**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, video observation, and interviews the facility failed to ensure the residents' right to be free from neglect for all residents who resided on Hall A (Rooms 1-30). Nursing staff neglected to respond to call lights and provide any care and services to all resident's residing on Hall A from 11:00 p.m. to 2:30 a.m. on the night of [DATE]. As a result of the identified noncompliance, serious harm, serious impairment, death, or psychosocial harm was likely to occur to the residents residing on Hall A. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on [DATE] at approximately 11:00 p.m. when Resident #1, who had a physician's order for staff to visually check the resident every 2 hours, activated her call light for staff assistance. No staff responded to her call until approximately 2:39 a.m. when S6CNA found Resident #1 in here room on the floor, kneeling on a fall mat at the bedside, unresponsive and pulseless. Resident #1 expired after unsuccessful CPR was initiated. On [DATE] at approximately 2:53 a.m., S6CNA found Resident #3, who had a physician's order for staff to visually check the resident every 2 hours, lying on the floor. This resulted in psychosocial harm for Resident #3 who verbalized in an angry tone that she felt aggravated and neglected when staff did not help her after she slid out of bed and had to stay on the floor for a long time. Interviews with staff revealed the last time staff visualized or provided care for any residents residing on Hall A on [DATE] was at 10:00 p.m.; and not again until 2:30 a.m. on [DATE]. S2ADM was notified of the Immediate Jeopardy on [DATE] at 7:02 p.m. The Immediate Jeopardy was removed on [DATE] at 1:31 p.m., as confirmed by onsite verification through record reviews and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. This deficient practice continued at a potential for more than minimal harm to the remaining 100 residents residing in the facility. Findings: Review of the facility's policy titled Abuse/Neglect Prevention Program with a revision date of [DATE], revealed the following in part: Abuse/Neglect Policy Statement: Each resident also has the right to be free from neglect. 9. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental or mental illness. Resident #1 Review of Resident #1's Clinical Record revealed she was readmitted to the facility on [DATE] with diagnoses, which included Foot Drop of Right and Left Foot, Repeated Falls, Muscle Weakness (generalized), Muscle Wasting and Atrophy, Primary Insomnia, Primary Generalized Osteoarthritis, Abnormal Posture, Cognitive Communication Deficit, and Need Assistance for Personal Care. Further review revealed Resident #1 resided on Hall A when she expired on [DATE]. Review of Resident #1's most recent completed Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #1 was dependent on staff assistance with bed mobility and transfers. Review of Resident #1's [DATE] Physician's Orders revealed an order was implemented on [DATE] for visual checks to be completed by staff every 2 hours for the resident's location. Review of Resident #1's Nurses' Note dated [DATE] revealed the following, in part: On [DATE] at 2:42 a.m.: Upon doing rounds, aide walked into room and found Resident #1 unresponsive on fall mat. Nurse was immediately called to the room. Upon entering room, nurse noticed resident on her fall mat in a kneeling position facing the bed. Unable to obtain pulse or blood pressure upon assessment. Initiated CPR immediately. 911 notified. CPR in progress. At 2:53 a.m., fire department arrived and continued CPR. Coroner's office notified, family notified. At 3:43 a.m., attempted to contact physician. At 4:00 a.m., coroner arrived, okay to release the body to funeral home. Signed by: S5LPN. Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Muscle Wasting, Muscle Weakness, and Lack of Coordination. Review of Resident #3's most recent completed MDS, with an ARD of [DATE], revealed a Brief Interview of Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. Further review revealed she required partial to substantial/max assist with bed mobility and transfers. Review of Resident #3's [DATE] active Physician's Orders revealed an order was on [DATE] for visual checks to be completed by staff every 2 hours for the resident's location. Review of Resident #3's Nurses Note dated [DATE] revealed the following, in part: On [DATE] at 2:53 a.m.: Upon doing rounds, aide found Resident #3 lying down on the floor, nurse was immediately called to the room. Signed by: S5LPN. Review of the CNA Daily Assignment Sheet from 10:00 p.m. to 6:00 a.m. dated [DATE] revealed the following, in part: S7CNA was assigned to care for the residents residing on Hall A Rooms 1-10 S8CNA was assigned to care for the residents residing on Hall A Rooms 11-20 S6CNA was assigned to care for the residents residing on Hall A Rooms 21-30 On [DATE] at 2:04 p.m., a review of the facility's video surveillance footage of Hall A, dated [DATE] from 12:00 a.m. until approximately 4:45 a.m., was conducted with S2ADM. Prior to reviewing the footage, S2ADM stated he did not have access to any surveillance footage prior to [DATE] at 12:00 a.m. The surveillance footage revealed from 12:00 a.m. to approximately 2:35 a.m., staff failed to perform visual checks on Resident #1 and #3 every two hours as ordered, or any other residents on Hall A. The surveillance footage further revealed during that time, staff neglected to provide any care and services to any resident's residing on Hall A, and at 12:35 a.m., a call light was observed to be on in Hall A but S2ADM was unable to identify if it was coming from Resident #1's room or the room next to her. S2ADM confirmed the above review of the facility footage revealed no staff rounded on or provided care to any resident on Hall A from 12:00 a.m., on [DATE] until approximately 2:37 a.m. On [DATE] at 11:58 a.m., an interview was conducted with S6CNA. She stated she worked the 10:00 p.m. to 6:00 a.m. shift on [DATE] and was assigned to provide care for Resident #1 and Resident #3, as well as the residents in Rooms 21-30 on Hall A. S6CNA stated Resident #1 and #3 required staff assistance to get out of bed. She stated Resident #1 and #3 were ordered to have visual checks every 2 hours, which meant the staff were to visualize the resident every two hours. She stated she typically rounded on her residents every two hours, beginning at 10:00 p.m., then again at 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m. She stated CNAs should sit on the halls, in the section they were assigned, so they could respond to call lights and assist residents with needs because there was no ward clerk responsible to answer call lights after 10:00 p.m. She stated S5LPN notified her on [DATE], at the beginning of her shift that staff could not walk on the floor to get to the resident's rooms on Hall A due to floor