**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility (Skilled Nursing Facility-SNF) failed to provide a safe environment to prevent falling for one of two sampled residents (Resident 1), by failing to ensure: 1. Maintenance Worker 1 (MW 1) notified Resident 1 and the resident's roommate/s that the floor was wet after mopping Resident 1's room with a wet mop. 2. MW 1 placed a wet floor sign on the floor in Resident 1's room to alert Resident 1 that the floor was wet. 3. MW 1 supervised/monitored the wet floor and re-directed Resident 1 to avoid the wet floor. As a result, on 10/25/2024, Resident 1 slipped and fell, and suffered severe pain of 10 out of 10 (10/10- a numerical pain scale assessment tool where zero is no pain and 10 is severe pain) to the left knee treated with opioids (a class of drugs used to treat moderate to severe pain). Resident 1 was transferred to General Acute Care Hospital 2 (GACH 2) via 911 (a telephone number used to reach emergency medical, fire, and police services). GACH 2 diagnosed Resident 2 with a left femur fracture (broken thigh bone). On 10/29/2024, GACH 2 performed open reduction and internal fixation (ORIF - a type of surgery used to stabilize and repair broken bones, using screws, plates, sutures, or rods to hold the bone together and for healing) on Resident 1. Findings: During a review of Resident 1's General Acute Care Hospital 1 (GACH 1) History & Physical (H&P), dated 10/6/2024, the H&P indicated Resident 1 presented to GACH 1 Emergency Department (ED - The department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) after having a mechanical fall at home. The H&P further indicated the resident was attempting to get out of bed, reached for a walker, tripped, and fell onto the left wrist with no injuries. During a review of Resident 1's admission Record, the admission Record indicated the SNF originally admitted Resident 1 on 10/11/2024 and re-admitted the resident on 10/31/2024. The admission Record indicated Resident 1's diagnoses included left femur fracture, left eye blindness, history of falling and history of healed traumatic fracture (occurs when significant or extreme force is applied to a bone). During a review of Resident 1's admission Assessment, dated 10/11/2024, the admission Assessment indicated Resident 1 was admitted to the facility from GACH 1. The admission Assessment further indicated Resident 1 was alert and oriented times four (person, place, time/date, and situation) with period of forgetfulness. The admission assessment indicated the resident was continent (the ability to voluntarily control) of bladder and bowel, generalized weakness, ambulated with assist, and was admitted for physical therapy (PT - treatment that uses physical activities and exercises to help improve movement, relieve pain, and strengthen muscles) and occupational therapy (OT -therapy that helps improve one's ability to perform everyday tasks, like eating and drinking). During a review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 1 scored 16 for risk for fall (the resident was at low risk for falls). During a review of Resident 1's admission Rehabilitation Screening, dated 10/12/2024, the admission Rehabilitation Screening indicated Resident 1 did not have any impairment ( a significant difference or absence in a person's body structure or function or mental functioning) in functional range of motion (ROM -how far you can move a joint in any direction) to the lower extremities (hip, knee, ankle, and foot). During a review of Resident 1's care plan titled, At Risk for Falls/Injury, initiated on 10/14/2024, indicated Resident 1 was at risk for falls due to general weakness, history of falls, history of left ankle fracture, osteopenia (low bone density), and muscle weakness. The care plan goal was to reduce the risk of falls and injury to Resident 1. The care plan interventions indicated staff would visibly observe the resident frequently and provide resident with a safe and clutter-free environment. During a review of Resident 1's admission Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/15/2024, indicated Resident 1's cognition (ability to think, understand, and reason) was intact. The MDS also indicated Resident 1 ' s vision was impaired, and the resident required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, showering, dressing, and personal hygiene. The MDS further indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with walking 10 feet. The MDS also indicated Resident 1 used a walker for mobility. During a review of Resident 1's Change of Condition (COC- clinically important deviation from a patient's baseline) form, dated 10/25/2024 timed at 9:45 AM, the COC indicated Resident 1 was observed lying on the floor on the left side by housekeeping staff and the charge nurse. The COC also indicated the resident reported 6/10 pain level to the left leg and Resident 1 was transferred to a General Acute Care Hospital 2 (GACH 2). During a review of Resident 1's Physician Order, dated 10/25/2024 timed at 10 AM, the Physician order indicated to transfer Resident 1 to GACH 2 via 911 for evaluation after a fall onto her left side with left leg pain. During a review of Resident 1's GACH 2 Note, dated 10/25/24, the note indicated Resident 1 came into the ED after a fall onto the resident's left side and suffered severe knee pain. The ED notes indicated that from 10:44 AM to 3:03 PM, Resident 1 received fentanyl (an opioid pain medication) 50 micrograms (mcg-unit of measurement) intravenously (IV -inside a vein), Dilaudid (an opioid pain medication) 0.5 milligrams (mg-unit of measurement) IV, Toradol (a medication is used to treat moderately severe pain and