**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice when the nursing staff failed to recognize, assess, intervene, and document a resident's condition after a fall to avoid delayed treatment for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for falls. This deficient practice resulted in an Immediate Jeopardy situation on 01/24/2025 at approximately 3:15 p.m., when resident #1 had a fall in his room. The resident's nurse failed to assess the resident after the fall, document the incident, and report the incident to the resident's physician and the director of nursing. On 01/28/2025, it was determined that the resident had obtained a left displaced femoral neck fracture, which required surgical repair on 01/29/2025. This deficient practice resulted in a delay of treatment for resident #1. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 02/11/2025. It was determined to be a Past Noncompliance Citation. Findings: Review of the facility policy, Falls-Clinical Protocol (no date noted), revealed in part: Assessment and Recognition: 2. The nurse shall assess and document/report the following: recent injury, especially fracture or head injury; musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; pain; precipitating factors, and details on how fall occurred. 4. The staff will evaluate and document falls that occur while the individual is in the facility. 6. Falls should also be identified as witnessed or unwitnessed events. Monitoring and Follow-up: 1. The staff will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture have been ruled out or resolved. Delayed complications such as late fracture and major bruising may occur hours or several days after a fall. Review of the facility policy, Accidents and Incidents-Investigating and Reporting (no date noted), revealed in part: All accidents or incidents involving residents occurring on the premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation: 1. The nurse supervisor and/or nurse shall promptly initiate and document an investigation of the accident or incident. 2. The following data shall be included on the Report of Incident/Accident form in part: date and time of incident; nature of the injury/illness; notification of attending physician and family; the condition of the injured person; any corrective action taken; follow-up information; and the signature and title of the person completing the report. 6. Incident/Accident reports will be reviewed for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Review of the record for resident #1 revealed a [AGE] year old with an admit date of 05/21/2024. Diagnoses included but not limited to the following: unspecified dementia with other behavioral disturbance, major depressive disorder, coronary atherosclerosis, atrial fibrillation, weakness, and left displaced femoral neck fracture. Further review revealed resident #1 was unable to verbally communicate his needs effectively. He also had behaviors (i.e. yelling out, resisting care, combative with staff) and he had increased muscle tone which cause his legs to be stiff. Review of resident #1's quarterly Minimal Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severely impaired cognitive skills for daily decision making. Resident #1 was unable to walk and used a wheel chair for locomotion. He also required substantial/maximal assistance for toileting, personal hygiene, chair to bed transfer, and lying to sitting on the side of the bed. Review of the Fall Risk assessment dated [DATE] revealed resident #1 had a score of 10 which indicated he was at a high risk for falls. Review of resident #1's current care plan revealed on 05/24/2024 he was totally dependent on 1 staff for assistance with toileting, personal hygiene, and for transfers. Further review revealed he was at risk for falls. Review of the Electronic Health Record (EHR) Progress Notes dated 01/28/2025 at 6:40 a.m. revealed Certified Nursing Assistants (CNAs) informed this nurse (S5Licensed Practical Nurse [LPN]) that resident #1 had a bruise to left hip and was complaining of pain. When S5LPN assessed resident, there was a small purple bruise noted to his left hip. Resident #1 complained of pain even when not being touched, and kept his left hand at side. S5LPN notified S2Director of Nursing (DON) and the resident's physician assistant. Further review of the resident #1's EHR Progress Notes dated 01/28/2025 at 9:40 a.m. revealed the facility received the resident's left hip x-ray results and he had a displaced femoral neck fracture. The resident's physician was notified and at 10:40 a.m., the resident was transferred to the emergency room. On 01/29/2024 at 11:30 a.m., S2DON was informed by hospital nurse that the resident was supposed to have surgery for his hip today. Review of the S2DON's