**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 38 residents, with four residents reviewed for elopements (when a resident leaves the premises or a specific safe area without authorization and/or necessary supervision). Based on record review, observation, and interview, the facility failed to provide adequate supervision to prevent an elopement for cognitively impaired Resident (R) 1, who the facility identified as a high risk for elopement. On 04/05/24 at approximately 04:18 PM, R1 exited the facility's 200 hall through an unlocked door, which did not alarm. R1 walked approximately the length of a football field over cracked sidewalks, uneven grassy areas, a parking lot full of large potholes, and over several curbs before falling, between two apartment buildings, behind the facility. A community member living in the apartment building called 911 and reported R1 lying on the apartment complex lawn. At 04:45 PM, Certified Medication Aide (CMA) R saw an ambulance behind the facility and identified R1 on the ambulance stretcher. Emergency Medical Services (EMS) transported R1 to the local hospital for evaluation. The facility's failure to ensure R1 received adequate supervision to prevent an elopement which resulted in a fall outside of the facility, and the failure to ensure functioning door alarms and locks placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), unsteadiness on her feet, abnormalities of gait (manner or style of walk), and muscle weakness. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R1 had physical and verbal behaviors directed towards others during the look-back period. The MDS documented R1 had episodes of wandering during the look-back period, and the wandering episodes placed R1 at significant risk of getting to a potentially dangerous place. The MDS documented R1 was dependent on staff for toileting, bathing, and personal hygiene; and required substantial staff assistance with dressing and donning and doffing footwear. The MDS documented R1 required supervision or touching assistance with transfers, ambulation, and bed mobility. The MDS documented R1 had one non-injury fall and one minor injury fall during the look-back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/31/25, documented R1 had diagnoses of Alzheimer's disease, dementia, irritability, anger, and altered mental status. The CAA documented R1 displayed physical and verbal outbursts and wandering, and staff would redirect R1 as needed. The Falls CAA, dated 01/31/25, documented R1 had poor safety awareness and had fallen during the look-back period. The CAA directed staff to monitor R1 closely. R1's Care Plan documented R1 was independent most of the time with transfers, ambulation, and locomotion, but needed assistance at times when her gait was unsteady. The care plan documented R1 was at risk for falls and needed appropriate footwear. The plan directed staff to have R1's call light within reach. The plan directed staff to keep pathways in R1's room clear and unobstructed and when R1 had increased wandering, offer her activities to redirect her (12/13/22). The care plan documented R1 had cognitive deficits that affected her memory (02/15/24). The care plan directed staff to consider R1's physical needs when R1 was wandering (09/22/23). The Facility Incident Report, dated 04/07/25, documented on 04/05/25 at approximately 04:00 PM, CMA R reported she saw R1 at the front nurse's station. At 04:15 PM, video camera footage showed R1 pushing on the far-left side of the exit door on 200 hall. R1 pushed on the right side of the 200 hall exit door, and the door opened. R1 quickly exited the building and turned to shut the door. CMA R passed medication on the 400 hall at the back of the facility when she observed an ambulance behind the facility with someone on the stretcher with a purple jacket on. CMA R asked another CNA what color R1's jacket was, and the aide said purple. At that point, EMS turned the stretcher, and staff saw it was R1. CMA R ran down the hall, alerted LN G, ran back to the parking lot, and spoke to EMS personnel. At 04:47 PM, the ambulance pulled up in front of the facility to get a copy of R1's face sheet and told staff they were transporting R1 to the local hospital for testing and possible treatment. The emergency room Dismissal Instructions, dated 04/05/25, documented R1 had a urinary tract infection (UTI - an infection in any part of the urinary system) requiring antibiotics, and abrasions to her face due to a fall. The dismissal instructions directed R1 to take all of her antibiotics and to monitor the wounds on her face; keep the wound clean and dry, and if the wound started to have increased redness, purulent (producing or containing pus) drainage, or swelling, the wounds would need to be re-evaluated for infection. The dismissal instruction directed the facility that if R1 developed a fever, worsening altered mental state, or any other new, concerning symptoms, R1 should return to the emergency room for evaluation. CMA R's Notarized Witness Statement, dated 04/05/25, documented CMA R last saw R1 physically in the facility at 04:00 PM at the front nurse's station. CMA R stated she started her medication pass on the back hall at about 04:15 PM when CMA R started looking on the 400 hall to see if R1 was in one of the rooms. CMA R went into a room and saw an ambulance in the back parking lot, when she looked out the window. CMA R noted she saw EMS placing someone wearing a purple jacket on a stretcher. The statement documented CMA R asked another Certified Nurse Aide (CNA) what color jacket R1 had on, and she said Purple. EMS then turned the stretcher towards the window, and CMA R saw R1 lying on the stretcher. CMA R ran out to the parking lot and spoke with EMS personnel who told CMA R that R1 fell on the sidewalk. R1 was able to tell them her name. The statement recorded the ambulance came around to the front of the facility to get R1's face sheet around 04:47 PM. Certified Nurse Aide (CNA) M's Notarized Witness Statement, dated 04/05/25, documented CNA M saw R1 with another staff member, and then saw R1 headed around the corner with a nurse. The statement noted that after a while, CNA M asked a co-worker if she had seen R1 and the co-worker said she had not seen R1. CNA M noted she then kept her eye out for R1 and went to check with a co-worker if she had checked R1's room for her. CNA M's co-worker came out of R1's room and said R1 was not there. CNA M searched the front hall but saw no signs of R1, so CNA M went to the back hall to see if anyone had found R1. CNA M noted two aides came out of a room in a hurry, yelling something about R1. CNA M noted the ambulance was outside, and CNA M and another staff member stopped the ambulance, told them R1's name, and then ran back to the facility to report to the nurse. CNA N's Notarized Witness Statement, dated 04/05/25, documented CNA N saw R1 at approximately 04:00 PM, before staff started getting residents up. R1 stood at the end of the 400 hall with another resident. CNA N noted R1 stood at the end of 400 hall and CNA N called for R1 and then assisted R1 into a chair at the back nurse's station. CNA N documented that a co-worker approached her and asked if she had seen R1, so CNA N started looking for R1, but did not see R1. CNA N noted she and another aide went down the 400 hall looking for R1 when they saw an ambulance at the apartments behind the facility. CNA N noted she saw R1 being placed on the stretcher, and immediately notified the nurse. Licensed Nurse (LN) G's Notarized Witness Statement, dated 04/05/25, documented the last time LN G saw R1, R1 was walking down the 200 hall and had stopped around room [ROOM NUMBER], turned around and started walking north. LN G stated after the incident, she went down to the 200 hall exit door and attempted to open the door, but could not open the door using her whole body weight while she pushed the door handle. The Nurse's Note, dated 04/05/25, documented R1 arrived back at the facility via a private vehicle driven by R1's responsible party. A nurse-to-nurse report documented R1 had abrasions to her face and Bacitracin (antibiotic ointment) was applied to the abrasions; all the scans of R1's face and knees came back with no concerns. The note recorded R1 had a severe (UTI - an infection in any