**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide supervision to prevent elopement for one resident (#1) out of four residents reviewed for elopement risk. On 7/26/25 Resident #1 exited the facility at 6:30 p.m., unnoticed by staff. Resident #1 was mildly impaired, confused, and had an electronic monitoring device in place. Resident #1 followed another resident out the door which was remotely opened by staff. The door alarm was disabled by a resident who was aware of the code after Resident #1 triggered the alarm upon exit. Resident #1 walked approximately 0.2 miles to a hospital near the facility and was returned with assistance of law enforcement to the facility at 9:00 p.m. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 9/10/2025. The findings of Immediate Jeopardy were determined to be removed on 9/11/2025 and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Findings included: A review of Resident #1's admission record revealed an admission date of 1/19/24 with diagnoses to include encephalopathy, unspecified, generalized anxiety disorder, mild cognitive impairment of uncertain or unknown etiology, syncope and collapse, and alcohol use, unspecified. A review of Resident #1‘s quarterly Minimum Data Set (MDS), dated [DATE], under section C-Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section GG - Functional Abilities, revealed the resident used a walker for mobility and ambulated independently. Section P, Restraints and Alarms, revealed a wander/elopement alarm was used daily. A review of Resident #1's quarterly MDS, dated [DATE], revealed the same information was marked in sections C, GG, and P as in the assessment date of 7/26/25. A review of Resident #1's order summary report, to include completed and discontinued orders, revealed the following:- LOA [leave of absence] with escort for impaired cognition/elopement risk, with an order date of 1/29/24.- Electronic Wander Bracelet: Apply electronic wander bracelet to the L [left] ankle due to elopement risk, with a start date of 1/22/24 and discontinued 6/6/25.- Electronic Wander Bracelet: Check function with the transponder daily on night shift. Replace electronic wander bracelet if not working correctly. every night shift for poor safety awareness, with a start date of 1/22/24 and discontinued 9/3/25.- Electronic Wander Bracelet: Apply electronic wander bracelet to the L ankle due to elopement risk exp [expiration] 3/22/27 every day shift until 03/19/2027 23:59 change the wanderguard, with an order date of 6/6/25 and discontinued 9/3/25. - CBC [complete blood count] with diff [differential], CMP [comprehensive metabolic panel] and UA&PCR [urinalysis and polymerase chain reaction test] one time only for Behaviors for 1 Day. with a start date of 7/7/25 and end date of 7/8/25. A review of Resident #1's care plan revealed the following:- COGNITION: [resident name] has impaired cognitive function/dementia or impaired thought processes r/t [related to] Impaired decision making Date Initiated: 08/01/2025 Revision on: 08/01/2025, with interventions to include, Report to Nurse any changes in cognitive function, specifically changes in: . memory . confusion . Date Initiated: 08/01/2025.- FALL: [resident name] is at Risk for falls or fall related injury because of: Deconditioning, hx [history] of falls Date Initiated: 01/21/2024 Revision on: 01/29/2024 . - ELOPEMENT RISK: [NAME] is at risk for elopement The resident has cognitive impairment and is independently mobile Date Initiated: 01/23/2024 Revision on: 01/29/2024., with a goal to include the following, [resident name] will not exit the facility without staff knowledge, or appropriate supervision Date Initiated: 01/23/2024 Revision on: 07/29/2025., and with interventions to include the following, . Apply electronic wander bracelet due to elopement risk Date Initiated: 02/09/2024 . Obtain an order for LOA with escort Date Initiated: 02/09/2024 . A review of Resident #1's progress notes revealed the following: - 2/8/24 social services note, SW [Social Worker] was made aware that [resident name] continues to ambulate throughout the facility and has been noted to go to the door and look out the glass. He continues to have a wander guard to ankle. He told SW that he wanted to be discharged to [address] where he was going to reside with his [family member]. SW contacted [family member] at [phone number] . SW was told that [address] was an address where [resident] resided at in [state] and that resident's [family member] had passed away in [year]. She further explained that resident did not have a home in [state] and has been staying at a homeless shelter prior to being admitted to the hospital and subsequently [facility name]. She further stated that when talking to her [family member] he has told her that he has been staying at a motel and that he was wanting to leave to go to the bar and was planning on returning to the motel. SW met with resident following this conversation and conducted a BIMS [Brief Interview for Mental Status] assessment which indicated that [resident name] score was at this time an 11. During conversation it was also determined that he thought that he was in [state] at this time and had forgotten he was now in [state]. He asked why he could not just walk out the facility and stated that he would make his way there. It was discussed that in order to discharge from the facility it would have to be a safe and appropriate discharge and walking out of facility with no predetermined location would not be safe.- 7/7/25 general progress note, Resident observed with behaviors of going to other residents rooms and followed staff easy to redirect by staff.PA [Physician Assistant] made aware. New order received for labs. POA [power of attorney] notified.- 7/9/25 general progress note CBC,CMP results reviewed by PA with no new order at this time.UA result reviewed resident start Bactrim. POA notified.- 7/26/25 change in condition (CIC) evaluation completed at 22:01, . The Change In Condition/s reported on this CIC Evaluation are/were: Behavioral symptoms (e.g. [example] agitation, psychosis) . Mental Status Evaluation: Increased confusion(e.g. disorientation) Other symptoms or signs of delirium (e.g. inability to pay attention, disorganized thinking) . Behavioral Status Evaluation: Other behavioral symptoms . Nursing observations, evaluation, and recommendations are: . wander guard in place and intact and functioning properly. B. New Testing Orders: - Blood Tests Urinalysis or culture . - 7/26/25 post event note, . The following event has occurred: Patient left facility without the proper sign out process . The resident is cognitively impaired, and evaluation of facial expression indicates there is no pain. - 7/27/25 general progress note, 1:1 [one to one] care s/p [status post] elopement continues, patient is cooperative with no signs or symptoms of distress.- 7/28/25 general progress note, Clarification: Unauthorized leave/behavior. - 7/28/25 psychotropic medication note, . Medication Type: . Antianxiety Targeted Behaviors: What behaviors is the resident demonstrating that warrants the use of the psychotropic medication(s)? . Wandering . Care Plan Update (Elopement Risk): FOCUS: Elopement Risk - Resident is at risk for elopement GOAL: The resident will not exit the facility without staff knowledge, or appropriate supervision INTERVENTION: Apply electronic wander bracelet due to elopement risk INTERVENTION: Verify the location of the electronic wander bracelet during routine care . - 8/8/25 psychiatry progress note, Date of Service: 2025-07-26 . The patient is seen today at the request of staff after he went outside, he stated that he took a walk and went to the hospital that is across the street from the facility. He was returned unharmed to the facility by law enforcement . he stated that he was just going out for a walk because he was going to a reunion with some friends. The patient has a BIMS of 12 and is doing well and shows no signs or symptoms of any abuse, neglect and no psychosocial distress or injuries noted. History of Present Illness: This patient was admitted to the facility on [DATE] due to encephalopathy with no known allergies. Patient has a medical history of anxiety, alcohol use . Medical necessity/Reason for encounter for today? S visit: . Reportable Incident .- 9/3/25 social services note, Spoke with [resident name] on this date about moving back to the memory care unit per care plan team, due to his prior attempt to leave building. I also spoke with his [family member], on this date to inform her of the move and she agreed but is worried that he won't have as much area to walk around. I let her know that we would monitor how he does in MC [memory care] and let her know if we notice any changes. A review of Resident #1's physician's notes revealed the following: - 5/29/25, . Chief Complaints: 1. Monthly medical visit-s mild dementia . Interim History: [age of resident] male, with medical history including ETOH [alcohol] abuse, previous episodes of syncope . General Examination: . MENTAL STATUS: alert and oriented 2- 3 - some confusion and disorientation. NEUROLOGIC: cognitive deficits noted at admission - likely chronic encephalopathy secondary to EtOH . Plan: . 4. Generalized anxiety disorder . Clinical Notes: May 29th- patient is seen ambulating throughout the facility. He was friendly, outgoing and show no signs of anxiety. He is followed monthly by Psychiatry. April 21st- . He was last seen by psych on March 31st, with their documentation indicating that he reported to them that he does not like being here but is coping well on his own without medications. -7/9/25, . Chief Complaints: 1. Altered mental status - confusion . HPI: . seen today for follow-up after nursing had reported a significant change in mental status and requested UA to rule out organic cause for his confusion. Urinalysis consistent with UTI [urinary tract infection]. Examination: . MENTAL STATUS: alert and oriented 2-3- some confusion and disorientation. Plan: . 1. Urinary tract infection, site not specified . Clinical Notes: July 9th - urinalysis consistent with urinary tract infection. Patient seen today and does appear mildly more confused. Nursing reports patient had been wandering into other patient's rooms and had been very confused when attempts were made to redirect . 2. Muscle wasting and atrophy, not elsewhere classified, multiple sites . July 9th - . does appear to be more confused and uncertain as to where his room in his - patient does not have any confusion at baseline .- 7/29/25, .HPI: . seen today for follow-up on labs that were ordered due to concern for AMS [altered mental status] after recent elopement. Examination: . MENTAL STATUS: alert and oriented 2- 3 - some confusion and disorientation. Plan: Treatment: 1. Altered mental status, unspecified Clinical Notes: July 29th- labs reviewed. No leukocytosis, electrolyte imbalance, anemia, acute kidney injury or urinary tract infection . His previous urinary tract infection showed strong case for a urinary tract infection, but PCR was negative. Patient did receive full 7 days of Bactrim at that time. July 28th- patient appears to be very close to baseline level of cognition. Recent elopement - He does present with mild increase in anxiety and possibly increased confusion . A review of Resident #1's psychiatry notes revealed the following:- 3/31/25, HPI [history of present illness] General: . Past psych [psychiatric] history includes alcohol use, tobacco use, GAD [generalized anxiety disorder], cognitive impairment. The patient reports that he does not like being at the facility. He reports he does have some anxiety and depression feelings due to being at the facility, but he is coping well on his own. A review of Resident #1's evaluations revealed the following:- 2/9/24 elopement risk, A. Evaluation 1. Does the resident have a diagnosis of dementia, or is the resident cognitively impaired or confused AND Is the resident independently mobile either by ambulation or in a wheelchair? 1. Yes . 2. Does the resident exhibit any if the following elopement risk factors? (Select all that apply) . 5. Wandering . - 7/26/25 BIMS evaluation, . Score: 10 . Category: Moderate Impairment . - 7/26/25 elopement risk, A. Evaluation 1. Does the resident have a diagnosis of dementia, or is the resident cognitively impaired or confused AND Is the resident independently mobile either by ambulation or in a wheelchair? 1. Yes . 2. Does the resident exhibit any if the following elopement risk factors? (Select all that apply) . 3. Desires to leave facility; verbalizes desires to leave facility such as I don't want to stay here, how do I get out of here, I'm looking for my [family member] etc. 5. Wandering . 10. Attempting to tailgate behind staff, visitors, and/or other residents . A review of the abuse/neglect log revealed Resident #1's elopement was not documented in July 2025. A review of the incident and accident report from 7/8/25 to 9/8/25 revealed Resident #1's elopement was not documented. On 9/8/25 at 9:17 a.m., an observation of Resident #1 revealed he was laying down in bed. Resident #1 did not have a wander monitoring device on. He said he has never tried to leave the facility and could not recall a time when he successfully did. Resident #1 stated, Staff don't let me leave. He stated if he tried to leave, Everyone in the world comes to get me. He said he recalled being in another room before. Resident #1 said he was not sure why there was a room change. He stated he walked around a lot. On 9/8/25 at 11:25 a.m., an interview was conducted with Staff F, Registered Nurse (RN) Supervisor. He confirmed he was the supervisor on duty when Resident #1 left the faciity on 7/26/25. He said a Certified Nursing Assistant (CNA), Staff G, opened the door for Resident #10 who had signed out on LOA. Staff F, RN Supervisor said Staff G, CNA did not see Resident #1 follow Resident #10 out the door. He said Resident #10 called him and said Resident #1 followed him outside. Staff F, RN Supervisor said Resident #10 called the facility approximately five minutes after leaving the facility. He said a code silver was called and a head count was completed in which they discovered Resident #1 was missing. He stated, Staff looked everywhere. Staff F, RN Supervisor said Resident #1 was found by the hospital and police brought him back to the facility. He said he thought the resident was out of the facility for approximately 30 minutes. Staff F, RN Supervisor said the wander exit alarm was functioning and he did not know who shut it off. He stated, It alarmed when the resident came back into the facility. He said Resident #1 told him he went to see if he could get a drink at the bar. Staff F, RN Supervisor said Resident #1 was put on 1 to 1 supervision after the event. He said Resident #1 is now in the memory care unit because they do not want to repeat what happened. He stated, We don't have the manpower to keep him on 1 to 1. Staff F, RN Supervisor said Resident #1 being in the memory care unit is safer and more appropriate. On 9/8/25 at 11:51 a.m., an interview was conducted with Resident #10. He said on 7/26/25 he was trying to leave the facility to take the bus and Resident #1 was by the front door. Resident #10 said he was signing out at the front desk when Resident #1 approached him about the door code. He said he told Resident #1 he did not know the code. He said he went to Staff G, CNA to ask him to open the door and also attempted to warn him about Resident #1 trying to exit. Resident #10 said Staff G, CNA opened the front door remotely from the unit, he heard the wander guard alarm go off and then went left towards the bus stop. He said he recalled three or four staff members who came out while he was waiting at the bus stop and then saw them return inside the facility. He said he never called the facility or saw where Resident #1 went. He stated, When I leave, I don't worry about what happens. Resident #10 stated when he returned from LOA, I got cornered by staff. He stated they asked him, Why did you let him [Resident #1] through. He said the police brought Resident #1 back to the facility. He said facility staff never asked him for a statement. Resident #10 stated, I never signed anything. On 9/8/25 at 12:38 p.m., a phone interview was conducted with Staff F, Advanced Practice Registered Nurse (APRN). She said she saw Resident #1 due to the incident. She stated, He stepped outside for a second and his BIMS was repeated after the incident. Staff F, APRN said Resident #1 told her he took a walk to the hospital which was across the street. She stated, He had mild forgetfulness. Staff F, APRN said she thought he might have had a lapse that day. She said she was not sure how long Resident #1 was away from the facility. Staff F, APRN said when she asked the resident what he was trying to do, his response was he hoped to meet some friends that worked at the hospital. She stated law enforcement had found him and brought the resident back to the facility. On 9/8/25 at 3:03 p.m., a phone interview was conducted with Resident #1's family member. She said Resident #1 has a history of dementia and alcohol abuse. She said his dementia is of unknown origin but potentially related to the resident's issue with alcoholism. The family member said the facility called her around 10:20 p.m. the day the resident exited the facility unwitnessed. She stated she was told he, Snuck out with another resident and found him 20 minutes later. The family member said she suspected Resident #1 was looking for alcohol, and the facility confirmed he told them he was looking for beer. She stated, Sometimes he has better days than others. The family member said Resident #1 referenced family members who have passed, but thinks they are alive, or say he's going to walk down the street of a state he used to reside in. She said the resident's sister and father had dementia. The family member said she did not think the resident had a wander guard on before the incident. She said the staff told her, the day she was notified he had left, about putting a wander guard on him in case he tried to