investigation summary for the resident's incident of unknown injury revealed after interviews were conducted with staff regarding the resident's left hip bruise, initially there was no known incident or cause of the bruise. However, on 01/30/2025, S2DON conducted an interview with S4CNA and she informed S2DON that she was providing care for the resident when he had a fall from his bed on 01/24/2025. S4CNA reported she had asked S6CNA to assist her with transferring the resident. After that, resident #1 was aggravated and he had unplugged the bed, attempting to poke her with the plug. The resident jumped at her and fell out of the bed hitting the floor. Further review of S2DON's notes revealed camera footage was reviewed from 01/24/2025 and the footage supported S4CNA's statement. S4CNA was observed leaving to go to the nurses' station and then she and S3LPN went back into the resident's room. After S2DON further interviewed S4CNA and S6CNA they revealed resident #1 had no apparent injuries and no complaint of pain with transfer or during care. Immediate action taken by facility on 01/28/2025: -A body audit of resident #1 was completed by the S2DON with no other significant findings discovered. -Resident #1 was placed in the dayroom so he could be observed by nursing staff and when the CNA's provided personal care, a management nurse was in attendance. -An investigation regarding the injury of unknown origin was initiated. -Initially, staff interviews initiated with no significant findings noted. -Interviews with residents that resided on resident #1's hall were initiated with no significant findings noted. -Left hip x-ray results received and indicated a displaced femoral neck fracture and resident #1 was transferred to the emergency room for evaluation and transfer for orthopedic care. Review of resident #1's medical record revealed there was no documentation of resident #1's fall on 01/24/2025. Further review revealed there was no documentation the resident was assessed after the 01/24/2025 fall, and the fall was not reported to the resident's physician nor the director of nursing. On 02/12/2025 at 12:15 p.m., an interview with S2DON revealed she interviewed S3LPN regarding the above incident and S3LPN told her she could not remember S4CNA reporting to her that resident #1 had a fall on 01/24/2025. She confirmed S3LPN viewed video footage from 01/24/2025 with her. They watched as she entered resident #1's room with S4CNA, but S3LPN still could not recall that the resident had a fall on 01/24/2025 or if she had assessed him after the fall. S2DON confirmed S3LPN failed to report the resident's fall to her and there was no documentation in the nurse's notes and no incident report was completed regarding resident #1's fall. S2DON revealed the last day that S3LPN worked at the facility was on 01/30/2025 and after the investigation into the incident, she was terminated on 02/07/2025. On 02/12/2025 at 2:12 p.m., a phone interview was conducted with S3LPN and she was unable to recall S4CNA reporting to her that the resident had a fall on the evening on 01/24/2025. She confirmed she worked on 01/24/25 but could not remember any details regarding resident # 1's fall or if she had assessed him after the fall. On 02/12/2025 at 3:58 pm, a phone interview with S4CNA revealed she was trying to change resident #1 and he unplugged the bed and he was trying to poke her or hit her with the plug. He lunged at her with the plug and this caused him to fall out of his bed (that was in low position) onto his left side on the floor. She yelled for S6CNA to come stay with the resident while she went to get his nurse. S4CNA revealed she informed the nurse at the nurse's station that she needed the resident's nurse. She reported that S3LPN came quickly to the room and instructed S4CNA and S6CNA to transfer resident #1 back to bed. S4CNA reported she did not observe S3LPN assess the resident but she had left the room soon after the resident was transferred back to bed. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. On 01/28/2025, the facility implemented the following actions to correct the deficient practice with a completion date of 01/31/2025: 01/28/2025 - Weekly body audits reviewed for 01/27/2025 to determine if there were any unknown injuries or significant findings. Body audits will continue until full facility body audits are completed. Statewide Incident Management System (SIMS) report opened. 01/28/2025- Staff education initiated: Abuse and neglect, staff rounding requirements: CNA even hours/nurses odd hours, ensure staff using proper transfer techniques, report changes in condition, change in behavior, change in skin condition to the nurse in a timely manner and any issues identified with a resident should be assessed immediately and addressed in a timely manner. 