manager, Staff B confirmed the loose pills in the handrail area between rooms [ROOM NUMBERS]. She expressed surprised that the loose pills were there and unsupervised. She confirmed that when nursing staff do medication pass, they were to always ensure each resident receiving medications took the medications properly and swallowed them. She further confirmed that nurses were to supervise residents as they took their medications. She did not know how the loose pills got out in the hallway and in the handrail area and did not know how long they had been there. She immediately spoke with Staff A, Certified Nursing Assistant (CNA) and Staff C as they were in the immediate area. Staff A revealed that she did not know how the medications got there and that the staff look for items placed in between handrails and the hallway wall. Staff C said that she and the other housekeeping staff clean high touch surfaces to include wiping down of the hallway handrails about every two hours. Staff C could not recall if the loose medications were in that area earlier when she wiped down the handrails. Staff C could not recall any other time that she or other housekeeping staff had found loose pills. She indicated that if she had, she would immediately take them to a nurse for disposal. On 3/12/2021 at 8:00 a.m., the Nursing Home Administrator provided documentation that indicated that they thought the medications belonged to a newly admitted resident and each of those medications combined were in her medication order sheet. However, it could not be verified that the medications that were loose, were indeed hers. The Nursing Home Administrator was made aware that the medications were loose, unsupervised, and out in the open with residents at and near them for at least one hour. The Nursing Home Administrator confirmed that all medications were to be passed and taken with nurse supervision prior to leaving the resident, and that there should not be any medications over the counter or prescribed left out in the open unsupervised. On 3/12/2021 the Nursing Home Administrator provided the Storage of Medication policy for review. The policy was last updated on 12/2008. However, the Nursing Home Administrator provided evidence that this policy was reviewed annually. Review of the policy revealed, Medications and Biologicals are stored properly, following manufacturer's recommendations of those of the supplier to maintain their integrity and to support safe administration. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy procedure #1 indicated, The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). Medications are kept in these containers in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers.

Based on record review and interviews the facility failed to provide surgical wound care as ordered by the physician and in accordance to professional standards for one (Resident #2) out of three (3) residents sampled for the administration of wound care. This failure resulted in the potential for delayed treatment and wound care infection for Resident #2. Findings included: Resident #2 was admitted in the facility on 9/23/20. The clinical record indicated the medical [DIAGNOSES REDACTED]. The acute hospital Discharge Summary that the facility had received dated 9/23/20 indicated that Resident #2 was discharged following a small bowel resection (abdominal surgery). The acute hospital Wound/Dressing Care instructed the Nursing Home facility to change dressing daily and to keep wound clean and dry. Review of the physician orders [REDACTED].#2 was at the facility (9/23/20 - 10/1/20) did not include orders to change the dressing to the residents abdominal surgical wound. There was no documented evidence Resident # 2's the surgical wound dressing orders from the hospital were carried out. At 2:56 p.m., the DON stated that staff take orders from the Discharge Summaries from the hospital when residents were admitted . She reviewed the Discharge Summary from the acute facility and confirmed it instructed to change the dressing daily and would expect the physician dressing change orders to be included on the Medication and Treatment Administration Records. She confirmed she was unable to locate documentation that the nurses had documented wound care was done in the progress notes. The facility SNF/NF to Hospital Transfer Form dated 10/1/20 indicated Resident #2 was transferred back to the hospital. The document indicated Reason for transfer: electrolyte imbalance and decreased BP (blood pressure). medications: [REDACTED]. The acute hospital Emergency Provider Report dated 10/1/20 indicated Patient send to ED (emergency department) due to inability to safely [MEDICATION NAME] patient in the setting of low blood pressure as well as worsening electrolytes. Patient currently on [MEDICATION NAME] for treatment of [REDACTED].

Based on observations, medical record review, policy and procedure review, interviews with the facility's nursing and administrative staff, and photographic evidence, the facility failed to ensure that it provided effective supervision and support services to prevent elopement for 1 (Resident #1) of 1 sampled residents. On 09/15/19 at an unknown time, through an unknown exit, Resident #1 exited the facility unsupervised, walked approximately 5.3 miles along heavily traveled roads, crossed the highway, to a parking lot where she fell on her face, hands and knees. A bystander reported the fall, Emergency Responders arrived assessed Resident #1 and, subsequently, the resident was transported via ambulance to a local hospital emergency room . During the survey, conducted 09/17/19 through 09/20/19, facility staff reported that prior to the elopement, Resident #1 was a known wanderer, had the behavior of packing clothes, and had to be redirected by staff from the facility front exit because Resident #1 wanted to catch a bus. Resident #1 had been in receipt of therapy services starting 09/01/19, to provide cognition training to reduce confusion and wandering as well as exit seeking behaviors. The facility posted pictures of Resident #1 at the employee time clock that included the words, Elopement Risk, 2-3 weeks prior to the elopement. Nursing staff did not communicate to Resident #1's doctor that she was an elopement risk. The facility failed to implement their Elopement /Wandering Policy and Procedure by not timely reassessing, and care planning a resident with a [DIAGNOSES REDACTED]. The facility failed to follow their Care of a Wandering Resident Policy and procedure by identifying Resident #1 as an elopement risk, but not implementing the interdisciplinary team review of Resident #1 to formulate interventions to reduce the risk for elopement. The facility failed to follow their Missing Resident policy and procedure in regard to the timely implementation of a core component of calling the police when the search of the facility and immediately outside the building was accomplished, a delay of approximately 1 hour. This resulted in the findings of Immediate Jeopardy, occurring on 09/15/19 and removed at 5:30 p.m. on 09/20/19 with the scope and severity reduced to a D. Findings include. Resident #1, an [AGE] year-old female was admitted to the facility on [DATE]. Resident #1 was admitted with [DIAGNOSES REDACTED]. A review of the local County Emergency Medical Services (EMS) Patient Care Report, date of service 09/15/19, documented the location of response as 833 E. Lake Rd. North, Tarpon Springs, FL. The location of response (where Resident #1 was found) was confirmed via phone call to the local Ambulance representative on 09/23/19 at 10:18 a.m. The transcription stated (Resident #1) in parking lot. Bystanders state they were driving by and saw her fall on the ground. PD (police department) state she is a missing person from a memory care facility down the road. Pt (patient) states she tripped and fell .Pt has scrapes and bruises to face, hands, elbows, and knees .Further review of the report documented that the call was received at 9:40 a.m., Responders were on the scene at 9:56 a.m., and that the patient was transported to a local hospital. A review of the local hospital emergency room record, dated 09/15/19 with provider contact time of 10:36 a.m., documented the history and physical information: [AGE] year-old female with history of dementia presents after escaping from her skilled nursing facility, and being found in