leave again. The family member said the social service staff member called her last week and told her Resident #1 is now in the memory care unit. She said they told her that it is closed off and easier to watch him. The family member said staff have expressed to her Resident #1 wanted to go to an assisted living facility (ALF), but he had never expressed that to her. She stated, It's a horrible idea. He asks about people who've been dead 20 to 30 years. He's been an alcoholic since he was [AGE] years old. He's a danger to himself and others, he cannot be out alone. On 9/8/25 at 3:30 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON). The DON said Resident #1 exited the facility on 7/26/25 at 5:00 p.m. The DON said code silver was completed, and it was determined he was out of facility for two and a half to three hours. She said he was evaluated when he returned to the facility, and he was alert and oriented to person, place, time, and event (x4). The DON said she interviewed the resident when he returned, and he knew what he was doing as he told them he planned to go across the street to get a drink. The DON confirmed he had an electronic monitoring bracelet on when he left, and it was functioning. The DON said Resident #1 has had an electronic monitoring bracelet for as long as she's been at the facility. The NHA said the alarm did go off at that time he left, and confirmed staff did not respond to the alarm. She said the alarm was shut off and it was unclear who did it at that time. She said they were not sure if a staff member turned off the alarm. The NHA said they heard a resident had shut it off, not knowing how they would know the code. She stated there were no staff present by the front door where Resident #1 exited. The NHA said Staff G, CNA confirmed he opened the door for Resident #10 but said he did not hear the alarm. She said there are cameras on the unit and Staff G, CNA must have opened the door remotely and did not see Resident #1 leave. The DON said Resident #1's assigned nurse told the supervisor she had just seen him eating dinner, then he was not there. The DON said Resident #1 had no exit seeking behaviors. The NHA said the capability of remotely opening the front door was removed after Resident #1 exited the facility. She said currently staff have to walk to the front door to let residents out. The NHA stated they did not report this because, It was an unauthorized exit. He didn't ask to go out. She said Resident #1 did not follow the LOA process. The DON stated, He was alert and oriented, had a plan, able to navigate himself here. She said Resident #1 was already on his way to the facility and he brought himself back. The NHA and DON said they did not feel he was in harm's way. The NHA said the criteria did not make Resident #1 an elopement risk. On 9/8/25 at 4:23 p.m., a review of Resident #1's change in condition evaluation, dated 7/26/25, was completed with the DON. She confirmed she completed the change in condition evaluation after the resident returned. She said she was assessing him for the behaviors marked on the evaluation, not that he had them. The DON stated it, Shouldn't have been marked like that. On 9/9/25 at 11:39 a.m., an interview was conducted with the Risk Manager (RM). She confirmed the facility was able to identify who turned the wander guard alarm off. She stated, [Resident #11] positioned himself in the lobby and turned it off. The RM said when Resident #11 was interviewed, he said he picked up on the codes to disable the exit alarm. She confirmed Staff G, CNA remotely opened the door, the alarm went off, and Resident #11 shut off the alarm. She said the NHA and DON interviewed Resident #1 and #11. She confirmed no other residents were interviewed. She said she was present, as a witness, during the interview with Staff G, CNA. She said he confirmed he didn't hear the alarm and acknowledged he unlocked the door remotely as he was in the back unit. The RM said Resident #10 was interviewed, but it was not documented. She stated, All he said was somebody let me out, he went out the door and didn't see anyone leave. On 9/9/25 at 1:31 p.m., a phone interview was conducted with Staff J, Physician Assistant (PA). He said Resident #1 had eloped. He said another resident let him out of the building, he was found by police and brought back to the facility. Staff J, PA confirmed he was initially called about the incident before Resident #1 returned. He stated, I can't say how long he was out for. He never eloped prior to that. He would walk around the building and do laps nonstop but never tried to leave before. Staff J, PA said Resident #1 is mildly cognitively impaired and has a BIMS of 12-13. He said the resident has a history of alcoholism and had a cognitive deficit from that. Staff J, PA stated there are, Somethings he [Resident #1] doesn't quite remember. When asked why Resident #1 is currently in the secured/memory care unit, he stated, Guessing it is because he eloped and impaired enough. He confirmed Resident #1 was previously mildly impaired. He stated, They got lucky, what if he tries to leave a second time. Staff J, PA confirmed when Resident #1 eloped, he was not safe because of his cognition. He stated, Unless they have a perfect BIMS score, they probably should not go out alone. He confirmed Resident #1 can go on LOA with assistance for cognition. Staff J, PA confirmed there was a risk for him being out on his own, due to his history of alcohol abuse and cognitive impairment. On 9/9/25 at 3:14 p.m., an interview was conducted with Resident #11. He confirmed he knew the code for the exit door and turned off the alarm the day Resident #1 left the facility. He said it is usually a false alarm when the alarm goes off, so he assumed a resident set it off when they passed by that area. Resident #11 said it's very loud. He said the next day, on 7/27/25, he found out a resident left the facility. Resident #11 stated, I know I shouldn't have done that, but it was going off and no staff were present. He stated he previously knew the code because, Staff don't hide it. He said they do not cover the code when they are putting it in the keypad. Resident #11 said staff members have yelled it out to each other as well. He said he thinks the alarm going off happened around 4:00 - 4:30. Resident #11 said the alarm woke him up and it was on long enough that he was able to get up and turn off the alarm. Resident #11 said there's been times when staff who do not normally work in the reception area do not know the code. He said he has told them he knows the code, gives it to them, and those staff have been thankful when he has done that. A review of Resident #11's annual MDS, dated [DATE], section C - Cognitive Patterns, revealed a BIMS score of 15 indicating intact cognition. On 9/9/25 at 5:28 p.m., a review of video footage from 7/26/25 revealed the following: - At 6:27:10 p.m., Resident #1 was observed walking towards the front door and stopped at the end of the reception desk. No staff were observed in the reception area.- At 6:27:21 p.m., Resident #1 was observed walking away from the front/reception area. - At 6:27:31 p.m., Resident #10 was observed ambulating to the reception area and wrote in the resident sign out log. Resident #1 was observed walking up behind him and stood to the right of Resident #10, next to the reception desk. - At 6:28:26 p.m., Resident #1 left the front area while Resident #10 continued writing in the sign out log. - At 6:28:32 p.m., Resident #1 came back to the front area. Throughout the observation, Resident #1 was standing slightly to the right side of the garbage can located in the front area. It was unclear if the wander guard alarm was going off at that time as there was no audio in the footage observed. - At 6:30:34 p.m., Resident #10 returned to the front reception area and positioned himself right in front of the door. Resident #1 was also in the same area, but in front of the garbage can. - At 6:30:55 p.m., the front doors opened, Resident #10 exited the facility going to the left, and Resident #1 exited right behind him walking towards the left. - At 6:31:24 p.m., Resident #11 was observed ambulating to the front of the facility, went to the keypad, and left the front reception area. - At 6:31:34 p.m., the front doors opened again and closed approximately ten seconds after. Throughout the footage observed, no staff were present, (Video Evidence Obtained). On 9/10/25 at 3:17 p.m., an observation of an electronic wander device was conducted with the RM, and when the device was in proximity to the door the alarm was activated. The RM was holding the device and walked to the point where the fire alarm and garbage can are located by the front door. The exit alarm went off when she passed the fire alarm and garbage can, (Photographic Evidence Obtained). An observation of the 200 unit, where Staff G, CNA was working on 7/26/25, revealed the exit alarm could be heard but it was not loud. Around room [ROOM NUMBER], the exit alarm could not be heard. From rooms 201 to 217, the exit alarm could be heard. During previous interviews with the RM, DON and NHA, they confirmed Staff G, CNA told them he did not hear the exit alarm. On 9/11/25 at 12:15 p.m., an interview was conducted with Staff I, CNA. She said Resident #1 was in the front/reception earlier in the day on 7/26/25. Staff I, CNA said he tried to leave through the front door earlier that day. She stated, We sent him back to nursing staff. She said she called the nurse to let them know he was exit-seeking. She said around the time residents are finished with dinner, the lobby is cleared, and no residents are present. She stated, I warned the nursing staff about him before I left. Staff I, CNA said she noticed his patterns had changed. She said he was usually with another resident walking around the facility, but around that time of the incident, he was wandering by himself. Staff I, CNA said she asked Resident #1 why he tried to leave and where he was going. She stated, He said he wanted to go get a few drinks across the street. Staff I, CNA said he seemed confused as he mentioned he wanted to go see his family member. She stated, I don't know if his [family member] was still alive and I asked social services about that. A review of the facility's policy titled, Abuse Prevention Program, dated November 2024, revealed the following: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Neglect . Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Alleged Violation . A situation or occurrence that is observed or reported by staff, resident, relative, visitor of others but has not yet been investigated, and if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. The Administrator, DON, and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. A review of the facility's policy titled, Elopement - Overview, dated October 2021, revealed the following, OVERVIEW The facility elopement definition is as follows: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The facility's immediate actions to remove the Immediate Jeopardy included: F689 Removal Plan- Resident #1 was put on enhanced supervision on 7/26/25 and then moved to the secure unit on 9/3/25.- On 7/26/25 and 7/27/25 an audit was completed by the DON and the facility's clinical administration team for current residents to ensure accuracy of assessment for cognition and mobility.- Through the course of the initial audit, identified variances were corrected regarding LOA status.- Staff were educated on the policy and procedures related to resident supervision, following procedures for residents leaving the facility for leave of absence, as well as the facility unauthorized exit protocols at 100% completion by 7/30/25. - Staff were educated by the DON and the facility clinical administration team on the door code process and the process to report unauthorized knowledge of the facility door codes at 100% completion by 7/30/25.- The remote door releases were deactivated on 7/27/25.- Code Silver drills were completed from 7/26/25 to 8/5/25 every shift.- Random audits were completed at 100% from 7/29/25 to 8/30/25 regarding unauthorized exit, resident LOA status, and resident elopement risk.- Ad hoc QA meeting was conducted on 7/27/25 to review the removal plan, which included the medical director. Verification

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure Advance Directives were properly documented in the medical record for three residents (#2, #12, and #13) out of three residents reviewed for code status. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury or death to Residents #2, #12, and #13 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E.Findings included: 1)Review of the Emergency Medical Systems (EMS) run report for Resident #2, dated [DATE], showed: Dispatch to rehab facility for [Resident #2] reported to have pink fluid coming from his tracheostomy tube. Upon arrival facility staff were in the hallways and reported that the patient (pt) is not doing well and appeared visibly shaken. Staff were unable to provide a time of onset. Upon entering the room, the patient (pt) was found in a semi-Fowler's position in bed. He was responsive to pain the patient was on blow by humified oxygen. There were thick secretions coming from the pt's tracheostomy tube. Breathing was labored. Lung sounds revealed bilateral rhonchi. Rapid pulse was thready and regular. Skin was normal color, hot and dry. 50 milliliters (ml) of emesis was suctioned from the pt's tracheostomy. Vitals revealed hypoxia. A blood pressure was unable to be palpated or auscultated. The pt was moved on to the stretcher. Prior to moving the pt to the unit [ambulance] his breathing changed from labored to agonal and pulses were no longer present. Cardiopulmonary resuscitation (CPR) was initiated with pulseless electrical activity (PEA) noted as [unreadable]. The pt was moved to the unit. In the unit the pt had an additional 100 ml of emesis suctioned from his tracheostomy. The [NAME] device was used for continuous compressions. The tracheostomy tube (uncuffed) was removed and replaced with a 6.0 ET (endotracheal) tube. He was placed on the ventilator. At the next rhythm check the pt's rhythm was slow PEA that quickly became asystole. CPR was resumed. An Intraosseous Intravenous access (IO) was established and the pt was given 1 milligram (mg) of Epinephrine. Enroute to the hospital CPR was continued with no changes in rhythm. A blood glucose level of 138 milligrams (mg)/deciliter (dL) was obtained. The pt was given 1 mg of epinephrine prior to transferring the pt inside the ED. At the hospital pt care was transferred to the nurse where CPR continued. Review of admission Records showed Resident #2 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including anoxic brain damage, persistent vegetative state, seizures, acute and chronic respiratory failure, tracheostomy status, gastrostomy status, and cardiac arrest due to underlying conditions Review of Resident #2's physician orders showed:-Do Not Resuscitate (DNR) Start: [DATE]. -Full Resuscitation Discontinued: [DATE] Start: [DATE]Review of Resident #2 Medical Certification for Medicaid Long-Term Care and Services and Patient Transfer Form (AHCA 5000-3008) from hospital discharge, dated [DATE], showed the resident had a Do Not Resuscitate order. Section H, Advanced Care Planning, listed the following: -Advanced Directives- indicated No with a checkmark-Living Will- indicated No with a checkmark-DO NOT Resuscitate (DNR)- indicated Yes with an X and No with a checkmark. The Yes was also circled and there was a line from the circle across the No and error written beside it. -DO NOT Intubate- indicated No with a checkmark-DO NOT Hospitalize- indicated No with a checkmark-No Artificial Feeding- indicated No with a checkmark-Hospice- indicated No with a checkmarkReview of Resident #2's medical record did not reveal a signed DNR Form DH1896. Review of Florida Statutes Chapter 401, Medical Telecommunications and transportation, section 401.45 (3)(a) regarding DNR Form DH1896 showed: Resuscitation may be withheld or withdrawn from a patient by an emergency medical technician or paramedic if evidence of an order not to resuscitate by the patient's physician or physician assistant is presented to the emergency medical technician or paramedic. An order not to resuscitate, to be valid, must be on the form adopted by rule of the department. The form must be signed by the patient's physician or physician assistant and by the patient or, if the patient is incapacitated, the patient's health care surrogate or proxy as provided in chapter 765, court-appointed guardian as provided in chapter 744, or attorney in fact under a durable power of attorney as provided in chapter 709. The court-appointed guardian or attorney in fact must have been delegated authority to make health care decisions on behalf of the patient. (https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0401/Sections/0401.45.html#:~:text=(3)(a)%20Resuscitation%20may,by%20rule%20of%20the%20department. Accessed on [DATE])An interview was conducted on [DATE] at 2:34 p.m. with Staff N, Registered Nurse (RN)/Unit Manager (UM). Staff N said when Resident #2 returned from the hospital in [DATE] he completed the admission process. Staff N said Resident #2 was discussed in the morning meeting prior to returning and it was mentioned the resident would be returning to the facility with a DNR status. Staff N said when the resident returned the AHCA 5000-3008 showed the resident was now a DNR. Staff N said he called the provider and received a verbal order for DNR. Staff N said then social services should have called to verify the family approved of the DNR status and the correct power of attorney (POA) or healthcare proxy (HCP) is in place. Staff N said after social services confirms the information, they initiate the DNR Form DH1896 from and get it signed by the resident or resident representative and the provider. Staff N said once the DNR Form DH1896 was completed and signed it was placed in front of the resident hard chart. Staff N said when there is a code called