01/29/2025- Investigation continues regarding resident #1's injury of unknown origin, and full facility body audits continued. 01/30/2025- Video footage was reviewed by S1Administrator and S2DON. The video footage supported S4 CNA's statement. S3LPN was witnessed entering the resident's room after being notified of the incident. There were no issues identified with review of the footage and routine care rounds were being provided. 01/30/2025- S3LPN was suspended pending investigation. 01/30/2025- Incidents and accidents for resident #1's hall reviewed, no injuries of unknown origin noted; no additional incidents/accidents were noted. 01/30/2025- QA started on reviewing nurse's notes and 24-hr report to ensure that incidents/accidents are reported, processed, and completed. QA will be done 5x a week x 8 weeks then 3x a week x 4 weeks then as needed. 01/30/2025- Residents that resided on resident #1's hall were assessed to identify any potential significant changes, any recent hospitalizations, or other abnormal findings and there were no concerns noted. 01/30/2025 - Staff members who worked with resident #1 through the weekend were re-interviewed in order to gain more details regarding his care, complaints, and activity level. No signs or report of distress or pain was noted. Resident appeared to continue normal activities, including being out of bed, in day room watching television, interacting with others and meal intake was normal. 01/30/2025 - Safety measures were assessed and found to be functioning properly. Included in these were the following: 1) Resident #1's call light was activated, the light lit up in the hall and at the switchboard (the clerk at the desk and nurse in the room could clearly hear each other speaking). 2) Wedge cushion was in place and properly fit the resident's wheelchair. 3) Assist bar was properly attached to resident #1's bed and raised/lowered correctly. 4) Functions of the bed were checked. The head and foot of the bed raised and lowered properly. The bed raised and lowered also with no issues. 5) The mattress fit was checked and was correct. There was no physical damage noted to the exterior of the mattress (no rips, tears or sunken spots). 01/30/2025- Resident #1's incidents were reviewed for the last six months and all prior interventions were assessed and found to be in place. 01/31/2025- Staff in-service for CNAs: Reporting any incident or accidents that occur with a resident. If unsure if something is new or if you should report, always report to the nurse or supervisor. If you feel like an additional assessment may need to be done then report to a management nurse. 01/31/2025- Staff in-service for nurses: An incident report should be done for any of the following (bruises, skin tears, falls, unintentional change in plane, setting a resident in the floor from getting weak, sliding out of bed or wheelchair, etc). Physician, responsible party, and DON should all be made aware. Proper documentation should be done and include any new orders or treatment. If any immediate actions should be put into place, then make sure those are done (increase supervision, increase monitoring, etc.). 01/31/2025- Staff in-service: Abuse & Neglect, reporting any change in condition or change in status to nurse/nurses station. 01/31/2025- QA initiated to ensure nurse competency and return demonstration for incident/accident reporting and completion of appropriate documentation. 01/31/2025- Resident #1 returned to the facility with orders for non-weight bearing status and hip rehab exercises. He is a two person assist with lift transfer. Nursing assessment completed. 01/31/2025- As an immediate protective action, S6CNA sat near the resident's door providing additional supervision due to him having had a fall and behaviors. On 01/30/2025, once the facility was aware of resident #1's fall, corrective action was initiated immediately, staff was suspended with subsequent termination, and all staff education and QA was initiated. Compliance was met on 01/31/2025 after the determination was made that no other residents were affected and the QA process was in place. Date facility asserts the likelihood for serious harm to any recipient no longer exists: 01/31/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 (#1) of 5 (#1, 2, 3, 4, 5) sampled residents by failing to ensure resident #1 was safely secured in a lift chair while bathing in the whirlpool room. This deficient practice resulted in an Immediate Jeopardy situation that began on 04/30/2024 at 9:15 a.m., when resident #1 was not properly secured with the seat belt in a lift chair while receiving a whirlpool bath. The resident fell from the chair to the floor and sustained a fractured skull, fractured left arm, laceration to the left side of the head and a brain bleed. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 05/06/2024. It was determined to be a Past Noncompliance Citation. Findings: Review of the facility's current Bath, Shower/Tub policy, which was last revised February 2018 revealed When using the lift system, be sure whirlpool lift is firmly positioned and locked. Assist the resident into the whirlpool chair lift. Secure the safety belts. Review of the resident #1's medical record revealed she was admitted to the facility on [DATE] and had diagnoses which included chronic obstructive pulmonary disease, hypothyroidism, hypertensive heart disease and hyperlipidemia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1's Brief Interview for Mental Status (BIMS) score was 11. A score of 11 indicated moderate cognitive impairment. The MDS also indicated the resident required partial to moderate assistance with bathing. Review of the care plan for resident #1 revealed she had impaired mobility and required 1 person assistance with bathing. The resident's care plan also indicated she was at high risk for falls. Review of the nurse's notes dated 04/30/2024 indicated resident #1 fell and was lying face down on the floor with blood around her head when the nurse entered the WP (whirlpool) room. The resident's respirations were shallow at 6-8 beats per minute and her heart rate was slow at 10 beats per minute. She did not respond verbally and S2DON (Director of Nurses) initiated deep sternal stimulation. After being stimulated her respirations and heart rate increased. The resident had a 5-6 centimeter laceration to her left forehead. The resident was placed on a stretcher and taken to the emergency room, which was connected to the facility. Review of the facility's incident report revealed on 04/30/2024 at 9:15 a.m., S3CNA (Certified Nurse Aid) was assisting resident #1 with a whirlpool bath which included using the lift chair attached to the bath. S3CNA failed to properly secure the seat belt and the resident fell to the floor. Nursing staff were called to the whirlpool room. They found the resident was unresponsive. S2DON opened resident #1's airway and applied oxygen. The resident was placed on a stretcher and taken to the local hospital's emergency room. Review of the facility's investigation which began on 04/30/2024 revealed S3CNA failed to use the lift seat belt and while she was looking down to lock the lifts wheels the resident fell to the floor. The investigation also indicated S3CNA was suspended while the investigation was ongoing. On 05/06/2024 at 9:10 a.m., an interview with S2DON revealed S3CNA failed to use the seat belt on the lift chair that was attached to the whirlpool bath, to properly secure resident #1 while bathing. S2DON reported the resident fell from the whirlpool lift chair on 04/30/2024 and sustained a laceration to the left side of the head. S2DON stated she was contacted on 04/30/2024 by the emergency room nurse at the local hospital with an update on the resident's status which included a brain bleed, a fractured skull, and a fractured arm. S2DON reported resident #1 was airlifted to another hospital from the local hospital's emergency room. On 05/06/24 at 10:00a.m., an interview with resident #1 revealed that she thought she passed out. Resident #1 reported the last thing she remembered was seeing the last of the water drain from the tub. The next thing she remembered she was on a stretcher on her way to the emergency room. Resident #1 reported her arm was broken and she had been experiencing pain. Observations at this time revealed resident #1 had a heavily bruised face and she was wearing a cervical neck collar. On 05/07/2024 at 10:25 a.m., an interview with S3CNA was conducted via telephone. S3CNA was upset that she forgot to apply the seat belt. S3CNA reported that resident #1 had been wheeled out of the whirlpool. S3CNA was talking to the resident and she walked to the back of the lift to lock the wheels. As she was looking down to lock the wheels resident #1 fell from the chair landing on the floor. S3CNA reported she immediately called for help. On 05/06/2024 at 11:30 a.m., an observation was made of resident #2 receiving a whirlpool bath using the lift. S5CNA and S6CNA were observed properly applying the seat belt of the lift. Interviews with the CNAs revealed whirlpool baths had recently been suspended. The CNAs reported only after they were retrained and performed competency demonstrations, were they able to resume using the lift to give whirlpool baths. The CNAs also reported a nurse has been supervising seat belt use during whirlpools. On 04/30/2024 the facility implemented the following actions to correct the deficient practice. 1. The facility immediately suspended use of the lifts used for whirlpools. 