maintenance. She stated she did not notify administration about not being able to see the residents and no staff monitored or provided care to any of the residents on Hall A from 10:00 p.m. to 2:30 a.m., when the floor maintenance was completed. She stated she sat in the day room across from the nurse's station with another aid waiting until the floors were finished and she could see call lights going off on Hall A. She stated she could not remember which residents needed assistance aside from Resident #1, and stated she did not respond to the call lights. She stated Resident #1's call light was on from approximately 10:00 p.m. to 2:30 a.m. She stated once the floor maintenance was completed at approximately 2:30 a.m., she started rounding on her residents. She stated she went into Resident #1's room first because she knew Resident #1's call light had been on for a while. She confirmed this was the first time during her shift she had visualized her assigned residents. She stated when she entered Resident #1's room she found the resident kneeling on the fall mat beside her bed, arm gripping the bed rail, unresponsive, cold, and pale. She stated she immediately notified S5LPN and left the room once help arrived. She stated she then rounded on Resident #3 and found Resident #3 lying on the floor uninjured. She stated Resident #3 did not say much to her other than she was not hurt and did not want to go to the emergency room. She stated she did not know how long Resident #3 was lying on the floor prior finding. She stated she notified S5LPN. She stated staff not performing visual checks or providing care to the residents on Hall A from 10:00 p.m. until 2:30 a.m., was neglect. She stated she should have performed visual checks and responded to call lights regardless of the floor maintenance and confirmed she had not. She stated she notified S2ADM once he had arrived to the facility, that staff were unable to perform rounds on residents on Hall A. On [DATE] at 3:29 p.m., an interview was conducted with S5LPN. S5LPN stated she was assigned to provide care for Resident #1, #3, and all of the residents on Hall A on [DATE] and worked the 10:00 p.m. to 6:00 a.m. shift. She confirmed Resident #1 and #3 had visual checks ordered every two hours which indicated staff were to visualize the resident every two hours. She stated Resident #1 and #3 required staff assistance to get out of bed. She stated she typically rounded on her residents beginning at 11:00 p.m., then again at 1:00 a.m., 3:00 a.m., and 5:00 a.m. She stated CNAs should sit on the halls, in the section they were assigned, so they could respond to call lights and assist residents with needs because there was no ward clerk responsible to answer call lights after 10:00 p.m. She stated on the night of [DATE], Hall A had floor maintenance being completed and the staff could not walk on the floor to get to the resident's rooms. She stated the floor maintenance started around 10:00 p.m., and did not finish until approximately 2:00 a.m. She stated during that time nursing staff did not round on the residents or provide any care on Hall A. She confirmed she did not communicate this with administration. She stated she was able to see all the resident on Hall A at 10:00 p.m., but did not see them again until approximately 2:30 a.m. She stated from 10:00 p.m. to 2:30 a.m., the CNAs were not allowed to sit on their assigned areas on the hall to respond to call lights and provide care like they normally would. She stated she sat behind the nursing station where the computers were at the charge nurse desk and could not see any call lights. She stated S6CNA went into Resident #1's room around 2:30 a.m., and found the resident unresponsive. She stated she immediately went into Resident #1's room and found Resident #1 on the floor kneeling on a fall mat at her bedside, unresponsive and pulseless. She stated shortly after that, S6CNA came to her and notified her Resident #3 had also been found on the floor. She stated once she got to Resident #3, she was lying on the floor, uninjured, with a pillow under her head. She confirmed staff not performing visual checks or providing care to the residents on Hall A from 10:00 p.m. until 2:30 a.m., was neglect. She stated the first time S2ADM was notified of staff not being able to round on the residents was when S2ADM arrived onsite around 4:00 a.m., after she had notified him of Resident #1's passing. On [DATE] at 10:58 a.m., an interview was conducted with S8CNA. S8CNA stated she worked the 10:00 p.m. to 6:00 a.m., shift on [DATE], and was assigned to Rooms 11-20 on Hall A. She stated she typically rounded on her residents every two hours, beginning at 10:00 p.m., then again at 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m. She stated the CNAs should sit on the halls in the section they were assigned so they could respond to call lights and assist residents with needs because there was no ward clerk responsible to answer call lights after 10:00 p.m. She stated on [DATE], she did not go to any of the resident's rooms or provide care for the residents on Hall A due to floor maintenance. She stated she was able to round on her residents at 10:00 p.m., but not again until approximately 2:30 a.m. She stated during that time, she sat at the beginning of Hall A and could see the call lights on Hall A. She stated she saw three call lights on from her assigned residents, but did not recall which residents had requested assistance. She stated she did not to respond to the call light or provide any care to those residents and should have. She stated once the floor maintenance was completed at approximately 2:30 a.m., she started rounding on her residents. She stated staff not performing visual checks on the residents and not providing care on Hall A from 10:00 p.m. until 2:30 a.m., was neglect. She stated she should have performed visual checks and responded to call lights regardless of the floor maintenance and confirmed she had not. She confirmed she did not notify S2ADM staff were unable to perform rounds or care on residents on Hall A. On [DATE] at 2:20 p.m., an interview was conducted with S7CNA. She stated she worked the 10:00 p.m. to 6:00 a.m., shift on [DATE], and was assigned to Rooms 1-10 on Hall A. She stated she typically rounded on her residents every two hours, beginning at 10:00 p.m., then again at 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m. She stated CNAs should sit on the halls, in the section they were assigned, so they could respond to call lights and assist residents with needs because there was no ward clerk responsible to answer call lights after 10:00 p.m. She stated S5LPN informed her staff could not get to the resident's rooms on Hall A due to floor maintenance. She explained the hall had been blocked off so she sat in the door way of the chapel and saw a resident call light on for about an hour at approximately 1:00 a.m. She stated she