inflammation [A normal part of the body's response to injury or infection]) 30 mg IV, and Morphine (an opioid pain medication) 4 mg IV for pain control. During a review of Resident 1's GACH 2 H&P, dated 10/25/2024 timed at 10:55 AM, indicated Resident 1was transferred to GACH 2 ED after a ground level fall. GACH 2 H&P also indicated Resident 1 stated that while at the facility, she got up to go to the bathroom, that someone had mopped the floor, and that Resident 1 did not realize that the floor was wet. GACH 2 H&P notes indicated Resident 1 slipped and crashed onto her left knee. GACH 2 H&P indicated Resident 1 experienced 9/10 pain to the left knee during left knee on palpation (touch). GACH 2 H&P further indicated the plan was for Resident 1 to have ORIF. During a review of the Resident 1's GACH 2 Pelvis X-ray of the result, dated 10/25/2024, the X-ray result indicated Resident 1 had a femur. During a review of Resident 1's GACH 2 Orthopedic (branch of medicine that focuses on the diagnosis and treatment of bones, muscles, and ligaments) Surgery Trauma (severe physical injury or damage)/General Consult Note, dated 10/26/2024, indicated, Resident 1 presented to GACH 2 with pain (pain level not indicated) in the left knee and thigh after falling to the ground on her the way to the bathroom at the facility earlier that morning. The orthopedic surgery trauma/general consult note indicated Resident 1 noted immediate pain to the left knee and thigh that was worse with movement. The orthopedic surgery trauma/general consult note further indicated Resident 1 reported that the floor was wet, which caused the resident to slip and fall. Moreover, the orthopedic surgery trauma/general consult note indicated; the physician strongly recommended an ORIF surgery to treat the resident's left femur fracture. During a review of Resident 1's GACH 2 Operative Note, dated 10/31/2024, GACH 2 Operative Note indicated Resident 1 had an ORIF surgery on 10/29/2024 to treat the resident's left femoral fracture. During an interview on 11/8/2024 at 8:38 AM, Resident 1 stated, a couple of weeks ago, while walking out of the bathroom, I slipped because the floor was wet. Resident 1 stated no one notified Resident 1 that the floor was wet prior to entering the bathroom, that there was no wet floor sign on the floor, and that Resident 1 fell onto her knees and screamed in pain. Resident 1 stated the pain level at the time of the fall was 10/10. Resident 1 stated she was transferred to a GACH where she was told that her left thigh bone was broken. Resident 1 stated that currently, her pain level was 8/10 and that she could no longer ambulate and I just stay in bed. During an interview on 11/8/2024 at 12:15 PM, Resident 2 (Resident 1's roommate currently and at the time of the fall) stated Resident 2 did not see but heard a loud boom and Resident 1 screamed out at the time Resident 1 fell. Resident 2 stated the medication nurse left about five minutes prior to the fall because MW 1 was sweeping and mopping Resident 1's room with a wet mop. Resident 2 further stated MW 1 never notified Resident 2 that the floor was wet, and that Resident 2 did not see a wet floor sign posted/placed on the floor. During an interview on 11/8/2024 at 1:17 PM, the Director of Rehabilitation (DOR) stated prior to the fall on 10/25/2024, Resident 1 was able to walk with maximum assistance. The DOR stated maintenance usually places a wet floor sign down once they have mopped. The DOR stated that a wet floor is a fall risk for any person. The DOR further stated after the fall, Resident 1 was unable to walk because the resident is in a lot of pain. The DOR stated, we premedicate (the administration of medication before a treatment or procedure to prepare the patient) her for pain before her therapy sessions. During an interview with Treatment Nurse 1 on 11/12/2024 at 9:54 AM, Treatment Nurse 1 stated staff are monitoring Resident 1's incision for swelling. During a concurrent observation, Resident 1 was lying in bed with head of bed up. Resident 1 was observed in a full leg immobilizing brace (a device that completely restricts movement in the leg) on her left leg with straps securing the brace closed from her upper thigh to her ankle. Resident 1 has 3 incisions along her lateral (situated at or on the side) left leg that is closed with Stryker's zip skin closure system (a non-invasive skin closure device). During an interview on 11/12/2024 at 12:14 PM, Licensed Vocational Nurse 1 (LVN 1) stated on 10/25/2024, LVN 1 exited Resident 1's room because MW 1 was sweeping the floor. LVN 1 stated MW 1 came out of Resident 1's room and stated, your resident [Resident 1] is on the floor. LVN 1 stated LVN 1 found Resident 1 on floor and that the resident crying out in pain. LVN 1 stated Resident 1told LVN 1 that the floor was wet. LVN 1 stated LVN 1 could tell the floor was wet and that there was no Wet Floor sign posted. LVN 1 further stated, maintenance must make residents and staff aware that the floor is wet. Maintenance is to tell us verbally and should place a sign on the floor. LVN 1 stated she asked MW 1, where was your sign [wet floor sign], and then MW 1 placed a sign down. LVN 1 further stated, MW 1, should have placed a sign down and let the residents know the floor was wet because a wet floor is a fall hazard and that is just what happened. LVN 1 also stated Resident 1 was a fall risk because the resident already had problems with her leg before admission to the facility. During a phone interview on 11/12/2024 at 12:45 PM, MW 1 stated he started mopping Resident 1's room with a wet mop after Resident 1 went to the restroom and exited/left Resident 1's room after mopping the