2. Signage was placed at the whirlpool instructing staff not to use it until they had received additional training. 3. A whirlpool safety assessment was completed for every resident in the facility, even if they did not require a lift or use the whirlpool. The assessments were completed on 05/01/2024. 4. All CNAs were trained on: belt safety when using the whirlpool lift chair, locking the lift wheels, keep lift chair in lowest position, proper disinfecting, do not exceed 105 degrees and making sure lift seat is locked when the resident is placed back on the lift. The final in-service was completed on 05/02/2024. 5. The CNAs were retrained and performed a demonstration of the proper use of the whirlpool lift chair x 3. Only after each CNA was reeducated and successfully completed the demonstrations were they allowed to resume use of the lift. The first in-service was conducted on 05/01/2024 and the final in-service was completed. 6. As part of the facility QA (Quality Assurance), S4RN (Registered Nurse), the person responsible for staff development, monitored for proper lift use by the CNAs when they were using the lift in the whirlpool. Review of the QA checkoff sheet developed to review CNAs' compliance to proper lift use showed there had been no issues found. The facility began using the Safety Belt Usage Log on 05/01/2024. 7. Review of the Quality Assurance monitoring logs revealed the monitoring was ongoing and will continue at present time. 8. The above actions were all completed as of 05/02/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure 1 (#1) of 5 (#1, #2, #3, #4 and #5) residents who was assessed at risk for elopement, was adequately supervised to prevent her from eloping from the facility. This deficient practice resulted in an Immediate Jeopardy situation on 04/19/2024 at approximately 6:20 p.m. when resident #1 (a severely cognitively impaired resident identified as an elopement risk) was found approximately 300 yards outside of the facility by a staff member. Resident #1 was located 10 minutes after she eloped on 04/19/2024 through a facility door and was returned to the facility at approximately 6:32 p.m. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 04/24/2024. It was determined to be a Past Noncompliance Citation. Findings: Review of the facility's Emergency Procedure for Missing Resident Policy revised August 2018 revealed: Policy Interpretation and Implementation Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety. Review of the medical record revealed resident #1 was admitted to the facility on [DATE] with diagnoses including depressive disorder, macular degeneration, dementia, and hypothyroidism. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a brief interview for mental status of 3 which indicated that resident #1 had severe cognitive impairment with daily decision making. The assessment also indicated the resident was independent with transfers, and did not require mobility devices. Review of the current care plan revealed resident #1 was at risk for elopement. The interventions for elopement included: determine the resident's walking pattern, encourage the resident to participate in activities, staff should attempt to keep the resident occupied, assess cognitive abilities. The care plan also noted to monitor the resident for possible risk factors such as history of elopement, wandering, and making statements regarding wanting to go home. Additional interventions were to monitor the resident for potential triggers of elopement such as visual/hearing impairment, hunger, pain or thirst, and educate staff on the resident's potential for elopement. Review of the facility's investigation report revealed on 04/19/2024 at approximately 6:32 p.m. resident #1 was brought back to the facility by a staff member. The resident was found walking approximately 300 yards outside of the facility. Further review of the investigation report documented the facility's camera footage revealed on 04/19/2024 at 6:20 p.m. resident #1 exited the building out of the exit door by the activity room. Review of the Elopement Risk assessment dated [DATE] revealed resident #1 had confusion and was disoriented. The resident had diagnoses of dementia and depression. The resident ambulated independently and verbally expressed the desire to go home during the assessment. Further review of the assessment revealed the facility assessed resident #1 to be at high risk for elopement. Review of the nurse notes dated 04/19/2024 at 6:45 p.m. revealed resident #1 was found about two blocks from the facility by an employee of the nursing facility. The employee brought the resident back to the facility, and a body audit revealed no apparent injuries noted. The resident stated, I just went out