**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to protect residents' rights to be free from neglect by failing to re-evaluate Resident #999's elopement risk and prevent unsafe wandering and elopement with onset of paranoid behaviors such as distrust of staff and verbal expression of desire and intent to leave the facility. Resident #999 diagnoses included dementia and psychosis. The resident used a wheelchair for mobility and was ambulatory with supervision. On [DATE] the facility neglected to re-evaluate the resident's elopement risk and neglected to adequately supervise Resident #999 when the resident's son and law enforcement reported Resident #999 called them believing he was under attack and requested they come to evacuate him. On [DATE] at approximately 3:30 p.m., staff observed Resident #999 outside, to the left of the building and did not intervene. On [DATE] at 4:35 p.m., facility staff were not able to locate Resident #999 and contacted law enforcement to assist in the search. On [DATE] at approximately 8:15 p.m., law enforcement notified the facility Resident #999 was found deceased , in a parking lot approximately half a mile from the facility. The facility's failure to provide the necessary care and services to prevent neglect created a likelihood of serious harm, serious injury, or death of Resident #999 and other cognitively impaired residents from unsafe wandering. This failure resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of Isolated (J) starting on [DATE]. On [DATE] at 10:11 a.m., the Administrator was informed of the determination of Immediate Jeopardy (IJ). The findings included: Cross reference to F689 and F867 A review of the facility's Abuse Policy-Prevention and Management Policy with a review date of 8/2024 noted, The facility prohibits the . neglect . of residents . The facility has designed and implemented processes, which strive to ensure the prevention of . resident . neglect . Neglect occurs when the facility is aware of or should have been aware of goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), resulting in, or may result in, physical harm, pain, mental anguish, or emotional distress . Examples of individual failures include, but are not limited to . Failure to identify, assess . for an acute change in condition, and/or a change in condition that requires the plan of care to be revised to meet the resident's needs in a timely manner; Failure to ensure staff respond correctly to medical or psychiatric emergencies; Failure to implement an effective communication system across all shifts for communicating necessary care and information between staff . Failure to monitor and/or provide adequate supervision to assure that environmental hazards are not present . Failure of the Quality Assurance and Assessment committee to develop and implement appropriate action plans to correct identified quality deficiencies . A review of the facility's Elopement Prevention and Management policy and procedure with a review date of 4/2024 noted, The facility will strive to identify residents at risk for unsafe wandering and exit seeking behavior and to develop individualized prevention and management interventions based on Exit Seeking/Elopement Evaluation. Elopement represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle . Procedure: . Review evaluations and risk factor data. Determine if the resident is at risk for elopement; history of elopement prior to admission. Include resident and/or resident representative in development of the Plan of Care. Develop individualized interventions in the care plan to address the potential for elopement . Communicate risk and interventions to the care giving team . Review and revise Plan of Care as needed. Review of the clinical record for Resident #999 revealed an admission Minimum Data Set (MDS) assessment with a target date of [DATE]. The MDS noted Resident #999's cognition was moderately impaired with a Brief Interview for Mental Status of 09. The resident required supervision or touching assistance for walking. The elopement evaluations completed on [DATE], [DATE], and [DATE] noted the resident had no history of elopement, was ambulatory or able to self-propel in a wheelchair. Each time the facility determined Resident #999 was not at risk for elopement. On [DATE] and [DATE] two physicians evaluated the resident and signed an incapacity statement noting Resident #999 lacked the capacity to give informed consent and make healthcare decisions based on advanced stage dementia and confusion. The care plan initiated on [DATE] noted the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. The interventions included to monitor, document and report as needed any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, mental status. Review of the clinical nurses notes revealed on [DATE] at approximately 4:40 p.m., Resident #999 could not be found. Staff searched the facility and the grounds but were unable to find him. The police were notified at approximately 5:00 p.m. The resident's wheelchair was found outside. On [DATE] at 8:15 p.m., the detective notified the facility the resident was found deceased in a bar parking lot just down the road from the facility. Review of the facility's incident investigations revealed on [DATE] the facility initiated an investigation of neglect related to Resident #999's elopement. The investigation noted Resident #999 was admitted to the facility in [DATE] with diagnoses including Dementia and Major Depressive Disorder. The admitting medications included Risperdal (antipsychotic) 0.5 milligram twice a day for Mood Disorder. The medication was discontinued on [DATE], due to the lack of diagnosis to support the use of the Risperdal. Resident #999 had not exhibited any behaviors since admission. On [DATE] at approximately 11:00 a.m., Resident #999's son called the facility and reported to the Director of Nursing (DON) his father was telling him there was going to be a war and that they needed to take cover. Resident #999 asked his son to come and get him. He said he thought his father was exhibiting paranoia regarding the staff at the facility and needed to be restarted on his antipsychotic medication. He also reported Resident #999 had been baker acted (involuntary admission for mental illness) several years ago. The Psychiatric APRN (Advanced Practice Registered Nurse) was at the facility and evaluated the resident on [DATE] at approximately 1:00 p.m., for medication review. She completed a note stating the resident was calm and without hallucinations. The resident was, Per usual and no changes. She reordered the Risperdal related to the son's concerns, but did not witness any type of issues with the resident during her evaluation. Nothing further was recommended as she felt that the resident was stable at this time. Review of the Psychiatric APRN progress note dated [DATE] revealed she saw Resident #999 as it was reported to her the resident was unstable requiring psychiatric assessment. The APRN documented Resident #999 appeared agitated, upset. His thought process was somewhat disorganized. His insight and judgement were impaired. The resident was oriented to person, with impaired recall and short term memory. Attention span and concentration were poor. Fund of knowledge was impaired. The practitioner documented the resident was unstable requiring medication changes. She wrote, As per collected information and interview, it appears that patient is unstable. I feel the symptoms are occurring due to exacerbation of underlying psychosis disorder. The symptoms are occurring almost daily and causing severe distress. Therefore, I decided to make medication changes to stabilize the symptoms. Further review of the incident investigation revealed on [DATE] at approximately 5:15 p.m., the police called the facility and stated Resident #999 had called them and claimed he was under attack and needed to be evacuated. The police came to the facility for a wellness check. They said the resident was fine and explained to him they could not take him out of the facility. The resident remained