floor. MW 1 stated that Resident 1 fell after coming came out of the bathroom. MW 1 stated MW 1 did not tell Resident 1 or Resident 2 that the floor was wet, and MW 1 did not put down a wet floor sign and I should have place the wet floor sign MW 1 stated MW 1 exited Resident 1's room MW 1 stated MW 1 knew that the floor was wet and f a fall hazard. MW 1 stated MW 1 forgot to place the wet floor sign. MW 1 stated this was the first time in 37 years, MW 1 forgot to place the sign. MW1 also stated, I feel really bad because she was really yelling in pain. During an interview on 11/12/2024 at 2:34 PM, the Administrator (ADM) stated, I would say the wet floor promoted or assisted the fall. The ADM further stated ADM went to Resident 1's room at the time of the fall and observed that the floor was wet. During a review of the facility's policy and procedures (P&P) titled, Falls and Fall Risk, Managing, revised 3/23, the P&P indicated staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P further indicated an environmental factor that contribute to the risk of falls included wet floors. During a review of the facility's P&P titled, Housekeeping Cleaning Sanitizing, Disinfecting, & Sterilizing, undated, the P&P indicated floor cleaning procedures are as follows: a. Vacuum or sweep floor thoroughly, paying close attention to corners and areas near or under furniture. b. Using a container of water with a detergent dash germicide added, wet mop one side of corridor or floor at a time, making sure that the first side is dry before mopping the other side. c. Obtain a fresh solution when water is dirty. d. Post a warning sign WET FLOOR on both ends of wet areas. Based on observation, interview and record review, the facility (Skilled Nursing Facility-SNF) failed to provide a safe environment to prevent falling for one of two sampled residents (Resident 1), by failing to ensure: 1. Maintenance Worker 1 (MW 1) notified Resident 1 and the resident's roommate/s that the floor was wet after mopping Resident 1's room with a wet mop. 2. MW 1 placed a wet floor sign on the floor in Resident 1's room to alert Resident 1 that the floor was wet. 3. MW 1 supervised/monitored the wet floor and re-directed Resident 1 to avoid the wet floor. As a result, on 10/25/2024, Resident 1 slipped and fell, and suffered severe pain of 10 out of 10 (10/10- a numerical pain scale assessment tool where zero is no pain and 10 is severe pain) to the left knee treated with opioids (a class of drugs used to treat moderate to severe pain). Resident 1 was transferred to General Acute Care Hospital 2 (GACH 2) via 911 (a telephone number used to reach emergency medical, fire, and police services). GACH 2 diagnosed Resident 2 with a left femur fracture (broken thigh bone). On 10/29/2024, GACH 2 performed open reduction and internal fixation (ORIF - a type of surgery used to stabilize and repair broken bones, using screws, plates, sutures, or rods to hold the bone together and for healing) on Resident 1. Findings: During a review of Resident 1's General Acute Care Hospital 1 (GACH 1) History & Physical (H&P), dated 10/6/2024, the H&P indicated Resident 1 presented to GACH 1 Emergency Department (ED - The department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) after having a mechanical fall at home. The H&P further indicated the resident was attempting to get out of bed, reached for a walker, tripped, and fell onto the left wrist with no injuries. During a review of Resident 1's admission Record, the admission Record indicated the SNF originally admitted Resident 1 on 10/11/2024 and re-admitted the resident on 10/31/2024. The admission Record indicated Resident 1's diagnoses included left femur fracture, left eye blindness, history of falling and history of healed traumatic fracture (occurs when significant or extreme force is applied to a bone). During a review of Resident 1's admission Assessment, dated 10/11/2024, the admission Assessment indicated Resident 1 was admitted to the facility from GACH 1. The admission Assessment further indicated Resident 1 was alert and oriented times four (person, place, time/date, and situation) with period of forgetfulness. The admission assessment indicated the resident was continent (the ability to voluntarily control) of bladder and bowel, generalized weakness, ambulated with assist, and was admitted for physical therapy (PT - treatment that uses physical activities and exercises to help improve movement, relieve pain, and strengthen muscles) and occupational therapy (OT -therapy that helps improve one's ability to perform everyday tasks, like eating and drinking). During a review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 1 scored 16 for risk for fall (the resident was at low risk for falls). During a review of Resident 1's admission Rehabilitation Screening, dated 10/12/2024, the admission Rehabilitation Screening indicated Resident 1 did not have any impairment ( a significant difference or absence in a person's body structure or function or mental functioning) in functional range of motion (ROM -how far you can move a joint in any direction) to the lower extremities (hip, knee, ankle, and foot). During a review of Resident 1's care plan titled, At Risk for Falls/Injury, initiated on 10/14/2024, indicated Resident 1 was at risk for falls due to general weakness, history of falls, history of left ankle fracture, osteopenia (low bone density), and muscle weakness. The care plan goal was to reduce the risk of falls and injury to Resident 1. The care plan interventions indicated staff would visibly observe the resident frequently and provide resident with a safe and clutter-free environment. During a review of