the parking lot, after witnessed fall. She was able to stand up fairly quickly after falling. She has multiple facial contusions, and extremity injuries, but appears to be ambulating. She is nervous and anxious because she is confused about where she is. (Family member) at bedside states that this is much worse than her normal mentation, appears to be on blood thinners. A review of Google maps, revealed that the nursing home address at 900 Beckett Way, Tarpon Springs, FL, is located west of US Highway 19 which is a heavily traveled highway (3 lanes north bound, 3 lanes south bound with some areas having 5 lanes in one direction with speed limit ranging 45-55 miles per hour). EMS (Emergency Medical Services) responded to a location, 833 East Lake Road North, Tarpon Springs, where Resident #1 had fallen and was found, which was 5.3 miles from the nursing home. The response location was on the opposite side of US Highway 19 from the nursing home facility. (photographic evidence) During the survey, a review of the facility exit doors was conducted which found that the facility had 7 exit doors. Each of the doors were reviewed and each door was observed to require a code to exit. In addition, at the front entrance/exit, a receptionist monitors the door and is required to depress a button to allow entrance or exit during daily working hours. Review of Resident #1's clinical chart documented an elopement risk assessment that was completed on the first day of her admission, 08/20/19 which documented that the resident was not an elopement risk. Review of Resident #1's clinical chart revealed no mention that she was an elopement risk from 08/20/19 through 09/15/19, with the exception of 1 nurse progress note, dated 09/09/19, that stated no-exit seeking behaviors this shift at this time today. On 09/18/19 at 4:30 p.m., during an interview with the Nursing Home Administrator (NHA). She stated that staff have competency for wandering residents. But, if a resident is identified to wander, they look for other placement. The facility is not a locked facility. On 09/17/19 at 10:16 a.m., an interview was conducted with Staff A, Licensed Practical Nurse, (LPN). Staff A was standing outside of Resident #1's room with her medication cart. She stated that she had not been working for the last 4 days. She stated, I am their (Resident #1 and #2) regular nurse. Resident #1 and #2 live together in the room. She stated, (Resident #1) was not on official 15-minute checks before. They have a usual routine. They go to the smoke porch (he smokes); the Cool Beans Café, therapy or they are in their room. She will start to pack. He will remind her we are going to stay the night. Resident #1 has dementia, she forgets. Staff A stated that the aide, Staff B, Certified Nursing Assistant (CNA) is supposed to stay with her. An observation was conducted at this time of Resident #1 coming out of the resident's room, pushing Resident #2 in the wheel chair. Resident #1 was observed to be independent with ambulation. Staff B, CNA, was with the 2 residents. On 09/17/19, at 10:20 a.m., Resident #1 and #2 were interviewed. The interview took place on a screened in porch in the center of the facility. Resident #1 was observed to have purplish bruising under and around her chin covering the majority of her chin. When asked how she got the bruising, Resident #1 answered, I tell them up at the park. I don't remember what happened. Resident #2 stated, she fell up at East Lake, about 6 miles from here. Someone called the ambulance. Resident #2 reported that his wife, Resident #1 went missing on 09/15/19 between 7:00 a.m. and 7:15 a.m. He stated that he had gone back to the room that they share, and she was not there. He stated that Staff L, Licensed Practical Nurse (LPN) and I started to look for her. Resident #2 stated he called 911. Then, I called my daughter. Resident #2 stated that somebody found Resident #1 and took her to the hospital. He was not sure when they found Resident #1. During the interview, Resident #1 stated, Feel sore today. Resident #2 followed this up with stating, She has more discomfort today than yesterday. When asked if she had any other areas that she hurt, Resident #1 lifted her left pant leg to show an abrasion the size of a quarter on her knee. Resident #2 had been admitted to the facility on [DATE] as a result of a fall. Resident #2 had been his wife's (Resident #1's) care giver prior to his entering the nursing facility. A review of Resident #2's Resident Face sheet, documented that he was admitted on [DATE] with a [DIAGNOSES REDACTED].#2's Minimum Data Set (MDS), section C, dated 08/20/19, Admission assessment, documented a Brief Interview for Mental status (BIMS) of 15, meaning the resident was cognitively intact. A review of Resident #1's MDS, section C, dated 08/27/19, Admission assessment, documented a BIMS score of 5. (A score of 0-7 indicates severe cognitive impairment.) A review of Resident #1's AHCA form 5000-3008, a Medical Certification for Medicaid Long -Term Services and Patient Transfer form, signed by an Advanced Registered Nurse Practitioner, (ARNP), dated 08/20/19, documented a medical condition of weakness and dementia and documented that the ARNP certified the individual required nursing facility services. A review of Resident #1's clinical chart, physician progress notes [REDACTED].#1's Primary physician on 09/04/19, documented the following entries: History of Present Illness: This is an [AGE] year-old female who suffers from dementia. Her husband is her primary care giver. Recently he was admitted to (nursing facility) after a fall. Resident #1 was admitted on [DATE] for continued care. 08/21/19: Due to her dementia the majority of the information was obtained from the medical record. 08/23/19: Patient is admitted to PCRC as her husband was admitted here as well who is her primary caregiver. History obtained from medical records. Patient is currently resting in bed without any significant distress. 08/30/19: Patient doing well. No acute distress or complaints. [DIAGNOSES REDACTED]. A review of Resident #1's 09/2019, physician orders, included the following medications: [REDACTED] [MEDICATION NAME] (quetiapine), tablet; 50 mg, dx: Mood disorder due to known physiological condition, unspecified, start date 08/21/19, open ended. [MEDICATION NAME], tablet extended release; 120mg, dx: other secondary hypertension, start date 08/21/19, open ended. A post event physician progress notes [REDACTED]. She can not remember why she left or how she got out. Discussed with administration in detail. Research is in place to determine how she was able to get out of the building. Patient is now on 1:1 monitoring. No history of this behavior in the past. A review of a Behavioral Medicine/Neuropsychiatric Assessment, dated 09/17/19, documented a patient review of Resident #1. The form documented the following information: Chief Complaint/Presenting Problem: Initial Psychiatric Assessment due to staff reports of attempts at elopement/ Dementia/Anxiety/Agitation. Resident's ability to provide history: Unable R/T (related to) Cognitive Impairment. History of Present Illness/Interval History: Patient was referred by the primary care physician for psychiatric assessment and treatment. Pt is pleasant woman with significant cognitive impairment and appears anxious and agitated. Pt attempted to eloped several days ago. Review of Systems: Patient has significant neurocognitive impairment and is an unreliable respondent. Review of Mental & Constitutional Status Examination: documentation included that Resident #1 had an unsteady gait, poor balance, orientation to person only, anxious, Loss of abstract mentation with slow processing, poor concentration, poor insight, poor anterograde and retrograde memory and grossly impaired judgment. Counseling and coordination of care: Counseling with Power of Attorney: Diagnostic impressions were given with education about disease and symptom process and probable etiology. Options for care and treatment with associated prognoses and my specific recommendations for treatment for [REDACTED]. An interview was conducted on 09/17/19 at 12:55 p.m. with Resident #1's daughter. She talked about Resident #2, her father, that he had fallen at home, gone to the hospital and subsequently had been transferred to this facility. She stated that prior to that, her father and mother, Resident #1, were living