for a resident the first thing staff grab is the resident's hard chart. He said the nurse can double check code status in the computer but the one that matters to us is the chart. Staff N said if a resident with a DNR went out to the hospital the nurse or UM gave a copy of the signed DNR Form DH1896 to EMS as well as letting them know during report the resident had a code status of DNR. Staff N reviewed Resident #2's AHCA 5000-3008 from [DATE]. Staff N said looked at Section H, Advanced Care Planning, and said it was interpreted as DNR initially being marked as No and error was written beside that. He said then Yes was marked indicating the resident was DNR. Staff N said a signed DNR Form DH1896 not come with Resident #2 was from the hospital and he did not remember a completed, signed DNR Form DH1896 from ever being returned to the unit to be placed in the resident's hard chart. Staff N said the process was that when a patient returned from the hospital their chart was brought to the morning clinical meeting and it was reviewed by staff including nursing and social services. Staff N said resident's code status was discussed and social services would then procced with getting the paperwork completed. Staff N said he was working the day Resident #2 went out and Staff Q, RN/UM asked me to see the resident. Staff N said Resident #2 was not looking good and 911 was called. Staff N said he was at the nurses' station completing paperwork and he was not aware of what happened while EMS was in the facility. Review of video footage from the facility's front entrance, dated [DATE], showed two paramedics pushing a stretcher carrying Resident #2. One paramedic was pulling the stretcher from the front. The second paramedic was walking alongside the stretcher with one hand on the center of Resident #2 chest doing one handed chest compressions while moving the patient from the facility to the ambulance outside the front door of the facility. An interview was conducted on [DATE] at 12:38 p.m. with Staff M, Registered Nurse (RN). Staff M said he was the nurse for Resident #2 the day the resident went out to the hospital. Staff M said the resident's vital signs were out of whack and the resident was not doing well. Staff M said 911 was called and Emergency Medical Services (EMS) came and took the resident. Staff M said Resident #2 was a DNR but he doesn't recall if the facility had the DNR Form DH1896 or if the paramedics were told. Staff M said normally the yellow DNR paper is in front of the resident's hard chart, often more than one copy. He said one copy would be sent with EMS if a resident with a DNR order was sent out and if there were not two copies in the chart, a copy would be made for EMS. Staff M said if a resident wanted to change their code status to DNR the provider would give the order, and they would sign the DNR Form DH1896 because they were in the building all the time. A follow-up interview on [DATE] at 1:34 p.m. with Staff M, RN. He said they did not visualize them [EMS] doing CPR. Staff M said when EMS arrived the resident was still alive, he gave report and backed up and the resident was put on a stretcher. Staff M said he knew the resident was a DNR but the Staff Q, RN/Unit Manager (UM) got the paperwork together. An interview was conducted on [DATE] at 12:57 p.m. with Staff Q, RN/UM. Staff Q said on [DATE] Resident #2's rate was elevated; the resident was suctioned the provider was called. Staff Q said Resident #2's heart rate continued to go higher, and the doctor said to send the resident to the hospital, therefore, 911 was called. Staff Q said paramedics came and not to my knowledge did they do CPR. Staff Q said he knew Resident #2 was a DNR but don't believe we had that [signed DNR Form DH1896]. Staff Q said the paperwork he gave the paramedic was the bed hold, AHCA form, medication list, orders, and facesheet. Staff Q said Resident #2 had gone out to the hospital in July and when the resident returned, he was a DNR. Staff Q said he did not know why the signed DNR Form DH1896 was not in the resident's chart and maybe it had still been in the process of being signed. An interview was conducted on [DATE] at 3:51 p.m. with the Risk Manager. The Risk Manager said Staff M, RN was doing rounds on [DATE] and found Resident #2 to be tachycardic (fast heart rate) and diaphoretic (excessive sweating). She said the doctor was notified and 911 was called to send the resident out. The Risk Manager said EMS was provided with a copy of the doctor's order, but the facility did not have the signed DNR Form DH1896. She said there was a breakdown in the process which is why they did not have the signed DNR Form DH1896. The Risk Manager said when a resident wanted to change from full code status to not resuscitate the order is printed, signed and placed in front of the resident's hard chart. She said the full code paperwork that would have previously been in the hard chart was removed to avoid confusion. She said the DNR Form DH1896 was completed, signed, then put in front of the chart also. The Risk Manager said the signed DNR Form DH1896 was given to EMS if a resident with DNR status goes to the hospital. She confirmed if EMS did not have the signed DNR Form DH1896 they do a full code on the resident. The Risk Manager said the reason there was a problem with Resident #2 was social services and the unit manager had the change of code status on their morning meeting homework sheets when the resident was readmitted to the facility, but the paperwork did not get completed that day and it was never transcribed to the next day's morning meeting homework sheet. An interview was conducted on [DATE] at 2:20 p.m. with Staff L, Social Services (SS). Staff L said if a resident wanted to have a DNR code status social services would have had them sign the DNR Form DH1896, if they are their own responsible party. Staff L said if the resident was unable to sign the social services would have called the resident's power or attorney and have them sign the paperwork, either by coming in, by email, by fax, or whatever needed to be done to get the DNR Form DH1896 from signed immediately. Staff L said Resident #2 returned to the facility in [DATE] with a new code status of DNR. Staff L said social services should have reached out to the family to verify the DNR status and get the paperwork completed. Staff L said I don't know that they did reach out to Resident #2's family to verify the code status and get the DNR Form DH1896 signed. When asked if Staff L saw a completed, sign DNR Form DH1896 for Resident #2, she stated, Correct To my knowledge I have never seen one. Staff L said she could not speak for nursing, but she did not reach out to Resident #2's family to confirm DNR status or get the paperwork completed. Staff L said after Resident #2 left the facility she heard about the facility not having Resident #2's signed DNR Form DH1896 form for EMS and CPR being done on the resident. An interview was conducted on [DATE] at 1:25 p.m. with Staff J, Physician Assistant (PA). Staff J said he was called on [DATE] about Resident #2 being in distress and being sent to the hospital. Staff J said there had been several discussions with Resident #2's family about code status and possible hospice prior to going out to the hospital in [DATE]. Staff J said Resident #2 went out with a full code status and returned to the facility on [DATE] with a DNR code status. He said they were told the family made the decision to change the code status while the resident was in the hospital. Staff J said typically when a resident changed to a DNR status the nurse would have given him the DNR Form DH1896 to sign. Staff J said he routinely signed the DNR Form DH1896 forms but had not signed one for Resident #2. Staff J said he was told on [DATE] Resident #2 was being evaluated by EMS and lost a heart rate, and EMS started a code while in the facility. 2)Review of admission Records showed Resident #12 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture of T5-T6 vertebra, encephalopathy, muscle wasting and atrophy and protein calorie malnutrition.Review of Resident #12's provider orders showed: -Full Resuscitation Start: [DATE]. Discontinued [DATE]-Do Not Resuscitate Start: [DATE]. Review of Resident #12's medical record revealed a printed and signed order for Full Code on the first page. The second page of the hard chart revealed a completed, signed DNR Form DH1896, dated [DATE]. An interview was conducted on [DATE] at 4:39 p.m. with Staff R, RN. Staff R said when a code was called staff pulled the residents chart to look for code status. Staff R was observed looking at Resident #12's hard chart. Staff R opened the chart and said, [Resident #12] is a full code. The front page was then flipped over and Staff R said, [Resident #12] has a signed DNR? Staff R said, it shouldn't be like that 3) Review of admission Records showed Resident #13 was admitted on [DATE] with diagnoses including altered mental status and urinary tract infection. Review of Resident #13's admission Assessment showed the resident was oriented to person, place, time and situation. Review of Resident #13's provider orders showed: -Do Not Resuscitate Start [DATE]. Review of Resident #13's medical record revealed a DNR Form DH1896 form signed by the provider, however, it had not been signed by the resident/resident representative. The resident's provider signed the form on [DATE]. An interview was conducted on [DATE] at 4:32 p.m. with the Risk Manager, Director of Nursing (DON) and Nursing Home Administrator (NHA). The DON said the facility should have had the completed, signed DNR Form DH1896, but the facility staff did not do CPR on Resident #2. The DON said they went by the [DATE] AHCA 5000-3008 to see that Resident #2 was a DNR status. She said, this is like our physician order form. The DON said they did not get any other information or DNR paperwork from the hospital, they just went by the AHCA 5000-3008 The DON said social services tried to call the family but did not get a response. She confirmed there was no documentation social services had reached out to the family to confirm Resident #2's updated code status. The NHA said Staff J, PA would have been the provider to sign the DNR Form DH1896 for Resident #2. The Risk Manager and DON reviewed the medical record of Resident #12. When the front of the chart was opened the DON said Resident #12 was a full code she then flipped the page and confirmed there was a signed DNR for the resident. The DON and Risk Manager said the hard chart should not have both a full code order and signed DNR order in the chart and confirmed it would lead to confusion. Upon review of the resident's medical record, they confirmed Resident #12 did have a DNR order and stated the full code order should have been removed from the hard chart when the resident changed their code status to DNR. The DON and Risk Manager reviewed Resident #13's DNR Form DH1896 and confirmed it was not signed by the resident. They both agreed the DNR form would not be valid since it was not signed. The DON said Resident #13 is her own responsible party and should have been asked to sign the DNR Form DH1896 upon admission. Review of a facility policy titled Advanced Medical Directives, effective [DATE], showed the following: PolicyAt the time of admission, Admissions shall furnish residents, family members, and/or the resident representative(s) with information regarding Advanced Medical Directives.The resident and/or resident representative shall be asked to provide Social Services with a copy of the resident's current Advanced Medical Directives. Social Services will place the Advanced Medical Directives in the resident's medical record and ensure that the presence, or absence, of Advanced Medical Directives is documented in the resident record.Completion of an Advanced Medical Directive is not a requirement for admission or continued stay in the facility. After admission to the facility, the Director of Social Services will assist in providing further guidance and/or information on Health Care Advanced Directives as required or requested.Procedure1. Verify that information about Advanced Medical Directives was provided to the resident and/or family / resident representative at the time of admission.2. Evaluate factors that may affect the resident capacity to communicate a decision.Notify Physician of any concerns. Consider vision/hearing/cognitive deficits Obtain language preference and utilize translation/interpreter as needed3. Provide culturally appropriate discussion/education for the resident and/or responsible party.4. Obtain any current Advanced Directives from the resident and/or family/resident representative. Read the content to understand the resident's wishes and place the document in the medical record.5. Document the Advanced Medical Directives that are current and in place on the medical record.6. Enter the information on the Advanced Directives/DNR Log upon admission, quarterly, with change in condition, and / or change in Advanced Medical Directive status.7. Update medical record with new or revised Advanced Medical Directives as indicated.8. When a resident rescinds or changes his/her Advanced Medical Directives, have the resident draw a line through the old document, note rescinded/changed, then sign and note date rescinded/changed. Remove the old document from the record and return it to medical records for filing in closed chart. Place updated document in the record and document in the medical record.DNRHow Implemented: An order by the physician that, should the resident's heart stop and/or should respirations cease, CPR is not to initiated. Specific to CPR initiation; does not address other life support measures. Considerations Signed by resident or authorized healthcare decision-maker if resident lacks capacity Means only that CPR will not be initiated; treatable conditions will still be treated Without a DNR order, CPR will be initiated State specific documentation may also be required e.g. yellow form (FL) for EMS The facility's immediate actions to remove the Immediate Jeopardy included: A whole house audit was completed on [DATE] regarding advance directives and two identified variances were corrected. One code status was updated in the medical record, and it is clear to staff of the resident wishes and one next of kin validated the resident's advance directives with a signature on [DATE]. The Regional Nurse Consultant educated the clinical management team at 100% [DATE] to the Code Status Response Policy. Licensed Nurses were educated by the Director of Nursing and the facility clinical administration team on Code Status Response Policy at 97% by [DATE]. The morning clinical worksheet was updated on [DATE]. ADHOC Quality Assurance meeting was conducted today [DATE] to review the removal plan including the medical director. Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with forty-three nurses and CNAs who worked across all shifts, the Director of Nursing, the Assistant Director of Nursing, the Nursing Home Administrator, and the Social Services team. The staff members were able to state that they had been trained and were knowledgeable about the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff had acknowledged education and training related to procedures for residents' code status, code drills, and advanced directives process. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of E.