Resident 1's admission Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/15/2024, indicated Resident 1's cognition (ability to think, understand, and reason) was intact. The MDS also indicated Resident 1 ' s vision was impaired, and the resident required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, showering, dressing, and personal hygiene. The MDS further indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with walking 10 feet. The MDS also indicated Resident 1 used a walker for mobility. During a review of Resident 1's Change of Condition (COC- clinically important deviation from a patient's baseline) form, dated 10/25/2024 timed at 9:45 AM, the COC indicated Resident 1 was observed lying on the floor on the left side by housekeeping staff and the charge nurse. The COC also indicated the resident reported 6/10 pain level to the left leg and Resident 1 was transferred to a General Acute Care Hospital 2 (GACH 2). During a review of Resident 1's Physician Order, dated 10/25/2024 timed at 10 AM, the Physician order indicated to transfer Resident 1 to GACH 2 via 911 for evaluation after a fall onto her left side with left leg pain. During a review of Resident 1's GACH 2 Note, dated 10/25/24, the note indicated Resident 1 came into the ED after a fall onto the resident's left side and suffered severe knee pain. The ED notes indicated that from 10:44 AM to 3:03 PM, Resident 1 received fentanyl (an opioid pain medication) 50 micrograms (mcg-unit of measurement) intravenously (IV -inside a vein), Dilaudid (an opioid pain medication) 0.5 milligrams (mg-unit of measurement) IV, Toradol (a medication is used to treat moderately severe pain and inflammation [A normal part of the body's response to injury or infection]) 30 mg IV, and Morphine (an opioid pain medication) 4 mg IV for pain control. During a review of Resident 1's GACH 2 H&P, dated 10/25/2024 timed at 10:55 AM, indicated Resident 1was transferred to GACH 2 ED after a ground level fall. GACH 2 H&P also indicated Resident 1 stated that while at the facility, she got up to go to the bathroom, that someone had mopped the floor, and that Resident 1 did not realize that the floor was wet. GACH 2 H&P notes indicated Resident 1 slipped and crashed onto her left knee. GACH 2 H&P indicated Resident 1 experienced 9/10 pain to the left knee during left knee on palpation (touch). GACH 2 H&P further indicated the plan was for Resident 1 to have ORIF. During a review of the Resident 1's GACH 2 Pelvis X-ray of the result, dated 10/25/2024, the X-ray result indicated Resident 1 had a femur. During a review of Resident 1's GACH 2 Orthopedic (branch of medicine that focuses on the diagnosis and treatment of bones, muscles, and ligaments) Surgery Trauma (severe physical injury or damage)/General Consult Note, dated 10/26/2024, indicated, Resident 1 presented to GACH 2 with pain (pain level not indicated) in the left knee and thigh after falling to the ground on her the way to the bathroom at the facility earlier that morning. The orthopedic surgery trauma/general consult note indicated Resident 1 noted immediate pain to the left knee and thigh that was worse with movement. The orthopedic surgery trauma/general consult note further indicated Resident 1 reported that the floor was wet, which caused the resident to slip and fall. Moreover, the orthopedic surgery trauma/general consult note indicated; the physician strongly recommended an ORIF surgery to treat the resident's left femur fracture. During a review of Resident 1's GACH 2 Operative Note, dated 10/31/2024, GACH 2 Operative Note indicated Resident 1 had an ORIF surgery on 10/29/2024 to treat the resident's left femoral fracture. During an interview on 11/8/2024 at 8:38 AM, Resident 1 stated, a couple of weeks ago, while walking out of the bathroom, I slipped because the floor was wet. Resident 1 stated no one notified Resident 1 that the floor was wet prior to entering the bathroom, that there was no wet floor sign on the floor, and that Resident 1 fell onto her knees and screamed in pain. Resident 1 stated the pain level at the time of the fall was 10/10. Resident 1 stated she was transferred to a GACH where she was told that her left thigh bone was broken. Resident 1 stated that currently, her pain level was 8/10 and that she could no longer ambulate and I just stay in bed. During an interview on 11/8/2024 at 12:15 PM, Resident 2 (Resident 1's roommate currently and at the time of the fall) stated Resident 2 did not see but heard a loud boom and Resident 1 screamed out at the time Resident 1 fell. Resident 2 stated the medication nurse left about five minutes prior to the fall because MW 1 was sweeping and mopping Resident 1's room with a wet mop. Resident 2 further stated MW 1 never notified Resident 2 that the floor was wet, and that Resident 2 did not see a wet floor sign posted/placed on the floor. During an interview on 11/8/2024 at 1:17 PM, the Director of Rehabilitation (DOR) stated prior to the fall on 10/25/2024, Resident 1 was able to walk with maximum assistance. The DOR stated maintenance usually places a wet floor sign down once they have mopped. The DOR stated that a wet floor is a fall risk for any person. The DOR further stated after the fall, Resident 1 was unable to walk because the resident is in a lot of pain. The DOR stated, we premedicate (the administration of medication before a treatment or procedure to prepare the patient) her for pain before her therapy sessions. During an interview with Treatment Nurse 1 on 11/12/2024 at 9:54 AM, Treatment Nurse 1 stated staff are monitoring Resident 1's incision for swelling. During a concurrent observation, Resident 1 was lying in bed with head of