in his room and calm without behaviors. The investigation did not include nonpharmacological interventions, including an elopement re-evaluation to determine the need for increased supervision to maintain the resident's safety with the onset of paranoid behavior and voiced intent to leave the facility. The description of the incident noted on [DATE] at 4:35 p.m., Licensed Practical Nurse (LPN) Staff D reported to the shift supervisor, Registered Nurse (RN) Staff H he could not locate the resident to administer his medications. Facility staff initiated a Code Pink (elopement), searched the facility and surrounding area. Staff were not able to locate Resident #999 and contacted law enforcement to assist with the search. On [DATE] at approximately 8:15 p.m., a detective notified the facility Resident #999 was found just down the road from the facility in a bar parking lot and that the resident was deceased . On [DATE] the facility completed the investigation and documented after chart review and interviews completed with staff and other members of the interdisciplinary team, the facility felt there was no neglect. The statements the resident made to the son and the new diagnosis of Bipolar on [DATE] were addressed by the Physician Assistant and the Psychiatric APRN. The police evaluated the resident on [DATE] and deemed that he was safe to remain at the facility. On [DATE] at 10:15 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON) to review Resident #999's elopement, and the neglect investigation. The DON verified on [DATE] Resident #999's risk for elopement was not re-evaluated and the care plan was not updated to maintain the resident's safety and prevent unsafe wandering and elopement. The DON said after the elopement, she interviewed staff and was not able to determine the root cause of the elopement. She said, The Root cause of the event was inconclusive per our findings because we did not have all the facts yet. We did not know where the resident was found. Once we had all the facts, we concluded the neglect was not verified as the resident did not display any behaviors and had no elopement history. She said, We did not provide that level of supervision because he did not need it. On [DATE] at 1:28 p.m., in an interview LPN staff D stated on [DATE] no one alerted him to the resident's change in mental status or update to his medications when he received report. He said Resident #999 did not display any changes at the time and was surprised that he eloped. He said he was aware the resident had called the police on [DATE], through word of mouth. On [DATE] at 3:52 p.m., in an interview Certified Nursing Assistant (CNA) staff E said another CNA and LPN Staff D told her the resident had called the police but no one instructed her to increase supervision for the resident. On [DATE] at 4:17 p.m., in an interview Maintenance Tech Staff F said on [DATE] at approximately 3:30 p.m. to 4:00 p.m., he observed Resident #999 outside to the right of the building. He said Resident #999 never went outside. It was the very first time he had seen him outside. He did not try to get him to go inside and did not notify any staff. On [DATE] at 4:41 p.m., in a telephone interview Resident #999's son said he notified the facility on [DATE] that his father said he intended to flee the facility by any means possible. He thought someone there was going to kill him. He was a flight risk and wanted to elope. His father called 911 and told them the same information. A police officer came out on [DATE] and spoke with his father. The son said, I spoke to the DON on [DATE] and told her that my father wanted me to immediately evacuate him from the facility because they were going to kill him. I told her they needed to take precautions and adjust his medications. He was hallucinating thinking people were going to kill him. I told them he would try and find a way out of the facility. I thought he would go to the front door, and someone would try and stop him, and he would hurt someone. He was seeing Psych, but I never spoke to them. Psych never contacted me after they saw him. I explained his previous psychiatric history to the DON and where to obtain it. On [DATE] at 10:00 a.m., in an interview Unit Manager Staff B said Resident #999 walked in his room from the bed to the wheelchair and the bathroom. She said the nurse and the CNA knew the police were here to see the resident but she never told them the reason for law enforcement visit. The resident's behavior would have been communicated in the nurse-to-nurse report. The Unit Manager said on [DATE] she overheard the resident speak to the two police officers. He said, I want you to take me. I am in danger. I want you to remove me from the facility. She said the resident did not exhibit any other behavior. She did not feel the resident needed one to one supervision or 15 minutes checks just because he called the police once. She said she did not see a reason to place a wander alert bracelet (alarms staff when a resident leaves a designated safe area) on the resident. On [DATE] at 12:47 p.m., in an interview LPN Staff I said she did not know Resident #999. On [DATE] at approximately 3:45 p.m., she was walking down the hallway and observed residents outside just to the right of the front doors by the patio of the Ford unit. After Resident #999 eloped she realized he was one of the residents she observed outside from the description of the bright yellow shirt he was wearing. On [DATE] at 5:50 p.m., in a telephone interview Resident #999's attending physician said the resident had a history of paranoia but she was not aware the resident had a history of elopement. The physician said it was hard to say if the resident was safe to go outside on his own or not. On [DATE] at 10:08 a.m., in an interview Unit Manager LPN Staff J said Resident #999 was not an elopement risk, he had never tried to leave the facility. She said, We had no way to think he would get up and leave the facility. He had the right to go outside. LPN Staff J said they would be restraining the resident if they tried to stop him from going outside. LPN Staff J said, He had the right to leave, and the right to fall. Isn't it what you people always say? He did not have a lack of capacity when he was here. When showed the certificate of incapacity signed by two different physicians, the Unit Manager turned her head and did not answer any additional questions. On [DATE] at 10:16 a.m., in an interview the Physician Assistant said Resident #999 spoke about the war a lot since he met him. He did not always make sense; he was confused but always compliant. He said it was hard to say if Resident #999 was safe to be outside as residents' rights come into play and they have residents who go outside for fresh air. He said Resident #999 was safe to go outside, right out the front door if staff could see him. The resident never said he wanted to leave the facility. On [DATE] at 2:25 p.m., in an interview the Social Service Director said she was responsible to update the care plan for changes in behavior. The nurses document changes in condition in the alerts section of the electronic clinical record. She follows up on what nursing documents. She said there was no clinical alert documented for Resident #999 on [DATE]. The Social Service Director said no one told her the son had called and voiced concerns about his father. No one told her the resident had called the police. The Social Service Director printed a copy of the alerts report for [DATE] through [DATE]. The report listed Resident #999's new antipsychotic medications for [DATE] but did not document the resident's paranoid behavior and voiced intent to leave the facility. On [DATE] at 10:44 a.m., a joint interview was conducted with the Administrator, the DON and the Regional Director. The Regional Director said the DON saw the resident the day he eloped and he was fine, his usual self. She asked the DON if she documented her assessment of the resident, the DON said it was the one time she did not do it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility's policies and procedures, resident representative and staff interviews the facility failed to recognize risk factors for elopement and adequately supervise 1 (Resident #999) of 3 sampled confused residents when Resident #999 exhibited new symptoms of paranoia and voiced intent to leave the facility. On [DATE] the facility failed to implement adequate supervision when Resident #999's son and law enforcement notified the facility the resident reported he was under attack and requested they come to evacuate him. On [DATE] at approximately 3:30 p.m., Resident #999 who was cognitively impaired was not supervised and exited the facility. Facility staff saw him outside to the right of the building and did not intervene. On [DATE] at 4:30 p.m., facility staff could not find Resident #999 and notified law enforcement to assist with the search. On [DATE] at 8:15 p.m., law enforcement notified the facility Resident #999 was found deceased in a parking lot, approximately half a mile from the facility. The facility failure to adequately supervise cognitively impaired and confused residents to prevent elopement created a likelihood of avoidable accidents for Resident #999 and other cognitively impaired residents at risk for elopement which could result in serious harm, serious injury, serious impairment or death of the residents. This failure resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of Isolated (J) starting on [DATE]. On [DATE] at 10:11 a.m., the Administrator was notified of the determination of Immediate Jeopardy. The findings included: Cross reference to F600 and F867 A review of the facility's Change in Condition Policy and Procedure with a review date of 6/2024 noted, The Clinical Nurse will recognize and appropriately intervene in the event of a change in resident condition. The Procedure noted, . The nurse will communicate to the nurse manager/supervisor any change in resident condition as it occurs. This will also be communicated in the 24 hour/and or shift report as well . If a significant change in condition occurs, a physical and or mental assessment with be completed by the Registered Nurse and documented in the medical record . Documentation of the change in condition will be present in the nurses' progress note and will continue q (each) shift for at least 72 hours . This episodic documentation will occur for, but not limited to . mental/behavioral changes . A review of the facility's Leave of Absence (LOA) with a review date of 3/2024 noted, It is the policy of this facility to encourage outside socialization for the resident/patient when appropriate . A cognitively impaired resident may leave the facility with family/resident representative, unless restrictions apply, with the appropriate physician order. The facility will tract the departure and return of a resident on the Release of Responsibility for LOA form . Procedure . When LOA is to occur: Evaluate resident for a change in condition, notify physician of any concerns/changes and document in the progress note . Review of the clinical record revealed Resident #999 was a vulnerable [AGE] year old admitted to the facility on [DATE] following hospitalization for altered mental status. Diagnoses included unspecified Dementia without behavioral disturbance, Psychotic disturbance, mood disturbance, Major Depressive Disorder, Anxiety, Bipolar II disorder (mood swings ranging from depressive lows to manic highs), and Generalized Muscle Weakness. The admission Minimum Data Set (MDS) assessment with a target date of [DATE] noted Resident #999's cognition was moderately impaired with a Brief Interview for Mental Status of 09 (Moderate level of cognitive impairment). The resident was ambulatory with supervision or touching assistance. The care plan initiated on [DATE] noted the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. The interventions included to monitor, document and report as needed any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, mental status. On [DATE] and [DATE] two physicians evaluated the resident and signed an incapacity statement noting Resident #999 lacked the capacity to give informed consent and make healthcare decisions based on advanced stage dementia and confusion. The elopement evaluations completed on [DATE], [DATE], and [DATE] noted the resident was ambulatory or able to self-propel in a wheelchair. The potential risk factors for elopement, such as history of elopement, desire to return home, expressed desire to leave, attempted elopement, and psychiatric history were not checked off on the elopement evaluation forms. Each time the facility determined Resident #999 was not at risk for elopement. The Physician's orders dated [DATE] included to consult Psychiatry Service to evaluate and treat the resident. Review of the Psychiatric Advanced Practice Registered Nurse (APRN) progress notes for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] noted Resident #999 was oriented to Person, insight and judgment were impaired, short-term and remote memory were impaired and the resident's fund of knowledge (used to determine if a patient has cognitive impairment) was impaired. The APRN documented in her notes Resident #999 did not exhibit behaviors or psychotic symptoms. Review of the Clinical Nurse's Note dated [DATE] at 10:56 a.m., noted Resident #999's son called and said his dad had called him and stated that he was under attack and that the son needed to come and evacuate him. The son stated that he knew the facility had discontinued one of his father's medications a while ago and that he probably needed it back. He stated his father had been diagnosed with Bipolar disorder, paranoia, schizoaffective disorder and had been [NAME] Acted a few years ago and started on Risperidone (antipsychotic). The psychiatric provider was at the facility and was notified of the son's concerns. The Psychiatric APRN ordered to restart Risperidone 0.5 milligram twice a day. On [DATE] the Psychiatric APRN documented in a progress note she saw Resident #999 as it was reported to her the resident was unstable requiring psychiatric assessment. Resident #999 appeared agitated, upset. His thought process was somewhat disorganized. His insight and judgement were impaired. The resident was oriented to person, with impaired recall and short term memory. Attention span and concentration were poor. Fund of knowledge was impaired. The practitioner documented the resident was unstable requiring medication changes. She wrote, As per collected information and interview, it appears that patient is unstable. I feel the symptoms are occurring due to exacerbation of underlying psychosis disorder. The symptoms are occurring almost daily and causing severe distress. Therefore, I decided to make medication changes to stabilize the symptoms. On [DATE] at 1:59 p.m., a nursing progress note documented Resident #999 was confused, and independent for all transfers, Will continue to monitor resident for behavior. The note did not describe what behavior was being monitored. On [DATE] at 5:23 p.m., a nursing progress documented the Fort [NAME] Police called the facility to say that Resident #999 had call them to report that he needed to be taken out of the facility. The resident said he was in danger of the war and needed evacuation. The police arrived at the facility and visited with the resident for about five minutes and left. There was no documentation on [DATE] Resident #999's risk for elopement was re-evaluated when the resident with a psychiatric history exhibited paranoid behavior and expressed desire, and intent to leave the facility. The care plan was not updated to address the acute change in behavior and ensure adequate supervision to maintain the resident's safety and prevent elopement. On [DATE] at 3:46 a.m., a nursing progress note documented Resident #999 was in bed and no behavior was observed at that time. On [DATE] at 5:20 p.m., Licensed Practical Nurse (LPN) Staff D documented in a Late Entry Clinical Nurse Note the resident's mood was stable and pleasant that morning. He was sitting near the nurse's station after