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure Advance Directives were honored and properly documented in the medical record for three residents (#2, #12, and #13) out of three residents reviewed for code status. Resident #2 received cardiopulmonary resuscitation (CPR), despite his preference to be a Do Not Resuscitate (DNR) code status, after he was found unresponsive by staff on [DATE]. Staff failed to inform the Emergency Response Team (EMT) of the DNR code status and CPR was begun at the facility and conducted during transport and care in the emergency room (ER). This failure created a situation that resulted in a worsened condition and the likelihood for serious injury or death to Residents #2 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E.Findings included: 1)Review of the Emergency Medical Systems (EMS) run report for Resident #2, dated [DATE], showed:Dispatch to rehab facility for [Resident #2] reported to have pink fluid coming from his tracheostomy tube. Upon arrival facility staff were in the hallways and reported that the patient (pt) is not doing well and appeared visibly shaken. Staff were unable to provide a time of onset.Upon entering the room, the patient (pt) was found in a semi-Fowler's position in bed. He was responsive to pain the patient was on blow by humified oxygen. There were thick secretions coming from the pt's tracheostomy tube. Breathing was labored. Lung sounds revealed bilateral rhonchi. Rapid pulse was thready and regular. Skin was normal color, hot and dry. 50 milliliters (ml) of emesis was suctioned from the pt's tracheostomy. Vitals revealed hypoxia. A blood pressure was unable to be palpated or auscultated. The pt was moved on to the stretcher. Prior to moving the pt to the unit [ambulance] his breathing changed from labored to agonal and pulses were no longer present. Cardiopulmonary resuscitation (CPR) was initiated with pulseless electrical activity (PEA) noted as [unreadable]. The pt was moved to the unit.In the unit the pt had an additional 100 ml of emesis suctioned from his tracheostomy. The [NAME] device was used for continuous compressions. The tracheostomy tube (uncuffed) was removed and replaced with a 6.0 ET (endotracheal) tube. He was placed on the ventilator. At the next rhythm check the pt's rhythm was slow PEA that quickly became asystole. CPR was resumed. An Intraosseous Intravenous access (IO) was established and the pt was given 1 milligram (mg) of Epinephrine.Enroute to the hospital CPR was continued with no changes in rhythm. A blood glucose level of 138 milligrams (mg)/deciliter (dL) was obtained. The pt was given 1 mg of epinephrine prior to transferring the pt inside the ED.At the hospital pt care was transferred to the nurse where CPR continued. Review of Resident #2's hospital record, dated [DATE], showed: History of Present Illness (HPI)[Age and gender] with history of anoxic brain injury from prior stroke, tracheal tube, PEG (percutaneous endoscopic gastrostomy) tube, BIBEMS (brought in by emergency medical service) after being found pulseless at this facility. Upon EMS arrival they found him/her in PEA with pink frothy sputum coming out of his/her tracheal tube, they switched out for endotracheal tube. Patient has some point was found to be asystole. Compression were continued until he arrived to the emergency department. He received several rounds of epinephrine and was coded for 30 minutes prior to arrival and transfer to emergency department care. Patient presented from local nursing facility as a pre-hospital cardiac arrest. Report from medics was that they were called because the patient was hypoxic and having significant drainage from his trach. When they arrived, the patient was saturating [oxygen saturation] in the 70s, They said that they suctioned the trach and were getting significant output. They report that it was pink and thick in color. Because of the amount of suctioning they were having to do they were concerned that the trach may have been clogged. Shortly after their arrival the patient went to a cardiac arrest, PEA was the initial rhythm. ACLS (Advanced Cardiac Life Support) protocol was followed. They opted to remove the trach, place a 6-0 endotracheal Lube within the Tracheostomy and then bag the patient. They were able to get improvement in his oxygenation to the 90s with bagging the patient but patient remained between PEA and asystole on pulse checks during transport. ACLS have been ongoing for least 30 minutes on patient arrival. Paramedics report that the patient's blood sugar was in the 130s. He had received 2 rounds of epinephrine prior to arrival. Patient arrived here with a [NAME] device providing chest compressions. Endotracheal tube was within the tracheostomy, and the patient had equal bilateral breath sounds. Additional intraosseous access was obtained and ACLS was continued. He received additional doses of epinephrine including a dirty epi drip and Levophed infusion. He also received bicarb, calcium and magnesium. We did obtain ROSC (return of spontaneous circulation) twice however each was brief. Labs were pulled from the I0 and did not result until after the patient had expired. During the code possible causes of asystole were reviewed, including hypoxia (100% oxygen via endotracheal tube through trach w equal bilateral breath sounds), hypothermia, hypo/hyperkalemia, hypomagnesemia, hydrogen ion acidosis (calcium given for membrane stabilization, sodium bicarb given for acidemia), hypovolemia (IV fluids running). Trauma (none reported, no evidence of on physical exam), toxins (no history), tension pneumothorax (bilateral breath sounds present), cardiac tamponade (no pericardial effusion noted on ultrasound), acute myocardial infarction and pulmonary embolism. Cannot rule our acute myocardial infarction or pulmonary embolus as causes in this patient's course and they may likely provide most reasonable etiology. Despite our efforts patient unfortunately expired, Patient had no spontaneous respirations, heart sounds, response to any stimulus including noxious stimuli. Patient's pupils were fixed and dilated at 8 mm and with no response to light, no corneal reflexes, no gag reflex, and no oculocephalic reflex. Patient was pronounced at 11:26 AM.Prior to the patient's arrival to the emergency department, we were given a heads-up radio call by EMS. I met with my nursing staff and discussed the radio call information with them. I assigned positions and rolls for the cardiac arrest. I instructed them that we will be using closed loop communication.Upon patient arrival via EMS, the patient was moved to trauma bay for initial examination and resuscitation as per ACLS guidelines. Patient was transferred to ER stretcher where patient was immediately placed on cardiac monitor/defibrillator, 02 sat, ET C02 (end tidal carbon dioxide) waveform (the breath-to-breath concentration of carbon dioxide in exhaled air) capnography , and assessed by nursing staff while simultaneously attempting to place two large bore IV lines. Patient arrived on an auto pulse device, and with an endotracheal tube inStat respiratory therapist was paged prior to patient arrival.Patient is in active cardiac arrest and patient's endotracheal tube was suctioned, easily bagged, with bilateral breath sounds. patient has symmetrical chest expansion, no chest crepitus, bilateral breath sounds, and color capnography changes indicating intubation.Continues waveform capnography is continued. Glucose within normal limits. At 1st pulse check at 10:47 a.m. patient was found to be asystole, chest compressions were resumed, and IO was inserted into the left tibia due to difficulty establishing further IV access. Epi was given every 4 minutes with pull check every 2 minutes. Patient was given calcium bicarbonate and magnesium. On all subsequent pulse checks patient was found to be in pulseless electrical activity. At 11:00 a.m. ROSC was achieved, patient started on no epi drip. At 11:07 a.m. patient was found to be in asystole again; epinephrine was given and ACLS was resumed. After multiple rounds of pulseless electrical activity ROSC was achieved at 11:13 a.m. Patient again went into pulseless electrical activity at 11:22 a.m., The ETC02 has remained at < 10 mmHg, patient expired at 11:26 p.m.Review of admission Records showed Resident #2 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including anoxic brain damage, persistent vegetative state, seizures, acute and chronic respiratory failure, tracheostomy status, gastrostomy status, and cardiac arrest due to underlying conditionsReview of Resident #2's physician orders showed:-Do Not Resuscitate (DNR) Start: [DATE].-Full Resuscitation Discontinued: [DATE] Start: [DATE]Review of Resident #2 Medical Certification for Medicaid Long-Term Care and Services and Patient Transfer Form (AHCA 5000-3008) from hospital discharge, dated [DATE], showed the resident had a Do Not Resuscitate order. Section H, Advanced Care Planning, listed the following:-Advanced Directives- indicated No with a checkmark-Living Will- indicated No with a checkmark-DO NOT Resuscitate (DNR)- indicated Yes with an X and No with a checkmark. The Yes was also circled and there was a line from the circle across the No and error written beside it.-DO NOT Intubate- indicated No with a checkmark-DO NOT Hospitalize- indicated No with a checkmark-No Artificial Feeding- indicated No with a checkmark-Hospice- indicated No with a checkmarkReview of Resident #2's medical record did not reveal a signed DNR Form DH1896.Review of Florida Statutes Chapter 401, Medical Telecommunications and transportation, section 401.45 (3)(a) regarding DNR Form DH1896 showed:Resuscitation may be withheld or withdrawn from a patient by an emergency medical technician or paramedic if evidence of an order not to resuscitate by the patient's physician or physician assistant is presented to the emergency medical technician or paramedic. An order not to resuscitate, to be valid, must be on the form adopted by rule of the department. The form must be signed by the patient's physician or physician assistant and by the patient or, if the patient is incapacitated, the patient's health care surrogate or proxy as provided in chapter 765, court-appointed guardian as provided in chapter 744, or attorney in fact under a durable power of attorney as provided in chapter 709. The court-appointed guardian or attorney in fact must have been delegated authority to make health care decisions on behalf of the patient.https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0401/Sections/0401.45.html#:~:text=(3)(a)%20Resuscitation%20may,by%20rule%20of%20the%20department. Accessed on [DATE])An interview was conducted on [DATE] at 2:34 p.m. with Staff N, Registered Nurse (RN)/Unit Manager (UM) Staff N said when Resident #2 returned from the hospital in [DATE] he completed the admission process. Staff N said Resident #2 was discussed in the morning meeting prior to returning and it was mentioned the resident would be returning to the facility with a DNR status. Staff N said when the resident returned the AHCA 5000-3008 showed the resident was now a DNR. Staff N said he called the provider and received a verbal order for DNR. Staff N said then social services should have called to verify the family approved of the DNR status and the correct power of attorney (POA) or healthcare proxy (HCP) is in place. Staff N said after social services confirms the information, they initiate the DNR Form DH1896 from and get it signed by the resident or resident representative and the provider. Staff N said once the DNR Form DH1896 was completed and signed it was placed in front of the resident hard chart. Staff N said when there is a code called for a resident the first thing staff grab is the resident's hard chart. He said the nurse can double check code status in the computer but the one that matters to us is the chart. Staff N said if a resident with a DNR went out to the hospital the nurse or UM gave a copy of the signed DNR Form DH1896 to EMS as well as letting them know during report the resident had a code status of DNR. Staff N reviewed Resident #2's AHCA 5000-3008 from [DATE]. Staff N said looked at Section H, Advanced Care Planning, and said it was interpreted as DNR initially being marked as No and error was written beside that. He said then Yes was marked indicating the resident was DNR. Staff N said a signed DNR Form DH1896 not come with Resident #2 was from the hospital and he didn't remember a completed, signed DNR Form DH1896 from ever being returned to the unit to be placed in the resident's hard chart. Staff N said the process was that when a patient returned from the hospital their chart was brought to the morning clinical meeting and it was reviewed by staff including nursing and social services. Staff N said resident's code status was discussed and social services would then procced with getting the paperwork completed. Staff N said he was working the day Resident #2 went out and Staff Q, RN/UM asked me to see the resident. Staff N said Resident #2 was not looking good and 911 was called. Staff N said he was at the nurses' station completing paperwork and he was not aware of what happened while EMS was in the facility. Review of video footage from the facility's front entrance, dated [DATE], showed two paramedics pushing a stretcher carrying Resident #2. One paramedic was pulling the stretcher from the front. The second paramedic was walking alongside the stretcher with one hand on the center of Resident #2 chest doing one handed chest compressions while moving the patient from the facility to the ambulance outside the front door of the facility. An interview was conducted on [DATE] at 12:38 p.m. with Staff M, Registered Nurse (RN). Staff M said he was the nurse for Resident #2 the day the resident went out to the hospital. Staff M said the resident's vital signs were out of whack and the resident was not doing well. Staff M said 911 was called and Emergency Medical Services (EMS) came and took the resident. Staff M said Resident #2 was a DNR but he doesn't recall if the facility had the DNR Form DH1896 or if the paramedics were told. Staff M said normally the yellow DNR paper is in front of the resident's hard chart, often more than one copy. He said one copy would be sent with EMS if a resident with a DNR order was sent out and if there weren't two copies in the chart, a copy would be made for EMS. Staff M said if a resident wanted to change their code status to DNR the provider would give the order, and they would sign the DNR Form DH1896 because they were in the building all the time. A follow-up interview on [DATE] at 1:34 p.m. with Staff M, RN. He said they did not visualize them [EMS] doing CPR. Staff M said when EMS arrived the resident was still alive, he gave report and backed up and the resident was put on a stretcher. Staff M said he knew the resident was a DNR but the Staff Q, RN/Unit Manager (UM) got the paperwork together. An interview was conducted on [DATE] at 12:57 p.m. with Staff Q, RN/UM. Staff Q said on [DATE] Resident #2's rate was elevated; the resident was suctioned the provider was called. Staff Q said Resident #2's heart rate continued to go higher, and the Dr said to send the resident to the hospital, therefore, 911 was called. Staff Q said paramedics came and not to my knowledge did they do CPR. Staff Q said he knew Resident #2 was a DNR but don't believe we had that [signed DNR Form DH1896]. Staff Q said the paperwork he gave the paramedic was the bed hold, AHCA form, medication list, orders, and face sheet. Staff Q said Resident #2 had gone out to the hospital in July and when the resident returned, he was a DNR. Staff Q said he did not know why the signed DNR Form DH1896 was not in the resident's chart and maybe it had still been in the process of being signed. An interview was conducted on [DATE] at 3:51 p.m. with the Risk Manager. The Risk Manager said Staff M, RN was doing rounds on [DATE] and found Resident #2 to be tachycardic (fast heart rate) and diaphoretic (excessive sweating). She said the doctor was notified and 911 was called to send the resident out. The Risk Manager said EMS was provided with a copy of the doctor's order, but the facility did not have the signed DNR Form DH1896. She said there was a breakdown in the process which is why they did not have the signed DNR Form DH1896. The Risk Manager said when a resident wanted to change from full code status to not resuscitate the order is printed, signed and placed in front of the resident's hard chart. She said the full code paperwork that would have previously been in the hard chart was removed to avoid confusion. She said the DNR Form DH1896 was completed, signed, then put in front of the chart also. The Risk Manager said the signed DNR Form DH1896 was given to EMS if a resident with DNR status goes to the hospital. She confirmed if EMS did not have the signed DNR Form DH1896 they do a full code on the resident. The Risk Manager said the reason there was a problem with Resident #2 was social services and the unit manager had the change of code status on their morning meeting homework sheets when the resident was readmitted to the facility, but the paperwork did not get completed that day and it was never transcribed to the next day's morning meeting homework sheet. An interview was conducted on [DATE] at 2:20 p.m. with Staff L, Social Services (SS). Staff L said if a resident wanted to have a DNR code status social services would have had them sign the DNR Form DH1896, if they are their own responsible party. Staff L said if the resident was unable to sign the social services would have called the resident's power or attorney and have them sign the paperwork, either by coming in, by email, by fax, or whatever needed to be done to get the DNR Form DH1896 form signed immediately. Staff L said Resident #2 returned to the facility in [DATE] with a new code status of DNR. Staff L said social services should have reached out to the family to verify the DNR status and get the paperwork completed. Staff L said I don't know that they did reach out to Resident #2's family to verify the code status and get the DNR Form DH1896 signed. When asked if Staff L saw a completed, sign DNR Form DH1896 for Resident #2, she stated, Correct to my knowledge I have never seen one. Staff L said she could not speak for nursing, but she did not reach out to Resident #2's family to confirm DNR status or get the paperwork completed. Staff L said after Resident #2 left the facility she heard about the facility not having Resident #2's signed DNR Form DH1896 for EMS and CPR being done on the resident. An interview was conducted on [DATE] at 1:25 p.m. with Staff J, Physician Assistant (PA). Staff J said he was called on [DATE] about Resident #2 being in distress and being sent to the hospital. Staff J said there had been several discussions with Resident #2's family about code status and possible hospice prior to going out to the hospital in [DATE]. Staff J said Resident #2 went out with a full code status and returned to the facility on [DATE] with a DNR code status. He said they were told the family made the decision to change the code status while the resident was in the hospital. Staff J said typically when a resident changed to a DNR status the nurse would have given him/her the DNR Form DH1896 to sign. Staff J said he routinely signed the DNR Form DH1896 forms but had not signed one for Resident #2. Staff J said he was told on [DATE] Resident #2 was being evaluated by EMS and lost a heart rate, and EMS started a code while in the facility. 