bed up. Resident 1 was observed in a full leg immobilizing brace (a device that completely restricts movement in the leg) on her left leg with straps securing the brace closed from her upper thigh to her ankle. Resident 1 has 3 incisions along her lateral (situated at or on the side) left leg that is closed with Stryker's zip skin closure system (a non-invasive skin closure device). During an interview on 11/12/2024 at 12:14 PM, Licensed Vocational Nurse 1 (LVN 1) stated on 10/25/2024, LVN 1 exited Resident 1's room because MW 1 was sweeping the floor. LVN 1 stated MW 1 came out of Resident 1's room and stated, your resident [Resident 1] is on the floor. LVN 1 stated LVN 1 found Resident 1 on floor and that the resident crying out in pain. LVN 1 stated Resident 1told LVN 1 that the floor was wet. LVN 1 stated LVN 1 could tell the floor was wet and that there was no Wet Floor sign posted. LVN 1 further stated, maintenance must make residents and staff aware that the floor is wet. Maintenance is to tell us verbally and should place a sign on the floor. LVN 1 stated she asked MW 1, where was your sign [wet floor sign], and then MW 1 placed a sign down. LVN 1 further stated, MW 1, should have placed a sign down and let the residents know the floor was wet because a wet floor is a fall hazard and that is just what happened. LVN 1 also stated Resident 1 was a fall risk because the resident already had problems with her leg before admission to the facility. During a phone interview on 11/12/2024 at 12:45 PM, MW 1 stated he started mopping Resident 1's room with a wet mop after Resident 1 went to the restroom and exited/left Resident 1's room after mopping the floor. MW 1 stated that Resident 1 fell after coming came out of the bathroom. MW 1 stated MW 1 did not tell Resident 1 or Resident 2 that the floor was wet, and MW 1 did not put down a wet floor sign and I should have place the wet floor sign MW 1 stated MW 1 exited Resident 1's room MW 1 stated MW 1 knew that the floor was wet and f a fall hazard. MW 1 stated MW 1 forgot to place the wet floor sign. MW 1 stated this was the first time in 37 years, MW 1 forgot to place the sign. MW1 also stated, I feel really bad because she was really yelling in pain. During an interview on 11/12/2024 at 2:34 PM, the Administrator (ADM) stated, I would say the wet floor promoted or assisted the fall. The ADM further stated ADM went to Resident 1's room at the time of the fall and observed that the floor was wet. During a review of the facility's policy and procedures (P&P) titled, Falls and Fall Risk, Managing, revised 3/23, the P&P indicated staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P further indicated an environmental factor that contribute to the risk of falls included wet floors. During a review of the facility's P&P titled, Housekeeping Cleaning Sanitizing, Disinfecting, & Sterilizing, undated, the P&P indicated floor cleaning procedures are as follows: a. Vacuum or sweep floor thoroughly, paying close attention to corners and areas near or under furniture. b. Using a container of water with a detergent dash germicide added, wet mop one side of corridor or floor at a time, making sure that the first side is dry before mopping the other side. c. Obtain a fresh solution when water is dirty. d. Post a warning sign WET FLOOR on both ends of wet areas.

Based on interview and record review, for one of six sampled residents (Resident 1), the facility failed to immediately transfer Resident 1 via 911 (telephone number used to reach emergency medical, fire, and police services) to a General Acute Care Hospital (GACH) in accordance with the American Heart Association (AHA- an organization that funds cardiovascular (cardio [heart] vascular [blood vessels]) medical research, educates consumers on healthy living and fosters appropriate cardiac (pertaining to the heart) care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke) Stroke (a medical emergency due to loss of blood flow to part of the brain) guidelines dated 2023. Resident 1 experienced signs (something a doctor, or other person, notices) and symptoms (is what a person/patient feels) of stroke (when blood supply to part of the brain is briefly interrupted) on 8/28/2023 at 4:35 p.m. This failure resulted in five hours and thirteen minutes delay for the facility to transfer Resident 1 to GACH 1 for further evaluation and management. GACH 1 diagnosed Resident 1 with acute (sudden onset/abrupt) on subacute (rather recent onset or somewhat rapid change) left basal ganglia infarct (death of brain tissue resulting from a failure of blood supply) and was admitted in telemetry unit (area in a hospital for patients who require constant monitoring of various bodily functions) at GACH 1. Findings: A review of Resident 1's admission Record indicated the facility initially admitted Resident 1 on 8/8/2023 and readmitted Resident 1 on 9/12/2023 with diagnoses including personal history transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and cerebral vascular accident (CVA- Stroke) without residuals, hypertension (HTN - elevated blood pressure) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough) A review of Resident 1's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 8/11/2023, indicated Resident 1 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 required extensive two staff assist for bed mobility, dressing and transfers. The MDS further indicated Resident 1 had clear speech. A review of Resident 1's change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) dated 8/28/2023 at 10:09 p.m., indicated Registered Nurse Supervisor 1 (RNS 1) documented that on 8/28/2023 at 4:35 p.m., Certified Nursing Assistant 