part of the urinary system) and received an injection of Rocephin (antibiotic) in the emergency room (ER). The Hospice Note, dated 04/06/25, documented R1 hurt her knee and had a lot of pain in the left knee. The note documented R1 had a hard time putting weight on her knee and used a wheelchair. R1 had a one-to-one CNA sitting with her. The note documented R1 had gotten out of the building and was brought to the ER on [DATE]. R1 had abrasions on her forehead, the bridge and tip of her nose, and her inner left eye was bruised. On 04/21/25 at 10:00 AM, observation of the area around the facility in which R1 traversed on 04/05/25, revealed R1 walked approximately the length of a football field around the facility. Observation of the area revealed cracked sidewalks, an uneven grassy lawn to the back parking lot, and the parking lot was cracked and uneven, with several very large potholes. On 04/21/25 at 10:30 AM, observation revealed R1 sat in a wheelchair watching an activity where other residents were playing a game. R1 had a large yellow/green bruise on the entire left side of her face with two abrasions to her nose. When asked if her face hurt, R1 said, Well, what's wrong with my face? On 04/21/25 at 11:00 AM, CMA R stated she last saw R1 around 04:15 PM, and then when she went to look for R1, she could not find her so she asked other CNAs if they knew where R1 was but no one knew, so they started searching rooms. CMA R stated she was in a resident's room and saw an ambulance out back loading someone in the ambulance, so CMA R asked another staff member what color R1's jacket was, and they said purple. CMA R said that EMS swung the cot around at that point, and CMA R saw R1. CMA R stated she ran out to the EMS and told them R1's name, and they said they were going to pull around and get a face sheet at the front of the building. CMA R stated she had received training regarding elopement. On 04/21/25 at 09:30 AM, Administrative Staff A stated they thought contractors working in the facility had unhooked the door alarm sensors, and then, when they went out the door, they did not shut it tight, so the mag-lock did not engage. Administrative Staff A stated that 1200-pound mag-locks had been installed on all doors on 04/16/25, and the 1200-pound mag-locks would pull the doors shut if they were within two inches of shutting. Administrative Staff A stated the door at the end of 200 hall was immediately secured and the mag-lock was functioning; the alarm was rewired and was now in working order. Administrative Staff A said all staff were re-educated on the facility's elopement policy, stop signs were placed on each exit door, and the signs also requested contractors to alert staff before using the exit doors so staff could stay at the exit doors until the contractors were done. Administrative Staff A stated the facility's elopement book was reviewed for accuracy, R1 was put on one-to-one over the weekend, and the findings of the incident were taken to an emergency Quality Assurance and Performance Improvement (QAPI) meeting. Administrative Staff A verified that all the door alarms and mag-locks were checked for functionality on 04/01/25. On 04/21/25 at 10:00 AM, Administrative Nurse D stated she thought contractors working on the back rooms down 200 hall had unhooked the door alarm from the censors, but the facility could not prove that. Administrative Nurse D verified the door alarm was not hooked up on 04/05/25. Administrative Nurse D showed the path staff thought R1 took when she exited the 200 hall. Administrative Nurse D stated R1 was on hospice and her ability to transfer and ambulate fluctuated from day to day; sometimes she was independent and all over the facility, and other days she was in a wheelchair. Administrative Nurse D stated R1 had been on 30-minute location checks because she was a high elopement risk. Administrative Nurse D stated all administrative staff were in the building fifteen to twenty minutes after R1 was seen outside, and all the doors were checked for functioning door alarms and mag locks. Administrative Nurse D stated that education on the Elopement Policy was started that day and that none of the staff could work before completing the education. Administrative Nurse D verified all education was completed on Wednesday, 04/09/25. The facility's Resident Elopement Policy and Procedure, revised December 2022, documented the facility strived to promote a safe and secure environment to help minimize the risk of residents leaving the premises or a safe area without the necessary supervision or authorization to do so. Risk for elopement was to be identified for residents, and an individualized care plan was developed based on risk. Staff are to investigate and report instances of potential elopement. The facility is to have a process to monitor the security of the premises on a routine basis. On 04/21/25 at 01:31 PM, Administrative Staff A was provided the Immediate Jeopardy [IJ] Template and notified the facility's failure to provide adequate supervision to prevent an elopement for R1 placed the resident in immediate jeopardy. The facility identified and implemented immediate corrective actions, which were completed on 04/16/25 and included: 1200-pound mag-locks were installed on all doors on 04/16/25. The door at the end of 200 hall was immediately secured, and the mag-lock was functioning. The alarm was rewired and in working order. All staff were re-educated on the facility's elopement policy. Stop signs were placed on each exit door, and the signs also requested contractors to alert staff before using the exit doors so staff could stay at the exit doors until the contractors were done. The facility's Elopement Book was reviewed for accuracy. R1 was put on one-to-one over the weekend. The findings of the incident were taken to an emergency QAPI. Because all corrective actions were completed before the onsite survey, the citation was deemed past noncompliance and existed at a J (isolated, immediate jeopardy) scope and severity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 42 residents. The sample included three residents reviewed for therapeutic diets (a modification of a regular diet to fit the nutrition needs of a particular person and are modified for nutrients, texture, and/or food allergies or intolerances). Based on observations, record review, and interviews, the facility failed to provide the physician-ordered thickened liquids to Resident (R) 1, who had a history of dysphagia (difficulty swallowing) and aspiration (inhaling liquid or food into the lungs). On 01/07/24, Certified Nurse Aide (CNA) M served R1 thin liquids during breakfast instead of nectar thick liquids (mildly thickened liquids). Licensed Nurse (LN) G observed R1 coughing and choking afterward. LN H suctioned R1 multiple times but R1 continued to sound congested. Staff sent R1 to the emergency room (ER). R1 arrived at the hospital in obvious respiratory distress, with abnormal lung sounds, and required bilevel positive airway pressure (BiPAP-medical device which helps with breathing) treatment. R1 returned to the facility later that day on antibiotics (medications used to treat bacterial infections) to treat aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit). The facility's failure to follow R1's therapeutic diet order for thickened liquids placed her in immediate jeopardy. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), personal history of transient ischemic attacks (TIA- temporary episode of inadequate blood supply to the brain), dysphagia, and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated 10/20/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. R1 required supervision or touching assistance with eating and had coughing or choking during meals or when swallowing medications. The Annual MDS dated 01/12/24, documented R1 had a BIMS score of 13 which indicated intact cognition. R1 required set-up/clean-up assistance with eating and had coughing or choking during meals or when swallowing medications. The Activity of Daily Living Functional/Rehabilitation Care Area Assessment (CAA) dated 01/23/24, documented R1 was dependent on staff for almost all of her activities of daily living (ADLs). She was able to feed herself once it was set up. The Nutritional Status CAA dated 01/23/24, documented R1 was on a pureed diet (mechanically altered therapeutic diet) with thickened liquids due to choking and aspiration pneumonia. R1's Care Plan, last revised on 12/11/23, documented she had a risk for choking due to pocketing food in her mouth and was sent to the ER for suspected aspiration on 12/11/23. The care plan directed staff to remind R1 to take small bites, chew, and swallow before putting more in her mouth. R1's Care Plan, dated 01/21/21, documented R1 was at risk to lose or gain weight due to her disease process. The care plan documented an intervention, dated 01/21/21, that directed staff to provide R1 her meals as ordered by the physician. The care plan documented an intervention, dated 01/04/24, that directed R1 had a regular diet with pureed texture and nectar-thick fluid consistency. The Orders tab of R1's EMR documented an order with a start date of 12/27/23 and discontinued date of 01/11/24, for a controlled carbohydrate diet (CCHO- a diet that manages the number of carbohydrates and benefits people with diabetes) with pureed texture and nectar consistency for aspiration pneumonia. The Orders tab documented an order with a start date of 01/11/24 for a CCHO diet with pureed texture and honey consistency liquids (thickened liquids consistent with honey or a milkshake) for aspiration pneumonia. The facility's investigative report, dated 01/10/24, documented on 01/07/24, R1 was eating breakfast in the main dining room and started to cough. A CNA brought R1 to LN H who noted R1's upper lung sounds evidenced fluid. LN H suctioned R1 and removed fluid but R1 continued coughing with less congestion. Staff called Emergency Medical Services (EMS) and they arrived quickly and took R1 to the hospital for evaluation and treatment. Upon further investigation, it was discovered that staff gave R1 regular juice when she was on nectar-thick liquids. R1 returned from the hospital at 12:30 PM via EMS with an order for antibiotics for possible aspiration pneumonia. In LN G's notarized Witness Statement on 01/07/24, LN G stated she went to the big dining room to get a blood pressure on a resident when she saw R1 choking. She told staff R1 was choking. R1 stated she was fine, but her voice was gurgling and LN G heard fluid in her throat. LN G stated R1 drank regular liquids. She stated staff took R1 out of the dining room to LN H and she followed behind. LN G stated she told LN H that R1 choked and needed to go to the ER to be suctioned. She stated R1 needed to be at the assisted table so she would not choke. LN G stated LN H suctioned R1 and got quite a bit of fluid out. She stated R1 talked a little better but was still full of fluid in her throat, so EMS was called, and staff sent R1 to the ER for aspiration. The Notes tab of R1's EMR revealed the following: A Nurse's Note on 01/07/24 at 08:45 AM documented R1 ate and drank at breakfast when she started to cough. The CNA brought R1 to LN H who noted R1's upper lungs were filled with fluid. LN H suctioned R1 several times and removed fluid with R1 still coughing but less congested. R1 was a puree diet with nectar thick liquids. R1 drank regular fluids. R1 left the facility at 08:36 AM to the ER. A Nurse's Note on 01/07/24 at 12:47 PM documented the nurse called the ER and the ER nurse stated R1 was resting. ER nurse reported they placed a BiPAP on R1 earlier to help with breathing. The ER nurse reported R1 received an injection of antibiotics and would return with an order for oral antibiotics. A Nurse's Note on 01/07/24 at 03:19 PM documented R1 returned from the ER at 12:30 PM via EMS. The CNA assisted R1 back to bed and R1 answered questions appropriately. R1 was hungry and wanted to eat a late lunch. R1's bilateral lungs had crackles (abnormal lung sounds that occur as a result of small airways suddenly snapping open and may indicate a person's lungs have fluid inside them or are not inflating correctly). R1 had a new order for Zithromax (azithromycin- antibiotic) for five days and Augmenting (antibiotic) for 10 days. A Nurse's Note on 01/07/24 at 03:24 PM documented that education was given to CNAs about R1 being on thickened liquids with a pureed diet. R1 sat at assist table for meals to ensure she received the proper diet. Upon request, the facility provided R1's hospital documentation from 01/07/24. The ED Provider Notes, dated 01/07/24, documented R1 arrived at the ER with complaints of sudden onset respiratory distress. The facility stated she was a high aspiration risk and was supposed to have thickened liquids but did not get thickened liquids with breakfast and staff believed she aspirated. R1 was in respiratory distress and mildly hypoxic (not getting enough oxygen). Upon arrival, R1 was alert and would respond by shaking her head yes or no. R1's breathing was labored and tachypneic (abnormally rapid breathing), BiPAP was initiated prehospital and was continued. R1 displayed obvious respiratory distress and her lung sounds were heavy with rales (crackles) bilaterally. The note documented a clinical impression for R1 as aspiration pneumonia of both lungs and R1 received new medications of Augmentin 875 milligrams (mg)/125 mg every 12 hours for 10 days for lower respiratory infection and Zithromax 500 mg daily for five days for lower respiratory infection. On 02/06/24 at 12:02 PM, R1 sat in her wheelchair at the assisted table in the dining room. She ate a pureed diet with honey thick liquids. Staff assisted residents at the table. On 02/06/24 at 12:34 PM, Dietary BB stated she reviewed diet orders, care plans, and communications for thickened liquids. She stated the diet cards listed the diets along with if a resident was on thickened liquids. Dietary BB stated dietary staff made the thickened liquids and on 01/07/24, a new staff member had brought R1 into the dining room who was not aware R1 was on thickened liquids. She stated the staff placed R1 at a table with her back to Dietary BB, so she was unable to see that the staff served her a beverage. On 02/06/24, CNA M was unavailable for an interview. On 02/06/24 at 12:39 PM, CNA N stated she knew who was on thickened liquids by their diet chart, and the nurses and dietary let them know. She stated communication was sent out for diet changes. She stated she did not hand out beverages at mealtimes and the only resident on thickened liquids was R1. On 02/06/24 at 12:54 PM, LN G stated on 01/07/24, she went into the dining room to get vitals and happened to look over at R1. She saw R1 was choking/coughing and stated to staff in the room that R1 was choking. LN G stated she went over to R1 and asked her if she was okay and R1 shook her head. She stated she noticed R1's cup had red juice in it, but it was not thickened. She stated she asked the staff in the dining room who gave R1 the juice, but Dietary BB stated she did not know, and it was probably one of the CNAs. LN G stated she told Dietary BB that she believed R1 was supposed to have thickened liquids and Dietary BB stated the staff member probably did not know that. LN G stated staff took R1 out of the dining room to LN H, who assessed her. LN G stated LN H suctioned R1 and got red liquid out. She stated R1 went to the hospital and came back that day with a diagnosis of aspiration pneumonia. LN G stated dietary staff were supposed to pass the thickened liquids since they served the food, silverware, and everything else. LN G stated staff knew who was on thickened liquids by the list at the nurses' station and it was listed on their dietary cards as well. On 02/06/24 at 01:06 PM, Administrative Nurse D stated R1 was served regular liquids instead of thickened. She stated usually dietary did the thickened liquids including making and serving them. Administrative Nurse D stated staff knew who received thickened liquids by their diet cards and on the [NAME] (a nursing tool that gives a brief overview of the care needs of each resident). She stated expected staff to look at the diet card or the [NAME] before serving anything to a resident. On 02/06/24 at 1:16 PM, Administrative Staff A stated he expected dietary to provide thickened liquids. He stated because of the incident, the facility bought pre-thickened liquids for staff to have available at all times. He stated staff knew who received thickened liquids by their care plan, in Point of Care (POC- EMR system for CNAs), and the resident's dietary card. The facility's Thickening Fluids policy, dated 2011, directed the dining service staff were responsible for thickening and distributing all thickened liquids for meals, snacks, activities, medication pass, and resident rooms. The facility failed to provide R1 with physician-ordered thickened liquids on 01/07/24 when she received thin liquids and aspirated. The facility sent R1 to the ER for evaluation and treatment for aspiration and R1 returned with antibiotics for aspiration pneumonia. This deficient practice placed R1 in immediate jeopardy. The facility put the following corrections in place by 01/11/24: Dietary and Nursing staff were educated on diets and fluid consistencies on 01/08/24. R1 was evaluated by speech therapy with diet recommendations for puree with honey-thickened liquids on 01/09/24. CNA M received a written warning for failing to follow policy on 01/10/24. R1's diet order was changed to puree with honey-thickened liquids on 1/11/24. R1's Care Plan was updated on 01/11/24. All corrections were completed before the onsite survey therefore the deficient practice was cited as past noncompliance and remained at a scope and severity of J.