together. The daughter stated that her mother was admitted on [DATE]. She had dementia. I was taking her everywhere. She wanted to stay at home. I took her money and her cards. Her car was broken down, so I did not have to worry about that. She was starting to spiral. She did not know who I was a couple of times. I asked Staff T, Director of Admissions (DOA), if she could be admitted . She has dementia, I thought maybe for respite. Because of the dementia, she (DOA) said they could treat her for cognitive skills and that she would be cared for. The DOA asked if she was a flight risk I said no. There was no way of me knowing she was a flight risk. Resident #1's daughter stated that she became aware of the elopement event on 09/15/19 at 7:45 a.m., when her father called her. He said they cannot find your mother, (Resident #1), everyone is looking for her. I said, (Dad), I am sure she (Mom) is there, because all the doors are locked. He called me back, . I was on the road; my husband and I both went in different directions in order to see if we could see her on the back roads. I think he (Resident #2) called me back at about 8:30 a.m. No sooner did that happen, somebody from here (the facility), called me. A Spanish woman with a heavy dialect. She interrupted the call with my father (when he called back) and she asked, do you know where your mother is? I told her I did not, and I was coming to the facility. And then, when I got here, I asked if anyone had called the police. I got no response. Resident #1's daughter stated that she spoke with the Spanish woman, the receptionist at the desk, and the Director of Nursing (DON). She stated that they had not called the police at that time. She stated that after that, the police were called. Then we got a call that she had been found (I may have gone out again). I wanted to check at the house to see if she was back there that is 3.3 miles away. I did go check that. I did get a call back and they said they found her. They had taken her to the hospital. They told me that someone had handed my mom a phone (at the time she was found by the bystander) and she called my father. Basically, she found herself. That is when I went to my father and told him that I was going to meet my mother at the hospital. Also, the police had arrived at that point; they were in the DON's room. At the Hospital, she had just gotten there, I waited in the ER (emergency room ). They told me they were going to do an EKG (electrocardiogram); cat-scan; she was scratched and bumped up pretty good. They put her on a saline drip. (Resident #1) said that she did not know what happened. She does not remember falling. I do not know the location that she was found. They (police) told me that she crossed (US Highway) 19, and over to Keystone. She must have walked all the way down 19 on the right side; to Tarpon Ave, crossed there, that becomes Keystone. My father (Resident #2) said that she was found at a Country club (Eastlake). There is a country club around there somewhere. Someone said it was 8 miles away. The police said that there would be an investigation. The only thing that I think that went awry is that they took so long to call the police. The only thing that she has to identify her is her wrist band. She looks perfectly normally. I have ordered a GPS (global positioning system) watch that will need to be charged every 48 hours. This will come tomorrow. I will have to figure that out. Due to the charge (that the watch requires). Someone will have to charge it for her. It will notify me if she crosses the perimeter of the building. I asked about a wander guard. They said they typically do not take residents that wander. My father said she left the room at 7 a.m. Three people said they saw her at 7:30 a.m. When my father called me, he was getting really worried. Have they said what they are doing for her to keep her safe? My father said they had no one in the room from 11-7 last night. They said that they would have someone with her for the time being 1:1. He was pretty broken up about this yesterday. I transported her back from the hospital to the facility. Resident #1's daughter was asked if Resident #1 had any behaviors while she was at the facility. Yes, she would pack every day. I would have to un-pack her every day. Staff were aware of her packing. If I was not here, they would have to unpack it. They had to take away the plastic bags in the trash containers, because she would use them to pack her clothes. Again, .I think it was too long .they told me that they have a company protocol to search the grounds inside and out; but I talked to one of the nurses, and she had gone all the way up to the Tahitian hotel, that is way up the road. They should have called the police sooner. An interview was conducted on 09/17/19 at 2:05 p.m. with Staff G, LPN. She stated, I am the weekend supervisor. She confirmed that she was working during the elopement event. She stated, I came at 6:30 a.m. to 11:00 p.m. It started out normal, I came at 6:30 a.m., I did a walk around. I came to east wing/200. I came down this hall, to see if there are any reports. I was on my way back to east wing and I saw Resident #1, a couple of times. She was in the hallway. One time on long hall east, by the smoke porch; and then in the hallway around room [ROOM NUMBER]. She was just walking. That was not an abnormal thing for her. Her husband was with her. She had these black shorts with a diamond shape pattern; and then a white; gold jewelry embedded shirt on. I have complemented her on them. Then Staff L, LPN came to me. No Staff L, LPN did not come to me. Staff L, LPN was in the hall with Resident #2. Staff L, LPN, said that Resident #2 and #1 had a little spat. Staff L, LPN said let us go out to the smoke porch. He went one way. I went another way. As I passed aides, (I would ask) did you see Resident #1? We all looked. We called the code green. I did not actually call it. Staff H, LPN, (called it) she is another nurse. What does code green mean? One of the residents is missing. Do you know what time the code green was called? No Do you know approximately? No, it was in the morning. Then? Everyone stops what they are doing. Two people go down the hallway. The other two go outside. Two outside? Outside, Staff L, LPN and I did. There was a lot more (staff that went outside). Were you able to find her? No. I got in my car and circled the area. Then I headed for (Resident #1's) house. I did not find it (the house). We went looking along US 19. How long do you think that this took? ½ hour, 45 minutes. Then, I was told to come back to the unit by Staff I, Registered Nurse (RN), Unit Manager. I came back and the DON was here. The Nursing Home Administrator was here. They handled the investigation from there. Did you call the police? I did not call the police, that would have been Staff I, RN's role. She is in charge of the east side. On 09/17/19 at 2:19 p.m. an interview was conducted with Staff I, RN, Unit Manager. She stated, on Sunday (09/15/19), I started at 3am in the morning until 7a.m. Someone had called in on the 11:00 p.m. to 7:00 a.m. shift, (the nurse that worked 3-11), covered the first ½; and then I came in at 3:00 a.m. to finish the shift. What happened? I finished giving my report to the next nurse that was coming on, this was around 7:40 a.m., 7:45 a.m. Then I heard green. One of the nurses, Staff L, he is a nurse, but worked Sunday as an aide. Everyone started looking. Checked the front door, looked at the patio; I called the DON and the administrator, called the family. What did you say to the (family member)? I asked her if she had seen (Resident #1). She immediately came to the facility. Did you call the police? I understand that the DON called the police. Do you know where the resident was found? I do not know exactly. I think East Lake Road. Does Resident #1 have special precautions at this time? Yes, now she is on one to one. Around the clock? 