the back door. When asked if she put a code in to get out the door she replied, If I did I don't remember it. Resident tearful saying I didn't mean to cause all this trouble. If ya'll would have left me alone I'd be home now. Review of the Resident Incident Report dated 04/19/2024 at 6:45 p.m. revealed resident #1 was found outside, about two blocks from the nursing facility. A staff member found resident #1 and brought the resident back to the facility. During the survey observations of resident #1 revealed she ambulated independently in the hallways. On 04/24/2024 at 10:30 a.m. interview with S3Licensed Practical Nurse (LPN) revealed resident #1 walks by herself in the halls. On 04/24/2024 at 11:00 a.m. interview with S4LPN revealed resident #1 ambulates independently. On 04/24/2024 at 12:50 p.m. interview with S5Certified Nursing Assistant (CNA) revealed resident #1 walks by herself in the halls and the resident goes all over the building. On 04/24/2024 at 1:00 p.m. interview with S6CNA revealed resident #1 walks in the halls independently. On 04/24/2024 at 1:10 p.m. interview with S7CNA revealed she has seen resident #1 walk in the halls by herself. On 04/25/2024 at 1:30 p.m. interview with S2Director of Nursing (DON) revealed resident #1 eloped from the building on 04/19/2024. S2DON revealed she assumed resident #1 entered the code to the locked door and exited the building on 04/19/2024 at approximately 6:20 p.m. On 04/25/2024 at 2:07 p.m. interview with S1Administrator confirmed resident #1 was at risk for elopement. On 04/19/2024 resident #1 eloped from the building, and it was assumed she entered the code and exited the building at approximately 6:20 p.m. On 04/19/2024, the facility implemented the following actions to correct the deficient practice with completion on 04/21/2024: 1. Resident #1 was placed on 1:1 supervision until 04/22/2024 at 2:30 p.m. Resident #1 was then monitored every 30 minutes for 24 hours and then placed on hourly monitoring. 2. All other residents were placed on every 30 minute monitoring until 04/21/2024, and then placed on hourly monitoring. 3. A census check for all residents was done immediately. 4. All exit doors were checked immediately for proper functioning. 5. All residents were reassessed for elopement risk on 04/19/2024. 6. All exit door keypad codes were covered with thick paper and tape on 04/19/2024. 7. Extra staff were called to work to monitor the exit doors. 8. On 04/19/2024 the staff were in-serviced regarding: Resident #1 placed on 1:1 monitoring and all other residents were placed on every 30 minute monitoring. The staff were in-serviced on monitoring the exit doors to ensure resident safety and a review of the missing resident protocol was presented. On 04/20/2024 an in-service for missing resident protocol, abuse and neglect policy was presented, and 1:1 care and supervision for the resident who eloped until it is discontinued by the Administrator and/or DON. 9. Staff were educated on residents at risk for elopement. 10. On 04/20/2024 exit doors functioning was checked to ensure proper functioning. 11. An additional camera was installed on the door in which the resident eloped. 12. On 04/22/2024 the plaques above the keypad with the exit code displayed were removed from every exit door and replaced with a small label with the exit code. 13. On 04/22/2024 part of the facility's action list provided by S2DON indicated that the door locks/keypad company would be changing the codes on the exit doors. The door alarm company was in the process of changing all of the door codes upon the surveyor's entrance to the facility on [DATE]. The keypad codes to all exit doors were changed on 04/24/2024. 14.Quality Assurance was conducted with the Administrator, DON and staff immediately following the incident and continues to evolve identifying areas of improvement including but not limited to daily door checks for proper functioning every day for two weeks and then three times a week for two week and then as needed. The hourly monitoring of all residents will continue until further notice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect the residents' right to be free from neglect by staff failing to provide the care needs every two hours as indicated in the care plan for 3 (#1, #2, and #3) of 3 (#1, #2, and #3) residents reviewed for neglect. This deficient practice resulted in an immediate jeopardy situation on [DATE] at 10:13 p.m. (two hours after resident #1 was last seen) when staff failed to make rounds every two hours on resident #1, who was on oxygen and was dependent on staff for transfers, toileting, and bed mobility. Video surveillance revealed the resident was administered medications on [DATE] at 8:13 p.m. by S3LPN (Licensed Practical Nurse) and no staff rounded on the resident or entered the resident's room until [DATE] at 5:57 a.m. (9 hours and 44 minutes). On [DATE] at 5:57 a.m., resident #1 was found in his room, lying on the floor, and deceased . S3LPN failed to perform rounds every two hours for resident #1 during his shift from 8:13 p.m. on [DATE] to 5:57 a.m. on [DATE]. S4CNA (Certified Nursing Assistant) failed to perform rounds on resident #1 every two hours during her shift from 11:00 p.m. on [DATE] to 7:00 a.m. on [DATE]. 