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 46 residents with three residents reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). Based on record review, observation, and interview, the facility failed to identify likely avenues of exit, including windows, and failed to ensure the windows were secured to prevent Resident (R) 1, who was severely cognitively impaired and a high risk for elopement, from exiting the facility through the window. On 12/20/23 at 08:00 PM, Certified Nurse Aide (CNA) M assisted R1 to bed and then began the constant surveillance of R1's room from the nurse's station due to R1's high elopement risk and his multiple attempts to elope. At 09:10 PM CNA N observed R1 outside the front door, knocking over the patio furniture. The temperature outside was approximately 39 degrees Fahrenheit (F). Staff assisted R1 back into the facility and noted he had no injuries but was cool to touch. Staff returned R1 to his room and noted that R1's window was open and lacked a screen. The facility failed to identify and secure likely avenues of exit for R1, who was at high risk for elopement and falls. As a result of this failure, R1 eloped from the facility via his bedroom window. The deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), muscle weakness, difficulty walking, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS), dated 12/15/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. The MDS documented R1 had physical and verbal behaviors directed toward others for one to three days during the observation period. The MDS documented R1's behaviors put R1 at significant risk for physical illness or injury, significantly interfered with R1's care, and significantly interfered with R1's participation in activities or social interactions. The MDS documented R1's behaviors put others at significant risk for physical injury, significantly intruded on the privacy and activities of others, and significantly disrupted the living environment. The MDS documented R1 wandered for one to three days during the look back period and R1's wandering placed him at significant risk of getting to potentially dangerous places and intruded on the privacy of others. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/15/23, documented R1 was unable to recall orientation questions or repeat words immediately or after five minutes. R1 had problems with wandering, physical, and verbal behaviors, and rejection of care. The CAA recorded a care plan would be initiated to provide orientation to R1 when able, assist him with cares, and remind him not to have aggressive or verbal behaviors. The Behavioral Symptoms CAA, dated 12/15/23, documented R1 wandered most of the day and when staff attempted to engage him in cares, he often rejected their cares. R1's Care Plan, dated 12/05/23, documented R1 as a high risk for elopement. The care plan directed staff to understand if R1 started packing his belongings it was a sign he was thinking about leaving. R1's Care Plan directed staff to report to the nurse increased wandering or pacing and try to determine triggers for R1's exit-seeking behaviors. The care plan directed staff to know where R1 was at all times and if R1 was in his room, staff were to sit near the nurse's station, watch the hallway, and be able to see if R1 exited his room. The admission Progress Note, dated 12/04/23, documented R1 was only oriented to family. R1 wanted to leave the building, was exit-seeking, and would go to the door but not open it. The Nurse's Note, dated 12/07/23, documented R1 saw the hairdresser walking out the front door and followed behind her. As R1 was walking out the front door, staff from the business office saw him and followed behind R1. R1 was not outside alone. The business office staff held the front door open so the alarm would go off and staff responded and were able to get R1 back into the facility. The Nurse's Note, dated 12/09/23, documented R1 was up all day walking the halls. R1 tried to get out of the building and walked up to each door trying to push the doors open. The Nurse's Note, dated 12/14/23, documented R1 was restless all evening and was up until 01:30 AM. All evening, R1 was at the doors wanting to leave. R1 continuously walked into other residents' rooms. The Behavior Note, dated 12/20/23, documented CNA N found R1 at the front door. The back nurse's station was occupied the entire time, and no one saw R1 walking around after he was laid down. The door alarm never sounded. CNA M took R1 to his room and discovered the window was open with no screen. It was unclear if R1 took off the screen. R1 also turned all of the patio furniture upside down. R1 had stickers (burweed) in his socks and his skin was cool to the touch. The Elopement Risk Assessment, dated 12/21/23, documented R1 had dementia, exhibited wandering and exit-seeking behavior, was cognitively impaired, and had impaired safety awareness. The assessment documented R1 was able to open doors, able to activate the keypad, and was able to exit doors independently. R1's elopement risk score was 31, a high risk for elopement. The Fall Risk Assessment, dated 12/21/23, documented R1 had multiple falls over the last six months. R1 exhibited a loss of balance while standing and strayed off of a straight path when walking. R1's fall assessment score was 21, high risk for falls. The Facility Incident Report, dated 12/22/23, documented CNA M helped R1 to bed at approximately 08:00 PM. CNA M then went back to the nurse's station where he could monitor R1's room door. At approximately 08:30 PM CNA M went to the front of the facility to help the front hall staff. Licensed Nurse (LN) G remained at the nurse's station to monitor R1's door. At approximately 09:10 PM staff witnessed R1 outside on the front porch knocking the patio furniture over. Staff escorted R1 back into the facility and notified the charge nurse. Staff completed a full assessment with no injury or adverse effect found. The temperature at the time of the event was 39 degrees F. CNA N's Witness Statement, dated 12/21/23, documented CNA N saw R1 around 06:30 PM walking the halls with staff. CNA N documented she sat down to chart at 09:15 PM and happened to look at the front door and saw a man standing at the front door. CNA N documented she went to investigate, and saw it was R1. CNA N documented she called for other staff and got R1 back into the building. CNA M's Witness Statement, dated 12/22/23, documented CNA M put R1 to bed at 08:30 PM. CNA M documented he stayed at the nurse's station until about 09:00 PM and R1 had not left his room. CNA M documented he (CNA M) went to the front to help, and at 09:10 PM to 09:15 PM staff found R1 outside in front of the building. CNA M documented nobody saw R1 leave his room and when staff went to R1's room, R1's window was open, so staff suspected R1 climbed out of his window. On 01/10/24 at 11:00 AM, observations revealed R1 sat in a chair at the nurse's station with a tray table in front of him, eating. R1 wore a short-sleeved button-down shirt, and jeans, and had bare feet. On 01/10/24 at 10:45 AM, Licensed Nurse (LN) G stated R1 had not been doing much wandering lately because he was sick and not feeling well. LN G stated when R1 felt good, he was up wandering in the halls, into other residents' rooms, and exit seeking. On 01/10/24 at 11:30 AM, Administrative Staff A stated R1 was placed on elopement risk precautions immediately upon admission to the facility on [DATE]. Administrative Staff A stated the Elopement Risk Assessment was not completed on admission day. Administrative Staff A stated all residents who were at risk for elopement had their windows now fixed with shims to only allow the windows to open three to four inches. Administrative Staff A stated a facility-wide door check was completed to ensure all alarmed doors were in proper working order on 12/21/23. Administrative Staff A stated all staff were educated on the elopement policy and R1's elopement incident before working their next shift. Administrative Staff A stated all residents' elopement assessments and care plans were reviewed for accuracy and appropriateness on 12/21/23. Administrative Staff A stated the elopement book was reviewed to ensure accuracy on 12/21/23, and an unscheduled Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss the incident. Administrative Staff A stated R1 was in a referral process for a locked unit. Administrative Staff A verified the facility failed to ensure the windows were secured to prevent residents at high risk for elopement from exiting the facility through the window. The facility's Resident Elopement Policy and Procedure, reviewed in December 2022, documented the facility strives to promote a safe and secure environment to help minimize the risk of residents leaving the premises or a safe area without the necessary supervision or authorization to do so. Risk for elopement is to be identified for residents and an individualized care plan developed based on risk. Staff are to investigate and report instances of potential elopement. The facility is to have a process to monitor the security of the premises on a routine basis. The facility failed to identify likely avenues of exit, including windows, and failed to ensure the windows were secured to prevent residents at high risk for elopement from exiting the facility through the window. As a result of this failure, R1 eloped from the facility via his bedroom window. The deficient practice placed R1 in immediate jeopardy. On 12/21/23 the facility identified and completed the following corrective actions: All residents at risk for elopement had their windows fixed with shims to only allow the windows to open three to four inches. The facility completed a facility-wide door check to ensure all alarmed doors were in proper working order. All staff received education on the elopement policy and R1's elopement incident before working their next shift. All residents' Elopement Assessments and care plans were reviewed for accuracy and appropriateness. The elopement book was reviewed to ensure accuracy, and an unscheduled QAPI meeting was held to discuss the incident. All actions were completed before the onsite survey therefore the deficient practice was deemed past noncompliance and remained at a J scope and severity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 44 residents with three reviewed for neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from neglect when the facility failed to provide the necessary care and services required by R1 to promote and maintain R1's highest level of health and wellbeing. R1 admitted to the facility on [DATE] with an order for losartan (medications used to lower blood pressure) 100 milligrams (mg) daily for hypertension (high blood pressure). The facility failed to administer the losartan for 12 days, until 04/29/23, when R1's representative noted the omission. On that same day, R1 had a high blood pressure of 244/110 millimeters of mercury (mmHg) (normal blood pressure range 120/80 mmHg) and fell. R1 went to the emergency room (ER) where it was determined he had a fractured right foot. R1 was placed in a controlled ankle movement (CAM) boot with orders for reduced mobility and non-weight bearing status. R1 returned to the facility and experienced ten falls between 04/29/23 and 05/20/23. Additionally, on 05/03/23, R1's physician evaluated and ordered a chopped meat diet and swallowing evaluation for R1. The facility failed to relay the swallowing evaluation order to Speech Therapy, therefore the evaluation was not completed. On 05/27/23, while eating ground ham and scalloped potatoes, R1 choked. Staff contacted 911 and attempted to perform the Heimlich maneuver, which did produce food items expelled from R1's airway. EMS arrived at the facility and attempted to suction the potatoes from R1's airway but were unsuccessful. R1 had respiratory arrest and was pronounced dead in the facility. The facility's cumulative neglect in providing the necessary care for R1 placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 was admitted to the facility on [DATE] with diagnoses of hypertension, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS), dated 04/26/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated R1 had moderate cognitive impairment. The MDS documented R1 required supervision with set-up help only for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. R1 was independent with walking in his room, locomotion on the unit, and eating. The MDS documented R1 did not have any falls in the six months prior to his admission to the facility. The Significant Change MDS, dated 05/16/23, documented R1 had a BIMS score of seven, which indicated R1 had severe cognitive impairment. The MDS documented R1 required extensive assistance of one to two staff for bed mobility, transfer, walking, locomotion, dressing, eating, toileting, personal hygiene, and bathing. The MDS documented R1 had two or more falls with no injury, two or more falls with minor injury, and two or more falls with major injury. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/16/23 documented R1 had a BIMS of seven and had short term memory loss and wandered in his wheelchair at night looking for something or someone. The Activity of Daily Living [ADL]/Rehabilitation Potential CAA, dated 05/16/23, documented R1 required assistance with all his ADL due to weakness and a fractured foot. R1's Care Plan would be reviewed for staff to assist R1 as needed and to have R1 participate in self-care as much as possible. The Fall CAA, dated 05/16/23, documented R1 had an unsteady gait (manner or style of walking) and fell frequently. R1's family requested for him to have physical and occupational therapy and R1 was started on therapies. R1 had major injuries from falls of a fractured right foot and laceration to his head. The care plan would be reviewed for R1 to start therapy for strengthening and staff to toilet and check on R1 more often. The Activity of Daily Living Care Plan, dated 04/28/23, directed staff R1 required one staff assistance with dressing and grooming needs. It instructed staff to ensure R1's call light was in reach, and R1 wore glasses and to make sure the glasses were clean and on R1. The Fall Care Plan, dated 04/21/23, directed staff to offer to assist R1 to the bathroom during each of their rounds, place a fall mat by the bed when R1 slept, and encourage R1 to change positions slowly. It directed staff to round on R1 every two hours during the night and offer R1 assistance to the bathroom if R1 was awake; assist R1 to the bathroom at 02:00 AM every night shift due to frequent falls while trying to get to the bathroom. It directed staff to assist R1 to the bathroom at least every two hours while awake and every four hours while sleeping; give R1 reminders to call for help before getting up, ensure a high-low bed was used appropriately before leaving R1's room, keep commonly used items close to R1's reach, and ensure R1 wore appropriate shoes and non-skin footwear. The care plan directed staff to ensure R1's call light was within reach and encourage R1 to use the call light to ask for assistance and ensure the pathway in R1's room remained clean and unobstructed. The Hospice Care Plan, dated 04/21/23, directed staff to administer medications as ordered. The Code Status Care Plan, dated 04/17/23, documented R1 was a Do Not Resuscitate (DNR). If R1's