24 hours? Yes. Are there doctor's orders for the 1:1? This is protocol, we notify the doctor to request the supervision. Did they tell you to do anything different the next time? Honestly, I hope that it does not happen again. (No further information was provided to the question.) Do you know what time they found the resident? Around 9:30 a.m. She confirmed that the resident was not on any special precautions prior to the elopement. An interview was conducted on 09/17/19 at 2:45 p.m. with Staff O, Occupational Therapist, (OT). She stated that Resident #1 had been screened by OT (occupational therapy). She stated that Resident #1 does all her own personal care. Her main problem was her knowing where she was at. Her (family member) told us she was having cognition problems at home. After a week here at the facility, staff and family said that she couldn't find where she was. So, we were brought in to try to orient her. On 09/17/19 at 3:30 p.m., an interview was conducted with Staff Q, Physical Therapy Assistant (PTA). She confirmed that she had been at the facility the date of event, 09/15/19. She stated that she arrived at 9:20 a.m. and she left at 5:15 p.m. She stated, When I got here, no one was really searching at that time. It appeared that way. Another co-worker, 9:15 a.m., Staff R, PTA, was here. Seemed like they had stopped. Around 10:00 a.m., the DON, NHA, Staff T, (Admissions Director), the family member, the police came, and it was shortly after that that the resident's wife, (Resident #1) called her husband, (Resident #2). Somewhere between 10:00 a.m. and 11:00 a.m. Do you know how long she was gone? Rumor was that she was last seen around 6:30 a.m. and around 7:00 a.m., (Resident #2) noticed her gone. At the front (door), no one is up there until 8:00 a.m., maybe later. After hours, they go through the ambulance door. On 09/17/19 at 3:34 p.m. the ambulance door exit was observed with Staff Q, PT[NAME] Staff Q, PTA explained that the ambulance door exit requires a staff member at the nursing station to enter a code to open the door. Staff Q, PTA reported that all the doors of the facility have the same type of process for a person to enter or exit, which is to enter a code in a key pad located at the door exit. Staff Q was asked if she had received post event training. She stated that the in-service she received was about the calling of the code green, to alert the manager, the process of who is told next. On 09/17/19 at 3:45 p.m., a tour of the facility doors was conducted with the Maintenance Director. He stated that he checks the doors every day to check the functioning appropriateness. He stated that for the weekend, he would check the door on Monday and check off the weekend. He stated that he had checked all the doors and they were functioning as intended. He stated that the facility does not use wander guards. He stated the facility has no cameras. A review of the front door was completed. The front door has a magnetic lock. In order to exit, a code has to be entered into the key pad next to the door frame. When the receptionist is present, they have a button behind the desk which they push in order to let someone in and out. The door will not open from the outside without the receptionist pressing the button. The receptionist locks the door at night. All exit doors were reviewed during the tour with the maintenance director (6 exit doors and 1 maintenance door). The resident hallways with door access to the outside were observed to have a code box present on the door. When the door handle was depressed and held for a length of time, the door did not open. The door required the code. Employee entrance doors (2) were reviewed, each had a code box on the inside and outside of the building. The employee hall was observed to have doors that required a code to access the employee exit doors. On 09/17/19 at 4:05 p.m., an interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). When they were asked, would you have done anything different? Both stated, no. During the interview, the DON confirmed that she was the Risk Manager (RM) for the facility. The NHA and DON reported that Staff L, LPN, discovered Resident #1 missing at 8:10 a.m. The NHA reported that Staff I, RN, called her around 8:30 a.m. The NHA stated that she notified the DON. Staff I, RN, let us know what they were doing. What were they doing? They had called the code green, they had searched the facility, they had searched outside, they had people in their cars searching. They got Resdient#1's (former) address and someone went to her address. The NHA reported that when she found out that the resident had been found, it was 9:39 a.m. She reported that how she found out was that Resident #1 had called Resident #2 and this information was relayed to me. I was not at the building at this time yet. Did you call the police? NHA answered, No. At this time, the DON reported, I did. The DON stated that she called the police at 9:12 a.m. For the investigation, the NHA stated that we checked all the doors for functionality. She stated she called the Maintenance Director to come in and check them as well. We started interviewing the staff. We notified (a State Agency) with the immediate report. We spoke with the medical practitioner. We spoke with the staff with anyone who could have come in or out at that time to see if she had tail gaited. We had the door company come out and check the functionality of the door. We made sure someone was watching the front door until the door company could come. We reviewed her elopement assessment and re-did it. Her (family member) is getting a GPS (Global Positioning System) for her. (A watch with a GPS system that the resident can wear to locate her if she is lost). The elopement assessment (for Resident #1) was updated, the singular event of her elopement, placed Resident #1 at risk. We evaluated all the residents in house. No other residents had changes. We updated Resident #1's care plan with her elopement care plan. If she had been identified as an elopement risk sooner, what would be different? NHA answered, more frequent checks. Possible room changes. The NHA reported We do not know how she left the facility. There was no one at the front desk at the time of exit. When asked if they knew how long Resident #1 was gone from the facility, the DON stated at 8:10 a.m., she was seen by several people. She was found at 9:39 a.m., 3.5-4 miles away. The NHA stated, We think that she got a ride. I do not think she could have made it on her own. The DON reported We have educated staff about the elopement policy, wandering residents. The DON reported that she called the police at 9:12 a.m. and that the police came to the facility at 9:20 a.m. The NHA reported that generally, it was one of us that would call the police. Anyone can call the police. When asked if the facility uses wander guards, the NHA, reported wander guards are a false sense (of security). (Resident #1) is a person that we would not have put a wander guard on anyway. On 09/17/19 at 5:15 p.m., the NHA was asked: Why would you call the police? She stated, to help with the search. The NHA and the DON provided 2 staff member statements as evidence of the staff interviews, they had conducted, Staff U, CNA and Staff C, CN[NAME] Both of the CNA's statements documented that the resident had been seen at approximately 7:30 a.m. on the date of elopement. The following are interviews conducted with staff about Resident #1 and the elopement day: An interview was conducted on 09/18/19 at 10:07 a.m. with Staff J, CN[NAME] She stated that she arrived at 7:00 a.m., Sunday (9/15/19). What I usually do is walk down the hall and check on my residents. Resident #1 was already in the hallway. She was walking toward the north hall. Do not recall what she was wearing. Resident #2 was in his room. Staff J reported that this was her first assignment with Resident #1. She stated, there were pictures at the time clock. We have known about her, she was a wanderer. I was given report that she was a wanderer. The pictures at the time clock were there so people would not let her out. Did she verbalize that she wanted to leave the building? There was one time that she wanted to go to the market and we just guided her back. When this happened, she was down the hall, the long hallway (from 40-52) we guided her back to the Cool Beans Café and she was fine after that. Would she pack her clothes? No, she just had her purse on her. She always has her purse on her. She walks a lot. Staff J, CNA, confirmed that she was involved in the search for Resident #1. When asked when she became aware Resident #1 was missing, she reported, I did not see her on Sunday morning. I heard that she was in the north Hall. I asked someone if they had seen her and they said that they had seen her head that way. You became aware that she was missing at what