was unable to recall which resident required assistance, but she stated she did not respond to the call light. She stated once the floor maintenance was done around 2:30 a.m., all 3 CNAs working went down the hall to perform visual checks on the residents. She stated S6CNA found Resident #1 kneeling on her fall mat at her bedside, and Resident #3 lying on the floor in her room. She confirmed nursing staff not performing visual checks on their residents every two hours or providing care for the residents from 10:00 p.m. until 2:30 a.m., was neglect. She stated she should have performed visual checks and responded to call lights regardless of the floor maintenance and confirmed she had not. She stated she notified S2ADM once he had arrived to the facility, that staff were unable to perform rounds on residents on Hall A. On [DATE] at 4:15 p.m., an interview was conducted with Resident #3. She stated on [DATE] she slid out of bed onto the floor. She stated she tried calling for assistance before she slid out the bed, but no one came to help her. She stated once she was on the floor it took a long time for staff to come. She stated she did not try to get back in bed on her own because she needed staff assistance. She stated she called when she was on the floor with the call button and it took a long time for staff to come. She stated, in an angry tone, it made her feel neglected and very aggravated when the staff did not come help her after calling for help and lying on the floor. On [DATE] at 1:17 p.m., an interview was conducted with S3DON. She stated nursing staff were expected to perform visual checks on the residents every two hours based on their Physician's Order and provide any needed care. She stated staff should have notified the administrator immediately if they were ever unable to follow physician's orders, perform visual checks, or provide care to residents for any reason. She stated she expected staff to respond to call lights in a timely manner and as quickly as possible. She stated neglect would be staff not providing care to residents and ignoring the needs of residents. On [DATE] at 4:36 p.m., an interview was conducted with S2ADM. He stated through his investigation it was discovered that the floor maintenance impeded care by not allowing the nursing staff to perform visual checks or provide care to residents on Hall A from 10:00 p.m. until approximately 2:30 a.m., on [DATE]. He confirmed Resident #1 and #3 were both found on the floor on [DATE], and by the time Resident #1 was found she was unresponsive. He stated staff should have notified him immediately when the maintenance vendor did not allow staff on Hall A. He confirmed if a resident had an order for visual checks every 2 hours he expected staff to follow the physician's order and they had not. He stated he preferred for a call light to be responded to by staff between 30 to 45 minutes at most. The facility implemented the following actions to correct the deficient practice: 1. Resident #1 and Resident #3 were identified as having been affected by the alleged deficient practice of not making Q2 visual checks per physician order. All residents had the potential to be affects as the result of the alleged non-compliance. 2. a. An in-service was conducted on [DATE] by the Administrator, DON and ADON for all CNA's and LPN's regarding Q2hr visual rounds. The in-service also included if there was anything that would prevent them making Q2hr rounds they should immediately notify the Administrator. To ensure that the staff understood the in-service a questionnaire was initiated on [DATE]. b. Staff unable to be in-serviced on [DATE] and forward will not be permitted to work until they are in-serviced. All new employees will be in-serviced regarding the information listed above during their orientation period. c. A log of each resident arranged by room was reimplemented on [DATE] to document direct observation checks every two hours on each shift. The monitor is broken into 2-hour increments and designated nursing staff are to sign off that the observations have been made. This monitoring will continue 24 hours/day 7 days/week for two weeks and then will be reviewed by the DON/designee. d. On [DATE], the Administrator notified the Vendor that the company employee will not be allowed to perform floor services in the absence of the Administrator. The Administrator will ensure a schedule is set for floor service times that will ensure the vendor reports directly to him at the time of the floor service. e. A QAPI monitor was reimplemented on [DATE] to ensure Q2hr rounds are completed 24hr a day 7 days a week. A nurse will be assigned to complete the Q2hr visual rounds and document the rounds on the QA Monitor. The QA Monitor will be ongoing. f. Effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performance Improvement Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implemented as needed. 3. As of [DATE], the facility has resolved the likelihood of serious harm or injury to any resident no longer exists. Throughout the survey from [DATE] to [DATE], observations, interviews, and record review revealed the above listed actions were implemented. Random staff interviews and observations revealed the above education for staff was completed. Observations, interviews, and record review, revealed monitoring had begun as mentioned above in the POR with no further issues identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, video observation, and interviews the facility failed to ensure residents received adequate supervision to prevent elopement from the facility for 1 (#1) of 5 (#1, #2, #3, R1 and R2) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 12/14/2024 at 4:32 a.m. when Resident #1, a moderately cognitively impaired resident with a physician's order for staff to visually check the resident every 2 hours, eloped from the facility. On 12/14/2024, staff last visualized Resident #1 at approximately 4:00 a.m. Resident #1 was observed on video footage eloping from the facility by climbing over the patio fence at 4:32 a.m., without staff knowledge. Facility staff had not realized Resident #1 eloped from the facility until approximately 8:00 a.m. The resident was found by local police officers at a local gas station on 12/18/2024 at approximately 2:38 p.m. S2ADM was notified of the Immediate Jeopardy on 12/19/2024 at 6:14 p.m. This deficient practice continued at a likelihood to cause more than minimal harm to the remaining 100 residents residing in the facility with orders to be visually checked. The Immediate Jeopardy was removed on 12/20/2024 at 2:03 p.m., when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews, observations, and record review. Findings: Review of the facility's undated policy, titled Wandering or Missing Resident, read in part . Procedure: 4. Any staff member becoming aware of a resident not being at the designated area or activity shall proceed to notify the charge nurse, Director of Nursing and the Administrator. Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE], and had diagnoses which included in part, Type 2 Diabetes Mellitus, Undifferentiated Schizophrenia and Disorganized Schizophrenia. Review of Resident #1's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 08/21/2024, revealed a Brief Interview for Mental Status (BIMS) of 12, which indicated Resident #1 had moderate cognitive impairment. Review of Resident #1's 12/2024 Physician's Orders revealed in part: Visual check for resident's location every 2 hours, every shift. Start date: 09/03/2024. Review of Resident #1's Nurses' Note dated 12/2024 revealed the following, in part: On 12/14/2024 at 11:38 a.m., Resident not noted in his room at breakfast time. Asked his roommate but he was unsure. Checked rooms on the hallway and the shower. Checked the patio areas. Notified RN supervisor and CNA supervisor. S4ADON called and informed S2ADM. Call placed to Resident's brother-in-law at 10:15 a.m. to let him know that resident was missing. Resident's sister called back about 10:50 a.m., and spoke to S2ADM. Staff drove on local highway to look for resident but were unsuccessful. After replaying the video footage resident climbed the patio fence at approximately 4:30 am. Call placed to physicians on call answering service. Signed by: S5LPN. Review of a written statement from S6CNA dated 12/14/2024 revealed the following: Upon arriving I did my room rounds, all residents was accounted for. Around 3:00 a.m. or 4:00 a.m., Resident #1 came out room to get ice and walk hall, this is a regular routine. On my last round, I went into Resident #1's room to turn his roommate, I noticed that Resident #1 wasn't in room, I finished my last round getting resident up. On 12/19/2024 at 10:37 a.m., a review of the facility's video surveillance footage dated 12/14/2024 from 4:00 a.m. until 9:00 a.m. was conducted with S2ADM of the hall Resident #1 resided on as well as the patio area. Review of the surveillance footage revealed on 12/14/2024 at 4:32 a.m., Resident #1 was observed using a chair to climb over the patio gate and left the facility's premises. Further review of the surveillance footage revealed staff failed to perform visual checks on Resident #1 every two hours as ordered, after he left the facility at 4:32 a.m., until 8:30 a.m. when staff are seen looking for Resident #1. On 12/19/2024 at 10:20 a.m., a telephone interview was conducted with S9LPN. She stated she was the nurse assigned to Resident #1 on 12/13/2024 and worked the 10:00 p.m. to 6:00 a.m. shift. She stated Resident #1 was cognitive and able to understand and be understood. She stated he was also able to ambulate independently. She confirmed Resident #1 had visual checks ordered every two hours which meant staff were to visualize the resident every two hours. She stated she conducted rounds at 10:00 p.m., 12:00 a.m., 2:00 a.m., and 4:00 a.m. She stated at approximately 4:00 a.m., she went in Resident #1's room to give his roommate medication, and saw Resident #1 in his bed. She confirmed this was the last time she visually saw Resident #1 on 12/14/2024 as her final round was at 4:00 a.m., and her shift ended at 6:00 a.m. She confirmed no staff had notified her Resident #1 had not been seen after 4:00 a.m. On 12/19/2024 at 1:48 p.m., a telephone interview was conducted with S6CNA. She stated was assigned to Resident #1 on 12/13/2024 and worked the 10:00 p.m. to 6:00 a.m. shift. She stated Resident #1 ambulated independently. She confirmed Resident #1 had visual checks ordered every two hours which meant staff were to visualize the resident every two hours. She stated she conducted rounds at 10:00 p.m., 12:00 a.m., 2:00 a.m., and begins her last round at about 4:00 a.m. She stated she last saw Resident #1 between 3:30 a.m. and 4:00 a.m. on 12/14/2024 getting ice from cooler in hallway. She stated she went into the resident's room to perform her last round between 4:45 a.m. and 5:00 a.m. and Resident #1 was not in his room at that time. She confirmed she did not notify staff Resident #1 was not observed during her last round, nor did she try to locate him at that time, and should have. On 12/19/2024 at 2:27 p.m., an interview was conducted with S7CNA. She stated she worked on 12/14/2024 on the 6:00 a.m. to 10:00 p.m. shift passing meal trays on Resident #1s hall but she was not his CNA for that day. She stated Resident #1 was ordered visual checks every 2 hours, which meant staff were to visualize the resident every two hours. She stated when she went in Resident #1's room around 7:30 a.m. to pass breakfast trays she asked his roommate if he had seen Resident #1. She stated his roommate said he just left out, but he would be right back. She stated she left Resident #1's tray in his room and walked out. On 12/19/2024 at 2:45 p.m., an interview was conducted with S11CNA. She stated she worked the 6:00 a.m. to 2:00 p.m. shift on 12/14/2024 and was the CNA assigned to Resident #1 on 12/14/2024. She stated Resident #1 was ordered visual checks every 2 hours, which meant staff were to visualize the resident every two hours. She stated she began rounding on residents at around 6:30 a.m. She stated by the time she made it into Resident #1's room it was about 7:30 a.m., and she did not see Resident #1. She stated she notified S5LPN that Resident #1 was not in his room. On 12/20/2024 at 1:05 p.m., a telephone interview was conducted with S5LPN. He stated he was the nurse assigned to Resident #1 on 12/14/2024. He stated Resident #1 had visual checks ordered every two hours. He stated he rounded on residents every two hours or every one hour if ordered sooner. He stated he did not observe Resident #1 come get his morning medication on 12/14/2024 before breakfast around 7:00 a.m., which was unusual since Resident #1 typically came out to the hall to receive his morning medications. He stated he asked Resident #1's roommate if he had seen him, and he answered no. He stated he asked CNAs if they had seen him and they were not sure. He stated between 8:00 a.m. and 8:30 a.m. after searching for Resident #1 and being unable to locate him, he notified the RN supervisor and the CNA supervisor that the resident could not be found. He stated staff searched the facility for Resident #1 and were unable to locate him. He stated at that time the supervisor notified S4ADON and S2ADM Resident #1 was missing from the facility. On 12/20/2024 at 1:50 p.m., an interview was conducted with S12CNAS. She stated at approximately 8:00 a.m. on 12/14/2024, S5LPN notified her he could not locate Resident #1. She stated she notified S13RNS and a Code W was called. She stated a Code w meant she and staff CNAs would go room to room and completed a total count of all residents. She confirmed Resident #1 was not present in the facility during the head count. She stated CNAs were expected to perform visual checks on