heart stopped beating and/or R1's respiration ceased, do not perform life sustaining measures. The Nutrition Care Plan, dated 04/18/23, documented R1 was on a regular diet, regular texture, regular fluid consistency, staff to assist R1 as needed during meals, and staff to weigh R1 weekly. The facility lacked a care plan which addressed R1's hypertension. The facility Electronic Medication Administration Record (EMAR), dated April 2023, documented the high blood pressure medication, losartan 100 mg by mouth daily, was not administered to R1 from 04/18/23 thru 04/29/23. The facility EMR lacked any blood pressure readings for R1 from 04/18/23 thru 04/29/23. The admission Orders, dated 04/17/23, documented R1's Primary Care Physician (PCP) ordered R1's admission to the facility, code status DNR, activity as tolerated, diet regular, and medications per list. The admission orders included staff to administer to R1 losartan, 100 mg by mouth daily. R1's PCP ordered for the facility to notify the physician of any blood pressures greater than 160/90 mmHg or less than 100/50 mmHg and to call for pulses greater than 120 beats per minute (bpm) or less than 50 bpm. The orders were noted by Licensed Nurse (LN) G on 04/14/23 at 01:45 PM. The Incident Note, dated 04/29/23 at 07:15 AM, revealed a Certified Nurse Aid (CNA) informed LN H that R1 was on the floor, she found R1 crawling on all fours from the bathroom, and there was urine on the floor. LN H went to R1's room and saw R1 seated on his bed with his pants around his knees. LN H obtained R1's vital signs and noted R1 had a red bruise with a bump on the right side of his head above his ear and a red bruised on the inner side of his right foot below R1's big toe. R1's seated blood pressure was 117/61 mmHg and R1's standing blood pressure was 122/66 mmHg. R1 stated he was going to the restroom and fell and denied pain. LN H assisted R1 to stand and noted R1 rubbed his right knee and seemed weak. LN H instructed the CNA to use the wheelchair when transferring R1. LN H began neurological assessments on R1. R1's representative came to visit R1, and LN H informed her of R1's fall. LN H reported R1's fall to hospice and the on-call nurse practitioner. The on-call nurse practitioner ordered LN H to let her know if R1's condition and instructed to continue neurological checks. The Incident Note, dated 04/29/23 at 03:00 PM, documented the CNA informed the LN H R1 fell. LN H went to R1's room and R1 was on the floor in front of his recliner leaning to the left side. R1 stated tried to go to the bathroom. LN H observed R1 had a bump on the left side of his forehead and some bruising to his left arm. LN H obtained R1's vital signs and had the CNA assist R1 up to his wheelchair. The CNA wheeled R1 to the nurse's station so LN H could keep an eye on him and perform neurological assessments. LN H called hospice, the on-call provider and R1's representative. R1's blood pressure was 214/110 mmHg. The on-call nurse practitioner ordered LN H to give R1 2.5 mg of amlodipine (medication used to lower blood pressure) and if R1's blood pressure did not go down in four hours, R1 should go to the ER. LN H gave R1 amlodipine 2.5 mg at 04:00 PM. LN H noted R1's blood pressure continued to rise, and at 05:50 PM, LN H called the on-call nurse practitioner and received orders to transfer R1 to the ER. LN H called R1's representative and she stated she would transport R1 to the ER. LN H called the ER nurse at 06:03 PM to give report on R1. At 06:30 PM, R1's representative arrived at the facility to transport R1 to the ER. The Incident Note, dated 04/30/23 at 12:07 AM, documented the CNAs on shift found R1 on the floor. The charge nurse went to R1's room and found R1 seated on the floor next to his bed. R1 stated he had rolled out of bed. The charge nurse noted R1 was incontinent of urine, had no visible signs of injuries, and had normal range of motion. Staff assisted R1 to his feet, cleaned and dressed him, applied non-skid socks, and assisted R1 back to bed. The charge nurse started neurological checks and R1's blood pressure was 117/61 mmHg. The Order Note, dated 04/30/23 at 03:15 AM, documented staff notified R1's hospice provider of the orders to start amlodipine 7.5 mg by mouth daily, and to notify R1's PCP if blood pressures were greater than 145/90 mmHg or less than 100/60 mmHg. The Nurse's Note, dated 04/30/23 at 10:12 AM, documented R1's pharmacy did not open until 10:00 AM and the facility needed amlodipine 7.5 mg, ordered the previous day. Staff called R1's pharmacy at 10:02 AM. R1's representative came to the nurse's station and stated the Certified Medication Aide (CMA) informed her R1 had not received his losartan for two weeks. The LN explained to R1's representative she was on the phone with R1's pharmacy to give the order for amlodipine and then the LN would investigate the other medication. The charge nurse gave the verbal order for amlodipine to the pharmacy and then confirmed losartan had been ordered upon R1's admission to the facility but it was not entered or administered. The charge nurse told R1's representative the losartan was reinstated. The Nurse's Note, dated 04/30/23 at 11:29 AM, documented the charge nurse spoke to the on-call nurse practitioner, who stated since the losartan was not administered for two weeks, to discontinue the amlodipine, and continue to monitor R1's blood pressure. The Nurse's Note, dated 04/30/23 at 01:52 PM, documented R1 continued fall follow up and had some swelling to his right ankle and a bruise above his left eye. R1 complained of pain and staff administered an as needed pain medication, which was effective. R1's blood pressure was 132/78 mmHg. The Nurse's Note, dated 05/01/23 at 01:19 AM, documented R1 continued fall follow up due to several falls on 04/29/23 and 04/30/23. R1 continued to have a bruised, small bump to the right side of his head and bruising noted around R1's left eye. R1's range of motion was normal and R1 denied any pain. Neurological checks were normal and R1's blood pressure was 136/77 mmHg. The Nurse's Note, dated 05/01/23 at 05:32 AM, documented R1's right foot in the metatarsal (bones in the foot) region was swollen and R1 complained of pain when he walked on the right foot. Staff contacted R1's hospice provider for an x-ray of R1's right foot and received orders for an x-ray of R1's ankle and foot. The RISK Progress Note, dated 05/01/23 at 10:33 AM, documented on 04/29/23, staff found R1 on the floor in his room. R1 told staff he tried to get to the bathroom. Upon assessment, the nurse found a bump on the right side of R1's head and a bruise on his right foot. The following day, staff noted swelling to R1's right foot and obtained an order for an x-ray. The RISK Progress Note, dated 05/01/23 at 10:39 AM, documented on 04/29/23 at approximately 03:00 PM R1 fell a second time that day. The nurse who assessed R1 noted a new bump on his head and bruising to his left arm. R1's blood pressure was in the 200's/100's mmHg, staff notified the on-call doctor and received an order to administer amlodipine and send R1 to the ER if his blood pressure did not come down with that medication. R1's family transported R1 to the ER approximately an hour later due to high blood pressure. The RISK Progress Note, dated 05/01/23 at 10:45 AM, documented on 04/30/23 at around 12:07 AM, staff found R1 on the floor for the third time in twenty-four hours. Upon assessment, the nurse on duty found no injuries, completed neurological checks, per protocol, and noted R1 was incontinent of urine. The Nurse's Note, dated 05/01/23 at 03:00 PM, documented the CNA alerted the nurse to R1's room. R1 had slid out of his recliner and did not hit his head. R1's blood pressure was 136/72 mmHg. The nurse performed a physical assessment and noted R1 did not have any injuries. Staff notified R1's representative and physician. The Nurse's Note, dated 05/01/23 at 05:36 PM, documented R1's x-ray results of his right foot and revealed R1 had sustained two fractures in his right foot. The results were faxed to R1's PCP and staff notified R1's representative of the results. The X-ray Results, dated 05/01/23, documented a non-displaced fracture of the right foot fifth metatarsal and an avulsion (when a bone fragment is p0ulled away from its main body by soft tissue that is attached