**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to protect the resident's right to be free from neglect for one resident (#59) out of two residents sampled for abuse/neglect. The facility neglected to properly report, assess, document, and intervene in a timely manner for Resident #59 related to an unwitnessed fall with major injury that occurred on [DATE]. This lack of intervention resulted in physical pain and suffering for the resident until his death on [DATE]. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #59 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 a D after verification of removal of immediacy of harm. Findings included: Resident #59 was admitted to the facility on [DATE] with diagnoses to include: dementia, coronary artery disease, atrial fibrillation, hypertension, failure to thrive, major depression disorder, insomnia, and cardiac pacemaker. The resident was placed in Hospice care on [DATE]. A review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #59 had a Brief Interview of Mental Status score of 00, indicating severe cognitive impairment. A review of the Order Summary Report, dated [DATE], for Resident #59 revealed the following: -Regular diet, soft and bite sized texture, thin liquids consistency -Alerting bracelet: located on left ankle, check for placement every shift -Do Not Resuscitate, Palliative Care -Hospice Diagnosis: Cerebral Atherosclerosis -May go on leave with supervision -Citalopram Hydrobromide oral tablet 40 milligram (mg) one time a day for depression -Depakote sprinkles 250 mg twice a day for depression -Morphine Sulphate 0.25 milliliter (ml) every 4 hours as needed (PRN) for pain 5-10/SOB (shortness of breath) order started on [DATE] -Trazodone Hydrochloride 25 mg daily at bedtime -STAT (Emergent) x-ray Right hip ordered [DATE] -Lorazepam 0.5 mg every 8 hours for anxiety/agitation/restlessness/sob started [DATE] -Morphine Sulphate 0.25 ml every six hours for chronic pain and continue PRN Morphine started [DATE] -Release body to FH (funeral home) [DATE] A review of a radiology report, dated [DATE] revealed: X-ray Right Hip Acute intertrochanteric fracture of the right femur with varus angulation and mild displacement. Lesser trochanteric avulsion fragment is mildly displaced. No dislocation. No other fractures are identified. Moderate right and mild left hip arthrosis. Conclusion: Acute fracture of the right hip. A review of the Care Plan for Resident #59 revealed the following: Focus: Risk for falls--initiated [DATE] Interventions included: 1:1 supervision started on [DATE] and completed on [DATE] Family educated not to transfer resident [DATE] Post event skin check [DATE] Focus: Right Hip fracture-initiated [DATE] Interventions included: Monitor signs/symptoms complications related to mobility alteration; joint stiffness/pain, swelling, decline in mobility/self-care, contracture formation, creaking/clicking with joint movement, pain after exercise/weight bearing. A review of the Progress Notes for Resident #59 revealed the following: -[DATE] post fall review completed reads: 3/31 at 915 a.m. Therapy walking by room and saw resident become unsteady and fall. nonskid socks floor not wet. call light within reach. adequate lighting. -[DATE] Resident fall--no nursing notes indicating the event occurred at all -[DATE] Resident family is at bedside and reporting that resident is having pain to right hip. Resident does not verbalize pain but grimaces with movement. MD notified and stat X-ray ordered. -[DATE] LATE ENTRY: IDT (Interdisciplinary team) note-for [DATE] at 1640 CNA (Certified Nursing Assistant) found resident on the floor and notify nurse. Nurse assessed resident and full ROM (range of motion) to all extremities. Nurse attempted to get resident off the floor and resident was being combative, kicking and hitting the staff. After giving resident some space making sure there was no items around resident that would harm him. Resident was able to assist with transfer and 2 other staff members helped. He was placed back on his w/c (wheelchair) and brought to the dining room. Snack given and resident ate it without discomfort. No complaints of pain or facial grimacing noted. He had a small skin tear to his elbow. Cleansed with NS (normal saline) and LOTA (left open to air). Hospice was notified with NNO (no new orders) at this time. Resident [family member] came in about an hour after incident . He was notified of incident, and he stayed to assist with dinner resident ate 100% of his dinner and [family member] stated he transferred his dad back to bed and he complained of pain. He stated, I hope I didn't hurt him. Nurse educated son on not transferring resident without staff assistance. Medications administered and resident is resting in bed . -[DATE] IDT note: CNA reported resident was on the floor on [DATE] at 1640 p.m. Nurse assessed resident and full ROM to all extremities. Son came in to assist resident with dinner and transferred resident to bed without waiting for assistance. He was educated by nurse on calling for assistance he stated, He complained of pain I hope I didn't hurt him. Resident was medicated at the time. Following day resident was not complaining of pain and continued his normal activities without difficulties .On [DATE] Resident [family member] took resident outside to the courtyard as usual without any concerns. She brought him back to his room and transferred him to bed without assistance. She then grabbed hospice nurse and told her that her dad was complaining of pain. Hospice ordered X-ray of right hip, and result obtained with right trochanteric fracture mild displaced . [DATE] Resident with family at bedside. No VS noted, pronounced by 2. MD notified, order to release body received. Spouse notified. Hospice notified. Resident passed at 1045 a.m. -[DATE] Minimally responsive to verbal/tactile stimulation. Per family report, no longer able to swallow and is not accepting fluids .lethargic. -[DATE] Resident with family at bedside. No vital signs noted., pronounced by 2 A review of the Narcotic Log for Resident #59 revealed a prn pain medication order for Morphine Sulphate was available since [DATE]. No pain medications were administered to the resident until after the unwitnessed fall on [DATE]. The first doses of Morphine were administered on [DATE] after an X-ray was taken and confirmed a fracture to the right hip. On [DATE] at 2:56 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated Resident #59 had a fall on [DATE] but it was not reported to her until [DATE]. She stated the incident was reported by a family member to the hospice nurse and her at the same time. She stated she had