2)Review of admission Records showed Resident #12 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture of T5-T6 vertebra, encephalopathy, muscle wasting and atrophy and protein calorie malnutrition.Review of Resident #12's provider orders showed: -Full Resuscitation Start: [DATE]. Discontinued [DATE]-Do Not Resuscitate Start: [DATE]. Review of Resident #12's medical record revealed a printed and signed order for Full Code on the first page. The second page of the hard chart revealed a completed, signed DNR Form DH1896, dated [DATE]. An interview was conducted on [DATE] at 4:39 p.m. with Staff R, RN. Staff R said when a code was called staff pulled the residents chart to look for code status. Staff R was observed looking at Resident #12's hard chart. Staff R opened the chart and said, [Resident #12] is a full code. The front page was then flipped over and Staff R said, [Resident #12] has a signed DNR? Staff R said, it shouldn't be like that 3) Review of admission Records showed Resident #13 was admitted on [DATE] with diagnoses including altered mental status and urinary tract infection. Review of Resident #13's admission Assessment showed the resident was oriented to person, place, time and situation. Review of Resident #13's provider orders showed: -Do Not Resuscitate Start [DATE]. Review of Resident #13's medical record revealed a DNR Form DH1896 from signed by the provider, however, it had not been signed by the resident/resident representative. The resident's provider signed the form on [DATE]. An interview was conducted on [DATE] at 4:32 p.m. with the Risk Manager, Director of Nursing (DON) and Nursing Home Administrator (NHA). The Risk Manager said when she watched the facility video of EMS leaving with Resident #2 she did not feel like the paramedics were doing compressions. She said the paramedic's hand was on the resident's chest, but she did not feel like what the paramedic was doing was compressions. The DON said the facility should have had the completed, signed DNR Form DH1896, but the facility staff did not do CPR on Resident #2. The DON said they went by the [DATE] AHCA 5000-3008 to see that Resident #2 was a DNR status. She said, this is like our physician order form. The DON said they did not get any other information or DNR paperwork from the hospital, they just went by the AHCA 5000-3008 The DON said social services tried to call the family but did not get a response. She confirmed there was no documentation social services had reached out to the family to confirm Resident #2's updated code status. The NHA said Staff J, PA would have been the provider to sign the DNR Form DH1896 for Resident #2. The Risk Manager and DON reviewed the medical record of Resident #12. When the front of the chart was opened the DON said Resident #12 was a full code she then flipped the page and confirmed there was a signed DNR for the resident. The DON and Risk Manager said the hard chart should not have both a full code order and signed DNR order in the chart and confirmed it would lead to confusion. Upon review of the resident's medical record, they confirmed Resident #12 did have a DNR order and stated the full code order should have been removed from the hard chart when the resident changed their code status to DNR. The DON and Risk Manager reviewed Resident #13's DNR Form DH1896 and confirmed it was not signed by the resident. They both agreed the DNR form would not be valid since it was not signed. The DON said Resident #13 is her own responsible party and should have been asked to sign the DNR Form DH1896 upon admission.Review of a facility policy titled CPR Code Status Orders & Response, updated February 2023, revealed the following:Policy: The facility provides Basic Life Support (BLS) CPR only. The physician's order for full code or Do Not Resuscitate is written based on the wishes of the resident/resident representative. Advanced Directives will be honored.Do Not Resuscitate (DNR) ORDER: Cardiopulmonary resuscitation will not be initiated in the absence of pulse or respirations.In the absence of Advanced Directives or physician orders, the resident will be considered a Full Code status, unless the resident and/or resident representative verbalizes wishes on admission assessment to change to withhold CPR.Code status orders and wishes will be reviewed on admission, quarterly, PRN and with significant change of condition by the Interdisciplinary team.Code status orders will be renewed by physician's review and signature on monthly orders. Code status physician's order (DNR or Full Code), state specific forms and/or resident preference documentation will be filed as the first item within the medical record.Social Services will be notified if resident has any general questions and concerns about advance directives.The facility does not provide Advanced Life Support.ON ADMISSIONStaff will verify the presence of Advance Directive documents and confirm resident or resident representative wishes with regard to CPR. The resident will be considered full code unless the resident/representative wishes to change their decision.1. Obtain Advance Directive decision making documents at the time of admission. If not available at time of admission, request the resident representative to bring copies to the facility as soon as possible.2. Discuss code status preference with the resident/resident representative.3. Document resident/resident representative preferences in the medical record. If the resident's wishes are different than the admission orders, or if the orders do not address the code status, and the resident does not want to receive CPR, staff will document resident's wishes in the record and contact the physician to obtain the order.4. Notify physician if the resident/resident representative preference is changed, obtain order. In the event that the physician is not available the medical director may be contacted for the order.5. While awaiting the physician's order to withhold CPR, facility staff should document discussions with the resident or resident representative, including the resident's wishes to refuse CPR. If the resident or resident representative verbalizes the wish not to receive CPR two staff members will witness and document this request, the conversation of the request will be printed and placed as the first document of the medical record.a. While the physician's order is pending, staff will honor the documented verbal wishes of the resident or the resident's representative, regarding CPR.Changing code status/while awaiting physician's order:The resident and/or resident representative may change the code status at any time. The staff must notify the MD, describe the requested change and request an order for the DNR or Full Code status to execute the change.The resident wishes will be communicated verbally shift to shift, both witnesses must document conversation in the in the medical record, print and placed as the first document of the medical record.The facility's immediate actions to remove the Immediate Jeopardy included: -On [DATE] a house wide audit was completed verifying advanced directives and two identified variances were corrected. One code status was updated in the medical record, and it is clear to staff of the resident wishes and one next of kin validated the resident's advance directives with a signature on [DATE].-Regional Nurse Consultant provided education to 100% of the clinical management team related to Advanced Directives on [DATE].-Licensed Nurses were educated by the Director of Nursing and the facility clinical administration team related to Advanced Directives, reviewing AD/CS orders, process for completing a DNR order and honoring a resident choice, code blue process and placement of code status in resident hard chart at 97% by [DATE].-The Regional [NAME] President completed the Essential Core Functions: Resident care and Quality of Life, Human Resources, Physical Environment and Atmosphere and Leadership and Management with the Nursing Home Administrator on [DATE].-The Director of Risk Management completed the Essential Core Functions: Resident Care and Quality of Life, Human Resources, Physical Environment and Atmosphere and Leadership and Management with the Director of Nursing on [DATE].-Code Blue drills started on [DATE] and completed on [DATE] each shift.-ADHOC Quality Assurance meeting was conducted today [DATE] to review the removal plan including the medical director.Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with forty-three nurses and CNAs who worked various shifts, the Director of Nursing, the Assistant Director of Nursing, the Nursing Home Administrator, and the Social Services team. The staff members were able to state that they had been trained and were knowledgeable about the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff had acknowledged education and training related to procedures for residents' code status, code drills, and advanced directives process. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of E.

Based on record review, review of facility's policies and procedures, resident and staff interviews, the facility failed to protect the residents' rights to be free from neglect. The facility failed to ensure timely evaluation of resident's condition, and immediate physician notification in the presence of an acute change in condition to avoid physical harm for 1 (Resident #98) of 4 residents reviewed for coordination of care. Resident #98 had a diagnosis of Atrial Fibrillation (Type of irregular heartbeat) with long term use of anticoagulant (blood thinner) medication with a potential side effect of bleeding. On 8/28/23 Resident #98 underwent multiple dental extractions, arranged by the facility. The facility had no documentation of coordination with the dentist and medical practitioners related to the use of the blood thinner before and after the dental extractions, and no documentation of timely evaluation and physician notification when Resident #98 experienced significant bleeding from the extraction sites upon return to the facility. On 8/28/23 at approximately 5:30 p.m., Resident #98 was transferred to the hospital with uncontrollable bleeding of the gums status post dental extractions. Resident #98 was critically ill, required a blood transfusion and was admitted to the Intensive Care Unit. The failure of the facility's staff to prevent neglect resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 8/28/23. On 2/2/24 at 5:00 p.m., the Administrator was informed of the determination of Immediate Jeopardy and provided the IJ templates. The findings included: Cross reference F684, F835, and F867. The facility's abuse Prevention Program Policy and Procedure with a review date of August 2022 noted neglect is, Failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The policy noted the Administrator, DON or designee are responsible for the investigation and reporting of suspected neglect. The Administrator, DON and/or designated individual are responsible for the following: Implementation, ongoing monitoring, investigation, reporting, and tracking and trending. The investigation for Neglect includes initiating an Event Report. The Administrator or designee is notified and will initiate and conclude a complete and thorough investigation within the specified timeframe. The facility will follow Federal regulations and State specific reporting requirements. The resident's physician is notified. Resident #98 was a long term resident of the facility with a reentry date of 9/8/22. Resident #98's diagnoses included Atrial Fibrillation (type of irregular heartbeat). Resident #98's medication regimen included Apixaban (Eliquis) (blood thinner) 5 milligrams (mg) twice a day. The manufacturer's insert for Eliquis noted under warning and precautions, Bleeding. Eliquis increases the risk of bleeding and can cause serious, potentially fatal, bleeding, and adverse reactions . Get medical help right away if you have any of these signs or symptoms of bleeding when taking Eliquis: . Unexpected bleeding, or bleeding that lasts a long time, such as: Unusual bleeding from the gums . Bleeding that is severe or you cannot control . Review of the care plan revised on 7/18/22 noted Resident #98 was at risk of complications from anticoagulant for Atrial Fibrillation. The interventions included to observe for abnormal bleeding, including bleeding gums when teeth are brushed. If the resident develops minor bleeding (for example a nosebleed or bleeding from the gums that stops within a few minutes) notify the physician. On 7/24/23 at 11:33 a.m., Social Service Director Staff H documented in a progress note she contacted a local dentist's office and arranged a dental appointment for 8/7/23 for Resident #98. The note read, Resident was noted to verbalize the need for appointment due to loose and broken teeth . SW (Social Worker) also provided appointment time and location to charge nurse . Review of the facility's appointment log showed Resident #98 had scheduled appointments with a local dentist on 8/7/23 and 8/28/23. The clinical record lacked documentation the facility followed up with the dentist after the appointment of 8/7/23. There was no documentation that the facility notified the physician of the upcoming 8/28/23 dental appointment for the multiple extractions. Review of the Medication Administration Record revealed the nurse administered the scheduled dose of apixaban on 8/28/23 at 9:00 a.m., to Resident #98 prior to the dentist appointment for the multiple extractions. The clinical record lacked documentation the physician was notified and approved the administration of the blood thinner on the day of the extractions. On 8/28/23 at 3:53 p.m., a nursing progress noted documented, Resident came back from the Dentist Appointment with no hard copies, but order was transferred to [pharmacy name] by the dentist Nurse. The clinical record lacked documentation of a nursing evaluation upon Resident #98's return from the dentist after the multiple extractions. Review of the Medication Administration Record (MAR) showed documentation the nurse administered the scheduled dose of Apixaban 5 mg to the resident on 8/28/23 at 5:00 p.m. On 8/28/23 at 5:37 p.m., a nursing progress note documented, Resident continues to have moderate bleeding of the gum and c/o [complain of] feeling dizzy. PA [Physician Assistant] notified with order to send resident to the ER [Emergency Room] for eval [evaluation]. On 1/30/24 at 11:37 a.m., Resident #98 said he had multiple dental extractions in August 2023. They were supposed to hold the blood thinner for a week but did not. Resident #98 said he ended up in the hospital due to uncontrolled bleeding. On 1/30/24 at 4:59 p.m., Social Service Director Staff H said Resident #98 had decay and more than a few teeth to be removed. She verified the lack of documentation, or any paperwork in the clinical record related to coordination with the dentist and the physician related to the use of blood thinner before and after the scheduled dental extractions. On 1/31/24 at 9:19 a.m., in an interview Unit Manager Registered Nurse (RN) Staff D said Social Service Director Staff H was now trying to see why they did not give the order to hold the Eliquis. He said they normally get a clearance from the physician for anyone going to have a procedure. The dentist is supposed to send the paperwork. The physician signs the clearance, and they fax it over to the dentist. On 1/31/24 at 9:47 a.m., in an interview, the Physician Assistant (PA) said he was not aware Resident #98 was having the extractions and did not fill out any forms prior to the extractions. He became aware of the incident when he gave the authorization to send Resident #98 to the hospital when he returned from the dental appointment and was bleeding. On 1/31/24 at 2:07 p.m., in an interview Resident #98 said the morning of the extractions the nurse gave him the blood thinner. He mentioned getting his teeth pulled and thought he should not take the blood thinner. The nurse just told him to take his pills and that is what he did. On 1/31/24 at 4:52 p.m., in an interview the Medical Director said he was not aware Resident #98 was having nine teeth extracted and it was not really discussed. He said he thought there was a good process in place, but some will fall through the cracks. On 2/1/24 at 9:23 a.m., the DON said Resident #98 told Licensed Practical Nurse (LPN) Staff I he was having the dental extractions. She said the facility had no policy addressing outside medical practitioners however she expected the nurse to contact the consulting physician if the resident came back without any documentation from the appointment. The DON verified the lack of documentation Resident #98 was evaluated upon return to the facility after the extractions to promptly address any complication, including bleeding from the extraction sites. On 2/2/24 at 9:06 a.m., in a telephone interview Licensed Practical Nurse (LPN) Staff I said on 8/28/23 she worked the morning shift, did not know Resident #98 was scheduled for dental extractions and administered the Eliquis (Apixaban) at 9:00 a.m., as ordered. She could not recall when Resident #98 returned to the facility. LPN Staff I said, he was doing fine and there was not a lot of blood from the mouth. She said she took the resident's vital signs (Temperature, pulse, respiration, and blood pressure) upon his return to the facility but could not remember what they were or where they documented the vital signs. She verified the lack of documentation she evaluated Resident #98 upon his return. On 2/2/24 at 1:00 p.m., in a telephone interview, Registered Nurse (RN) Staff J said when she came on duty on 8/28/23 at 3:00 p.m., the morning nurse (LPN Staff I) gave her report and left. She did not tell her Resident #98 had the extractions. When she made rounds at 3:00 p.m., Resident #98 was already in the room and was bleeding. She said there was blood everywhere, on the resident's shirt, and his bed. There was blood on the resident's face, he was spitting blood out. RN Staff J said she took the resident's vital signs but could not remember what they were or where she documented them. RN Staff J said she did not immediately call the physician but called the Unit Manager. That's when the Unit Manager told her Resident #98 had his teeth pulled out that day. She said she did not administer the Eliquis on 8/28/23 at 5:00 p.m., despite the documentation on the MAR. The clinical record lacked documentation RN Staff J immediately notified the physician of the significant oral bleeding upon the resident's return to the facility. Review of the Emergency Medical Services (EMS) report showed on 8/28/23 at 5:30 p.m., (approximately two and a half hour after Resident #98 returned to the facility), they received a call and responded to the facility for a hemorrhage. The report noted staff stated the resident had multiple teeth pulled today and has bleeding since. The primary impression was hemorrhage and the chief complaint Hemorrhage from dental work. Pt (patient) takes Eliquis, which was not paused for the dental work. Assessment shows a steady flow of blood from the gums . Review of the hospital record revealed a progress note dated 8/28/23 that read Resident #98 presented to the Emergency Department, for persistent oral bleeding s/p [status post] multiple dental extractions. He has consistent oral bleeding since surgery. Currently feels lightheaded and weak. He received 1 unit of PRBC (packed red blood cells) and LR (Lactated Ringers used to replace water and electrolyte loss in patients with low blood volume or low blood pressure) 1L(liter) prior to his CBC (Complete Blood Count). Oral packing changed every 30 minutes to control the bleeding . Bleeding currently mildly improved to oozing. Estimated loss was around 500 ml (milliliters). Oral cavity hemorrhage s/p multiple dental extractions in the setting of chronic anticoagulation . Hold Eliquis in setting of acute bleed . Patient is critically ill requiring ICU (Intensive Care Unit) admission . After verification of implementation of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/2/24. The Immediate actions implemented by the facility and verified by the survey team included: 1. Nurse identified in the IJ was immediately suspended pending the outcome of the investigation and the Federal Immediate Report for the allegation of neglect was submitted. Completed 2/2/24. On 2/2/24, the survey team verified through record review and interview with the Administrator. 