time? Between 7:30 a.m. and 8:00 a.m. Closer to 7:30 a.m. She was due for her medications. Did you participate in the search? Yes, I participated in the building and the outside. Outside, I went on my 15-minute break, I drove toward north Pinellas (turns into alternative 19 St./ towards the sponge docks. Then I went back down US 19 towards the Walmart, then the little neighborhoods on Beckett way. I did that too. Do you know what time this was? This was after breakfast. It had to be around 10 a.m. Then I came back to the facility. (Staff J was not specific about who she talked to when she returned (to the facility), she stated, CNAs and the nurses.) Did not speak to the DON until she got here. Not sure when she got here. She stated that she worked here before and that she participated in an elopement drill last year. Did you participate in an elopement drill prior to this occurrence? No, not an elopement drill. You get training on elopement during the orientation. On 09/18/19, at approximately 11:00 a.m., Staff J, CNA was asked to tour the employee time clock area to review for Resident #1's posted picture. She escorted the surveyor back to the employee corridor door, a locked door (code) to the time clock area. No picture of Resident #1 was observed posted. Staff J, CNA stated, oh, they must have taken it down. During an interview conducted on 09/18/19 at 10:33 a.m. with Staff L, Licensed Practical Nurse (LPN), he reported that he worked as a CNA on Sunday, 09/15/19. He stated that he worked 7:00 a.m. -11:00 p.m., that he had Resident #1 once as a nurse, that he would pass her in the hall. (Resident #1) was always very pleasant, and always with (Resident #2). He confirmed Resident #1 could walk by herself. When asked if he had to redirect Resident #1, he stated, I have not. I am sure other people have had to, she is confused. Can you tell me about Sunday (09/15/19)? I got to the facility at 6:50 a.m., I was doing my normal rounds, started to get people up for the breakfast. I was diets and lights. That is where I answer the call lights on the floor if people need bathroom or food exchange. As I was walking by Resident #2, he asked if I could take him out the smoking porch. (Resident #1) was always with him pushing him around. That is when I asked where is your wife (Resident #1) at? Resident #2 said Resident #1 went for a walk. So, I said, I will take you to the porch, but, let us find your wife (Resident #1) first. So, I walked around to the porch, and Resident #1 was not there. Then I checked the basics, the coffee shop, I walked ar

Based on observations, medical record review, policy and procedure review, interviews with direct care nursing staff, ancillary staff, administrative staff and photographic evidence, the facility failed to revise the care plan to incorporate the identified problem area of elopement risk and implement care plan interventions to keep the resident safe and reduce the resident's elopement risk for 1 (Resident #1) of 1 residents reviewed for elopement. Resident #1 was assessed the day of admission to the nursing facility, 08/20/19, as Not an elopement risk. Post admission Resident #1 was known to the facility staff to display wandering behavior, packing clothes behavior, verbalized a desire to leave, required redirection and cueing and Resident #1's photo was posted at the employee time clock, nursing station, and front desk area with the words Elopement Risk on it. As of 09/01/19, Speech Therapy initiated services for Resident #1 for reorientation to the facility, cognitive impairment, and to reduce exit seeking. On 09/15/19 at an unknown time, through an unknown exit, Resident #1 exited the facility unsupervised, walked approximately 5.3 miles along heavily traveled roads, crossed the highway, to a parking lot where she fell on her face, hands and knees. A bystander reported the fall, Emergency Responders arrived assessed Resident #1 and subsequently the resident was transported via ambulance to a local hospital emergency room . The facility failed to implement the facility Elopement / Wandering policy and procedure, by not timely reassessing Resident #1, who was identified as a elopement risk, not care planning for the identified elopement risk problem and not providing interventions to reduce or prevent elopement risk. The facility failed to implement the facility Care of a Wandering Resident Guidelines Policy in regard to planning the care Resident #1 to include the provision of interventions to reduce the risk of exit seeking behavior, and to preserve the resident dignity. The facility failed to implement the facility's Comprehensive Care Plans Policy and procedure in regard to updating the care plan to include a focus for Resident #1's problem area of being an elopement risk, formulating a goal to attempt to keep Resident #1 safe and interventions to reduce unsafe wandering. This resulted in the findings of Immediate Jeopardy, occurring on 09/15/19 and removed at 5:30 p.m. on 09/20/19 with the scope and severity reduced to a D. Findings include: On 09/17/19 at 4:05 p.m., an interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) in regard to the elopement of Resident #1 on the date of 09/15/19. The NHA and DON reported that Staff L, LPN, (Licensed Practical Nurse) discovered Resident #1 missing at 8:10 a.m. The NHA reported that she found out that Resident #1 had been found at 9:39 a.m. For the investigation of Resident #1's elopement, the NHA stated that we checked all the doors for functionality. The NHA stated she called the Maintenance Director to come in and check them as well. The NHA stated, we started interviewing the staff, we notified (State Agency), we had the door company come out and check the functionality of the door, we made sure someone was watching the front door until the door company could come. We reviewed Resident #1's elopement assessment and re-did it. Her daughter is getting a GPS (global positioning system) for her. The elopement (assessment) was updated, the singular event of her elopement, placed the resident at risk. We evaluated all the residents in house. No other residents had changes. We updated Resident #1's care plan with her elopement care plan. If she had been identified as an elopement risk sooner, what would be different? NHA answered, more frequent checks. Possible room changes. During the interview, the NHA reported that they did not know how Resident #1 left the facility. A review of the local County Emergency Medical Services (EMS) Patient Care Report, date of service 09/15/19, documented the location of response as 833 E. Lake Rd. North, Tarpon Springs, FL. The location of response (where Resident #1 was found) was confirmed via phone call to the local Ambulance representative on 09/23/19 at 10:18 a.m. The transcription stated (Resident #1) in parking lot. Bystanders state they were driving by and saw her fall on the ground. PD (police department) state she is a missing person from a memory care facility down the road. Pt (patient) states she tripped and fell .Pt has scrapes and bruises to face, hands, elbows, and knees .Further review of the report documented that the call was received at 9:40 a.m., Responders were on the scene at 9:56 a.m., and that the patient was transported to a local hospital. A review of Google maps, revealed that the nursing home address at 900 Beckett Way, Tarpon Springs, FL, is located west of US Highway 19 which is a heavily traveled highway (3 lanes north bound, 3 lanes south bound with some areas having 5 lanes in one direction with speed limit ranging 45-55 miles per hour). EMS (Emergency Medical Services) responded to a location, 833 East Lake Road North, Tarpon Springs, where Resident #1 had fallen and was found, which was 5.3 miles from the nursing home. The response location was on the opposite side of US Highway 19 from the nursing home facility. (photographic evidence) A review of the local hospital emergency room record, dated 09/15/19, with provider contact time of 10:36 a.m., documented the history and physical information: [AGE] year-old female with history of dementia presents after escaping from her skilled nursing facility, and being found in the parking lot, after witnessed fall. She was able to stand up fairly quickly after falling. She has multiple facial contusion, and extremity injuries, but appears to be ambulating. She is nervous and anxious because she is confused about