no knowledge of the fall prior to [DATE] and she could find no notes related to the fall on [DATE] in the progress notes. The DON stated an investigation was started but no other reports were filed related to the incident. The DON stated the family member reported to the hospice nurse that an aide told her Resident #59 had a fall on [DATE]. The DON said during an interview with Staff D, CNA, she told her on [DATE] she saw Resident #59 on the floor by the roommates bed, and the door to the room, and he was laying on his right side. Staff D, CNA told the DON she notified Staff B, Registered Nurse (RN), and the nurse came to do an assessment. The DON stated this was an unwitnessed fall. The DON said she spoke with Staff B, RN to take a statement about the incident. The DON stated, Staff B, RN said she assumed this was a behavior problem because the resident would be on the floor occasionally. The DON stated Staff B, RN did not call the doctor, notify the DON, or report the incident as a fall. The DON said Staff D, CNA told her the resident did not complain of pain and was put in a wheelchair after being found on the floor. The DON said the aide told her a family member helped Resident #59 back to bed after dinner, and mentioned the resident had pain so she went to tell the nurse. The DON said the family member was unaware the resident was found on the floor at the time. The DON stated the nurse noted a scratch to the elbow at the time and said the resident had no obvious signs of pain. The DON stated the nurse said Resident #59 was combative when they tried to get him off the floor and it took three of them. The DON said she spoke with other nurses and aides who provided care to Resident #59 on [DATE] and they reported no pain was observed. The DON said hospice ordered an X-ray to be done stat on [DATE]. The DON stated the resident complained of pain when she went in to assess him after finding out about the fall. She stated, He definitely had pain when I moved his leg around. The DON stated the family member said the resident was complaining of pain. She said the X-ray results came back with confirmation of a fracture. She stated, she completed the investigation and determined the nurse did not follow policy and report the incident as an unwitnessed fall immediately. On [DATE] at 4:51 p.m. an interview was conducted with Staff B, RN. Staff B stated she was familiar with the resident and had cared for him intermittently because she was a float person. She stated she would provide care once or twice a week for Resident #59. Staff B, RN, stated on [DATE] she was coming on shift, and she had just finished counting narcotics. She said Staff D, CNA came to her to let her know Resident #59 was on the floor and she did not know what happened. She stated the resident would get on the floor sometimes and sometimes he would need help to get up. She stated she went to see the resident and noticed a scratch on his arm, and she called for help. She said Resident #59 was combative and it took three of them to get him up and put him in a wheelchair. Staff B, RN stated the resident was kicking them and, His range of motion seemed fine to me because he kicked me in the stomach, so I assumed it was one of his get down on the floor days. She said, I documented the incident somewhere, but I do not recall exactly where. The nurse stated the resident sat in his wheelchair until his family member came at dinner time around 6:00 p.m. The nurse stated the family member took the resident back to his room and the aide told her the family member put Resident #59 back to bed and said the resident was uncomfortable. The nurse stated it was time for the night medications, so she gave the resident some Lorazepam and Trazodone. She said she left around 11:00 p.m. after her shift and she did not do another assessment on Resident #59. Staff B, RN stated she found out two days later the resident was injured. She said she could not say it was a fall because the incident was unwitnessed. She stated for the residents that are care planned and get down on the floor she would not report the incident. She stated she did provide care for Resident #59 after the incident and he was always in bed, agitated, and receiving Morphine for the pain. She stated she was not aware if Resident #59 had a previous fall or if he was care planned for falls. An interview was conducted on [DATE] at 10:56 a.m. with Staff D, CNA. Staff D stated, On [DATE] I went down the hall to check on all my residents and I saw the resident on the floor by the roommates bed. I checked on him and he was ok, so I went and got the nurse, I did not touch him or move him. The nurse came down to see the resident. She took vitals and looked at his head. Then three of us picked him up off the floor. He was combative swinging, punching and kicking us so that is why we had three people. He was placed in his wheelchair. Staff D stated Resident #59 did not speak so he could not say he was in pain, and they would have to see if he had a grimace to know if he was in pain. She said she did not see the resident do that. She stated she wheeled the resident to the dining room and gave him a cookie. She said he sat in the chair and ate his cookie. She said she did not see him again until after dinner and he was in his room with a family member who had helped him back into bed. She said the family member told her the resident had pain and stated, I hope I did not hurt him. She said she informed the nurse what the family member told her. She said on [DATE] a family member told her she heard the resident had a fall and she asked me what happened. She stated she told the family member she had found the resident on the floor on [DATE]. She said they took x-rays and found out the resident had a fracture. She stated when she found the resident on the floor she did what she was supposed to do and notified the nurse. She stated she did not tell anyone else. The aide stated she had received education on reporting falls and had signed a paper yesterday. An interview was conducted on [DATE] at 11:16 a.m. with the NHA and the DON. The NHA stated she did not report the incident because she felt finding the resident on the floor was not the cause of the injury. She stated she felt after looking at all the information and doing the investigation the injury occurred when the family member admitted transferring the father to the bed and stated, I hope I did not hurt him. The DON and the NHA stated the nurse did not follow the proper policy and procedure required for a change of status, or unwitnessed fall and report it immediately to the DON. An interview was conducted on [DATE] at 3:51 