residents every two hours and if the staff were unable to locate the resident upon visual checks they were to notify the nurse immediately. She stated nursing staff were expected to search the facility and locate the resident if unable to visualize the resident in their room prior to documenting completion of a round. On 12/20/2024 at 1:43 p.m., an interview was conducted with S3DON. She stated she was notified on 12/14/2024 sometime between 9:00 a.m. and 9:30 a.m. Resident #1 had eloped from the facility by S13RNS. She stated staff initiated a code W, which meant staff search the entire facility for the resident, and do a complete head count to ensure all other residents are accounted for, and inform Resident representative, doctors, and local law enforcement that a resident was missing. She confirmed Resident #1 eloped from the facility on 12/14/2024 at approximately 4:32 a.m. She stated on 12/18/2024 S1CADM notified her Resident #1 was located at a local gas station. At that time, Resident #1 signed the Against Medical Advice (AMA) form, and refused to return to the facility or seek medical attention. She stated nursing staff were expected to perform visual checks on the residents every two hours based on their Physician's Order. She stated staff were expected to search the facility if unable to visually observe the resident during rounds, and notify the nurse, herself, S4ADON, or S2ADM immediately. On 12/26/2024 at 2:10 p.m., an interview was conducted with S2ADM. S2ADM confirmed Resident #1 was missing for four days and no staff had visually observed him since 12/14/2024 at 4:00 a.m. until he was found on 12/18/2024 at 2:38 a.m. He stated he was notified by staff on 12/14/2024 around 9:00 a.m. that Resident #1 was not on the premises. He then reviewed the facility surveillance footage where Resident #1 was observed climbing over the patio fence and left the facility premises on 12/14/2024 at 4:32 a.m. S2ADM confirmed staff did not realize he was gone until approximately 8:00 a.m. S2ADM further confirmed staff failed to adequately supervise Resident #1 by not performing visual checks every two hours on Resident #1 as ordered. The facility had implemented the following actions to correct the deficient practice on 12/19/2024: 1) Resident #1 left the facility against medical advice on 12/14/2024. The facility allegedly failed to effectively maintain its highest practical physical, mental, psychosocial well-being for this 1 resident by failing to ensure the resident was adequately supervised to monitor a resident who is leaving against medical advice without signing the sign-out log. All residents had the potential to be affected as the result of the alleged non-compliance. 2) The Administrator and DON in-serviced all present nursing staff on 12/19/2024 at 6:30 p.m. The in-service included performing every 2 hour visual checks on all residents. The in-services also included the existing policy Wandering or Missing Resident that includes Code W. Staff unable to be in serviced on 12/19/2024 at 6:30 p.m. will not be permitted to work until they are in-serviced. All new employees will be in-serviced regarding the information listed above during their orientation period. A log of each resident arranged by room was implemented on 12/19/2024 to document direct observation checks every two hours on each shift. The monitor is broken into 2-hour increments and designated nursing staff are to sign off that the observations have been made. This monitoring will continue 24 hours/day 7 days/week for two weeks and then will be reviewed by the DON/designee. Resident patios will be monitored by a designated staff member to help ensure resident safety. Beginning at 7 p.m. on 12/19/2024, the staff will sit at the north and south smoking patio doors and go outside to monitor any resident who exits. This monitoring will continue 24 hours/day 7 days/week for two weeks and then 3 times a week for six weeks and then as needed thereafter. The Wander Data Collection Tool is completed by the MDS nurses at time of admission, quarterly, significant change in status. The tool is a scoring system indicating if a resident has a Definite Risk for elopement with a score of 3 or more YES answers, and is At Risk with a YES answer. The tally of the answers for YES is completed, and the nurse summarizes her findings on the back of the risk page which determines the most appropriate intervention accordingly, or if needed. On 12/20/2024, the MDS nurses began an audit of all elopement risk assessments. All residents that are identified as a risk for elopement will be discussed with the IDT in the QA meeting to determine if a plan of action is needed for those residents. To ensure the facility staff understand the in-service that was started on 12/19/2024, a questionnaire will be created by the Administrative Staff. Beginning on 12/20/2024, employees will complete the questionnaire to validate their understanding of the facility policy related to Wandering or Missing Resident. 3) As of 12/19/2024, the facility has resolved the likelihood of serious harm or injury to any resident no longer exists. Throughout the survey from 12/19/2024 to 12/26/2024, observations, interviews, and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on supervision, visual checks, wandering or missing residents and completed questionnaires testing their knowledge. Observations were made throughout the survey with no supervision concerns identified. Observations, interviews, and record review, revealed monitoring had begun with no further issues identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's significant change in status was reported to the physician for 1 (#1) of 3 (#1, #2 and #3) sampled residents reviewed for notification of change. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at approximately 1:12 p.m. for Resident #1, a resident requiring mechanical lift with 2 person assistance for transfers, when S8CNA transferred the resident without another staff member's assistance. The transfer resulted in Resident #1 falling from the lift to the floor. On [DATE] from 1:48 p.m. to 1:53p.m., Resident #1 told S5CNA, S6CNA and S7CNA, I am going to die and showed symptoms of increased anxiety. None of the CNAs reported this to the nurse. Resident #1 was found unresponsive at 1:55 p.m., CPR initiated, and transferred to the hospital via emergency transportation. Resident #1 expired in the hospital at 2:24 p.m. from cardiac arrest. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. S1ADM was notified of the Past Noncompliance Immediate Jeopardy on [DATE] at 1:30 p.m. Findings: Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Guillain-Barre Syndrome, Lack of Coordination, Contracture of Right and Left Hand, Hypertensive Heart Disease with Heart Failure, Generalized Pain, Muscle Wasting and Atrophy, Schizoaffective Disorders, Bipolar Disorder, Severe Recurrent Major Depressive Disorder with Psych Symptoms, and Generalized Anxiety Disorder. Review of Resident #1's MDS with an ARD of [DATE] revealed Resident #1 had a BIMS of 10, which indicated her cognition was moderately impaired. Further review of the MDS revealed Resident #1 had speech difficulty with communicating some words or finishing thoughts, and if prompted or given time, made herself understood. Review of Resident #1's current Care Plan revealed the following, in part: Problem: [DATE] Mood Disorder related to diagnosis of Depression, Schizophrenia, and Anxiety. Intervention: Assess for changes in mood status. Review of the facility's Investigation Report dated [DATE] at 1:05 a.m. revealed: S8CNA transferred Resident #1 by herself with the mechanical lift. Resident #1 fell from the lift and landed with her shoulders/back on the leg of the lift. S8CNA immediately called for assistance, and nurses assessed Resident #1. At that time, the only complaint Resident #1 had was she felt she had cracked some ribs. Resident #1 maintained her normal faculties and was able to appropriately, answer all questions. Approximately forty minutes later, S2DON made a round on Resident #1 and found her to be unresponsive. At that time, CPR was started and Resident #1 was taken to a local hospital for evaluation and treatment. Review of the facility's surveillance video footage on [DATE] at 1:30 p.m. with S1ADM and S2DON revealed the following: Date: [DATE] 1:48 p.m. S6CNA entered Resident #1's room. 1:49 p.m. S6CNA exited Resident #1's room. 1:50 p.m. S7CNA and S5CNA entered Resident #1's room. 1:52 p.m. S7CNA and S5CNA exited Resident #1's room. 1:52 p.m. S5CNA re-entered Resident #1's room. 1:53 p.m. S5CNA exited Resident #1's room. 1:55 p.m. S2DON entered Resident #1's room and Resident #1 was found unresponsive. Review of the hospital's Emergency Department Provider's Notes for Resident #1 dated [DATE] at 2:31 p.m. revealed the following, in part: Resident #1 was a level 1 trauma activation after a fall and cardiac arrest in the field per ambulance, Resident #1 had a fall at her nursing home and was transported back to her room. Approximately 15 minutes later, she was found pulseless. Ambulance arrived and performed ACLS with 3 rounds of Epinephrine and pulseless electrical activity consistently. Resident #1 arrived with supraglottic airway in place and compressions being performed. Total time of ACLS prior to arrival 35 minutes. At that time bedside cardiac ultrasound showed no cardiac activity, patient's pupils were fixed and dilated, no spontaneous breathing noted, no pulses palpable. Time of death called on [DATE] at 2:24 p.m. An interview was conducted on [DATE] at 8:27 a.m. with S8CNA. She stated, on [DATE], during transfer of Resident #1 with the mechanical lift, the resident fell from the lift. S8CNA stated, after the fall, Resident #1 was agitated and anxious, but easily consoled. An interview was conducted on [DATE] at 9:46 a.m. with S6CNA. S6CNA stated, on [DATE] Resident #1 fell from the mechanical lift. S6CNA stated at 1:48 p.m., Resident #1 said she fell off the mechanical lift and thought her ribs were broken. The resident then stated, I think I am going to die. S6CNA stated Resident #1 was hyperventilating and seemed anxious. S6CNA stated she did not report the resident's statement or appearance to the nurse. An interview was conducted on [DATE] at 11:26 a.m. with S7CNA. S7CNA stated, on [DATE], Resident #1 fell from the mechanical lift. S7CNA stated at 1:50 p.m., she checked on Resident #1, and when she entered the room, Resident #1 looked panicked. S7CNA stated Resident #1 said her ribs were broken, call my sister, and I am about to die. S7CNA stated she did not report Resident #1's statement or appearance to the nurse. An interview was conducted on [DATE] at 2:52 p.m. with S5CNA. S5CNA stated, on [DATE], Resident #1 fell from the mechanical lift. S5CNA stated at 1:50 p.m., she checked on Resident #1, and when she entered the room, Resident #1 was nervous and fidgety and asking to call her sister. S5CNA stated she tried to calm Resident #1 down and was unsuccessful. S5CNA stated Resident #1 said, I am about to die, I am about to die. S5CNA stated at 1:52 p.m., she reentered Resident #1's room and the resident was screaming call my sister, call my sister. She stated she did not report Resident #1's statements or appearance to the nurse. An interview was conducted on [DATE] at 11:08 a.m. with S16RN. S16RN stated she was made aware Resident #1 fell from the mechanical lift soon after the incident happened. S16RN stated she did not receive report Resident #1 was showing signs of increased anxiety and difficult to calm or that Resident #1 was saying I am about to die. S16RN stated if a resident stated to a CNA I am about to die, she would expect the CNA to report it to the nurse immediately. She confirmed she would have assessed the resident and contacted the doctor had she known. An interview was conducted on [DATE] at 1:16 p.m. with S3LPN. S3LPN stated, on [DATE], Resident #1 fell from the mechanical lift. S3LPN stated when she got to Resident #1's room, the resident was on the floor. S3LPN stated Resident #1 complained of pain to her upper back at first and then her right flank area. S3LPN stated she did not receive report from nursing staff that Resident #1 had increased anxiety and was difficult to calm or that Resident #1 was saying I am about to die. S3LPN confirmed she would have contacted the doctor had she known. An interview was conducted on [DATE] at 11:07 a.m. with S12NP. S12NP stated Resident #1 was cognitive and able to communicate her needs. S12NP stated, on [DATE] at 1:15 p.m., she was notified Resident #1 fell from the mechanical lift and complained of back pain. S12NP said she was again contacted on [DATE] at 1:40 p.m. about Resident #1's complaint of rib pain. S12NP stated she was not notified of Resident #1's increased anxiety, hyperventilation, inability to be calmed, or the resident's statements that she thought she was going to die. She stated she received a text on [DATE] at 1:56 p.m. reporting Resident #1 was receiving CPR. An interview was conducted on [DATE] at 3:14 p.m. with S2DON. S2DON stated, on [DATE], she was made aware Resident #1 fell from the mechanical lift. S2DON stated she entered Resident #1's room at 1:55 p.m. and found her with eyes open, agonal breathing and a faint, thready pulse. S2DON stated Resident #1 was unresponsive. S2DON stated she started CPR. S2DON stated if a resident were to state to staff I am about to die, she would expect the staff to notify the nurse immediately. S2DON stated she started the plan of correction immediately on [DATE] after the incident with Resident #1. The facility implemented the following actions to correct the deficient practice: 1. Resident #1 was sent out to local hospital for evaluation and treatment on [DATE]. 2. A root cause analysis and 5 Whys was completed by the Administrator/DON on [DATE] to help identify the reason for the employee non-compliance. 