where she is. (Family member) at bedside states that this is much worse than her normal mentation, appears to be on blood thinners. On 09/17/19 at 4:05 p.m., an interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). When they were asked, would you have done anything different? Both stated, no. During the interview, the DON confirmed that she was the Risk Manager (RM) for the facility. The NHA and DON reported that Staff L, LPN, discovered Resident #1 missing at 8:10 a.m. The NHA reported that Staff I, RN, called her around 8:30 a.m. The NHA stated that she notified the DON. Staff I, RN, let us know what they were doing. What were they doing? They had called the code green, they had searched the facility, they had searched outside, they had people in their cars searching. They got Resident #1's (former) address and someone went to her address. The NHA reported that when she found out that the resident had been found, it was 9:39 a.m. She reported that how she found out was that Resident #1 had called Resident #2 and this information was relayed to me. I was not at the building at this time yet. Did you call the police? NHA answered, No. At this time, the DON reported, I did. The DON stated that she called the police at 9:12 a.m. For the investigation, the NHA stated that we checked all the doors for functionality. She stated she called the Maintenance Director to come in and check them as well. We started interviewing the staff. We notified (a State Agency) with the immediate report. We spoke with the medical practitioner. We spoke with the staff with anyone who could have come in or out at that time to see if she had tail gaited. We had the door company come out and check the functionality of the door. We made sure someone was watching the front door until the door company could come. We reviewed her elopement assessment and re-did it. Her (family member) is getting a GPS (Global Positioning System) for her. (A watch with a GPS system that the resident can wear to locate her if she is lost). The elopement assessment (for Resident #1) was updated, the singular event of her elopement, placed Resident #1 at risk. We evaluated all the residents in house. No other residents had changes. We updated Resident #1's care plan with her elopement care plan. If she had been identified as an elopement risk sooner, what would be different? NHA answered, more frequent checks. Possible room changes. The NHA reported We do not know how she left the facility. There was no one at the front desk at the time of exit. When asked if they knew how long Resident #1 was gone from the facility, the DON stated at 8:10 a.m., she was seen by several people. She was found at 9:39 a.m., 3.5-4 miles away. The NHA stated, We think that she got a ride. I do not think she could have made it on her own. The DON reported, We have educated staff about the elopement policy, wandering residents. The DON reported that she called the police at 9:12 a.m. and that the police came to the facility at 9:20 a.m. The NHA reported that generally, it was one of us that would call the police. Anyone can call the police. When asked if the facility uses wander guards, the NHA, reported wander guards are a false sense (of security). (Resident #1) is a person that we would not have put a wander guard on anyway. On 09/17/19 at 5:15 p.m., the NHA was asked: Why would you call the police? She stated, to help with the search. The NHA and the DON provided 2 staff member statements as evidence of the staff interviews, they had conducted, Staff U, CNA (Certified Nurse Assistant) and Staff C, CN[NAME] Both of the CNA's statements documented that the resident had been seen at approximately 7:30 a.m. on the date of elopement. Resident #1, an [AGE] year-old female was admitted to the facility on [DATE]. Resident #1 was admitted with [DIAGNOSES REDACTED]. A review of Resident #1's elopement risk evaluation, dated 08/20/19, at 19:03, documented that Resident #1 is determined to NOT be at risk for elopement. Further review of the Elopement Risk Evaluation, directions included: Complete if elopement potential exists. If the resident is deemed at risk, a prevention protocol should be initiated and documented in the care plan. The form listed questions for the nurse to complete, Potential Risk Factor/Resident Status: 1. Is resident cognitively impaired? Yes 2. Is resident independently mobile (ambulatory or wheelchair)? Yes 3. Does resident have poor decision-making skills? Yes 4. Has resident demonstrated exit-seeking behavior? No 5. Does resident wander oblivious to safety needs? No 6. Does resident have a history of elopement? If yes, # of times, if known. No 7. Does resident have the ability to exit the facility? Yes Yes, to questions 4, 5, or 6 automatically place the resident AT RISK. The bottom of the form reflected a check mark next to: Resident is determined to NOT be at risk for elopement. A review of a 2nd elopement risk for Resident #1, completed on 09/15/19 at 12:33 p.m., changed the resident's status to at risk, due to question #4 being marked yes, resident demonstrated exit seeking behavior, which triggered staff to determine the resident to be at risk for elopement. A review of Resident #1's Minimum Data Set (MDS), Version 3.0, Resident Assessment and Care Screening, dated 09/06/19, for Resident #1's 5 day scheduled assessment, documented in section E0900, Wandering-Presence & Frequency, a 0, which meant Behavior not exhibited. Further review of the choices available, reflected that 1 meant, Behavior of this type occurred 1-3 days; 2 meant, Behavior of this type occurred 4-6 days, but less than daily; 3 meant, Behavior of this type occurred daily. A review of Resident #1's MDS, Version 3.0, Resident Assessment and Care Screening, dated 09/13/19, for Resident#1's 14 day scheduled assessment, documented in section E0900, Wandering-Presence & Frequency, a 0, which meant Behavior not exhibited. A review of Resident #1's Care Plan identified a Focus area: Resident #1 has impaired Cognition with memory problems related to [DIAGNOSES REDACTED]. She is able to verbalize all of her needs to staff. She has clear speech and is understood by others. Declines/changes/fluctuations in overall status is anticipated with the progression of disease process related to [DIAGNOSES REDACTED]. The goal of the plan: Will continue to be alert and oriented x 1 and continue to recognize her husband, (Resident #2) and family. Interventions included the following with an effective date of 08/28/19: Always identify self to resident and explain tasks before doing them; Encourage resident to attempt communication/conversation. Encourage her to express her needs, monitor body language for cues for needs. Allow resident ample time to process information and respond. Involve resident in daily decision making per resident's preference and /or ability. Provide consistency with caregivers as able and a routine that promotes a sense of familiarity and sense of security. Provide cues/reminders prn (as needed) to reorient/redirect resident. Provide environment prompts as desired (e.g. clock, calendar, etc.) Provide regular? In house? Chaplain visits. A Focus area, Falls: Resident #1 is at risk for fall related to: she states that she does not recall having any recent or history of falls; She is alert and oriented x 1 with noted disorientation and confusion. She is able to verbalize all of her needs to staff. She has clear speech and is understood by others. She is mostly independent, but at times requires supervised assistance with her locomotion/ambulation/mobility/transfers and toileting needs. She has steady gait and balance. She is receiving an Antipsychotic medication daily, effective 08/28/19. The goal of the plan was to minimize risk of falls and fall related injuries. The approaches listed were: Place call bell within easy reach, effective 08/21/19; keep frequently used items and call bell within reach to prevent reaching, effective 08/28/19; Keep environment free of obstacles, keep bed in lowest position; Therapy eval/tx/referrals as indicated/ordered; Monitor for s/s of drug related side effects; Assure resident is wearing appropriate non-skid footwear when OOB (out of bed). A review of Resident #1's Care plan for the period of 08/20/19 thru 09/15/19 a.m. (pre-elopement event), found no identified problem of Resident #1 being an Elopement Risk, interventions for elopement