p.m. with Staff C, Hospice RN. Staff C, RN stated she had taken care of Resident #59 the entire time he was in hospice care at the facility. She stated he was declining from dementia, and he was still eating some and was able to get out of bed and take walks with his family. She stated due to his dementia he was always combative, and he had a few falls while at the facility. She stated he did not speak, and he could be hard to handle but he had never hurt himself before. She stated he was never able to get up and walk or get into a wheelchair by himself, he always needed assistance. She stated prior to the fall he was having a slow decline due to dementia that was typical for the disease. She stated he had started to lose weight and was weak. She stated she was in to see the resident early in the morning of the 14th. She said they had him up in a wheelchair. She said she was seeing another patient when an aide told her the family member wanted to talk to her. Staff C, RN stated the family member told her there was something not right and informed me the facility had found him on the floor a few days before. She said that was the first time she had heard of a fall. She said she informed the DON, the nurse, and the unit manager and none of them appeared to know he was on the floor at all. She said she got an order for an X-ray, and they determined he had a fracture. She stated the family was very involved in the care of Resident #59 and spent many hours a day with him. She stated the family was able to properly assist the resident from a wheelchair to the bed. The hospice doctor gave orders for him to remain in bed and have pain medication around the clock as well as needed. The RN stated a meeting was held with the family and the decision was to allow the resident to just receive comfort measures and pain management for the fracture. She stated the family members were able to tell when the resident was in pain and they would call and let her know if he was comfortable or if he needed more. She stated Ativan was added for agitation as he got closer to death. She stated prior to the fracture he did not appear to be in a lot of pain and really did not require the Morphine that was ordered for him. She stated she was not aware that the resident would throw himself on the floor and it was not ever relayed to her he did so. A telephone interview was conducted on [DATE] at 4:24 p.m. with the Power of Attorney (POA) for Resident #59. The POA stated she was notified by another family member on [DATE] that the resident had a fracture, and he had been found on the floor a couple of days before. The POA stated a family member who was visiting on the 14th observed the resident during a transfer to the bed and the resident yelling in pain. The family member told her she went to the hospice nurse and asked the nurse to come and see the resident and informed her of the incident from [DATE] when he was found on the floor. The POA stated she was not informed of the resident being found on the floor and the nurse never even filed a report or told the doctor. The POA stated the family has been assisting the resident with all of his care and they were capable of assisting him in and out of bed. She stated they knew how to be careful, go slowly, and pivot him into the bed. The POA said on [DATE] when the family helped him at dinner and then took him back to his room he had pain when moving and it was reported by the family member to the facility nursing staff. The POA stated prior to the hip fracture they were getting him up in his chair and taking him to meals. She said they would take him outside for a walk and he never had pain. The POA stated they did have some type of normal routine prior to the fall. The POA stated the doctor said surgery was not an option, and he was too weak to be treated so the best thing we could do is keep him comfortable. A telephone interview was conducted on [DATE] at 9:09 a.m. with the Primary Care Provider (PCP) for Resident #59. The PCP stated he had taken care of Resident #59 for 40 years and knew the entire family well. He stated the resident suffered from bad dementia and was quite combative. The doctor stated the resident had trouble walking and had a history of falls. He stated he received a call from the family about a hip problem and told him the resident had a broken hip. The PCP stated after a discussion with the family it was decided Resident #59 had no quality of life and due to dementia he would not be a candidate for an operation. The PCP stated it was decided to just provide palliative care and pain medications for the fracture. The doctor stated he heard there was a fall, but no one had witnessed the fall so he was not aware of the details. He stated he was not notified on [DATE] of a fall and did not find out until [DATE] when the family called him. The doctor stated Resident #59 had a high tolerance for pain and when he went to see him he was on medications, and his pain was about a six. He stated the resident could withstand a lot of pain. A review of the facility policy entitled Abuse and Neglect Prohibition, revised 8/2023, revealed the following: Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, exploitation, and misappropriation of property. Fundamental information: Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Procedure: Training 1 The center will train each employee regarding these policies. Prevention 3 Staff will be instructed to report any signs of stress from family and other individuals involved with the resident that may lead to abuse, neglect, or misappropriation of resident property, and intervene as appropriate. 4 Residents identified by staff as being self-injurious or exhibiting abusive behavior, which requires professional services not provided in the center, will be reviewed by the physician and treatment plans modified as appropriate. A review of the facility policy entitled Procedural Guidelines: Change in Condition, revised 9/2023 revealed the following: Purpose: The center will inform the resident, consult with the resident's physician, and notify the resident's family member or legal representative when there is a change requiring such notification. Fundamental Information: Situations requiring notification include: 1 An accident involving the resident which: -Resulting in injury. -Potential to require physician intervention. 2 A significant change in the resident's physical, mental, or psychosocial status that is , a deterioration in health, mental, or psychosocial status in life-threatening conditions or clinical complications. 