1 (CNA 1) informed RNS 1 that Resident 1's family member (FM) reported that Resident 1 was not talking normally, and that Resident 1 was stuttering which was unusual for the resident. On 8/28/2023 at 6:46 p.m., RNS 1 relayed Resident 1's condition to Nurse Practitioner (NP) who gave an order to contact the case manager (CM) for Resident 1's Medical Doctor (MD) to make arrangements to transfer Resident 1 to GACH. RNS 1 documented that per the CM, the estimated time of arrival (ETA) for transport was 12 a.m. because GACH was on diversion and that MD and NP were aware. RNS 1 also documented that MD said, if [Resident 1] is having slurred speech, just call 911. A review of Resident 1's transfer/discharge summary notes dated 8/28/2023 at 6:40 p.m., indicated Resident 1 was transported to GACH 1 via 911 on 8/28/2023 at 9:48 p.m. A review of GACH 1 Neurology (branch of medicine concerned with the study and treatment of disorders of the nervous [brain and spinal cord} system)Consult Note for Resident 1 dated 8/29/2023, indicated Resident 1 was brought in on 8/28/2023 due to right sided weakness, numbness (loss of sensation or feeling in an area of the body) and slurred (difficulty saying words) speech. The Magnetic Resonance Imaging (MRI -a type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body) brain performed at GACH 1, revealed acute on subacute left basal ganglia infarct (death of tissue resulting from a failure of blood supply). Resident 1 was examined in telemetry unit. Resident 1 was awake, alert, interactive, and oriented to person, place, and time. Resident 1 continued to complain of slow speech. Resident 1 was found with right (R) hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) on exam but is unaware of these deficits and maintains that her deficits and their presentation were on the left (L) side. Resident 1 also said, that yesterday, I could not see my thoughts. A review of Resident 1's Licensed Nursing Note dated 9/6/2023 at 9:21 p.m., indicated that on 8/28/2023 at around 8:50 p.m., the facility called 911 and paramedics arrived at the facility at 9 p.m. FM at bedside wanted Resident 1 transferred to GACH. On 9/23/2023, at 8:30 a.m., during a telephone interview with Resident 1's FM, FM stated that on 8/28/2023 around 6 p.m., she was in Resident 1's room visiting Resident 1 when Resident 1 started to show signs of a stroke such as stuttering, confusion and change in speech. FM stated it took the facility three hours before calling 911 and to transfer Resident 1 to GACH. On 9/23/2023 at 9:06 a.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on 8/28/2023 around 5 p.m. to 5:30 p.m., Certified Nursing Assistant 1 (CNA 1) reported to her that Resident 1 was different and was stuttering when speaking. LVN 1 stated she noticed that Resident 1 was taking long to speak, and Resident 1, took longer for words to come out (speak) and that was different from usual. LVN 1 further stated some signs and symptoms (S/S) of a stroke included slurred speech. LVN 1 stated 911 must be called immediately for anyone experiencing S/S of stroke. LVN 1 stated she left RNS 1 to care for Resident 1 because she needed to go and administer medications to the other residents. On 9/23/2023 at 1:30 p.m., during an interview with CNA 1, CNA 1 stated that on 8/28/2023 around 4:45 p.m. to 5:30 p.m., FM was at Resident 1's bedside, and that FM asked her (CNA 1) to come into the Resident 1's room because Resident 1 did not look right. CNA 1 stated she went to Resident 1's room and observed that Resident 1's, face was droopy (falling to a position that is lower than normal), and Resident 1, was stuttering (significant problems with normal fluency and flow of speech). Not bringing out words at all. CNA 1 stated, this is not [Resident 1's] usual speech or appearance at all. I think she is having a stroke. CNA 1 immediately went to the nurses' station and notified RNS 1 and LVN 1 about Resident 1's condition. On 9/25/2023 at 3:44 p.m., during a concurrent interview and record review with RNS 1, Resident 1's COC dated 8/28/2023 was reviewed. RNS 1 stated that on 8/28/2023 at 6 p.m., CNA 1 informed her that FM was concerned that Resident 1's speech was stuttered which was unlike Resident 1. RNS 1 stated she assessed Resident 1, and the resident was no longer stuttering. RNS 1 stated FM requested Resident 1 be transferred to GACH. RNS 1 stated she telephoned Registered Nurse Practitioner (RNP), but RNP did not answer. RNS 1 stated she then texted RNP on 8/28/2023 at 6:46 p.m. and RNP texted back and instructed her to call the CM. RNS 1 stated she contacted the CM, but the CM did not answer. RNS 1 stated she then contacted MD on 8/28/2023 at 8:40 p.m., who instructed her to call 911 and transfer Resident 1 to GACH because Resident 1 was having slurred speech. RNS 1 stated she called 911 and Resident 1 was transported to GACH 1 on 8/28/2023 at 9 p.m. RNS 1 stated risk factors for stroke include heart diseases, HTN, and overweight. RNS 1 stated S/S of stroke include facial droop, confusion, weakness, unsteady gait (a manner of walking), speech alteration and to immediately call 911 if a resident/person had S/S of stroke. RNS 1 stated failure to immediately call 911 when a resident/person is experiencing S/S of stroke could result in stroke and death. On 9/26/2023 at 11:28 a.m., during an interview with MD, MD stated individuals at higher risk of stroke include and not limited to advanced age and history of a stroke. MD stated when RNS 1 notified him that Resident 1 had slurred speech on 8/28/2023, he instructed RNS 1 to call 911 and transfer Resident 1 to GACH for immediate evaluation particularly because FM was the one concerned about