2. The Risk Management Consultant completed a 30 day look back of residents with external appointments as well as internal podiatry & dental appointments who are also taking anticoagulants and no concerns or adverse incidents were identified. Additionally, the Risk Management Consultant completed a review of residents currently taking anticoagulants who have upcoming external appointments as well as internal podiatry & dental service appointments and their providers were notified of the residents' anticoagulant status. Completed 2/2/24. On 2/2/24 the survey team verified through record review and interview with the Administrator and Director of Nursing. 3. Resident evaluated, remains in the facility with no change in condition or signs of distress. On 2/2/24 the survey team verified through record review. 4. The Risk Management consultant completed education to the Administrator, Director of Nursing and Interdisciplinary Team on the following topics: a. The facility's Abuse, Neglect and Exploitation Prevention Program with a focus on the prevention of neglect. Completed 2/1/24. b. Event Management process to ensure root cause is established for events and interventions implemented are based on the root cause. Completed 2/1/24. On 2/2/24, the survey team verified through review of the completed education, and interview with the Administrator, and the Director of Nursing. They both were able to verbalize understanding of the content of the education provided. 5. The facility Director of Nursing, Staff Development Coordinator and Assistant Director of Nursing conducted education on the facility's Abuse, Neglect and Exploitation Prevention Program. Facility staff education currently at 96% to total and all remaining staff will be removed from the schedule until education occurs. On 2/2/24 the survey team interviewed six Licensed Nurses on the North and South Units. All six Licensed Nurses interviewed were able to verbalize the facility's abuse, neglect, and exploitation prevention program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement processes to ensure effective coordination between staff, physicians, and outside medical providers in accordance to professional standards of care to meet the needs of 4 (Residents #98, #9, #99, and #110) of 4 residents reviewed. Resident #98 had a diagnosis of Atrial Fibrillation (Type of irregular heartbeat) with long term use of anticoagulant (blood thinner) medication with a potential side effect of bleeding. The facility arranged an appointment for multiple dental extractions for Resident #98. The facility did not ensure coordination between facility staff, the dentist, or the attending physician related to the use of anticoagulant (Eliquis) before and after the dental extractions. On 8/28/23 Resident #98 underwent nine extractions and returned to the facility around 3:00 p.m. There was no documentation Resident #98 was evaluated upon return to the facility. On 8/28/23 at approximately 5:25 p.m., Resident #98 was transferred to the hospital with uncontrollable bleeding of the gums status post (s/p) dental extractions. Resident #98 was critically ill, required a blood transfusion and was admitted to the Intensive Care Unit. The facility failure to develop and implement resident care policies to ensure ongoing collaboration and communication processes resulted in noncompliance at the Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 8/28/23. On 2/2/24 at 5:00 p.m., the Administrator was notified of the determination of Immediate Jeopardy and provided the IJ templates. There were 38 residents receiving anticoagulant medications. The findings included: Cross reference F600, F835, and F867. 1. The facility's policy and procedure for referral services with an effective date of February 2021 noted, . The Director of Social Services or designee works with the interdisciplinary team to identify needs, evaluate resources, and coordinate community resources to meet the needs of the resident . Referral services may include, but are not limited to Dental Services . Follow up on the referrals to community services as appropriate and document the outcome of referrals in the resident/patient chart . Resident #98 had a reentry date of 9/8/22. Diagnoses included Atrial Fibrillation, anxiety disorder, and depression. Resident #98's medication regimen included Apixaban (Eliquis) (blood thinner) 5 milligrams (mg) twice a day. The manufacturer's insert for Eliquis noted under warning and precautions, Bleeding. Eliquis increases the risk of bleeding and can cause serious, potentially fatal, bleeding, and adverse reactions . Get medical help right away if you have any of these signs or symptoms of bleeding when taking Eliquis: . Unexpected bleeding, or bleeding that lasts a long time, such as: Unusual bleeding from the gums . Bleeding that is severe or you cannot control . counseling information . To tell their physicians and dentists they are taking Eliquis, and/or any other product known to affect bleeding . before any surgery or medical or dental procedure is scheduled . Review of the care plan revised on 7/18/22 noted Resident #98 was at risk of complications from anticoagulant for Atrial Fibrillation. The interventions included to observe for abnormal bleeding, including bleeding gums when teeth are brushed. If the resident develop minor bleeding (for example a nosebleed or bleeding from the gums that stops within a few minutes) notify the physician. The care plan did not include coordination with the physician or dentist to address the use of the blood thinner (anticoagulant) before any surgery, medical or dental procedure is scheduled. On 7/24/23 at 11:33 a.m., Social Service Director Staff H documented in a progress note she contacted a local dentist's office and arranged a dental appointment for 8/7/23 for Resident #98. The note read, Resident was noted to verbalize the need for appointment due to loose and broken teeth . SW (Social Worker) also provided appointment time and location to charge nurse . The clinical record lacked documentation of the outcome of dentist's visit for 8/7/23. The facility's appointment log showed Resident #98 had a second dental appointment scheduled for 8/28/23. The clinical record lacked documentation of the reason for the dental appointment, or coordination with the dentist and the physician to address the use of the blood thinner in the event Resident #98 required a dental procedure such as an extraction. On 8/28/23 at 3:53 p.m., a nursing progress noted documented, Resident came back from the Dentist Appointment with no hard copies, but order was transferred to [pharmacy name] by the dentist Nurse. The clinical record lacked documentation of a nursing evaluation upon Resident #98's return from the dentist. On 8/28/23 at 5:37 p.m., a nursing progress note documented, Resident continues to have moderate bleeding of the gum and c/o [complain of] feeling dizzy. PA [Physician Assistant] notified with order to send resident to the ER [Emergency Room] for eval [evaluation]. Review of the hospital record revealed a progress note dated 8/28/23 that read Resident #98 presented to the Emergency Department, for persistent oral bleeding s/p multiple dental extractions . He has consistent oral bleeding since surgery . Currently feels lightheaded and weak . He received 1 unit of PRBC (packed red blood cells) and LR (Lactated Ringers) 1L(liter) prior to his CBC (Complete Blood Count) . Oral packing changed every 30 minutes to control the bleeding . Bleeding currently mildly improved to oozing. Estimated loss was around 500 ml (milliliters) . Oral cavity hemorrhage s/p multiple dental extractions in the setting of chronic anticoagulation . Hold Eliquis in setting of acute bleed . Patient is critically ill requiring ICU (Intensive Care Unit) admission . On 1/30/24 at 11:37 a.m., Resident #98 said he had multiple dental extractions in August 2023. They were supposed to hold the blood thinner for a week but did not. Resident #98 said he ended up in the hospital due to uncontrolled bleeding. On 1/30/24 at 4:59 p.m., Social Service Director Staff H said Resident #98 had decay and more than a few teeth to be removed. She verified the lack of documentation in the clinical record of coordination with the dentist and medical practitioners (Physician, Physician Assistant, Advanced Practice Registered Nurse) related to the use of blood thinner before and after the scheduled dental extractions. On 1/31/24 at 9:19 a.m., in an interview Unit Manager Registered Nurse (RN) Staff D said they normally get a clearance from the physician for anyone going to have a procedure. The physician signs the clearance, and they fax it over to the dentist. The Unit Manager verified the lack of documentation Resident #98's physician was notified of the multiple dental extractions and cleared the resident for the dental procedure. On 1/31/24 at 9:47 a.m., in an interview, the Physician Assistant (PA) said he was not aware Resident #98 was having the extractions and did not fill out any forms prior to the extractions. He became aware of the incident when he gave the authorization to send Resident #98 to the hospital when he returned from the dental appointment and was bleeding. In collaboration with the dentist, they determine whether to hold the blood thinner. He said if the cardiologist saw him, the cardiologist would have done the clearance, especially for advanced procedures. Review of the progress notes showed on 8/24/23 the Advanced Practice Registered Nurse (APRN) documented in a follow up cardiology note, Patient is somewhat a limited historian, therefore most information regarding past cardiac medical history has been gained from available records at facility . Patient was previously maintained on coumadin (blood thinner) prior to a hospital admission in 2022, when he developed a severe upper GIB (Gastrointestinal bleed). He was transitioned off coumadin (anticoagulant) to Eliquis . There was no documentation the facility informed the APRN of the upcoming appointment for the multiple extractions scheduled for 8/28/23. On 1/31/24 at 1:45 p.m., the Regional Nurse Consultant said they completed an incident report when Resident #98 was transferred to the hospital. She said they were following the physician's orders. The Regional Nurse Consultant said she realized Resident #98 was sent out to the hospital and received the packed cells (blood transfusion) but, really it all turned out well for the resident. He was back in less than 36 hours. On 1/31/24 at 2:07 p.m., Resident #98 said the morning of the extractions the nurse gave him all his pills, including the blood thinner. He mentioned getting the teeth pulled and thought he should not take the blood thinner. The nurse just told him to take his pills and that is what he did. He said he was at the dentist for a while, they drilled and pulled and drilled and pulled. He said they pulled all of his teeth, and he needed stitches after the extractions. On 1/31/24 at 3:01 p.m., in a telephone interview, a representative of the dental office said there was no medical clearance, or a complete medication list in the chart of Resident #98 for the dental extractions done on 8/28/23. On 1/31/24 at 4:52 p.m., in an interview the Medical Director said he was not aware Resident #98 was having nine teeth extracted and it was not really discussed. He said he thought there was a good process in place, but some will fall through the cracks. The Medical Director said it would be good to know of any type of procedures in high risk patients. He said he would not have stopped the Eliquis due to the risk of a cerebrovascular accident if the blood thinner is stopped. On 2/1/14 at 8:55 a.m., during a joint interview with the Director of Nursing (DON), and the Administrator, the DON said Resident #98 specifically told the Social Service Director he was going to have teeth removed. The Administrator said the Social Service Director arranged the dental services. The DON verified the lack of documentation of coordination with the dentist and the attending physician prior to the dental extractions. On 2/1/24 at 9:06 a.m., in an interview Social Service Director Staff H said at the end of July, Resident #98 came to her and said he wanted some teeth extracted. He said he had broken teeth and wanted to be seen by a dentist. She said she made the initial appointment on 8/7/23. She said the facility did not receive any paperwork from the dentist. She verified the lack of documentation the facility followed up on the dental appointment on 8/7/23 or coordination with the dentist for the upcoming 8/28/23 appointment for the multiple dental extractions. On 2/1/24 at 9:23 a.m., the DON said Resident #98 was not really able to take care of himself. She said on 8/28/23 Resident #98 told Licensed Practical Nurse (LPN) Staff I he was having the dental extractions. She said when residents go out for appointments, the physician may not be aware of procedures done such as a wound debridement (Removal of dead tissue) prior to the appointment. She said the facility had no policy addressing outside medical providers however she expected the nurse to contact the consulting physician if the resident came back without any documentation from the appointment. On 2/1/24 at 9:35 a.m., the DON said Resident #98 was sent out within two hours of coming back from the dental appointment. The DON said the facility did not think the incident represented a safety risk and did not put anything in place other than what they currently do for outside medical providers' appointments. On 2/2/24 at 9:06 a.m., in a telephone interview Licensed Practical Nurse (LPN) Staff I said she did not know Resident #98 was scheduled for dental extractions, and on 8/28/23 at 9:00 a.m., she administered the Eliquis as ordered. She could not recall when Resident #98 returned to the facility and verified the lack of documentation she evaluated Resident #98 upon his return. LPN Staff I said, he was doing fine and there was not a lot of blood from the mouth. Review of the Medication Administration Record (MAR) showed on 8/28/23 at 5:00 p.m., Registered Nurse (RN) Staff J documented she administered the scheduled dose of Apixaban (Eliquis) 5 milligrams to Resident #98. On 2/2/24 at 1:00 p.m., in a telephone interview, RN Staff J said when she came on duty on 8/28/23 at 3:00 p.m., the morning nurse (LPN Staff I) gave her report and left. She did not tell her Resident #98 had the extractions. When she made rounds at 3:00 p.m., Resident #98 was already in the room and was bleeding. She said there was blood everywhere, on the resident's shirt, and his bed. There was blood on the resident's face, he was spitting blood out. She said she called Unit Manager RN Staff D and informed him the resident refused to get changed. That's when the Unit Manager told her Resident #98 had his teeth pulled out that day. RN Staff J said the anticoagulant should have been held the week prior to the extractions and it wasn't. She verified she did not document her evaluation. RN Staff J said she took the resident's vital signs (Temperature, pulse, respiration, and blood pressure) but could not remember what they were or where she documented them. She said she did not administer the Eliquis on 8/28/23 at 5:00 p.m., despite the documentation on the MAR. The clinical record lacked documentation the physician was immediately notified of the significant oral bleeding upon the resident's return to the facility. Review of the Emergency Medical Services (EMS) report showed on 8/28/23 at 5:30 p.m., they received a call and responded to the facility for a hemorrhage. The report noted staff stated the resident had multiple teeth pulled today and has bleeding since. The primary impression was hemorrhage and the chief complaint Hemorrhage from dental work. Pt (patient) takes Eliquis, which was not paused for the dental work. Assessment shows a steady flow of blood from the gums . 