6 Upon the identification of a change in condition in a resident, the nurse will complete an evaluation of the resident's status, and document findings on the SBAR Change in Condition in the resident's medical record. A review of the facility policy entitled Incident Reporting for Residents or Visitors, revised 8/2023, revealed the following: Policy: All accidents and unusual occurrences involving a resident or visitor will be documented and reported so as to meet all regulatory requirements. Fundamental Information: Adverse Event-An untoward, undesirable, and usually unanticipated event that causes death or serious injury to risk thereof. Procedure 1 When an unusual occurrence is discovered, the employee making the discovery will notify his or her immediate supervisor of the discovery. The supervisor will notify the Administrator and DON immediately. 8 The person discovering the event must complete the Incident/Accident Report prior to completing the shift. Facility immediate actions to remove the Immediate Jeopardy included: A. Reported to the Abuse Hotline. Completed on [DATE] B. The 1-day report was submitted to AHCA. Completed on [DATE] C. Review of facility staff for current background checks. Completed [DATE] D. Licensed staff will be re-educated on the centers policy on Change of Condition and AI\TE to include recognition, assessment, interventions, documentation, and reporting of a change in condition or unwitnessed falls to determine if an injury exists in a timely manner. Completed 100% (16 RN's, 17 LPN's, and 53 CNA's) by 5 pm on [DATE]. E. All staff will be re-educated prior to working their next scheduled shift regarding abuse, neglect, exploitation allegations. Ongoing. F. New hire orientation will continue to have education to include Change of Condition and ANE to include recognition, assessment, interventions, documentation, and reporting of a change in condition or unwitnessed falls to determine if an injury exists in a timely manner. The facility does not utilize agency or temporary staff. G. Licensed and certified staff will have retention questions after education to gauge competency of timely recognition, notification, documentation, timely assessment and reporting a change in condition are completed. Verification of the facility's removal plan was conducted by the survey team on [DATE]. On [DATE] interviews with facility staff was conducted for 4 RN's, 12 CNA's, and 3 LPN's to verify education and training had been completed related to topics to include: change of status, abuse/neglect, reporting, unwitnessed falls, resident assessments, and documentation of all unusual occurrences. All staff were able to voice understanding of the policies and processes required to provide competent care to residents. The staff interviewed have worked across all shifts. A review of the sign in sheets was conducted to verify education and training was completed as outlined in the IJ removal plans. --In-service topic completed for nursing staff members to include Change in Condition, Stop and Watch Alerts, ANE and signed off for 102 employees and was completed on [DATE]. --In-service topic completed for nursing staff members to include Pain Evaluation and signed off for 90 employees and was completed on [DATE]. --In-service topic completed for all other employees to include Change in Condition, ANE, and Stop and Watch Alerts and signed off for 100% of staff was completed on [DATE]. 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 D.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure licensed nursing staff were knowledgeable and competent to provide care and services for four residents (#59, #74, #29, and #35) out of forty residents sampled related to: 1) failure to recognize and provide treatment for an unwitnessed fall; 2) failure to follow physician orders for laboratory testing; 3) failure to provide a safe hazard free environment; and 4) failure to complete resident identification prior to administration of medications. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #59 and resulted in the determination of Immediate Jeopardy on 6/04/2025. The findings of Immediate Jeopardy were determined to be removed on 6/05/2025 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: 1. Resident #59 was admitted to the facility on [DATE] with diagnoses to include: dementia, coronary artery disease, atrial fibrillation, hypertension, failure to thrive, major depression disorder, insomnia, and cardiac pacemaker. The resident was placed in Hospice care on 2/7/2025. A review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #59 had a Brief Interview of Mental Status score of 00, indicating severe cognitive impairment. A review of the Order Summary Report, dated May 2025, for Resident #59 revealed the following: -Regular diet, soft and bite sized texture, thin liquids consistency -Alerting bracelet: located on left ankle, check for placement every shift -Do Not Resuscitate, Palliative Care -Hospice Diagnosis: Cerebral Atherosclerosis -May go on leave with supervision -Citalopram Hydrobromide oral tablet 40 milligram (mg) one time a day for depression -Depakote sprinkles 250 mg twice a day for depression -Morphine Sulphate 0.25 milliliter (ml) every 4 hours as needed (PRN) for pain 5-10/SOB (shortness of breath) order started on 2/03/2025 -Trazodone Hydrochloride 25 mg daily at bedtime -STAT (Emergent) x-ray Right hip ordered 5/14/2025 -Lorazepam 0.5 mg every 8 hours for anxiety/agitation/restlessness/sob started 5/22/2025 -Morphine Sulphate 0.25 ml every six hours for chronic pain and continue PRN Morphine started 5/22/2025 -Release body to FH (funeral home) 5/26/2025 A review of a radiology report, dated 5/14/2025 revealed: X-ray Right Hip Acute intertrochanteric fracture of the right femur with varus angulation and mild displacement. Lesser trochanteric avulsion fragment is mildly displaced. No dislocation. No other fractures are identified. Moderate right and mild left hip arthrosis. Conclusion: Acute fracture of the right hip. A review of the Care Plan for Resident #59 revealed the following: Focus: Risk for falls--initiated 3/1/2025 Interventions included: 1:1 supervision started on 4/3/2025 and completed on 4/7/2025 Family educated not to transfer resident 5/16/2025 Post event skin check 4/3/2025 Focus: Right Hip fracture-initiated 5/15/2025 Interventions included: Monitor signs/symptoms complications related to mobility alteration; joint stiffness/pain, swelling, decline in mobility/self-care, contracture formation, creaking/clicking with joint movement, pain after exercise/weight bearing. A review of the Progress Notes for Resident #59 revealed the following: -4/3/25 post fall review completed reads: 3/31 at 915 a.m. Therapy walking by room