lunch. At around 4:15 p.m., he went to the resident's room to administer medications. Resident #999 was not there. He asked the assigned Certified Nursing Assistant to help him search for the resident from room to room and unit by unit and they could not find him. At 4:35 p.m., he notified the supervisor on duty. At around 4:40 p.m., the supervisor called a code pink for missing resident according to facility's protocol. On [DATE] at 8:15 p.m., a nursing progress note documented the facility notified law enforcement that Resident #999's was missing at approximately 5:00 p.m. Law enforcement arrived at the facility at 5:15 p.m. The resident's wheelchair was found outside by the Ford Unit. The police received a call for a possible civilian on [NAME] street just down from the facility. The police left to go to the area. On [DATE] at approximately 8:15 p.m., a detective notified the facility the resident was found deceased in a bar parking lot just down the road from the facility. On [DATE] at 10:15 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON) related to Resident #999's elopement and the facility's process to prevent unsafe wandering and elopement. The DON said the facility used to have a sign out book at the front desk but they did not require residents to sign out if they just wanted to sit outside in front of the facility. Residents were free to get around, go outside, and sit there without staff supervision and there was no monitoring camera outside. The DON said Resident #999 lacked capacity. She verified on [DATE] Resident #999's son called and told her his father was acting fearful. He thought he was in the war and said he had to leave the facility. He requested the son come and get him. The son told her his father was prescribed antipsychotic medication for a diagnosis of schizophrenia and he was paranoid. He also was diagnosed with Bipolar disorder. He thought he should be put back on Risperidone, the antipsychotic medication which had been prescribed for paranoia. She said that same day the Psychiatric APRN assessed the resident and re-ordered the Risperdal (Risperidone). That afternoon, the police called the facility to inform them Resident #999 had called them requesting to be evacuated as he thought there was going to be a war and the staff were going to kill him. The police then came to the facility and spoke with Resident #999 for five minutes. They said he was fine and they left. The DON said she checked on the resident the next day and he was fine. She did not tell the staff of the concerns voiced by Resident #999's son. She did not feel he needed increased supervision. She verified the resident's elopement risk was not re-evaluated despite knowledge of the psychiatric history and expressed intent to leave the facility. She said the facility was not aware of the resident's elopement history. He had previously eloped from the Assisted Living Facility where he resided and was trying to get back to Missouri. He was [NAME] acted (involuntary hospitalization for mental illness). The Administrator said on [DATE] at approximately 3:30 p.m., to 4:00 p.m., the Maintenance Assistant (Tech) observed Resident #999 outside to the left of the door. The resident was not visible from the front desk. He did not sign out in the leave of absence log per policy. The Maintenance Assistant tried to bring the resident back into the building but Resident #999 refused to go back inside. He left the resident outside and did not notify anyone. The Administrator said LPN Staff I observed Resident #999 sitting outside to the side of the building from a window of the Ford Unit. She did not report it to anyone. The Administrator said the facility did not have a policy specifying which residents could come and go from the facility. Resident #999 was not an elopement risk. He enjoyed the freedom to get fresh air. On [DATE] at 1:28 p.m., in an interview LPN Staff D said on [DATE] no one informed him of the resident's change in mental status or update to his medications. He became aware the resident had called the police on [DATE] through word of mouth. On [DATE] at 3:52 p.m., in an interview Certified Nursing Assistant (CNA) Staff E said LPN Staff D and another CNA told her Resident #999 had called the police on [DATE] but no one told her she needed to supervise the resident. She said Resident #999 never left the unit. If she had seen him outside she would have brought him back in as no resident should be left unsupervised outside. On [DATE] at 4:17 p.m., in an interview the Maintenance Tech said he had never seen Resident #999 outside of the facility prior to [DATE]. When he saw the resident outside around 3:30 p.m., to 4:00 p.m., he asked the resident if he was ok, and he said he was. He said, I did not try to get him to go inside. I did not bother because he gets very agitated and would swear at you. The Maintenance Tech said, If I had known he was not allowed to go outside, I would have gotten him and brought him inside. He said he tells residents to stay away from the road. The road is so close and he does not want them to get hurt. On [DATE] at 4:41 p.m., in a telephone interview Resident #999's son said, I notified the facility the day before he passed, that he wanted to flee the facility by any means possible. He thought someone there was going to kill him. He was a flight risk and wanted to elope. He told me he wanted to get out of the facility because they were going to kill him. He called 911 and told them the same information. I spoke to the DON on [DATE] and told her that my father wanted me to immediately evacuate him from the facility because they were going to kill him. I told her they needed to take precautions and adjust his medications. He was hallucinating thinking people were going to kill him. I told them he would try and find a way out of the facility. The son said his father had Dementia; the facility should have monitored him. On [DATE] at 10:00 a.m., in an interview Unit Manager Registered Nurse Staff B said LPN Staff D and CNA Staff E were aware the police came to the facility, everyone saw them. She overheard Resident #999 asking the police to take him, he was in danger. The resident said to the police officers, I want you to remove me from the facility. She said she did not relay that information to the direct care staff. She did not tell them about the resident's onset of behavior and expressed intent to leave the facility and did not instruct them to supervise the resident. She did not see a reason to place the resident on one-to-one supervision or every 15 minutes checks just because he called the police one time. On [DATE] at 5:50 p.m., in a telephone interview Resident #999's attending physician said it was hard to say if the resident was safe to go outside on his own. She was not aware of the change in his behavior but perhaps the Physician Assistant was notified. On [DATE] at 10:16 a.m., in an interview the Physician Assistant said, It is hard to say if (Resident #999) was safe to be outside. He said the resident lacked capacity; he was confused but compliant. He was safe to go outside, right out the front door where staff could see him. When asked if it was safe for Resident #999 to be outside on the side of the building, out of view of staff at the front desk, the Physician Assistant did not reply. On [DATE] at 12:47 p.m., in an interview LPN Staff I said she did not know Resident #999. On [DATE] at approximately 3:45 p.m., she was walking down the hallway and observed residents outside just to the right of the front doors by the patio of the Ford unit. After Resident #999 eloped she realized he was one of the residents she observed outside from the description of the bright yellow shirt he was wearing. On [DATE] at 2:25 p.m., in an interview the Social Service Director said she was responsible to update the care plan for changes in behavior. The nurses document changes in condition in the alerts section of the electronic clinical record. She follows up on what nursing documents. She said there was no clinical alert documented for Resident #999 on [DATE]. The