Resident 1's condition. MD further stated, the probability of getting another stroke increases for someone who has had a stroke as opposed to someone who has never had a stroke. MD further stated delaying immediate care for someone experiencing S/S of stroke could result in major neurological (involving the brain and spinal cord) deficits including paralysis (inability to move the affected body part/s), weakness, sensory impairment, right or left sided weakness and death. On 9/26/2023 at 4:39 p.m., during an interview with the Director of Staff Development (DSD), the DSD stated she was unable to find any documented evidence that facility staff were inserviced on S/S stroke/ TIA prior to 8/28/2023. The DSD further stated she uses the AHA guidelines when providing inservice on stroke/TIA to staff and that the last inservice was on 9/8/2023. On 9/26/2023 at 5:15 p.m., during an interview with the Director of Nursing (DON), the DON stated when a resident has S/S of a stroke, the immediate action is to call 911. The DON stated potential adverse outcomes due to delayed care for a person/resident experiencing S/S of stroke include death. On 9/27/2023 at 9:13 a.m., during an interview with RNP, RNP stated that on 8/28/2023, RNS 1 notified her via text message that Resident 1 was stuttering. RNP stated, I have seen [Resident 1] and she does not stutter. I was thinking [Resident 1] was having signs of a stroke. RNP stated she advised RNS 1 to call the MD's CM and arrange to transfer Resident 1 to GACH. RNP then stated the facility should have called 911 because regular ambulance transportation, takes time and, time is critical. RNP stated a person experiencing S/S of stroke have two hours to receive treatment and must be transferred to acute care facility (GACH). RNP stated the potential adverse outcome for delayed care could result in permanent neurological damage, paralysis, weakness, sensory impairment), and death. A review of facility's Registered Nurse (RN) Job Description approved 8/23/2011, indicated . the following: -Makes assessments and interventions related to changes in patient conditions: .acute changes in condition. -Identifies/assesses emergency medical situations. A review of the facility's policy and procedures, titled, Transfer or Discharge, Emergency, revised 8/2018, indicated Emergency transfers of discharges may be necessary to protect the health and/or wellbeing of the resident(s). Resident will not be transferred unless : the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. A review of the facility's policy and procedures, titled, Stroke/TIA clinical protocol, revised 11/2018, indicated signs and symptoms of acute ischemic stroke may include .difficulty speaking . many symptoms associated with stroke are not specific, and could represent other causes such as . infection. A review of the facility's policy and procedures, titled, Change of Condition, revised 3/2023, indicated to ensure proper assessment and follow through for any resident with a change in condition . a change of condition is a sudden or marked difference in residents: .level of functioning . in cases of emergency changes in the condition of a resident . the nurse may dial 911. A review of the American Heart Association (AHA) Stroke guidelines Heart attack, Stroke and Cardiac Arrest Symptoms dated 2023, indicated if these warning signs are present call 911 . Stroke symptoms . speech slurred, are they unable to speak, or are they hard to understand .if the person shows any of these symptoms, even if the symptoms go away, call 911 and get them to the hospital immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) who was a high risk for elopement (leaving the facility unsupervised and without staff knowledge) was visually observed frequently, re-orient to key places such as his room, and monitored at frequent intervals to prevent elopement. This deficient practice resulted in Resident 1 ' s elopement and sustained a nasal (nose) bone fracture (is a break, usually in a bone), fracture of the anterior wall of the right maxillary sinus (a hollow space in the bones around the nose), right maxillary sinus hematoma (a solid swelling of clotted blood within the tissues), bruise under his right eye, abrasion (the surface layers of the skin has been broken) on his right knee, and suffered pain to his nose and right knee. Findings: A review of Resident 1's admission Record dated 3/21/2023, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), type II diabetes mellitus (a condition were your body has trouble controlling the level of sugar in the blood), lack of coordination, and muscle weakness. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and screening tool), dated 1/10/2023, indicated Resident 1 had memory problems. The same MDS, indicated, Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist, for walking in room, corridor, and locomotion (the ability to move from one place to another) on and off unit. A review of Resident 1 ' s Fall Risk Assessment, dated 1/3/2023, indicated Resident 1 was a high fall risk. A review of Resident 1 ' s Elopement Risk Evaluation, dated 1/3/2023, indicated Resident 1 was at risk for elopement/wandering. A review of Resident 1 ' s Fall Risk care plan, dated 1/14/2023, indicated Resident 1 was at risk for falls/injury related to dementia, generalized weakness, impaired cognition (ability to remember, understand, make decisions, and learn), poor body balance / control, poor safety awareness/judgement. Intervention includes monitor at frequent intervals. A review of Resident 1 ' s Elopement Risk care plan, dated 2/13/2023, indicated Resident 1 was at risk for wandering and leaving safe area without authorization because of his dementia diagnosis. Intervention includes visually observe resident frequently, re-orient to key places such as his room, and monitor at frequent intervals. A review of Resident 1 ' s Change of Condition (COC) Assessment Form with effective date of 3/18/2023, indicated: 6 pm resident walking around facility talking to everyone, 6:30 pm resident in the doorway of his room, 7 pm resident sitting in from lobby, 8 pm resident last seen sitting in lobby chair, 9:30 pm unable to find resident, looked in surrounding rooms, called a code for missing person, all staff looking for resident, 10:22 pm notified DON [Director of Nursing], Administrator, doctor, and responsible party. 