and saw resident become unsteady and fall. nonskid socks floor not wet. call light within reach. adequate lighting. -5/12/25 Resident fall--no nursing notes indicating the event occurred at all -5/14/25 Resident family is at bedside and reporting that resident is having pain to right hip. Resident does not verbalize pain but grimaces with movement. MD notified and stat X-ray ordered. -5/14/25 LATE ENTRY: IDT (Interdisciplinary team) note-for 5/12/2025 at 1640 CNA (Certified Nursing Assistant) found resident on the floor and notify nurse. Nurse assessed resident and full ROM (range of motion) to all extremities. Nurse attempted to get resident off the floor and resident was being combative, kicking and hitting the staff. After giving resident some space making sure there was no items around resident that would harm him. Resident was able to assist with transfer and 2 other staff members helped. He was placed back on his w/c (wheelchair) and brought to the dining room. Snack given and resident ate it without discomfort. No complaints of pain or facial grimacing noted. He had a small skin tear to his elbow. Cleansed with NS (normal saline) and LOTA (left open to air). Hospice was notified with NNO (no new orders) at this time. Resident [family member] came in about an hour after incident . He was notified of incident, and he stayed to assist with dinner resident ate 100% of his dinner and [family member] stated he transferred his dad back to bed and he complained of pain. He stated, I hope I didn't hurt him. Nurse educated son on not transferring resident without staff assistance. Medications administered and resident is resting in bed . -5/15/25 IDT note: CNA reported resident was on the floor on 5/12/25 at 1640 p.m. Nurse assessed resident and full ROM to all extremities. Son came in to assist resident with dinner and transferred resident to bed without waiting for assistance. He was educated by nurse on calling for assistance he stated, He complained of pain I hope I didn't hurt him. Resident was medicated at the time. Following day resident was not complaining of pain and continued his normal activities without difficulties .On 5/14/25 Resident [family member] took resident outside to the courtyard as usual without any concerns. She brought him back to his room and transferred him to bed without assistance. She then grabbed hospice nurse and told her that her dad was complaining of pain. Hospice ordered X-ray of right hip, and result obtained with right trochanteric fracture mild displaced . 5/26/25 Resident with family at bedside. No VS noted, pronounced by 2. MD notified, order to release body received. Spouse notified. Hospice notified. Resident passed at 1045 a.m. -5/17/25 Minimally responsive to verbal/tactile stimulation. Per family report, no longer able to swallow and is not accepting fluids .lethargic. -5/26/25 Resident with family at bedside. No vital signs noted., pronounced by 2 A review of the Narcotic Log for Resident #59 revealed a prn pain medication order for Morphine Sulphate was available since 2/04/2025. No pain medications were administered to the resident until after the unwitnessed fall on 5/12/2025. The first doses of Morphine were administered on 5/14/2025 after an X-ray was taken and confirmed a fracture to the right hip. On 6/03/2025 at 2:56 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated Resident #59 had a fall on 5/12/25 but it was not reported to her until 5/14/25. She stated the incident was reported by a family member to the hospice nurse and her at the same time. She stated she had no knowledge of the fall prior to 5/14/25 and she could find no notes related to the fall on 5/12/25 in the progress notes. The DON stated an investigation was started but no other reports were filed related to the incident. The DON stated the family member reported to the hospice nurse that an aide told her Resident #59 had a fall on 5/12/25. The DON said during an interview with Staff D, CNA, she told her on 5/12/25 she saw Resident #59 on the floor by the roommates bed, and the door to the room, and he was laying on his right side. Staff D, CNA told the DON she notified Staff B, Registered Nurse (RN), and the nurse came to do an assessment. The DON stated this was an unwitnessed fall. The DON said she spoke with Staff B, RN to take a statement about the incident. The DON stated, Staff B, RN said she assumed this was a behavior problem because the resident would be on the floor occasionally. The DON stated Staff B, RN did not call the doctor, notify the DON, or report the incident as a fall. The DON said Staff D, CNA told her the resident did not complain of pain and was put in a wheelchair after being found on the floor. The DON said the aide told her a family member helped Resident #59 back to bed after dinner, and mentioned the resident had pain so she went to tell the nurse. The DON said the family member was unaware the resident was found on the floor at the time. The DON stated the nurse noted a scratch to the elbow at the time and said the resident had no obvious signs of pain. The DON stated the nurse said Resident #59 was combative when they tried to get him off the floor and it took three of them. The DON said she spoke with other nurses and aides who provided care to Resident #59 on 5/13/25 and they reported no pain was observed. The DON said hospice ordered an X-ray to be done stat on 5/14/25. The DON stated the resident complained of pain when she went in to assess him after finding out about the fall. She stated, He definitely had pain when I moved his leg around. The DON stated the family member said the resident was complaining of pain. She said the X-ray results came back with confirmation of a fracture. She stated, she completed the investigation and determined the nurse did not follow policy and report the incident as an unwitnessed fall immediately. On 06/03/2025 at 4:51 p.m. an interview was conducted with Staff B, RN. Staff B stated she was familiar with the resident and had cared for him intermittently because she was a float person. She stated she would provide care once or twice a week for Resident #59. Staff B, RN, stated on 5/12/25 she was coming on shift, and she had just finished counting narcotics. She said Staff D, CNA came to her to let her know Resident #59 was on the floor and she did not know what happened. She stated the resident would get on the floor sometimes and sometimes he would need help to get up. She stated she went to see the resident and noticed a scratch on his arm, and she called for help. She said Resident #59 was combative and it took three of them to get him up and put him in a wheelchair. Staff B, RN