risk, wandering, or goal of reducing elopement risk. Further review of Resident #1's care plan, documented 2 new focus areas that were added on 09/15/19: A focus area, Cognitive Loss/Dementia: Resident has impaired Cognition with memory problems related to Onset of Dementia BIMS 8. Is alert and oriented x1, has clear speech and is able to make simple needs known. The goal of the plan: With cues/guidance as needed, remain oriented to self-through next review. The interventions, two, effective 09/15/19, Provide consistency with caregivers as able and a routine that promotes a sense of familiarity and sense of security. Provide cues/reminders prn to reorient/redirect resident. The 2nd new Focus area was Behavioral: Resident is at risk for elopement as evidenced by increased elopement observation score and actual attempts to elope, effective 09/15/19. The goal: Resident will remain safely within environment as evidenced by no elopement attempts or events. Interventions: As of 09/15/19, 1:1; Complete elopement observation on admission, quarterly and with significant changes; ensure resident is residing in the correct level of care (does he/she require a secured unit for their safety); Increase involvement with activities; Monitor behavior: review for recent changes in bed/room moves, medications, new staff members, loss of family members, verbal statements I'm leaving, packing belongings, following visitors closely as exiting or pushing on exit doors. Update elopement book at each nursing station with pictures. A review of Resident #1's nursing notes, dated 09/15/19 at 12:30 p.m.: Resident returned to facility after leaving after spat with (Resident #2). Resident found to be missing from facility this a.m.-writer, DON, and MD (Medical Doctor) notified-law enforcement notified-resident called (Resident #2) from a bystander's phone. Resident #1 transported to (local hospital), CT (Computed [NAME]ography) negative-new orders for UA (urinalysis)-(family) notified and hospital report reviewed-resident with bruising to chin and right elbow. Small abrasion to left knee and left eye. Treatment order in place-care plan review and update, signed by the NH[NAME] It was noted that no further notes had been entered into Resident #1's clinical chart the morning of the elopement, 09/15/19. A review of Resident #1's clinical chart revealed no mention that she was an elopement risk from 08/20/19 through 09/15/19 (pre-elopement), with the exception of 1 nurse progress note, dated 09/09/19, that stated no-exit seeking behaviors this shift at this time today. On 09/18/19 at 4:30 p.m., during an interview with the Nursing Home Administrator (NHA) she stated that staff have competency for wandering residents. But, if a resident is identified to wander, they look for other placement. The facility is not a locked facility. A review of A Speech Therapy Evaluation & Plan of treatment for [REDACTED]. Results revealed a score of 17, revealing moderate deficits. The pt. was administered the Brief Cognitive Assessment Tool (BCAT). The patient scored 18/50 revealing moderate to severe Dementia. Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: decreased leisure task participation, decreased participation with functional tasks, falls, further decline in function, increased dependency upon caregivers and social isolation. A review of the Speech Therapy (ST) service note, dated 09/10/19, documented: . Nurse cleared (Resident #1) for skilled ST for cognitive-communicative targeting orientation and use of compensatory strategies, including visual aids, to reduce confusion and wandering, as well as exit seeking behaviors . On 09/17/19, at 10:20 a.m., Resident #1 and #2 were interviewed. The interview took place on a screened in porch in the center of the facility. Resident #1 was observed to have purplish bruising under and around her chin covering the majority of her chin. When asked how she got the bruising, Resident #1 answered, I tell them up at the park. I don't remember what happened. Resident #2 stated, she fell up at East Lake, about 6 miles from here. Someone called the ambulance. Resident #2 reported that his wife, Resident #1 went missing on 09/15/19 between 7:00 a.m. and 7:15 a.m. He stated that he had gone back to the room that they share, and she was not there. He stated that Staff L, Licensed Practical Nurse (LPN) and I started to look for her. Resident #2 stated he called 911. Then, I called my daughter. Resident #2 stated that somebody found Resident #1 and took her to the hospital. He was not sure when they found Resident #1. During the interview, Resident #1 stated, Feel sore today. Resident #2 followed this up with stating, She has more discomfort today than yesterday. When asked if she had any other areas that she hurt, Resident #1 lifted her left pant leg to show an abrasion the size of a quarter on her knee. Resident #2 was admitted to the facility on [DATE] as a result of a fall. Resident #2 had been his wife's (Resident #1's) care giver prior to his entering the nursing facility. A review of Resident #2's Resident Face sheet, found that he was admitted with a [DIAGNOSES REDACTED].#2's Minimum Data Set (MDS), section C, dated 08/20/19, Admission assessment, documented a Brief Interview for Mental status (BIMS) of 15, meaning the resident was cognitively intact. A review of Resident #1's MDS, section C, dated 08/27/19, Admission assessment, documented a BIMS score of 5. (A score of 0-7 indicates severe cognitive impairment.) A review of Resident #1's AHCA form 5000-3008, a Medical Certification for Medicaid Long -Term Services and Patient Transfer form, signed by an Advanced Registered Nurse Practitioner, (ARNP), dated 08/20/19, documented a medical condition of weakness and dementia and documented that the ARNP certified the individual required nursing facility services. A review of Resident #1's clinical chart, physician progress notes [REDACTED].#1's Primary physician on 09/04/19, documented the following entries: History of Present Illness: This is an [AGE] year-old female who suffers from dementia. Her husband is her primary care giver. Recently he was admitted to (nursing facility) after a fall. Resident #1 was admitted on [DATE] for continued care. 08/21/19: Due to her dementia the majority of the information was obtained from the medical record. 08/23/19: Patient is admitted to PCRC as her husband was admitted here as well who is her primary caregiver. History obtained from medical records. Patient is currently resting in bed without any significant distress. 08/30/19: Patient doing well. No acute distress or complaints. [DIAGNOSES REDACTED]. A post event physician progress notes [REDACTED]. The physician progress notes [REDACTED]. She cannot remember why she left or how she got out. Discussed with administration in detail. Research is in place to determine how she was able to get out of the building. Patient is now on 1:1 monitoring. No history of this behavior in the past. A review of a Behavioral Medicine/Neuropsychiatric Assessment, dated 09/17/19, documented a patient review of Resident #1. The form documented the following information: Chief Complaint/Presenting Problem: Initial Psychiatric Assessment due to staff reports of attempts at elopement/ Dementia/Anxiety/Agitation. Resident's ability to provide history: Unable R/T (related to) Cognitive Impairment. History of Present Illness/Interval History: Patient was referred by the primary care physician for psychiatric assessment and treatment. Pt is pleasant woman with significant cognitive impairment and appears anxious and agitated. Pt attempted to elope several days ago. Review of Systems: Patient has significant neurocognitive impairment and is an unreliable respondent. Review of Mental & Constitutional Status Examination: documentation included that Resident #1 had an unsteady gait, poor balance, orientation to person only, anxious, Loss of abstract mentation with slow processing, poor concentration, poor insight, poor anterograde and retrograde memory and grossly impaired judgment. Counseling and coordination of care: Counseling with Power of Attorney: Diagnostic impressions were given with education about disease and symptom process and probable etiology. Options for care and treatment with associated prognoses and my specific recommendations for treatment for [REDACTED]. A review of Resident #1's 09/2019, physician orders, included the following