Social Service Director said no one told her the son had called and voiced concerns about his father wanting to leave the facility. No one told her the resident had called the police requesting they remove him from the facility. The Social Service Director printed a copy of the alerts report for [DATE] through [DATE]. The report listed Resident #999's new antipsychotic medications ordered on [DATE] but did not document the resident's paranoid behavior and voiced intent to leave the facility. On [DATE] at 10:24 a.m., in a follow up interview related to the lack of supervision resulting in Resident #999's elopement, the Administrator said the resident died of natural causes. He said the police came to the facility and did not recommend more supervision. The Administrator said, Why didn't the police tell us that he needed more supervision? They thought he was fine. The police said he was safer at the facility. The Administrator said at the time Resident #999 wandered off the property, he was safe to be outside unassisted per their assessment. A lot of people saw the resident, and no one, including the police, the psychiatric APRN recognized he was an elopement risk. On [DATE] at 11:40 a.m., the Regional Director provided a care plan with a canceled date of [DATE] which noted Resident #999's well-being was promoted by spending time outdoors, at times as well as watching television. The diagnoses listed included unspecified dementia. The care plan initiated on [DATE] with a revision date of [DATE] and a target date of [DATE] noted the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. The care plan did not include provision for supervision for outdoor activities and was not revised on [DATE] when the confused resident voiced intent to leave the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policies and procedures, the facility failed to thoroughly investigate an elopement incident for 1 (Resident #999) of 3 sampled residents reviewed for elopement, and failed to implement systemic appropriate corrective actions to prevent further incidents of unsafe wandering and elopement of mobile confused residents. On [DATE] the facility failed to ensure Resident #999's safety when the son and law enforcement notified the facility the resident called, said he was under attack, voiced intent to leave the facility and requested they come and get him. On [DATE] at 4:35 p.m., staff became aware Resident #999 was missing and contacted law enforcement to assist with the search. On [DATE] at approximately 8:15 p.m., law enforcement notified the facility Resident #999 was found deceased , in a parking lot approximately half a mile from the facility. The facility's investigation did not include the failure to reassess the resident's elopement risk with the onset of paranoid behavior. The systemic corrective actions did not include documentation of behaviors and appropriate actions to ensure residents safety with the onset of new behaviors that may lead to elopement. The facility failure to have an effective Quality Assurance and Performance Improvement program that identify quality deficiencies and implement appropriate corrective actions created a likelihood of unsafe wandering and elopement of cognitively impaired, confused residents which could result in serious harm, serious injuries or death of the residents. This failure resulted in the determination of isolated ongoing Immediate Jeopardy. On [DATE] at 10:11 a.m., the Administrator was notified of the determination of Immediate Jeopardy (IJ). The finding included: Cross reference to F600 and F689. A review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan with a review date of [DATE] noted, The Facility will maintain a quality management program which takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality . The purpose of a QAPI program is to ensure continuous evaluation of facility systems with the objective of: Ensuring care delivery systems function consistently, accurately, and incorporate current and Evidence-based practice standards where available. Preventing deviation from care processes, to the extent possible. Identifying issues and concerns with facility systems, as well as identifying opportunities for Improvement; and Developing and implementing plans to correct and/or improve identified areas. On [DATE] at 10:15 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON) to review the incident investigation related to Resident #999's unsafe wandering and elopement, the root cause analysis and systemic corrective actions implemented to prevent recurrence. The DON verified on [DATE] at approximately 11:00 a.m., the resident's son called the facility to speak with her. He reported Resident #999 had been diagnosed with Bipolar disorder (mood swings ranging from depressive lows to manic highs) and paranoia (overly suspicious and thinking others are out to harm you). Resident #999 told his son there was going to be a war, they needed to take cover and to come and get him. She verified on [DATE], the Psychiatric Advanced Practice Registered Nurse assessed Resident #999 and re-ordered the antipsychotic Risperdal which had been discontinued in [DATE]. She also verified on [DATE] at approximately 5:15 p.m., law enforcement called and informed the facility Resident #999 had called them and claimed he was under attack and needed to be evacuated. The DON verified Resident #999's risk for elopement was not re-evaluated and the care plan was not updated with nonpharmacological interventions, including adequate supervision to maintain the resident's safety and prevent unsafe wandering and elopement. The Administrator and the DON said on [DATE] the facility immediately initiated an investigation, held QAPI meetings to discuss the root cause of Resident #999's elopement, and corrective actions as appropriate to prevent further incidents of unsafe wandering and elopement of cognitively impaired residents. The DON said after the elopement, she interviewed staff and was not able to determine the root cause of the elopement. She said, The Root cause of the event was inconclusive per our findings because we do not have all the facts yet. We did not know where the resident was found. Once we found out all the information, we concluded it was not verified as he had no behaviors, and he had no elopement history. We did not provide that level of supervision because he did not need it and we did not substantiate the incident. The DON added she did not know the resident required that level of supervision. She said she assessed the resident on [DATE] and [DATE]. She did not document her assessment and Resident #999 did not need any higher level of monitoring or a wander alert bracelet (alerts staff when a resident leaves a determined safe area). The Administrator said the facility could not reach a conclusion due to Resident #999's pending autopsy result to determine the cause of death. He said they had no way of knowing the resident was an elopement risk despite the resident's son and law enforcement alerting them of the resident's voiced intent to leave the facility as he believed he was under attack and needed to take cover. The facility provided the minutes of a Risk Management/QAPI report dated [DATE] that read, Root cause determined that facility was not aware of the history of the resident. There was no information in the medical record nor did the family report any history of elopement. The facility determined that the neglect was not verified related to the incident based on evaluation of the medical record and history of the resident, the resident did not require an increased level of supervision . Facility still awaiting autopsy report and police report at this time. The facility's interventions consisted of staff interviews, education to the staff on resident elopements, code Pink for missing resident, the elopement binder, elopement policy and procedure, Leave of absence policy and procedure, elopement drills, sign-out binder at the front desk. The DON said she conducted the elopement drills; she placed an additional staff at the front