stated the resident was kicking them and, His range of motion seemed fine to me because he kicked me in the stomach, so I assumed it was one of his get down on the floor days. She said, I documented the incident somewhere, but I do not recall exactly where. The nurse stated the resident sat in his wheelchair until his family member came at dinner time around 6:00 p.m. The nurse stated the family member took the resident back to his room and the aide told her the family member put Resident #59 back to bed and said the resident was uncomfortable. The nurse stated it was time for the night medications, so she gave the resident some Lorazepam and Trazodone. She said she left around 11:00 p.m. after her shift and she did not do another assessment on Resident #59. Staff B, RN stated she found out two days later the resident was injured. She said she could not say it was a fall because the incident was unwitnessed. She stated for the residents that are care planned and get down on the floor she would not report the incident. She stated she did provide care for Resident #59 after the incident and he was always in bed, agitated, and receiving Morphine for the pain. She stated she was not aware if Resident #59 had a previous fall or if he was care planned for falls. An interview was conducted on 6/04/2025 at 10:56 a.m. with Staff D, CNA. Staff D stated, On 5/12/25 I went down the hall to check on all my residents and I saw the resident on the floor by the roommates bed. I checked on him and he was ok, so I went and got the nurse, I did not touch him or move him. The nurse came down to see the resident. She took vitals and looked at his head. Then three of us picked him up off the floor. He was combative swinging, punching and kicking us so that is why we had three people. He was placed in his wheelchair. Staff D stated Resident #59 did not speak so he could not say he was in pain, and they would have to see if he had a grimace to know if he was in pain. She said she did not see the resident do that. She stated she wheeled the resident to the dining room and gave him a cookie. She said he sat in the chair and ate his cookie. She said she did not see him again until after dinner and he was in his room with a family member who had helped him back into bed. She said the family member told her the resident had pain and stated, I hope I did not hurt him. She said she informed the nurse what the family member told her. She said on 5/14/2025 a family member told her she heard the resident had a fall and she asked me what happened. She stated she told the family member she had found the resident on the floor on 5/12/2025. She said they took x-rays and found out the resident had a fracture. She stated when she found the resident on the floor she did what she was supposed to do and notified the nurse. She stated she did not tell anyone else. The aide stated she had received education on reporting falls and had signed a paper yesterday. An interview was conducted on 6/04/2025 at 11:16 a.m. with the NHA and the DON. The NHA stated she did not report the incident because she felt finding the resident on the floor was not the cause of the injury. She stated she felt after looking at all the information and doing the investigation the injury occurred when the family member admitted transferring the father to the bed and stated, I hope I did not hurt him. The DON and the NHA stated the nurse did not follow the proper policy and procedure required for a change of status, or unwitnessed fall and report it immediately to the DON. An interview was conducted on 6/04/2025 at 3:51 p.m. with Staff C, Hospice RN. Staff C, RN stated she had taken care of Resident #59 the entire time he was in hospice care at the facility. She stated he was declining from dementia, and he was still eating some and was able to get out of bed and take walks with his family. She stated due to his dementia he was always combative, and he had a few falls while at the facility. She stated he did not speak, and he could be hard to handle but he had never hurt himself before. She stated he was never able to get up and walk or get into a wheelchair by himself, he always needed assistance. She stated prior to the fall he was having a slow decline due to dementia that was typical for the disease. She stated he had started to lose weight and was weak. She stated she was in to see the resident early in the morning of the 14th. She said they had him up in a wheelchair. She said she was seeing another patient when an aide told her the family member wanted to talk to her. Staff C, RN stated the family member told her there was something not right and informed me the facility had found him on the floor a few days before. She said that was the first time she had heard of a fall. She said she informed the DON, the nurse, and the unit manager and none of them appeared to know he was on the floor at all. She said she got an order for an X-ray, and they determined he had a fracture. She stated the family was very involved in the care of Resident #59 and spent many hours a day with him. She stated the family was able to properly assist the resident from a wheelchair to the bed. The hospice doctor gave orders for him to remain in bed and have pain medication around the clock as well as needed. The RN stated a meeting was held with the family and the decision was to allow the resident to just receive comfort measures and pain management for the fracture. She stated the family members were able to tell when the resident was in pain and they would call and let her know if he was comfortable or if he needed more. She stated Ativan was added for agitation as he got closer to death. She stated prior to the fracture he did not appear to be in a lot of pain and really did not require the Morphine that was ordered for him. She stated she was not aware that the resident would throw himself on the floor and it was not ever relayed to her he did so. A telephone interview was conducted on 6/04/2025 at 4:24 p.m. with the Power of Attorney (POA) for Resident #59. The POA stated she was notified by another family member on 5/14/2025 that the resident had a fracture, and he had been found on the floor a couple of days before. The POA stated a family member who was visiting on the 14th observed the resident during a transfer to the bed and the resident yelling in pain. The family member told her she went to the hospice nurse and asked the nurse to come and see the resident and informed her of the incident from 5/12/25 when he was found on the floor. The POA stated she was not informed of the resident being found on the floor and the nurse never even filed a report or