2. On 2/1/24 review of Resident #9's medical record revealed a re-admission date of 12/05/23 with diagnoses of secondary Parkinsonism, unspecified dementia, dysphagia, cognitive communication deficit, psoriasis, chronic kidney disease and adult failure to thrive. On 12/14/23 a consent for hospice services was signed by the primary caregiver and hospice staff representative. Review of Resident #9's medical record revealed a Physician's Order, dated 12/18/23, for Terminal Diagnosis: The resident is diagnosed with a terminal condition and is at risk for loss of dignity during dying process related to the terminal diagnosis of Parkinson's disease. Review of Resident #9's plan of care for nutrition, Parkinson's disease, discharge planning, cognition, advance directives, activity of daily living, and wound risk revealed the care plans were updated and revised on 12/15/23. The care plans stated the facility would collaborate care with Hospice. On 12/18/23 an invitation to the Care Plan meeting was extended to the Hospice representative. The attendees sign-in sheet for the care plan meeting noted that Hospice had been invited to the meeting, but the Hospice representative did not attend the Care Plan meeting. Review of Resident #9's medical record revealed it did not contain a record of the Hospice plan of care for Resident #9 and/or documentation related to the collaboration of care between Hospice services and the facility in the development of Resident #9's plan of care. 3. On 2/1/24 review of Resident #99's medical record revealed a re-admission date of 12/07/23 with a primary diagnosis of cerebral infarction to thrombosis of right cerebral artery, hemiplegia affecting left side, contracture of right and left knees, dysphagia, and adult failure to thrive. Review of Resident #99's Physician's Order, revealed an order dated 12/11/23 for Terminal Diagnosis: The resident is diagnosed with a terminal condition and is at risk for loss of dignity during dying process related to the Terminal diagnosis of: CVA (cardiovascular accident). Review of Resident #99's plan of care for nutrition, dental, discharge planning, cognition, advance directives, activity of daily living, and pain care plans were updated and revised on 12/15/23. The care plans stated the facility would collaborate care with Hospice. On 12/26/23, an invitation to the Care Plan meeting was extended to the Hospice representative. The attendees sign-in sheet for the Care Plan meeting noted it stated that Hospice was invited to the meeting, but the Hospice representative did not attend the care plan meeting. Review of Resident #99's medical record revealed it did not contain a record of the Hospice plan of care for Resident #99 and/or documentation related to the collaboration of care between Hospice services and the facility in the development of Resident #99's plan of care. On 2/1/24 at 5:09 p.m., during an interview with the Clinical Reimbursement Director (CRD), she said she was responsible for the development and creation of each resident's plan of care while at the facility. She said Resident #9 had a Physician's Order for Hospice services dated 12/18/23 and Resident #99 had a Physician's Order for Hospice services on 12/11/23. She confirmed both Residents #9 and #99 plan of care stated the facility and Hospice would collaborate in the development of each resident's plan of care. She further stated neither medical record had a copy of each resident's plan of care developed by Hospice services. She said the Hospice representatives were invited to Resident #9 and #99's plan of care meetings but did not attend their Care Plan meetings. She further said the facility did not have documentation the facility and Hospice had collaborated in the development and implementation of Resident #9 and #99's Care Plans to ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 4. Review of the clinical record revealed Resident's #110 was admitted to the facility on [DATE]. Diagnoses included Congestive Heart Failure, muscle wasting and atrophy. The physician's order as of 1/9/24 included to monitor the blood sugar four times a day via fingerstick, before meals and at bedtime. The physician's order did not include parameters for physician notification for the blood sugar. The admission Minimum Data Set (MDS) assessment with a target date of 1/11/24 did not list a diagnosis for the blood sugar monitoring. The hospital Discharge summary dated [DATE] did not list a diabetic medication. Resident #110's diet was for a regular mechanical soft diet. On 2/2/23 at 10:38 a.m., in an interview the MDS Coordinator said, I don't see a diagnosis of Diabetes. The resident is not on steroids, which can elevate blood sugar levels. She is not on insulin or on a hypoglycemic agent. On 2/2/24 at 11:05 a.m., in an interview the Physician Assistant (PA) he said he would have to look into it. On 2/2/24 at 11:41 a.m., in an interview, the PA said, we will stop the Accu Checks (finger sticks) for now. He said he would order blood test used to diagnose Diabetes and decide when he gets the results. On 2/2/24 at 1:10 p.m., in an interview Resident #110 said she did not know why they started doing the finger sticks to monitor her blood sugar. She said they just told her they had to do it. She said the doctor came in earlier, stopped the finger sticks and said he would order some lab work. On 2/2/24 at 4:50 p.m., in an interview Resident #110's spouse said he did not know why they were doing the finger sticks. He said his spouse has never had an issue with her blood sugar. After verification of implementation of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/2/24. The immediate actions implemented by the facility and verified by the survey team included: The nurse involved in the IJ was immediately suspended pending the outcome of the investigation and the Federal Immediate Report for the allegation of neglect was submitted. The survey team verified through record review and interview with the Administrator. Resident evaluated, remains in the facility with no change in condition or signs of distress. On 2/2/24 the survey team verified through observation and interview with Resident #98. The Risk Management Consultant completed a 30 day look back of residents with external appointments as well as internal podiatry and dental appointments who are also taking anticoagulants and no concerns or adverse incidents were identified. On 2/2/24 the survey team verified through review of the completed look back of residents with external appointments, as well as internal podiatry and dental appointments. Additionally, the Risk Management Consultant completed a review of residents currently taking anticoagulants who have upcoming external appointments as well as internal podiatry and dental service appointments and their providers were notified of the residents' anticoagulant status. On 2/2/24 the survey team verified through review of documentation the physicians were notified of the current residents taking anticoagulants who have upcoming external appointments as well as internal podiatry and dental services appointments. The Risk Management consultant completed education to the Director of Nursing, Staff Development Coordinator, and Assistant Director of Nursing on the following topics: a. Anticoagulant therapy including monitoring for side effects. Completed 2/1/24. b. Ensure communication with medical provider prior to procedures if resident is taking anticoagulents. Completed 2/1/24. c. Ensuring follow-up documentation is received and addressed following external appointments and coordination of care to meet the resident's physical, mental, and psychosocial needs. Completed 2/1/24. The survey team verified through record review of the education, and interview with the Director of Nursing, and Assistant Director of Nursing. The facility DON, Staff Development Coordinator, and Assistant Director of Nursing (ADON) educated all licensed nurses on the following topics: a. Anticoagulant therapy, including monitoring for signs and symptoms of side effects. Completed 2/1/24. b. Ensure communication with medical provider prior to procedures if resident is taking anticoagulents. Completed 2/1/24. c. Ensure follow-up documentation is received and addressed following external appointments and coordination of care to meet the resident's physical, mental, and psychosocial needs. Completed 2/1/24. On 2/2/24 the survey team interviewed six Licensed Nurses on the North and South Units. All six Licensed Nurses interviewed were able to verbalize anticoagulent therapy monitoring for signs and symptoms of side effects. All six Licensed Nurses were able to verbalize the process for timely evaluation of residents, appropriate interventions, and notification of physician to meet each resident's needs. The Risk Management consultant educated the facility Social Services Director on the coordination of care, following up with internal and external referrals to ensure documentation is reviewed and assessed to meet the resident's physical, mental, and psychosocial needs. Completed 2/2/24. On 2/2/24 the survey team verified through review of the education, interview with the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and the Social Services Director.

Based on record review, resident and staff interview the facility administration failed to use its resources effectively to protect residents' rights to be free from neglect, in that they failed to show effective coordination of care to ensure 1 (Resident #98) of 4 sampled residents received care and services in accordance with professional standards of care. Resident #98 had a diagnosis of Atrial Fibrillation (abnormal heart rhythm) with long term use of anticoagulant (blood thinner) medication. On 8/28/23 Resident #98 underwent multiple dental extractions, arranged by the facility. There was no documentation of coordination with the dentist and the physician related to the use of the blood thinner before and after the dental extractions. On 8/28/23 at approximately 5:25 p.m., Resident #98 was transferred to the hospital with uncontrollable bleeding of the gums status post dental extractions. Resident #98 was critically ill, required a blood transfusion and was admitted to the Intensive Care Unit. The failure of the facility's administration to prevent neglect and ensure timely assessment of the resident and coordination of care with the physicians resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 8/28/23. The Administrator was notified of the Immediate Jeopardy on 2/2/24 at 5:00 p.m. and provided the IJ templates. The findings included: Cross reference F600, F684, and F867. Review of the Nursing Home Administrator's job description signed and dated 8/11/23 showed the essential duties and responsibilities included, Enacts, implements, and enforces the facility policies regarding the management and operation of the facility. Analyzes . quality of care, compliance, regulatory and other management reports to determine the appropriate management interventions needed then implements the interventions resulting in improved outcomes . Identifies facility needs or issues and obtains consulting assistance, as needed, in the root-cause analysis, recommendation for improvement, education assistance or monitoring . Review of the Director of Nursing's job description signed and dated 10/9/20 noted, The Director of Nursing is responsible for developing, organizing, evaluating, and administering patient care programs and services of the Center. Has twenty four (24) hour responsibility for overall delivery of nursing services and ensures the implementation of all clinical policies and procedures . Accountable for adherence by staff to policies, procedures, and standards; delivery and proper documentation of patient care . Supervises nursing staff whether directly or indirectly in accordance with company policies and procedures . The facility's abuse Prevention Program Policy and Procedure with a review date of August 2022 noted neglect is, Failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The facility's policy and procedure for referral services with an effective date of February 2021 noted, . The Director of Social Services or designee works with the interdisciplinary team to identify needs, evaluate resources, and coordinate community resources to meet the needs of the resident . Referral services may include, but are not limited to Dental Services . Follow up on the referrals to community services as appropriate and document the outcome of referrals in the resident/patient chart . Resident #98 was a long term vulnerable resident of the facility with a reentry date of 9/8/22. Resident #98's diagnoses included Atrial Fibrillation (type of irregular heartbeat). Resident #98's medication regimen included Apixaban (Eliquis) (blood thinner) 5 milligrams (mg) twice a day. The manufacturer's insert for Eliquis noted under warning and precautions, Bleeding. Eliquis increases the risk of bleeding and can cause serious, potentially fatal, bleeding, and adverse reactions . Get medical help right away if you have any of these signs or symptoms of bleeding when taking Eliquis: . Unexpected bleeding, or bleeding that lasts a long time, such as: Unusual bleeding from the gums . Bleeding that is severe or you cannot control . Review of the care plan revised on 7/18/22 noted Resident #98 was at risk of complications from anticoagulant for Atrial Fibrillation. The interventions included to observe for abnormal bleeding, including bleeding gums when teeth are brushed. If the resident develop minor bleeding (for example a nosebleed or bleeding from the gums that stops within a few minutes) notify the physician. The care plan did not include coordination with the physician or outside providers to address the use of the blood thinner (anticoagulant) before any invasive procedure. Review of the facility's appointment log showed Resident #98 had scheduled appointments with a local dentist on 8/7/23 and 8/28/23. On 7/24/23 at 11:33 a.m., Social Service Director Staff H documented in a progress note she contacted a local dentist's office and arranged a dental appointment for 8/7/23 for Resident #98. The note read, Resident was noted to verbalize the need for appointment due to loose and broken teeth . SW (Social Worker) also provided appointment time and location to charge nurse . The clinical record lacked documentation of follow up on the 8/7/23 visit to the dentist, follow up care needed, and the scheduled 8/28/23 appointment for multiple dental extractions. The clinical record lacked documentation of coordination with the dentist, or the attending physician related to the use of the blood thinner before and after the scheduled dental extractions. On 8/28/23 at 3:53 p.m., a nursing progress noted documented, Resident came back from the Dentist Appointment with no hard copies, but order was transferred to [pharmacy name] by the dentist Nurse. The clinical record lacked documentation of a nursing evaluation upon Resident #98's return from the dentist. On 8/28/23 at 5:37 p.m., a nursing progress note documented, Resident continues to have moderate bleeding of the gum and c/o [complain of] feeling dizzy. PA [Physician Assistant] notified with order to send resident to the ER [Emergency Room] for eval [evaluation]. Review of the hospital record revealed a progress note dated 8/28/23 that read Resident #98 presented to the Emergency Department, for persistent oral bleeding s/p multiple dental extractions. He has consistent oral bleeding since surgery. Currently feels lightheaded and weak. He received 1 unit of PRBC (packed red blood cells) and LR (Lactated Ringers used to replace water and electrolyte loss in patients with low blood volume or low blood pressue) 1L(liter) prior to his CBC (Complete Blood Count). Oral packing changed every 30 minutes to control the bleeding . Bleeding currently mildly improved to oozing. Estimated loss was around 500 ml (milliliters). Oral cavity hemorrhage s/p (status post) multiple dental extractions in the setting of chronic anticoagulation . Hold Eliquis in setting of acute bleed . Patient is critically ill requiring ICU (Intensive Care Unit) admission. On 1/30/24 at 11:37 a.m., Resident #98 said he had multiple dental extractions in August 2023. They were supposed to hold the blood thinner for a week but did not. Resident #98 said he ended up in the hospital due to uncontrolled bleeding. On 1/30/24 at 4:59 p.m., Social Service Director Staff H said Resident #98 had decay and more than a few teeth to be removed. She verified the lack of documentation, or any paperwork in the clinical record related to coordination with the dentist and the physician related to the use of blood thinner before and after the scheduled dental extractions. On 1/31/24 at 9:19 a.m., in an interview Unit Manager Registered Nurse (RN) Staff D said Social Service Director Staff H was now trying to see why they did not give the order to hold the Eliquis. He said they normally get a clearance from the physician for anyone going to have a procedure. The dentist is supposed to send the paperwork. The physician signs the clearance, and they fax it over to the dentist. On 1/31/24 at 9:47 a.m., in an interview, the Physician Assistant (PA) said he was not aware Resident #98 was having the extractions and did not fill out any forms prior to the extractions. He became aware of the incident when he gave the authorization to send Resident #98 to the hospital when he returned from the dental appointment and was bleeding. On 1/31/24 at 1:45 p.m., the Regional Nurse Consultant said they completed an incident report when Resident #98 was transferred to the hospital. She said they were following the physician's orders. The Regional Nurse Consultant said she realized Resident #98 was sent out to the hospital and received the packed cells (blood transfusion) but, really it all turned out well for the resident. He was back in less than 36 hours. On 1/31/24 at 3:01 p.m., in a telephone interview, a representative of the dental office said there was no medical clearance, or a complete medication list in the chart of Resident #98 for the dental extractions done on 8/28/23. On 1/31/24 at 4:52 p.m., in an interview the Medical Director said he has been caring for Resident #98 for approximately two years. He was not aware the resident was having nine teeth extracted and it was not really discussed. He said he thought there was a good process in place, but some will fall through the cracks. The Medical Director said it would be good to know of any type of procedures in high risk patients. He said he would not have stopped the Eliquis due to the risk of a cerebrovascular accident if the blood thinner is stopped. On 2/1/14 at 8:55 a.m., in an interview the Director of Nursing (DON) said Resident #98 specifically told the Social Service Director he was going to have teeth removed. The Administrator present during the interview said the Social Service Director arranged the dental services. The DON verified the lack of documentation of coordination with the dentist and the attending physician prior to the dental extractions. On 2/1/24 at 9:06 p.m., in an interview Social