to it) of the calcaneus inferior aspect (inner heel bone). The Nurse's Note, dated 05/01/23, at 06:47 PM documented R1's representative went to the facility to get R1 to take him to the ER for a Computed Tomography (CT-a radiological test showing detailed images of any part of the body). The Nurse's Note, dated 05/01/23 at 11:50 PM, documented R1 arrived back from the hospital accompanied by his representatives at 09:50 PM. A report from the local hospital documented the CT results showed findings of old infarcts (localized area of tissue death due to lack of blood supply). R1's blood pressure was high during his visit and the ER administered clonidine (blood pressure medication) and Tylenol (pain medication) and applied an orthopedic shoe to R1's right foot. The Nurse's Note, dated 05/02/23 at 06:02 PM, documented fall tracking continued for R1 status post two fractures to R1's right foot. R1 wore an orthopedic shoe and was non-weight bearing until R1 has an orthopedic appointment ordered by his PCP. The Fall Note, dated 05/03/23 at 01:46 AM, documented staff found R1 on the floor beside his bed. The charge nurse noted R1 laid on his left side with his head toward the foot of the bed. R1 did not appear to be in pain, responded to verbal commands, and the nurse noted feces on the floor and in R1's brief. Neurological checks were initiated due to being an unwitnessed fall. The Nurse's Note, dated 05/03/23 at 02:22 AM, documented the CNA notified the charge nurse R1 was almost out of bed again at this time. The CNA informed the charge nurse R1's legs were falling out of the bed and his arm hung out of bed. The charge nurse told the CNA to increase rounds and frequently monitor R1 to prevent further falls. The Skin Condition Note, dated 05/03/23 at 04:54 AM, documented a 5 centimeter (cm) by 6 cm bruise to the back of R1's head with a raised bump and a 3 cm by 4 cm scab to the right side of R1's head. The Nurse's Note, dated 05/03/23 at 09:09 AM, documented the facility called R1's PCP's nurse about R1's blood pressure being 178/84 mmHg. The nurse stated R1 had an appointment with the doctor that morning at 10:00 AM and they would address R1's high blood pressure then. R1's representatives were with R1 and would attend the appointment with him. The Doctor's Orders, dated 05/03/23, documented R1's blood pressure at his appointment was 178/84 mmHg. The doctor noted he saw R1 for fall follow up, right foot fracture, and high blood pressure. R1's PCP ordered physical therapy and occupational therapy to evaluate R1 due to weakness, gait, and coordination. R1's PCP ordered a diet change which directed chopped up meats, no bread with meats i.e., sandwich. The orders directed for a swallow evaluation with a speech therapist, change potassium to powdered packet instead of tablet, amlodipine 2.5 mg by mouth twice a day as needed for blood pressure greater than 150/80 mmHg, a mattress by his bed due to falls, and a foot boot on in morning and off at bedtime. The orders were noted by Administrative Nurse D on 05/03/23. The RISK Progress Noted, dated 05/03/23, documented staff found R1 on the floor next to his bed around midnight. The nurse did an assessment and did not find any signs of any new injuries. R1 had two fractures to his right foot prior to this fall. The note included the facility would reach out to hospice about obtaining a high/low bed and start using a mat on the floor next to R1's bed. The Nurse's Note, dated 05/04/23 at 05:03 PM, documented the CNA called the charge nurse to R1's room and the nurse found R1 on the floor next to the matt on floor in front of R1's room door. The door was closed and R1 stated he tried to go to the bathroom. The staff placed R1's ortho boot on his right foot and three staff assisted R1 to a wheelchair and then placed R1 on the toilet. The staff noted R1's pull-up was wet. R1 denied pain. R1's blood pressure was 151/90 mmHg. The Risk Progress Note, dated 05/04/23 at 05:55 PM, documented R1 was found on the mat on the floor of his room. The nurse did not note any new injuries. R1 had two fractures in his right foot from a prior fall. R1 was incontinent of urine before he was found. Staff would continue to remind R1 to use his call light and make sure it was within reach before leaving the room. The Nurses Note, dated 05/07/23 at 07:20 PM, documented R1 fell at 06:40 PM. Another resident alerted staff R1 was on the floor. The charge nurse went to R1's room and found R1 on his back between the recliner and the wall, and his head against the bedside table. R1's cookies and water were spilled all over the floor. R1 wore his ortho boot and one shoe at the time of the fall. R1's call light was not on, R1 could not verbalize what happened, and R1 complained his head hurt. The nurse noted a small laceration to the back of R1's head and no other injuries noted at the time. The staff notified R1's representative of the laceration and she stated if the doctor wanted R1 to go to the ER she preferred to transport R1. Staff notified R1's PCP and received verbal order to send R1 to the ER for evaluation. R1's representative arrived to the facility at 07:15 PM to transport R1 to the ER. The Nurse's Note, dated 05/08/23 at 03:16 AM, documented R1 arrived back to the facility at 08:15 PM with his representatives and the following orders: return to the nursing home, continue all previous orders as directed, follow-up with PCP as needed, clean wound per facility protocol until healed. The Nurse's Note, dated 05/08/23 at 08:15 AM, documented R1 was up all night. R1 was up in his wheelchair that morning and was fidgeting, restless, and refused to eat breakfast or drink fluids. The Nurse's Note, dated 05/08/23 at 10:29 AM, documented the charge nurse placed a call to R1's PCP to inform her R1 had increase confusion, anxiety, and decreased appetite. The Nurse's Note, dated 05/08/23 at 11:59 AM, documented R1's PCP ordered a urinalysis, mirtazapine (antidepressant used to stimulate appetite) 15 mg, discontinue as needed Buspar (medication used to treat anxiety) and start Buspar 5 mg twice a day scheduled. The Nurse's Note, dated 05/09/23, documented R1 continued to have multiple bruises to the left side of his body and forehead from previous falls. The Speech Therapy Evaluation and Plan of Treatment, dated 05/09/23, documented R1 was referred to speech therapy due to exacerbation of cognitive impairment and decreased ability to respond to cues/instruction placing R1 at risk for decreased ability to return to prior level of supervision, falls, and further decline in function. R1's goals for therapy were: R1 would follow 1-step verbal commands with 80% accuracy and occasional visual cues in order to enhance R1's ability to decrease falls; R1 would recall daily events using visual aids as needed with 80% accuracy of opportunities and occasional visual cues in order to promote independence and safely participate with activities of choice; R1 would recall novel information with 60% accuracy when given minimal cues in order to increase participation in daily activities; and R1 would participate in conversational exchanges with minimal cues in order to increase quality of living. Certification period for R1 to participate in speech therapy was 05/09/23 through 08/06/23. The Speech Therapy Evaluation and Plan of Treatment lacked evidence of a completed swallow conducted. The RISK Progress Note, dated 05/15/23, documented R1 was found on the floor at approximately 03:30 AM. On assessment the nurse found small abrasion to right elbow. As of 10:00 AM this morning neurological checks were within normal limits. Care plan was updated to include more frequent rounding on R1 during the night. The Fall Note, dated 05/16/23 at 03:10 AM, documented the CNA notified the charge nurse R1 fell. The charge nurse found R1 on his right side with his knees pulled up to his chest in the doorway of his restroom in his bedroom. R1 did not appear to be in pain and denied pain. Nursing staff to toilet R1 at 02:00 AM to 03:00 AM related to previous falls at similar time. R1 placed on fifteen-minute checks to observe for R1's location. The Fall Note, dated 05/20/23 at 07:07 AM, documented the CNA came to get the charge nurse at the nurse's station and reported R1 fell. Upon entry into R1's room, R1 laid on the fall mat next to his bed. R1's