told the doctor. The POA stated the family has been assisting the resident with all of his care and they were capable of assisting him in and out of bed. She stated they knew how to be careful, go slowly, and pivot him into the bed. The POA said on 5/12/25 when the family helped him at dinner and then took him back to his room he had pain when moving and it was reported by the family member to the facility nursing staff. The POA stated prior to the hip fracture they were getting him up in his chair and taking him to meals. She said they would take him outside for a walk and he never had pain. The POA stated they did have some type of normal routine prior to the fall. The POA stated the doctor said surgery was not an option, and he was too weak to be treated so the best thing we could do is keep him comfortable. A telephone interview was conducted on 6/05/2025 at 9:09 a.m. with the Primary Care Provider (PCP) for Resident #59. The PCP stated he had taken care of Resident #59 for 40 years and knew the entire family well. He stated the resident suffered from bad dementia and was quite combative. The doctor stated the resident had trouble walking and had a history of falls. He stated he received a call from the family about a hip problem and told him the resident had a broken hip. The PCP stated after a discussion with the family it was decided Resident #59 had no quality of life and due to dementia he would not be a candidate for an operation. The PCP stated it was decided to just provide palliative care and pain medications for the fracture. The doctor stated he heard there was a fall, but no one had witnessed the fall so he was not aware of the details. He stated he was not notified on 5/12/25 of a fall and did not find out until 5/14/25 when the family called him. The doctor stated Resident #59 had a high tolerance for pain and when he went to see him he was on medications, and his pain was about a six. He stated the resident could withstand a lot of pain. 2. On 6/2/25 at 1:26 p.m., an observation of Resident #74 revealed she was seated in a wheelchair by the nurse's station with an activity book in her hand. She was observed looking at the activity book and turned the pages. A review of Resident #74's admission record revealed an admission date of 8/3/23 with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, recurrent, unspecified, and cognitive communication deficit. A review of Resident #74's physician orders revealed the following: -Sertraline Hydrochloride [HCl] tablet 100 milligrams (mg) give 1 tablet by mouth at bedtime for depression, with a start date of 11/22/24. -Depakote tablet delayed release 125 MG (divalproex sodium) give 1 tablet by mouth two times a day for mood disorder related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; major depressive disorder, recurrent, unspecified, with a start date of 4/7/25. -Depakote [also known as Valproate or Valproic Acid] level every night shift every 6 month(s) starting on the last day of month for 1 day(s), with an order date of 7/24/24, start date of 7/31/24, and no end date. A review of Resident #74's care plan revealed the following: -[Resident #74] is at risk for complication of Antidepressant Medication Therapy r/t [related to] Depression Date Initiated: 02/08/2024, with interventions to include, . Consult with pharmacy, provider to consider dosage reduction when clinically appropriate. Date Initiated: 02/08/2024 . Monitor for side effects and adverse reactions of psychoactive medications: anticholinergic effects, irregular heartbeat, drowsiness, unsteady gait, tardive dyskinesia, EPS [Extrapyramidal symptoms] (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal idealizations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 02/08/2024 . Monitor ongoing s/s [signs and symptoms] of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. [negative] mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance, Psych [psychiatry] evaluation as indicated. -[Resident #74] is at risk for complications r/t Anticonvulsant medication use Date Initiated: 06/12/2024, with interventions to include, . Consult with pharmacy, provider to consider dosage reduction when clinically appropriate. Date Initiated: 06/12/2024 . Educate family/caregivers about risks, benefits and the side effects of medications. Date Initiated: 06/12/2024 . Monitor for side effects and adverse reactions of psychoactive medications: anticholinergic effects, irregular heartbeat, drowsiness, unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal idealizations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 06/12/2024 . Monitor ongoing s/s of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear, of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. A review of Resident #74's laboratory (lab) results for Depakote levels revealed they were completed on 8/1/24 with no other lab results for Depakote found in the medical record. A review of Resident #74's Treated Administration Record (TAR), dated January 2025, revealed the following order marked as completed, Depakote level every night shift every 6 month(s) starting on the last day of month for 1 day(s) -Start Date 7/31/2024. A review of Resident #74's progress notes from 9/2024 to 6/2025 revealed no documentation related to Depakote levels being completed or notification to the medical provider (MD) about labs not being completed. On 6/3/25 at 5:36 p.m., an interview was conducted with the Director of Nursing (DON). She said the order on the TAR alerts the nurse of when a lab needs to be completed. She said Resident #74's lab order was placed for the night shift to complete. The DON stated the check mark in the TAR means, It was completed. She said she would look in the lab book to see if there was Depakote level results for Resident #74. A review of March 2025 pharmacy recommendations was completed with the DON which revealed the following comments, [Resident #74] receives Divalproex Sodium [also known as Depakote] DR [delayed release] does not have trough concentration documented in the medical record since August 21,2024. The DON stated, The resident was off of Depakote per her [family member's] request. The [family member] wanted her off the medication. She said she thinks Resident #74 was not taking Depakote from January 2025 to April 2025. A review of Resident #74's discontinued physician orders for Depakote, from 10/2024 to 4/2025, revealed the following: -Depakote tablet delayed release 125 MG (divalproex sodium) give 2 tablet by mouth two times a day for depression, with a start date of 10/29/24 and end date of 1/14/25. -Depakote tablet delayed release 125 MG (divalproex sodium) give 