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. Findings: Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting revealed the following: 1. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); and, c. Elimination (toileting). An interview with S2DON (Director of Nursing) on [DATE] at 12:45 p.m. revealed the facility's expectations for nurses and CNAs was to make rounds on each resident residing in the facility at least every two hours and according to the residents' plan of care. Resident #1 Review of the electronic health record revealed resident #1 was admitted to the facility on [DATE]. Further review revealed the date of discharge as [DATE] with a discharge status of death in the facility. The resident's diagnoses included in part, chronic obstructive pulmonary disease with (acute) exacerbation, dependence on supplemental oxygen, epilepsy, dementia, unspecified severity, anxiety disorder, major depressive disorder, viral hepatitis C without hepatic coma, and diverticulitis of large intestine with perforation and abscess without bleeding. Review of the annual minimum data set assessment dated [DATE] revealed in part, that resident #1 had a brief interview for mental status score of 15, indicating that he was cognitively intact with daily decision making. Further review revealed that resident #1 required set up/clean up assistance with toileting, dressing, personal hygiene, roll left to right, sit to lying, lying to sitting up in bed, transfer to toilet, and eating. Review of resident #1's care plan revealed the following: Problem Onset: [DATE]: I am high risk for pressure ulcers/altered skin integrity and impaired mobility. Documented approaches included, in part: assist me turning and repositioning every two hours and as needed. Review of the [DATE] physician's orders for resident #1 revealed an order dated [DATE]; O2 (oxygen) at 3 Liters per minute via nasal cannula to be used continuously. Review of the resident #1's AM/PM Care Roster revealed, in part, that on the date of [DATE] at 11:17 p.m. S4CNA documented that pericare was provided for resident #1, he was continent and had voided two times, resident was continent of stool and had two medium sized soft bowel movements during the shift. Further documentation revealed that S4CNA had performed a skin check on resident #1 with no new skin concerns. Review of the departmental/nursing note dated [DATE] at 6:51 a.m. revealed: Resident found deceased on floor in room next to bed during morning medication pass. Resident was lying face down. Body was lying straight. Slightly cold to touch. Skin color still intact. Bedside table sitting next to bathroom door and it's belonging all over the floor. Urine from urinal and tea spilled all over the floor. The note was signed by S3LPN. Review of the facility's incident report dated [DATE] and completed by S2DON revealed the following: Incident Occurred on [DATE]. Investigation Findings included: On the morning of [DATE], around 6:00 a.m., S3LPN walked into resident #1's room for morning med pass and found him face down on the floor. Further documentation on the incident report revealed that S3LPN stated that resident #1 had been seen last around 2 am and had no complaints during his shift, which had started at 7:00 p.m. on the night of [DATE]. S3LPN further assessed resident #1 and found him to be deceased . Additional documentation from the incident report completed by S2DON revealed that S4CNA was the aide on the hall at the time of resident #1's death and her (S4CNA) witness statement said Around 2 o'clock I proceeded to do my rounds and check on the residents as I should. I entered resident #1's room to check on him and he was sound sleep with his oxygen on. Further review of the facility incident report revealed that a review of the video surveillance from [DATE] had revealed that the last time that staff entered the resident's room was at 8:13 p.m. on the night of [DATE], when S3LPN was in the room during night time medication pass. On [DATE] at 12:40 p.m., an interview with S1Administrator revealed that S3LPN had notified S2DON that he was doing his med pass on Sunday morning ([DATE]) at approximately 5:45 a.m. to 6:00 a.m. and he had found that resident #1 was found on the floor and had passed away. She further reported that S4CNA