head rested against the wall and there was a dent in the wall directly above where R1's head was resting. R1 could not verbalize what happened. The Skin Condition Note, dated 05/21/23 at 04:58 AM, noted R1 had a bruise to his right shoulder measuring 5 cm by 6 cm. R1 had pain upon palpation. The Nurse's Note, dated 05/22/23 at 12:43 PM, documented R1 had an orthopedic appointment for his right foot fractures. New orders to continue to use wheelchair for long distances, weight bearing with transfers only with assistive device and staff, continue surgical shoe to right foot. A Nurse's Note, dated 05/27/23 at 01:07 PM, documented the charge nurse was called to the main dining room to help assist R1 as he was choking on scalloped potatoes. The CMA administered the Heimlich maneuver to R1 with assistance from the CNA. The charge nurse started performing the Heimlich maneuver while another nurse called 911 and obtained R1's code status. The note included some food came out of R1's mouth while staff did the maneuver. Staff laid R1 on the floor and R1 took a couple of breaths. Staff applied oxygen and noted food was still coming out of R1's mouth, and then R1 stopped breathing again. R1 was a DNR. The paramedics arrived and hooked R1 up to the heart monitor. The paramedics stopped what they were doing and pronounced R1 dead at 01:04 PM. A Nurse's Note, dated 05/27/23 at 05:02 PM, documented the nurse was called into the main dining room to help assist choking resident R1, around 12:40 PM. A CMA performed the Heimlich maneuver with assistance from a CNA. The nurse started to perform the Heimlich maneuver while the other nurse obtained R1's code status and called 911. More food came up and staff laid R1 down and R1 took a couple of respirations, and the nurse felt a pulse. Staff applied oxygen to R1 and food was still coming out of R1's mouth when R1 stopped breathing again. R1 had no pulse at that time. R1 was a DNR. Paramedics arrived and hooked R1 up to a heart monitor. One paramedic looked at the DNR paperwork and the other two paramedics suctioned R1 and were getting food out of R1's throat. The paramedic accepted the DNR paperwork and unhooked the heart monitor from R1 and pronounced R1 dead at 01:04 PM. On 06/12/23 at 10:00 AM, Physical Therapy Assistant (PTA) GG stated that physical therapy and occupational therapy started to work with R1 per doctor's orders but there was not much that physical therapy could do for gait and strengthening because R1 was non-weight bearing due to his right foot fracture. On 06/12/23 at 10:15 AM, Administrative Nurse E, stated that R1 had a Significant Change because he was taken off hospice care because R1's representatives were adamant R1 had declined tremendously since his admission to the facility and wanted R1 to have physical therapy and occupational therapy. On 06/12/23 at 10:30 AM, CNA M stated she never noticed R1 having difficulty with swallowing but did notice R1 had a decline after he started having multiple falls. On 06/12/23 at 10:45 AM, LN G stated he noticed R1 having difficulty swallowing his potassium pill and a request was made to R1's PCP to change the potassium to powder or liquid. LN G stated R1's blood pressure medication was not given to R1 for two weeks after R1 admitted , and R1's blood pressure did get high. LN G stated R1's representatives thought R1 had a stroke because of his rapid decline after not receiving his blood pressure medications. LN G stated prior to R1's decline, R1 was walking the halls with his cane, visiting with staff and residents, and joking around telling jokes. LN G stated after R1 started falling, R1's decline was obvious. On 06/12/23 at 11:00 AM, Dietary Staff (DS) BB stated on the day R1 choked on his food the menu was ham, scalloped potatoes, and boiled cauliflower. DS BB stated R1's ham was ground with gravy on top of it. DS BB stated she was unaware of R1 having any difficulty swallowing. On 06/12/23 at 11:40 AM, Speech Therapist (ST) HH stated she started working with R1 for cognition and memory. Upon learning of the physician order for a swallow evaluation, ST HH was shocked the order was for a swallowing evaluation and stated nursing staff informed ST HH the evaluation to treat was for cognition and memory. ST HH stated she had never seen R1 for a swallowing evaluation. ST HH stated therapy did not receive written orders, all orders come to therapy verbally by nursing staff. On 06/12/23 at 12:14 PM, R1's representative stated she and her sister had taken R1 to his follow up appointment with his primary care provider on 05/03/23. They informed R1's PCP R1 had choked on a sandwich recently and coughed and coughed and was finally able to bring up the food, so R1's PCP ordered a swallowing evaluation by speech therapy. She said R1's PCP also ordered physical therapy and occupational therapy to see R1 because he was having so many falls. R1's representative felt upset that R1 had not received his blood pressure medications as ordered and felt that this was the start of R1 progressive decline. On 06/12/23 at 01:00 PM, Administrative Nurse D stated she thought R1's blood pressure medication was placed in the computer but for some reason it came up Pending and the EMR did not show to administer R1's losartan. Administrative Nurse D stated the day shift nurses put the orders into the computer, night nurses checked the orders, and then medical records completed a third check, but R1's losartan was missed. Administrative Nurse D stated therapy orders were put in the computer by nursing staff and then nursing staff verbally communicated the orders to therapy. Administrative Nurse D was unaware R1 had an order for speech therapy to conduct a swallow evaluation for R1. On 06/12/23 at 02:00 PM, Administrative Staff A stated he just found out from Administrative Nurse D that R1 had an order to have speech therapy see R1 for a swallowing evaluation. Administrative Staff A stated the facility needed to come up with a better way of communicating orders to therapy rather than just verbally. Administrative Staff A stated due to R1's losartan order being missed, administrative LNs would input all new admission orders into the computer. On 06/12/23 at 02:15 PM, Consultant KK stated she had become aware of R1's losartan not being given on the follow up appointment on 05/03/23. R1's representatives told Consultant KK R1 had a choking episode with a sandwich but was able to get the food up, so Consultant KK ordered speech therapy for a swallowing evaluation. Consultant KK changed R1's dietary order to chopped meat without bread, for example sandwiches, pending the results of the swallowing evaluation. Consultant KK stated she expected the facility to follow the orders given to them. The facility's Abuse, Neglect, and Exploitation Policy, reviewed October 2022, documented the facility would treat each resident with respect, kindness, dignity, and care, to keep them free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. Neglect is the failure to provide the goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs on an individual basis when a resident receives lack of care in one or more areas. The facility failed to ensure R1 remained free from neglect when the facility failed to provide the necessary care and services required by R1 to promote and maintain R1's highest level of health and wellbeing. This deficient practice placed R1 in Immediate Jeopardy. The facility implemented the following corrective actions to remove the immediacy: Staff were notified administrative nurses would input admission orders and conduct a second check on 05/03/23. Medical Records audits new admission medication reconciliation with each new admit or readmit and daily for order changes initiated on 05/03/23 Staff were educated on medication reconciliation on admission by two licensed nurses on 05/17/23 A Quality Assurance and Performance Improvement (QAPI) meeting held on 05/30/23. All diet orders reviewed for all residents, and verified consistent on their care plans on by 05/31/23. All employees and therapy educated on the Therapy Communication Form, medication reconciliation, fall prevention and root cause analysis, on 06/13/23. Staff educated on Abuse and Neglect on 06/13/23. After removal of the immediacy, the deficient practice remained at a scope and severity of a G.