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

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

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

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