1 tablet by mouth two times a day for depression, with a start date of 1/15/25 and end date of 3/3/25. -Depakote tablet delayed release 125 MG (divalproex sodium) give 1 tablet by mouth two times a day for depression related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; major depressive disorder, recurrent, unspecified, with a start date of 3/22/25 and end date of 4/7/25. On 6/4/25 at 9:23 a.m., a follow-up interview with the DON was conducted. She said she checked the lab book and did not find Depakote lab results for Resident #74. The DON said the unit manager (UM) was calling the lab to see if it was completed and if there are results. O 6/4/25 at 9:49 a.m., an interview was conducted with Staff G, Licensed Practical Nurse (LPN)/UM. She said the lab orders are reflected on the TAR. Staff G, LPN/UM stated, The 11:00 a.m. - 7:00 p.m. shift takes care of the lab. She said the nurse would see the lab order in the resident's TAR, then they would prepare the lab requisition, and put it in the lab book for the lab staff member when they arrive. Staff G, LPN/UM said she looked at the 24-hour report in the mornings and on Monday's they look at the 72-hour report for lab orders that need to be completed. She stated the Depakote lab order for Resident #74 was a standing order and it was a Glitch in the system. She said Staff H, Regional Nurse Consultant and former DON put in the original order which should have been triggered to complete every 6 months, but the order didn't populate. She stated, It didn't populate the next day that I had a lab to follow-up on. Staff G, LPN/UM confirmed the lab order did populate on the TAR for the nurse that night on 1/31/25. She said the check mark on the TAR for Depakote levels, on 1/31/25, meant the nurse signed off and acknowledged they were going to prepare the requisition for the lab. She said it did not mean the lab was completed. Staff G, LPN/UM said she had not been able to find a lab requisition for Resident #74. She said she spoke to the Medical Director today to let him know it was a missed lab. Staff G, LPN/UM said she received orders from the Medical Director to get the lab completed today and to change the Depakote level labs to be completed annually. She said there should have been documentation about what happened with the lab orders, if the MD was notified, and if the MD still wanted the lab completed and if so, then it needed to be re-ordered. On 6/4/25 at 4:48 p.m., the DON said the facility does not have a policy related to following physician orders, including lab orders. 3. During an observation on 06/02/2025 at 9:55 a.m., A pink disposable razor was identified on top of the toilet bowl of Resident #29's bathroom. (photographic evidence obtained) Review of Resident #29's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview Mental Status (BIMS) score of 05 out of 15, indicating severe cognitive impairment. During an interview on 06/02/2025 at 2:17 p.m., Staff N, Certified Nursing Assistant (CNA), stated razors are kept by staff and brought out when residents need them. She observed the pink razor on the back of the toilet and stated she believed it belonged to Resident #29's roommate because of the cognition level of the two residents. She stated the razor did not look like it came from the facility because the razors from the facility are blue. During an interview on 06/03/2025 at 12:29 p.m., Staff O, CNA stated she assists residents with shaving. She stated they have disposable razors that they use. Once the razor has been used it is tossed. During an interview on 06/03/2025 at 1:36 p.m. Staff P, CNA, stated razors should not be in the rooms of the residents, CNA's get the razors from the supply room on shower days. They are put in a sharps container once they have been used. All residents need assistance with using a razor and cannot use them on their own. During an interview on 06/03/2025 at 1:38 p.m., Staff Q, Licensed Practical Nurse (LPN), stated razors are only used on shower days. Sometimes family members bring in big bag of supplies and when they go into the residents' rooms, they find items they should not have. When they find the items, they usually take the items from the residents and educate the family. She said they do not know what the family is bringing in to the facility. During an interview on 06/03/2025 at 4:49 p.m., Staff R, LPN, stated she was assigned to Resident #29 and her roommate. She stated Resident #29 requires assistance to go to the bathroom so she would not enter the bathroom by herself. She stated Resident #29 cannot use a razor by herself because of her cognition and there should not be a razor in her room. During an interview on 06/03/2025 at 5:20 p.m., the Director of Nursing (DON), stated family can bring any items of preference if it is not prescription or over-the-counter medications. Family can bring in razors for an alert and oriented resident. The family goes to the nurse station with the items so everything can be labeled and inventoried. Alert and oriented residents who could use razors on their own have a lock box to keep these items in. The razor found in Resident #29's bathroom belonged to Resident #29. It was brought in by Resident #29's son and they sent out a text for education. It cannot be Resident 29's roommate because she does not have family to bring in items. 4. Resident #35's admission record revealed an admission date of 2/25/25 with diagnoses to include heat failure, hypertension and Diabetes Type 2. During a medication administration observation on 6/4/25 at 4:33 P.M. with Staff M, Registered Nurse (RN) administered Zofran and Tylenol extra strength to Resident #35 and did not verify the resident's identification prior to allowing the resident to take the medication. During an interview on 6/5/25 at 2:00 P.M. the Director of Nursing (DON) said staff are expected to verify resident identification prior to administering medications for safety. A review of the facility policy titled General Dose Preparation and Medication Administration, effective 12/1/07; revised 11/15/24 revealed the following: 3. Verify each time medication is administered that it is the correct resident. 5. During medication administration facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 5.1 Verify resident identification per facility policy (e.g.; picture, armband, name). A review of the facility policy entitled Abuse and Neglect Prohibition, revised 8/2023, revealed the following: Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, exploitation, and misappropriation of property. Fundamental information: Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or m[TRUNCATED]