10:45 pm called 911(universal telephone number the gives the public direct access to the Public Safety. Answering point where emergency services such as the fire department, police or paramedics can be dispatched to a location) Police Department (PD) for missing person, PD came to facility to gather information called additional units and helicopter for search. A review of Resident 1 ' s GACH emergency room record dated 3/19/2023, indicated Resident 1 was admitted to GACH on 3/19/2023 at 1:17 am with chief complaint of fall, nose pain and right knee pain. A review of Resident 1 ' s GACH Computed Tomography (a medical imaging technique used to obtain detailed internal images of the body) scan report, dated 3/19/23, indicated, acute bilateral (both side) nasal bone fractures, acute fracture of the anterior wall of the right maxillary sinus, and right maxillary sinus hematoma. A review of Resident 1 ' s GACH Discharge summary dated [DATE], indicated Resident 1 was discharge with Tylenol (pain medication) 500 milligrams (mg, unit for measurement) two tablets as needed for pain and Amoxicillin Clavulanate (Antibiotics) 875-125 mg oral tablet two times a day for 10 days. A review of Resident 1 ' s Physician Order dated 3/20/2023, indicated apply ice cold pack to nose for 20 minutes three times a day for five days. Treatment for nose with abrasion: Cleanse with normal saline, pat dry, apply A&D (skin protectant) ointment every day shift for 30 days. A review of Resident 1 ' s Medication Administration Record (MAR)for March 2023 indicated, Resident 1 received two Tylenol (pain medication) 325 mg oral tablets ordered for mild pain on 3/20/23 at 10:07 pm for a pain level of 5/10 (numerical pain assessment whereas zero is no pain and 10 as the worst pain). During an interview with the Receptionist, on 3/21/2023 at 2:15 pm, in the facility ' s front entrance lobby, the Receptionist stated she was working on Saturday (3/18/2023) the day Resident 1 eloped. The Receptionist stated she saw Resident 1 came and sat down frequently at the front lobby chairs. The Receptionist further stated when she left at 4:30 pm for the day, the front doors were locked from the outside, so no one comes in. The Receptionist further stated, one can still go out through the doors from inside the facility without a key or alarm. During an interview with the DON on 3/21/2023 at 2:22 pm, the DON stated Resident 1 was known to wander and the day he left the facility, he used the front lobby entrance doors which had no alarm system, around 9:30 pm. During an observation and a concurrent interview on 3/21/2023 at 2:45 pm with Resident 1, a small bruise was observed under his right eye, a minor scratch running down the right side of his nose and healing scabs (a dry, rough protective crust that forms over a cut or wound during healing) on his right knee. Upon Resident 1 touching his nose, he exclaimed ouch!. Resident 1 stated he was outside by a bus and on the corner where he fell over, started crying and was helped by a man in a passing car. Resident 1 stated, A man helped him and called an ambulance, there were a lot of sirens, then they took me to the hospital. Resident 1 was not able to remember the name of the facility where he resided. During a telephone interview with Licensed Vocational Nurse 1 (LVN 1), on 3/21/2023 at 3:14 pm, LVN 1 stated Resident 1 usually hangs around the facility ' s front area by the nursing station (across from the front entrance lobby). LVN 1 further stated she noticed Resident 1 to be missing on 3/18/2023 at around 9:30 pm, and he was found and returned to the facility the next day (3/19/2023) around 3 pm. LVN 1 stated, Resident 1 left the facility from the front doors of the building entrance because they are not alarmed. LVN 1 was not about to state how often Resident 1 was visually monitored. During an interview and a concurrent review of the facility ' s surveillance camera video footage from 3/18/2023, with the DON on 3/21/2023 at 4:41 pm, Resident 1 was observed sitting in a chair in the front entrance lobby at 7:54 pm. Resident 1 was observed getting up from the chair and leaving through the front entrance lobby doors at 8:08 pm. The DON confirmed and verified Resident 1 left at 8:08 pm on 3/18/2023. A request for the facility ' s policy and procedures (P &P) for elopement was made to the DON on 3/21/23 at 4:45 pm. The facility failed to provide a policy and procedures for elopement when requested. A second request was made to the DON for the facility ' s P &P for elopement on 4/6/2023 at 11:36 am. The facility was unable to provide the P &P for elopement as requested. A review of the facility ' s P &P titled Accident/Incident Prevention undated, indicated This facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accidents/incidents. A review of the facility ' s P &P titled Care of Wandering Residents undated, indicated Wanderers are to be checked on a regular basis. Monitoring the resident ' s locations with visual checks as needed.