medications: [REDACTED] [MEDICATION NAME] (quetiapine), tablet; 50 mg, dx: Mood disorder due to known physiological condition, unspecified, start date 08/21/19, open ended. [MEDICATION NAME], tablet extended release; 120mg, dx: other secondary hypertension, start date 08/21/19, open ended. An interview was conducted on 09/19/19 at 12:30 p.m. with Resident #2. Resident #2 and #1 were in their room eating their lunch. (an aide was present in the room). Resident #2 was asked if he and his wife ate their lunch together. He stated that we eat all 3 meals together. Resident #2 was asked if any staff assisted him on 09/15/19, (Sunday) to get up in the morning. He stated no, I got up on my own. (Resident #1) got up on her own. (Resident #1) and I went together to the smoking porch. (Resident #1) pushed me down there. She was sitting across from me. Her back was against the screen. She stood up to go into the dining area. I said, where are you going. She did not answer. I said, I will see you back at the room. I went back to the room, she was not there. Staff L, LPN, helped me look for her. Was there a staff member on the smoking porch? He stated that I am not a good person to ask, I am legally blind, but it was too early for a staff member to be on the porch, they come out there around 9:00 a.m. I got to the facility a week before (Resident #1). She would come and visit me every day. Pretty sure she would come with my (family member). Did you have an argument that morning? No. An interview was conducted on 09/17/19 at 12:55 p.m. with Resident #1's daughter. She talked about Resident #2, her father, that he had fallen at home, gone to the hospital and, subsequently, had been transferred to this facility. She stated that prior to that, her father and mother, Resident #1, were living together. The daughter stated that her mother was admitted on [DATE]. She had dementia. I was taking her everywhere. She wanted to stay at home. I took her money and her cards. Her car was broken down, so I did not have to worry about that. She was starting to spiral. She did not know who I was a couple of times. I asked Staff T, Director of Admissions (DOA), if she could be admitted . She has dementia, I thought maybe for respite. Because of the dementia, she (DOA) said they could treat her for cognitive skills and that she would be cared for. The DOA asked if she was a flight risk I said no. There was no way of me knowing she was a flight risk. Resident #1's daughter stated that she became aware of the elopement event on 09/15/19 at 7:45 a.m., when her father called her. He said they cannot find your mother, (Resident #1), everyone is looking for her. I said, (Dad), I am sure she (Mom) is there, because all the doors are locked. He called me back, . I was on the road; my husband and I both went in different directions in order to see if we could see her on the back roads. I think he (Resident #2) called me back at about 8:30 a.m. No sooner did that happen, somebody from here (the facility), called me. A Spanish woman with a heavy dialect. She interrupted the call with my father (when he called back) and she asked, do you know where your mother is? I told her I did not, and I was coming to the facility. And then, when I got here, I asked if anyone had called the police. I got no response. Resident #1's daughter stated that she spoke with the Spanish woman, the receptionist at the desk, and the Director of Nursing (DON). She stated that they had not called the police at that time. She stated that after that, the police were called. Then we got a call that she had been found (I may have gone out again). I wanted to check at the house to see if she was back there that is 3.3 miles away. I did go check that. I did get a call back and they said they found her. They had taken her to the hospital. They told me that someone had handed my mom a phone (at the time she was found by the bystander) and she called my father. Basically, she found herself. That is when I went to my father and told him that I was going to meet my mother at the hospital. Also, the police had arrived at that point; they were in the DON's room. At the Hospital, she had just gotten there, I waited in the ER (emergency room ). They told me they were going to do an EKG (electrocardiogram); cat-scan; she was scratched and bumped up pretty good. They put her on a saline drip. (Resident #1) said that she did not know what happened. She does not remember falling. I do not know the location that she was found. They (police) told me that she crossed (US Highway) 19, and over to Keystone. She must have walked all the way down 19 on the right side; to Tarpon Ave, crossed there, that becomes Keystone. My father (Resident #2) said that she was found at a Country club (Eastlake). There is a country club around there somewhere. Someone said it was 8 miles away. The police said that there would be an investigation. The only thing that I think that went awry is that they took so long to call the police. The only thing that she has to identify her is her wrist band. She looks perfectly normally. I have ordered a GPS (global positioning system) watch that will need to be charged every 48 hours. This will come tomorrow. I will have to figure that out. Due to the charge (that the watch requires). Someone will have to charge it for her. It will notify me if she crosses the perimeter of the building. I asked about a wander guard. They said they typically do not take residents that wander. My father said she left the room at 7 a.m. Three people said they saw her at 7:30 a.m. When my father called me, he was getting really worried. Have they said what they are doing for her to keep her safe? My father said they had no one in the room from 11-7 last night. They said that they would have someone with her for the time being 1:1. He was pretty broken up about this yesterday. I transported her back from the hospital to the facility. Resident #1's daughter was asked if Resident #1 had any behaviors while she was at the facility. Yes, she would pack every day. I would have to un-pack her every day. Staff were aware of her packing. If I was not here, they would have to unpack it. They had to take away the plastic bags in the trash containers, because she would use them to pack her clothes. Again, .I think it was too long .they told me that they have a company protocol to search the grounds inside and out; but I talked to one of the nurses, and she had gone all the way up to the Tahitian hotel, that is way up the road. They should have called the police sooner. The following are interviews conducted with staff about Resident #1 and the elopement day: On 09/17/19 at 10:16 a.m., an interview was conducted with Staff A, Licensed Practical Nurse, (LPN). Staff A was standing outside of Resident #1's room with her medication cart. She stated that she had not been working for the last 4 days. She stated, I am their (Resident #1 and #2) regular nurse. Resident #1 and #2 live together in the room. She stated, (Resident #1) was not on official 15-minute checks before. They have a usual routine. They go to the smoke porch (he smokes); the Cool Beans Café, therapy or they are in their room. She will start to pack. He will remind her we are going to stay the night. Resident #1 has dementia, she forgets. Staff A stated that the aide, Staff B, Certified Nursing Assistant (CNA) is supposed to stay with her. An observation was conducted at this time of Resident #1 coming out of the resident's room, pushing Resident #2 in the wheel chair. Resident #1 was observed to be independent with ambulation. Staff B, CNA, was with the 2 residents. An interview was conducted on 09/17/19 at 2:05 p.m. with Staff G, LPN. She stated, I am the weekend supervisor. She confirmed that she was working during the elopement event. She stated, I came at 6:30 a.m. to 11:00 p.m. It started out normal, I came at 6:30 a.m., I did a walk around. I came to east wing/200. I came down this hall, to see if there are any reports. I was on my way back to east wing and I saw Resident #1, a couple of times. She was in the hallway. One time on long hall east, by the smoke porch; and then in the hallway around room [ROOM NUMBER]. She was just walking. That was not an abnormal thing for her. Her husband was with her. She had these black shorts with a diamond shape pattern; and then a white; gold jewelry embedded shirt on. I have complemented her on them. Then S