door for three days to monitor since she did not know through which door the resident exited the facility. The facility's corrective actions did not include staff education on ensuring the elopement evaluations accurately reflected residents' risk factors, or recognizing, documenting and implementing adequate supervision with onset of behavior that may lead to unsafe wandering and elopement. On [DATE] at 10:24 a.m., in an interview related to the neglect of Resident #999 and systemic interventions to prevent further incidents of unsafe wandering and elopement of mobile, confused and cognitively impaired residents, the Administrator said the Psychiatric APRN (Advanced Practice Registered Nurse) assessed Resident #999 on [DATE] and changed the resident's psychotropic medications. He said Resident #999 died of natural causes. On [DATE] law enforcement came to check on Resident #999 when he called them to say he was under attack and requested assistance to leave the facility. They did not recommend increased supervision of the resident. On [DATE] at 10:44 a.m., in an interview the Regional Director said the staff did their due diligence in monitoring Resident #999. She said a change of behavior and a change in medication were the same thing. She said, You put a label on it but the facility did document and kept an eye on this resident throughout the shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the clinical record showed Resident #2 was admitted to the facility on [DATE] with a diagnosis of dementia, depression and lung cancer. On [DATE] Resident #2 completed the Advanced Directives Check List, instructed I do desire cardiopulmonary resuscitation (CPR) to be performed while at Page Rehabilitation and Healthcare Center if I suffer from cardiac or respiratory arrest. On [DATE] Resident #2 had a signed Florida Designation of Health Care Surrogate, permitting the Surrogate to make all health care decisions for Resident #2, when the physician determines that Resident #2 was unable to make her own decisions. On [DATE] the Physician signed a Certification of Incapacity to Give Informed Consent, for Resident #2. On [DATE] the Health Care Surrogate and the Physician signed a Do Not Resuscitate Order (DNR). On [DATE] the Physician signed the [DATE] Monthly Physician Orders that documented Resident #2 was a Full Code. The clinical record showed a nurse's note dated [DATE] at 1:45 p.m., documented Resident #2 expired. There was no documentation Resident #2 received CPR. On [DATE] at 1:50 p.m., in an interview the DON said there needed to be a Physician Order for the DNR order that was faxed to the Pharmacy, to be included on the monthly Physician Orders. The DON confirmed Resident #2 did not have a Physician Order when the DNR was signed on [DATE]. The DON confirmed the May Physician Orders signed by the Physician on [DATE] documented Resident #2 was a full code and should have received CPR on [DATE]. On [DATE] at 6:00 p.m., the Administrator was informed of the determination of Immediate Jeopardy. The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed on [DATE] when corrective actions were verified in place, lowering the scope and severity of F578 to a D, isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Based on record review, review of the facility's policies and procedures, and staff and family member interviews the facility failed to implement their policies and procedures and demonstrate ongoing coordination to promote residents rights and ensure 3 (Resident #1, #3 and #2) of 22 residents reviewed for end of life received care and services according to their expressed wishes at the end of life. (Cross reference to F836) The facility failed to properly document Resident #1's expressed wishes to receive life-saving Cardiopulmonary Resuscitation (CPR) resulting in Resident #1's demise without initiation of CPR as per the Resident's documented request. The facility failed to ensure Resident #2's clinical record accurately reflected wishes for advance directives. Resident #2 did not receive CPR at the time of death despite the most recent physician's order specifying Resident #2's code status as full code. The facility failed to notify Resident #3's legal representative after a significant decline in condition. The facility did not afford Resident #3's legal representative the right to participate in medical care decisions as the Resident's medical condition declined and Resident #3 ultimately expired. Based on facility infection control records and staff interview, the facility also failed to identify and implement interventions to prevent urinary tract infections (UTIs) for twenty-eight residents identified as having UTIs in facility's records. The findings included: The facility's policy titled Advance Directives-Social Service with a creation date of 1-2017 specified: The facility staff will abide by resident advance directives, if known . 3. Social Services and/or Admissions staff must document, which must be a part of the resident's file confirming the parties were appropriately informed and an advance directive, if one exists, was obtained or was identified as to its location . f) Document discussion . i) After admission Social Services must be aware of wishes by the resident or responsible party regarding changes or revocation of any advance directives and communicate these desires to Administration and Medical and Nursing staff. Review of the admission process form (no date) revealed: Intake Paperwork Received and reviewed by supervisor or charge nurse. Review of 3008 [Medical certification for Medicaid Long-Term Care Services and Patient Transfer form], Advance Directives and H & P [History and Physical]. If there are no advance directives a FULL CODE form placed in front of chart. When a discrepancy occurs Social Services/DON [Director of Nursing] notified. Authorization to Treat Obtained. If a resident is disoriented their emergency contact is notified for verification, code status and advance directives. Legal representative to fax or Provide documentation upon admission. Nursing Data collected and documented. Reconciliation of admission orders to include code status and notify MD [physician] for verification. admission nurses note documented. Remainder of admission packet completed. All new admission records are reviewed by the interdisciplinary Team next business day for completion and accuracy. 1. Review of the clinical record on [DATE] showed Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to atrial fibrillation (irregular heartbeat) and Congestive Heart Failure. The clinical record contained a Do not resuscitate order form signed and dated [DATE] by a physician and the resident's spouse directing the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the resident in the event of the patient's cardiac or respiratory arrest. Review of the nurse's admission note dated [DATE] at 7:00 p.m., showed at the time of admission Resident #1 was AXO3 [Alert and oriented to person, time and place] and able to make needs known. The admitting nurse documented medications and baseline care reviewed copy given. The resident signed the authorization for treatment on [DATE]. Review of the physician's orders dated [DATE] showed a checkmark indicating Resident #1's code status was Do not resuscitate. Review of the Social Service Initial Assessment form dated [DATE] showed documentation the Social Service Director (SSD) obtained information from the resident. Under psychological evaluation the SSD documented Resident #1 was alert, cooperative, friendly, talkative and quick to understand. Under the mental status section, the SSD placed a checkmark in the boxes indicating Resident #1 was oriented to person, place and time. Under the advance directives section of the assessment, the SSD placed a checkmark in the box Not interested at this time. The clinical record lacked clear documentation of the resident's wishes to receive receive cardiopulmonary resuscitation (CPR) in case of cardiac . No clear documentation of the resident wishes was communicated to the Administrative, Nursing and