Service Director Staff H said at the end of July, Resident #98 came to her and said he wanted some teeth extracted. He said he had broken teeth and wanted to be seen by a dentist. She said she made the initial appointment on 8/7/23. She spoke with the resident and asked him how the appointment went. Resident #98 said the appointment went ok. The resident did not tell her he had a follow up appointment, he set up the follow up appointment himself. She said the facility did not receive any paperwork from the dentist. She verified the lack of documentation of the content of the dental appointment on 8/7/23 or coordination with the dentist for the upcoming 8/28/23 appointment for the multiple dental extractions. On 2/1/24 at 9:23 a.m., the DON said the facility investigation from 8/28/23 through 8/30/23 showed Resident #98 knew he was getting the extraction and communicated that to Licensed Practical Nurse (LPN) Staff I. She said Resident #98 was not really able to take care of himself. She said when residents go out for appointments, the physician may not be aware of procedures done such as a wound debridement (Removal of dead tissue) prior to the appointment. She said on 8/28/23 the resident told his nurse he was having the extractions. The DON verified the facility had no documentation related to the resident's dental appointments. She said the facility had no policy addressing third party providers however she expected the nurse to contact the consulting physician if the resident came back without any documentation from the appointment. The facility provided a document with a nursing incident description dated 8/28/23 at 5:26 p.m., which noted Resident #98 had, Uncontrollable bleeding of the gums s/p (status post) tooth extraction. The Physician Assistant was notified and issued an order to send the resident to the emergency room for evaluation. The facility lacked documentation of an investigation of the incident, including statements of all staff involved in the resident's care, a root-cause analysis, or recommendation for improvement. On 1/31/24 at 1:26 p.m., in an interview the Administrator said he started employment at the facility in August 2023, and was the risk manager for the facility. He said they do discuss any return to hospital. He said he did not remember the incident involving Resident #98 as a reportable event, or an adverse incident. On 2/01/24 at 8:55 a.m., a meeting was held with the Administrator, the DON and the Social Service Director. The DON said when someone is sent out each morning they go over the events of the prior day, The interdisciplinary team talks about it in Quality Assurance. The NHA said the Social Service Director arranged the dental services. He said the incident involving Resident #98 was not reported in Quality Assurance because it did not meet criteria for an adverse incident. On 2/1/24 at 9:35 a.m., the DON said Resident #98 was sent out within two hours of coming back from the dental appointment. The DON said the facility did not think the incident represented a safety risk and did not put anything in place other than what they currently do for outside providers' appointments. After verification of implementation of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/2/24. The immediate actions implemented by the facility and verified by the survey team included: Resident evaluated, remains in the facility with no change in condition or signs of distress. On 2/2/24 the survey team verified through observation and interview with Resident #98. The Risk Management Consultant completed a 30 day look back of 38 residents with external appointments as well as internal podiatry and dental appointments who are also taking anticoagulants and no concerns or adverse incidents were identified. On 2/2/24 the survey team verified through review of the completed look back of 38 residents with external appointments, as well as internal podiatry and dental appointments. Additionally, the Risk Management Consultant completed a review of residents currently taking anticoagulants who have upcoming external appointments as well as internal podiatry and dental service appointments and their providers were notified of the residents' anticoagulant status. On 2/2/24 the survey team verified through review of documentation the physicians were notified of the 38 current residents taking anticoagulants who have upcoming external appointments as well as internal podiatry and dental services appointments. The Risk Management consultant completed education to the Administrator. Director of Nursing and Interdisciplinary team on the following topics: a. The facility's Abuse, Neglect and Exploitation Prevention Program with a focus on the prevention of neglect. Completed 2/1/24. b. Timely evaluation of patients. Completed 2/1/24. c. Appropriate Interventions. Completed 2/2/24. d. Notification of physician to meet each resident's needs. Completed 2/2/24. On 2/2/24 the survey team verified through review of the education, interview with the Administrator and the Director of Nursing. On 2/2/24 the survey team interviewed six Licensed Nurses on the North and South Units. All six Licensed Nurses interviewed were able to verbalized the Abuse, Neglect and Exploitation Prevention Program with a focus on prevention of neglect. All six Licensed Nurses were able to verbalize process for timely evaluation of residents, appropriate interventions, and notification of physician to meet each resident's needs.

Based on record review, resident and staff interview, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program that recognize quality deficiencies in the areas of neglect and effective coordination of care related to the use of anticoagulant (blood thinner). Resident #98's medication regimen included long term use of Eliquis (anticoagulant). On 8/28/23 the facility arranged for multiple dental extractions for Resident #98 without documentation of coordination with the dentist or the attending physician related to the use of anticoagulant before and after the extractions. Resident #98 experienced uncontrollable bleeding from the extractions resulting in a transfer to an acute care hospital. Resident #98 was critically ill, required a blood transfusion and was admitted to the Intensive Care Unit. The facility failure to recognize, systematically analyze quality deficiencies and implement corrective actions resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 8/28/23. On 2/2/24 at 5:00 p.m., the Administrator was notified of the determination of Immediate Jeopardy and provided the IJ templates. There were 38 residents receiving anticoagulant medications. The findings included: Cross reference F600, F684 and F835. The facility's Policy and Procedure related to the Quality Assurance Performance Improvement (QAPI) Plan with an effective date of October 2017 noted, The facility will develop a QAPI plan to . identify and prioritize deviations for performance and other problems and issues; systematically investigate and analyze to determine underlying causes of systemic problems and adverse events; develop and implement corrective actions or performance improvement activities; monitor/evaluate the effects of corrective actions/performance activities . The facility's abuse Prevention Program Policy and Procedure with a review date of August 2022 noted the Administrator, DON or designee are responsible for the investigation and reporting of suspected neglect. The Administrator, DON and/or designated individual are responsible for the following: Implementation, ongoing monitoring, investigation, reporting, and tracking and trending. The investigation for Neglect includes initiating an Event Report. The Administrator or designee is notified and will initiate and conclude a complete and thorough investigation within the specified timeframe. The facility will follow Federal regulations and State specific reporting requirements. The resident's physician is notified. The Nursing Home Administrator's job description signed and dated 8/11/23 noted the Administrator is responsible and accountable for the Facility Quality Assurance Performance Improvement for all aspects of the facility including but not limited to establishing and implementing policies and procedures, quality of care and regulatory compliance. Review of the clinical record for Resident #98 revealed a reentry date of 9/8/22. Resident #98's medication regimen included long term use of Eliquis (anticoagulant) 5 milligrams twice a day for Atrial Fibrillation (Type of irregular heartbeat). On 8/28/23 at 3:53 p.m., a nursing progress noted documented, Resident came back from the Dentist Appointment with no hard copies, but order was transferred to [pharmacy name] by the dentist Nurse. On 8/28/23 at 5:37 p.m., a nursing progress note documented, Resident continues to have moderate bleeding of the gum and c/o [complain of] feeling dizzy. PA [Physician Assistant] notified with order to send resident to the ER [Emergency Room] for eval [evaluation]. Review of the hospital record revealed a progress note dated 8/28/23 that read Resident #98 presented to the Emergency Department, for persistent oral bleeding s/p (status post) multiple dental extractions . Oral cavity hemorrhage s/p multiple dental extractions in the setting of chronic anticoagulation . Hold Eliquis in setting of acute bleed . Patient is critically ill requiring ICU (Intensive Care Unit) admission. On 1/30/24 at 11:37 a.m., Resident #98 said he had multiple dental extractions in August 2023. They were supposed to hold the blood thinner for a week but did not. Resident #98 said he ended up in the hospital due to uncontrolled bleeding. Review of the Medication Administration (MAR) for August 2023, showed Resident #98 received the Apixaban (Eliquis) 5 mg twice a day, every day in August 2023, including before, and after the dental appointment for the multiple extractions on 8/28/23. The manufacturer's insert for Eliquis noted, Bleeding. Eliquis increases the risk of bleeding and can cause serious, potentially fatal, bleeding, and adverse reactions . The clinical record lacked documentation of coordination with the dentist or the physician for instructions related to the anticoagulant before and after the scheduled multiple dental extractions. On 1/30/24 at 4:59 p.m., Social Service Director Staff H said Resident #98 had decay and more than a few teeth to be removed. She verified the lack of documentation, or any paperwork in the clinical record related to coordination with the dentist and the physician related to the use of blood thinner before and after the scheduled dental extractions. On 1/31/24 at 9:47 a.m., in an interview, the Physician Assistant (PA) said he was not aware Resident #98 was having the extractions and did not fill out any forms prior to the extractions. On 1/31/24 at 1:45 p.m., the Regional Nurse Consultant said they completed an incident report when Resident #98 was transferred to the hospital. She said they were following the physician's orders. The Regional Nurse Consultant said she realized Resident #98 was sent out to the hospital and received the packed cells (blood transfusion) but, really it all turned out well for the resident. He was back in less than 36 hours. On 1/31/24 at 3:01 p.m., in a telephone interview, a representative of the dental office said there was no medical clearance, or a complete medication list in the chart of Resident #98 for the dental extractions done on 8/28/23. On 1/31/24 at 4:52 p.m., in an interview the Medical Director who is Resident #98's attending physician said he was not aware the resident was having nine teeth extracted and it was not really discussed. He said he thought there was a good process in place, but some will fall through the cracks. The Medical Director said it would be good to know of any type of procedures in high risk patients. He said he would not have stopped the Eliquis due to the risk of a cerebrovascular accident if the blood thinner is stopped. On 2/1/24, the Director of Nursing (DON) provided a document which she said was the investigation related to Resident #98's uncontrollable bleeding after the nine dental extractions and transfer to the hospital. The document consisted of a nursing incident description dated 8/28/23 at 5:26 p.m., which noted Resident #98 had, Uncontrollable bleeding of the gums s/p (status post) tooth extraction. No injuries observed at time of incident. Immediate action taken. Description: PA (Physician Assistant) notified, and order received to send resident to the ER (Emergency Room) for eval (evaluation). A handwritten statement from Unit Manager, Registered Nurse (RN) Staff D noted, The nurse came and asked me to do an evaluation on the resident (Resident #98) because he was complaining of lightheaded, and he also had gum bleeding. I notified the PA and he gave an order [sic] send resident to the ER. Resident refused to chew on the gauze that he was provided with by the dentist, stating it was not helping. The facility investigation did not include a thorough review of the clinical record to include a timeline, review of the MAR which showed Eliquis was administered to the resident on 8/28/23 at 5:00 p.m., statements of all staff involved in the resident's care, a root-cause analysis, or recommendation for improvement. The investigation did not consider the lack of coordination between staff, the dentist, and the physician. On 2/1/24 at 9:00 a.m., a joint interview was conducted with the Administrator and the Director of Nursing (DON). The DON said the incident involving Resident #98 was reviewed by the Interdisciplinary team (IDT) the next morning, and an event report filed. The DON said the event was locked on 8/30/23 which meant the event had been reviewed and concluded. Both the Administrator and the DON said the consensus of the IDT team was the investigation did not yield any reason to investigate further or implement any interventions. The Administrator said the incident was not discussed in QAPI since it did not meet criteria for adverse incidents. On 2/2/24 at 9:06 a.m., in a telephone interview Licensed Practical Nurse (LPN) Staff I said she did not know Resident #98 was scheduled for dental extractions on 8/28/23 and administered the Eliquis as ordered. She said if she had known the resident was getting his teeth pulled she would not have given him the blood thinner as it would cause Resident #98 to bleed more. She could not recall when Resident #98 returned to the facility and verified the lack of documentation she evaluated Resident #98 upon his return. LPN Staff I said, he was doing fine and there was not a lot of blood from the mouth. On 2/2/24 at 1:00 p.m., in a telephone interview, RN Staff J said when she came on duty on 8/28/23 at 3:00 p.m., the morning nurse gave her report and left. She did not tell her Resident #98 had the extractions. When she made rounds at 3:00 p.m., Resident #98 was already in the room and was bleeding. She said there was blood everywhere, on the resident's shirt, and his bed. There was blood on the resident's face, he was spitting blood out. She said she called Unit Manager Staff D and informed him the resident refused to get changed. That's when the Unit Manager told her Resident #98 had his teeth pulled out that day. RN Staff J said the anticoagulant should have been held the week prior to the extractions and it wasn't. She verified she did not document her evaluation. RN Staff J said she took the resident's vital signs (Temperature, pulse, respiration, and blood pressure) but could not remember what they were or where she documented them. She said she did not administer the Eliquis on 8/28/23 at 5:00 p.m., despite the documentation on the MAR. Review of the Emergency Medical Service (EMS) report showed the facility called EMS on 8/28/23 at 5:30 p.m., two and a half hours after the resident was observed to be bleeding. EMS noted they responded to the facility, Pt (patient) has bleeding from the mouth. Staff states pt had multiple teeth pulled today and has been bleeding since. Pt takes Eliquis, which was not paused for the dental work. Assessment shows a steady flow of blood from the gums . After verification of implementation of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/2/24. The immediate actions implemented by the facility and verified by the survey team included: Resident evaluated, remains in the facility with no change in condition or signs of distress. On 2/2/24 the survey team verified through observation and interview with Resident #98. The Risk Management Consultant completed a 30 day look back of 38 residents with external appointments as well as internal podiatry and dental appointments who are also taking anticoagulants and no concerns or adverse incidents were identified. On 2/2/24 the survey team verified through review of the completed look back of 38 residents with external appointments, as well as internal podiatry and dental appointments. Additionally, the Risk Management Consultant completed a review of residents currently taking anticoagulants who have upcoming external appointments as well as internal podiatry and dental service appointments and their providers were notified of the residents' anticoagulant status. On 2/2/24 the survey team verified through review of documentation the physicians were notified of the 38 current residents taking anticoagulants who have upcoming external appointments as well as internal podiatry and dental services appointments. The Regional Risk Consultant completed education to the Administrator and Director of Nursing on implementing an effective Quality Assurance and QAPI program as verified on 2/2/24 by the survey team through review of signed completed education and interviews with the Administrator and DON. The Regional Nursing Consultant completed education to the facility Interdisciplinary Team on ensuring follow-up documentation is received and addressed following external appointments and coordination of care. On 2/2/24 the survey team verified through review of signed completed education and verbal acknowledgement by the DON and Administrator who are members of IDT team.