3. Lift and lift pad were both checked by DON on [DATE] after the incident - no issues noted with lift and the lift pad was in good repair. 4. S8CNA was immediately pulled from the section on [DATE]. She gave a statement and was sent home pending investigation. 5. A list of Physician Orders were printed to determine lift status for all residents. All residents who require assistance via lifts have the potential to be affected on [DATE]. 6. All lifts were immediately taken out of service on [DATE] by DON/Maintenance until re-education and lift check-offs of present staff were completed. 7. No staff were allowed to use a lift until after education and check-off by DON/nursing administration. 8. The lift competency check-off created by Central Management (and a part of orientation) was used to re-educate staff beginning [DATE]. A post-test was created from the check-off, and was utilized to help ensure understanding. 9. Throughout the evening of [DATE] and the weekend of [DATE] through [DATE], the Administrative Nursing staff came to the facility to re-educate, test, and check-off all CNA, LPN, and RN prior to using a lift to ensure compliance. Return demonstrations were observed on all above-listed staff. Hours were staggered by the Nursing Administration to ensure supervisor and training on all shifts. 10. A new protocol by DON/nursing administration was implemented on [DATE] that all lifts must be completed with at least 3 certified/licensed/registered staff members (and 2 CNAs must have an LPN or RN present to perform a lift transfer) to ensure compliance with protocol. 11. Effective [DATE], the hall LPNs were required to sit on the hall to do documentation to help ensure availability and accessibility during transfers if needed. 12. All lifts and lift pads were inspected on [DATE] by mechanical lift medical supply company- no issues noted with lift operability or lift pads. One lift did have a part ordered and was taken out of commission until [DATE] to ensure maximum safety. 13. All wall care plans were checked by MDS on [DATE] to ensure that transfer status was correct for each resident. 14. Monitors were implemented beginning [DATE] by Nursing Administration to help ensure lifts were being done per care plan and safely. Re-educated provided as needed. 15. An in-service staff on the reporting of changes of resident condition was begun on [DATE] in regards to a different matter, but was applicable to this plan of correction also. 16. A multifaceted monitor on nurse's notes, treatment notes, physician orders, incident/accidents, and verbal notifications was put into place to help ensure the reporting of potential changes of resident status. This was implemented on [DATE]. 17. A QAPI monitor had been developed to ensure that lift transfers were done correctly and per care plan. This monitor was to be performed twice weekly for 6 weeks on a random sample by the DON or their designee, and then monthly thereafter until compliance was maintained. 18. Effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performance Improvement Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implemented as needed. 19. Date of completion [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure residents, who required two person assistance with mechanical lift transfers, remained free of accident hazards for 1 (#1) of 8 (#1, #2, #3, R1, R2, R3, R4, and R5) residents reviewed for transfers. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at approximately 1:12 p.m. for Resident #1, a resident requiring mechanical lift with 2 person assistance for transfers, when S8CNA transferred the resident without another staff member's assistance. The transfer resulted in Resident #1 falling from the lift to the floor. Resident #1 was found unresponsive at 1:45 p.m., CPR initiated, and transferred to the hospital via emergency transportation. Resident #1 expired in the hospital at 2:24 p.m. from cardiac arrest. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. S1ADM was notified of the Past Noncompliance Immediate Jeopardy on [DATE] at 1:30 p.m. Findings: Review of the facility's undated policy Hydraulic Lift revealed the following, in part: Policy: The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. Require two or three staff members to operate and accomplish the transfer. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Guillain-Barre Syndrome, Lack of Coordination, Contracture of Right and Left Hand and Muscle Wasting and Atrophy. Review of Resident #1's most recent MDS with an ARD of [DATE] revealed Resident #1 required two-person staff assistance for transfers. Review of Resident #1's current Care Plan revealed: Problem: Self -care ADL deficit: dependent upon staff for transfers related to Bilateral Hand Contractures and limited range of motion due to multiple muscles in bilateral lower extremities and bilateral upper extremities. Intervention: [DATE]- Use mechanical lift for transfers times 2 person Review of Resident #1's current Physician Orders revealed, in part: [DATE] Resident requires 2 person assist with transfers, uses a mechanical lift. Review of the facility's surveillance video footage on [DATE] at 1:30 p.m. with S1ADM and S2DON revealed the following: Date: [DATE] 1:12 p.m., S8CNA transported Resident #1 via geriatric chair into her room. 1:16 p.m., S8CNA retrieved a mechanical lift and entered Resident #1's room alone. No other staff member was seen to enter Resident #1's room with S8CNA. 1:19 p.m., S9CNA was in the hallway by Resident #1's door and S8CNA stepped into the hallway to talk to S9CNA. 1:21 p.m., S3LPN, S9CNA, S2DON and other nursing staff entered Resident #1's room. 1:55 p.m., S2DON entered Resident #1's room. Review of the facility's Investigation Report dated [DATE] at 1:05 p.m. revealed: S8CNA transferred Resident #1 by herself with the mechanical lift. Resident #1 fell from the lift and landed with her shoulders/back on the leg of the lift. S8CNA immediately called for assistance, and nurses assessed Resident #1. At that time, the only complaint Resident #1 had was she felt she had cracked some ribs. Resident #1 maintained her normal faculties and was able to appropriately, answer all questions. Approximately forty minutes later, S2DON made a round on Resident #1 and found her to be unresponsive. At that time, CPR was started and Resident #1 was taken to a local hospital for evaluation and treatment. Review of the facility's written staff member statements revealed the following: Staff member: S8CNA. Staff Statement on the fall that occurred on [DATE]: After lunch when I was making my last round I went to get Resident #1 to put her in bed before I went home. When I rolled Resident #1 into the room I went to get the lift from down the hallway and didn't see anyone. When I went back to Resident #1's room, I hooked her up to the lift and lifted her up and that's when the lift bars were tilted, and Resident #1 was leaning sideways on the lift pad. I put her back into her Geri chair and tried to fix the lift pad under her correctly. When I lifted her out of her chair and pulled the lift from under it, Resident #1 said she was falling. That is when Resident #1 slid out of the side of the lift pad on the right and hit her side on the legs of the lift. Review of the [DATE] Nurse's Notes for Resident #1 revealed the following: [DATE] at 1:34 p.m.