Medical staff. Review of the Minimum Data Set assessment dated [DATE] showed documentation Resident #1 scored a 13 on the Brief Interview for Mental Status (BIMS) test. The BIMS test indicates a patient's cognitive ability and is scored from 0-15. A score of 13 to 15 indicates a cognitively intact. Review of the Advanced Registered Nurse Practitioner's (ARNP) notes showed the ARNP visited Resident #1 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. During each visit, the ARNP indicated in her note the discussion during/regarding the visit took place with the resident and nursing. On [DATE], the ARNP documented Hospice present to eval [evaluate] at spouse req [request]. Pt [patient] is A &O [alert and oriented] per Hospice declining services at this time. Review of the nurse's notes revealed on [DATE] at 7:00 a.m. This nurse was called into room [ room #], patient observed in bed on supine position with head of bed elevated at 30 [degrees], mouth slightly open eyes closed. No pulse, no respirations, no blood pressure reading. Night shift supervisor notified and came to see patient. DON notified at 7:10 a.m., unable to reach Dr. [name] or [name] ARNP, they did not answer [phone #] .left message to call us back. Dr. [name] notified at 7:35 a.m., and said 'yes, you can release the body' . The clinical record lacked documentation that the nursing staff had initiated CPR per Resident #1's documented wishes. On [DATE] at 1:25 p.m., in an interview the Social Services Director (SSD) said he completed Resident #1's Social Service assessment on [DATE]. The SSD said the resident was alert, oriented and was able to make her own decisions. He said Resident #1 made it clear she was not interested in a DNR (do not resuscitate) at the time. Her plan was to go home with home health. He said he wasn't aware of the presence of a DNR form in the clinical record. The SSD said It's not legal if somebody else signs it [DNR]. He said Resident #1 was not deemed incapable. The SSD added, from my perspective the DNR is not valid. He said when he looked at the chart, he did not see a DNR form in there. On [DATE] at 2:25 p.m., the DON reviewed the nurse's progress note for [DATE] and said it didn't look like they did CPR on Resident #1. She said she audits all new admissions and fills out an audit form. The form addressed the advance directives and code status. If there was no DNR they put full code in front of the chart. Review of the audit form dated [DATE] revealed DNR documented under the physician's orders section followed by the word incomp which was circled. She said the SSD was present when the chart was audited but she didn't know what was done to fix the incomplete DNR. On [DATE] at 3:10 p.m., the DON said when someone dies, she goes through the chart with the Administrator. They discuss the patient's code status and comorbidities, including COVID-19 status. She said she did not review Resident #1's chart after she passed away. On [DATE] at 2:00 p.m., in an interview with Licensed Practical Nurse (LPN) Staff A she said on [DATE] she admitted Resident #1. During a side by side review of the nurse's note LPN Staff A said Resident #1 was alert and oriented X3 (person, place and time) and was able to answer questions. LPN Staff A said she could not recall discussing advance directives or code status with Resident #1 upon admission. She said: The facility's policy is that if they come with the yellow DNR paper then they can honor that. LPN Staff A said she since she checked off DNR on the physician's orders Resident #1 must have been a DNR. She said Resident #1 came with a yellow DNR form, so she marked the resident's status as DNR in the chart. On [DATE] at 2:50 p.m., in an interview with the Medical Director he said if the resident was competent, she should have signed her own DNR. After reviewing the clinical record, the Medical Director said he could not find a diagnosis of mental incompetency. He said the patient was perfectly competent to make her own decisions. After conducting a review of the chart, including the hospital records and the attending physician's progress note, the Medical Director pointed at the yellow DNR form and said This is wrong. We shouldn't have accepted it. He said Resident #1 should have signed her own DNR. He said if there was doubt, he would ask the psychiatrist to assess and document competency. On [DATE] at 3:20 p.m., in an interview with the ARNP, she said Resident #1 was pretty alert and oriented and was able to make her own health care decisions. She said she remembered Resident #1 refusing hospice services and she documented it in her notes. On [DATE] at 3:40 p.m., in a telephone interview the Night Shift Nursing Supervisor said when Resident #1 expired she checked the chart to make sure she was a DNR. She said there was a DNR in the chart. The Night Shift Nursing Supervisor said she checked the chart for the presence of a completed and valid DNR form because she came across some that were not completed. She verified Resident #1 did not receive CPR. On [DATE] at 3:45 p.m., in an interview with Registered Nurse (RN) Staff B she said when Resident #1 died they called her because she was the RN on the unit. She said Resident #1 had a yellow DNR paper in her chart, so they did not do CPR. She said once the DNR was placed in the clinical record it means that it's all complete and was valid. On [DATE] at 10:15 a.m., in an interview the admission Coordinator said she typically greeted the patients on the day they arrived at the facility depending on the time of admission. She said her role included to review the admission packet with the residents and fill out an Advance Directives Checklist form based on the information faxed from the hospital. She said she wasn't sure but thought she tried to see Resident #1 on the day she was admitted . She said she believes the patient refused to sign any form, including the advanced directives checklist form. She said she did not inform the DON or the SSD of the resident's refusal to sign the form but mailed it to the husband who returned it blank. Review of Resident #1's Advance Directives checklist form dated [DATE] revealed a blank form. The form did not indicate Resident #1's wishes for CPR in case she suffered from cardiac or respiratory arrest. On [DATE] at 12:00 p.m., in a telephone interview the Attending Physician verified he saw Resident #1 on [DATE]. He said he could not remember the resident. He said he reviewed his note but could not say if she was competent or not to make her own decisions. 2. Review of the policy and procedure titled Change in Condition Notification with a creation date of 6/2016 showed: a) Nurse immediately notifies physician, resident and designated representative of a significant improvement or decline in the resident's physical, mental or psychosocial status. b) Nurse immediately notifies resident and designated representative of any significant alteration in treatment (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) d) Notification is documented in nurses notes and reflects name of person notified and the change in condition and/or treatment . Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE]. Review of the advance directives showed on [DATE] Resident #3 appointed a health care representative to a) authorize, arrange for, consent to, waive and terminate any and all medical and surgical procedures on my behalf (including any election or election and agreement under the Life-Prolonging Procedures Act with request to providing, withholding or withdrawing life-prolonging procedures should I fail to make a declaration hereunder) and to pay or arrange compensation for my care. b) To make health care decisions for me and to provide informed consent if I am incapable of making health care decisions or providing informed consent. (i) To be the final authority to act for me and to make health care decisions for me in matters regarding my health care during any period in which I have the incapacity to consent. (ii) To expeditiously consult with appropriate health care providers to provide informed consent in my best interest and make health care decisions for me which my said Surrogate believes I would have made under the circumstances if I were capable of making such decisions . On [DATE], the physician signed a certification of incapacity indicating Resident #3 lacked capacity to give informed consent and make health care decisions based on a diagnosis of dementia. Review of the seven nurse's notes from [DATE] through [DATE] showed documentation Resident #3 was alert and responsive. On [DATE], the nurse documented Resident #3 was alert, responsive, no signs and symptoms of pain or distress. The resident had one episode of emesis (vomiting) after lunch. Review of the attending physician's progress note showed documentation on [DATE], he examined at the request of the nurse because of change in mental condition: Lethargic, mouth breathing. Examined in her bed: Does not respond to verbal stimuli .This is an elderly female with advanced dementia, she is DNR. Will order comfort measures . Plan of Care . comfort measures. At the time of the survey, the clinical record lacked documentation Resident #3's health care surrogate was notified of the acute change in condition and afforded the right to participate in the decision to initiate comfort measures. On [DATE] at 5:30 a.m., the nurse documented: Resident without pulse + respirations @ [at] 5:10 AM. RP [Name] (POA [power of attorney]/niece) notified of the expiration. On [DATE] at 11:45 a.m., in an interview the DON said if there was a decline, they would notify the family. She said If they are really bad we let the family come and visit. If they are a DNR or hospice we will inform the family of the decline and ask if they want the resident sent out to the hospital. It is documented in the chart, in the nurse's notes. On [DATE] at 1:05 p.m., in an interview the Attending Physician said the nurses called him and discussed a change of condition. He said Resident #3 may have had COVID-19 since a change of mental condition was often the first sign in the elderly. He verified he ordered comfort measures only. He said he did not call the family to inform them of a change of condition but relied on the nurses to do that. He said due to Resident #3's medical condition and her age he did not have her sent to the hospital, since there was nothing they could have done for her. He said if the family wanted to transfer her to the hospital, he would have contacted them himself and spoke to them to make them change their mind. The Attending Physician said in the case of Resident #3 no one informed him the family wanted to send her to the hospital. On [DATE] at 2:00 p.m., the DON said she could not find any documentation of family notification for the decline. She said normally the nurse would call the family and the facility allowed the family to come and visit under those circumstances. She said the Medical Record Supervisor was currently looking for additional documentation. The DON said she did not review the resident's clinical record upon her death. On [DATE] at 4:35 p.m., in a telephone interview Resident #3's legal representative replied absolutely not when asked if the facility called to report a change in condition in the days prior to the resident's death. She said They called me on a Friday morning to tell me she had passed. I was shocked. No one told me her condition had deteriorated. On [DATE] at 4:45 p.m., the DON said she spoke to the nurse on duty on [DATE]. She said the nurse could not remember contacting the legal representative about the change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policies and procedures, and staff and family member interviews the facility failed to manage the facility resources and processes effectively in order to ensure and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as it relates to residents' rights and infection control during the COVID-19 pandemic. This failure to consistently implement policies and procedures resulted in lack of coordination of advance directives to ensure 3 (Resident #1, #3 and #2) of 22 residents reviewed for end of life received care and services according to their expressed wishes at the end of life. This failure can likely cause confusion as to the residents wishes, and lead to a serious outcome. The failure of the facility to consistently implement policies and procedures and respect residents formulated wishes for advanced directives at the end of life resulted in a pattern of noncompliance at the Immediate Jeopardy level starting on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 6:00 p.m. The immediacy was removed on [DATE] at 5:00 p.m., after credible evidence of measures taken to correct the Immediate Jeopardy. The scope and severity was subsequently lowered to a level II, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Cross reference F 578 and F 880 The findings included: 1. The facility failed to properly document Resident #1's expressed wishes to receive life-saving Cardiopulmonary Resuscitation (CPR) resulting in Resident #1's death without initiation of CPR as per the Resident's documented request. 2. The facility failed to ensure Resident #2's clinical record accurately reflected wishes for advance directives. Resident #2 did not receive CPR at the time of death despite the most recent physician's order specifying Resident #2's code status as full code. 3. The facility failed to notify Resident #3's legal representative after a significant decline in condition. The facility did not afford Resident #3's legal representative the right to participate in medical care decisions as the Resident's medical condition declined and Resident #3 ultimately expired. 4. Record review of the facility's admission and discharge log for the month of [DATE] revealed that there were twenty-two resident deaths in twenty-three days, during the Coronavirus Disease 2019 (COVID-19) pandemic. The records were reviewed to see how many residents died of COVID-19 and if the records were complete and accurate. The records were also reviewed for monitoring of residents for COVID-19 and an operational infection control program to deter the spread. On [DATE] at 1:23 p.m., in an interview with Director of Nursing (DON), a request was made regarding any documentation that the infection control logs were analyzed on a daily or weekly basis as the information came in and in the case of the urinary tract infection (UTI) was there any education to staff certified nursing assistants and nurses. The DON said the Assistant Director of Nursing (ADON) who did the infection control logs had been out of the facility for the past two weeks. When asked about the information on the March and [DATE] logs, DON did not comment. On [DATE] at 1:38 p.m., in an interview the Administrator said the requested information should be in the infection control books. When the infection control books were reviewed with the Administrator there was no evidence that the infection control nurse did any active program and just collected the date and placed it on the logs and totaled the numbers at the end of the month. The Administrator said the ADON/Infection Control Nurse was not available for interview and was unable to show any evidence of a working infection control program. On [DATE] at 9:50 a.m., in an interview the DON said she didn't know how many residents passed away in May and maybe 20 or 30. She said the Administrator goes over the death charts and kept a list. She said the most deaths in one day was three and was unaware there were five deaths on [DATE]. She said they went over the death the next day in the clinical stand-up meeting, but they didn't do a formal chart audit and document issues. When asked about several of the particular residents and their charts she said, I didn't do that one. She said it's the Administrator and her responsibility to review the charts after a death. She said she believed she reviewed each chart, but she did not have any evidence to show for that. The DON was unable to say how many of the twenty-two residents that died in the month of May were COVID-19 positive.