-1:15 p.m. S3LPN was called to Resident #1's room by S9CNA, and observed Resident #1 lying supine with her head on the feet on the mechanical lift and lower extremities on the floor. Resident #1 complained of pain to the sacrum, back and right flank. S12NP gave an order to send the resident to the local hospital for evaluation. At 1:45 p.m. nursing staff was summoned to Resident #1's room due to Resident #1 becoming unresponsive. Nursing staff and administration begun CPR efforts. At 1:51 p.m., the ambulance arrived on scene and continued CPR. At 1:58 p.m. Resident #1 was intubated, no pulse. At 2:00 p.m. Resident #1 exited facility via ambulance for local hospital. Signed by S3LPN. Review of the hospital's Emergency Department Provider's Notes for Resident #1 dated [DATE] at 2:31 p.m. revealed the following, in part: Resident #1 was a level 1 trauma activation after a fall and cardiac arrest in the field. Per ambulance Resident #1 had a fall at her nursing home and was transported back to her room. Approximately 15 minutes later she was found pulseless. Ambulance arrived and performed ACLS with 3 rounds of Epinephrine and pulseless electrical activity consistently. Resident #1 arrived with supraglottic airway in place and compressions being performed. Total time of ACLS prior to arrival 35 minutes. At that time bedside cardiac ultrasound showed no cardiac activity, patient's pupils were fixed and dilated, no spontaneous breathing noted, no pulses palpable. Time of death called on [DATE] at 2:24 p.m. An interview was conducted on [DATE] at 8:27 a.m. with S8CNA. She stated on [DATE] she transported Resident #1 via geriatric chair to her room. S8CNA stated she then retrieved the mechanical lift and pushed it to Resident #1's room. S8CNA stated during transfer of Resident #1 with the mechanical lift, Resident #1 slipped out of the lift pad and fell on top of the legs of the lift hitting her right flank. She stated she did not ask for help with the mechanical lift transfer and transferred Resident #1 without assistance. S8CNA stated she knew she was supposed to use two person assistance with the lift. An interview was conducted on [DATE] at 11:37 a.m. with S13CNAS. She stated she required the CNA's to use two person assistance with all mechanical lift transfers. She stated S8CNA should have had another staff member to assist her with the mechanical lift transfer with Resident #1. An interview was conducted on [DATE] at 2:18 p.m. with S2DON. S2DON stated she was made aware of the incident with S8CNA and Resident #1 on [DATE]. She stated the facility's policy had always been two person assistance with a mechanical lift transfer. She stated she would expect all mechanical lift transfers to be completed with two staff members. She stated S8CNA was suspended and sent home immediately after the incident with Resident #1. S2DON stated she started the plan of correction immediately after the incident with Resident #1 on [DATE]. The facility implemented the following actions to correct the deficient practice: 1. Resident #1 was sent out to local hospital for evaluation and treatment on [DATE]. 2. A root cause analysis and 5 Whys was completed by the Administrator/DON on [DATE] to help identify the reason for the employee non-compliance. 3. Lift and lift pad were both checked by DON on [DATE] after the incident - no issues noted with lift and the lift pad was in good repair. 4. S8CNA was immediately pulled from the section on [DATE]. She gave a statement and was sent home pending investigation. 5. A list of Physician Orders were printed to determine lift status for all residents. All residents who require assistance via lifts have the potential to be affected on [DATE]. 6. All lifts were immediately taken out of service on [DATE] by DON/Maintenance until re-education and lift check-offs of present staff were completed. 7. No staff were allowed to use a lift until after education and check-off by DON/nursing administration. 8. The lift competency check-off created by Central Management (and a part of orientation) was used to re-educate staff beginning [DATE]. A post-test was created from the check-off, and was utilized to help ensure understanding. 9. Throughout the evening of [DATE] and the weekend of [DATE] through [DATE], the Administrative Nursing staff came to the facility to re-educate, test, and check-off all CNA, LPN, and RN prior to using a lift to ensure compliance. Return demonstrations were observed on all above-listed staff. Hours were staggered by the Nursing Administration to ensure supervisor and training on all shifts. 10. A new protocol by DON/nursing administration was implemented on [DATE] that all lifts must be completed with at least 3 certified/licensed/registered staff members (and 2 CNAs must have an LPN or RN present to perform a lift transfer) to ensure compliance with protocol. 11. Effective [DATE], the hall LPNs were required to sit on the hall to do documentation to help ensure availability and accessibility during transfers if needed. 12. All lifts and lift pads were inspected on [DATE] by mechanical lift medical supply company- no issues noted with lift operability or lift pads. One lift did have a part ordered and was taken out of commission until [DATE] to ensure maximum safety. 13. All wall care plans were checked by MDS on [DATE] to ensure that transfer status was correct for each resident. 14. Monitors were implemented beginning [DATE] by Nursing Administration to help ensure lifts were being done per care plan and safely. Re-educated provided as needed. 15. An in-service staff on the reporting of changes of resident condition was begun on [DATE] in regards to a different matter, but was applicable to this plan of correction also. 16. A multifaceted monitor on nurse's notes, treatment notes, physician orders, incident/accidents, and verbal notifications was put into place to help ensure the reporting of potential changes of resident status. This was implemented on [DATE]. 17. A QAPI monitor had been developed to ensure that lift transfers were done correctly and per care plan. This monitor was to be performed twice weekly for 6 weeks on a random sample by the DON or their designee, and then monthly thereafter until compliance was maintained. 18. Effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performance Improvement Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implemented as needed. 19. Date of completion will be [DATE].