had wrote (Referring to a witness statement) that she had last been in resident #1's room around 2:00 a.m. S1Administrator further reported that an in-house investigation was conducted. S1Administrator reported that she and S2DON had reviewed the facility's video camera footage and found that both S4CNA and S3LPN had not been in resident #1's room since the nighttime med pass at approximately 8:30 p.m. on [DATE]. On [DATE] at 2:46 p.m. an interview with S2DON revealed that she had received a telephone call from S3LPN on the morning of [DATE], informing her that he had found resident #1 on the floor and deceased around 5:57 a.m. She further reported that S3LPN had told her (S2DON) that resident #1 had been seen at 2:00 a.m. on the morning of [DATE], but he had not said which employee had seen the resident. S2DON revealed that S4CNA had reported that on [DATE] at 2:00 a.m., she had seen resident #1 in his room, in bed, and with his oxygen on. Further interview revealed that upon S2DON's return to work on [DATE], she viewed the facility's video camera footage from the date of [DATE] to [DATE] and confirmed that no staff made rounds or had seen resident #1 from approximately 8:15 to 8:30 p.m. on [DATE], when S3LPN had passed medications to resident #1, until [DATE] at approximately 5:57 a.m. when S3LPN found resident #1 in his room, on the floor, and deceased . During the telephone interview on [DATE] at 8:13 p.m., S4CNA was notified of the findings regarding her documentation on the AM/PM Care Roster of care being provided for resident #1 on [DATE] at 11:17 p.m. S4CNA reported that she had documented the ADLs for resident #1. She stated I was tired, but that is not an excuse, it was a big mistake, and that was dumb on my part. S4CNA confirmed that she had not checked on resident #1 at any time during her shift on [DATE] from 11:00 p.m. to approximately 5:57 a.m. when S3LPN had found resident #1 on the floor, in his room, and deceased . S4CNA confirmed that she had initially lied to S2DON about making rounds on resident #1 on the date of [DATE] at 2:00 a.m. During a telephone interview on [DATE] at 10:59 a.m., S3LPN reported that he had worked on [DATE] from 7:00 p.m. - 7:00 a.m. Further interview revealed that he had administered resident #1's medications during medication pass at approximately 8:50 p.m. to 9:00 p.m. S3LPN confirmed that he had not performed rounds on resident #1 after approximately 9:00 p.m. until he found resident #1 in his room, on the floor, and deceased on [DATE] at approximately 6:00 a.m. Resident #2 Review of the electronic heath record revealed resident #2 was admitted to the facility on [DATE]. Further review revealed the resident's diagnoses included, in part, transient cerebral ischemic attack, dementia, and unspecified severity with behavioral disturbance, weakness, and acute bronchitis. Review of the quarterly minimum data set assessment dated [DATE] revealed resident #2 had a brief interview for mental status of 13 which indicated that resident #2 was cognitively intact with daily decision making. Further review revealed that resident #2 had a function limitation in range of motion to one of her upper extremities with impairment on one side. Review of the [DATE] Physician Orders for resident #2 revealed an order dated [DATE] to assist to turn and reposition every two hours and as needed. Review of resident #2's care plan revealed, in part an onset date of [DATE]: resident #2 required staff assistance with her mobility/ADL's, diagnoses were dementia, TIA (Transient Ischemic Attack), weakness, lower upper extremity weakness, she required staff assistance for all ADLs secondary to weakness due to her diagnoses of cardiovascular accident, and was at risk for contractures. Documented approaches included, in part: Resident #2 required one person extensive assistance with all ambulation, bed mobility, and transfers, her primary mode of locomotion was her wheelchair, and she required assistance to turn and reposition every two hours and as needed. Review of the AM/PM Care Roster dated [DATE] at 11:15 p.m. revealed documentation of resident #2 being provided with pericare and her skin was checked with no new skin conditions. Further review revealed the on [DATE] at 11:16 p.m., resident #2 was continent of urine, had voided two times, had one medium sized soft bowel movement, and was provided pericare. During the telephone interview on [DATE] at 8:13 p.m., S4CNA was notified of the findings regarding her documentation on the AM/PM Care Roster of care being provided for resident #2 on [DATE] at 11:15 p.m. and 11:16 p.m. S4CNA reported that she had documented the ADLs for resident #2. S4CNA confirmed that she had not checked on resident #2 at any time during her shift on [DATE] from 11:00 p.m. - 7:00 a.m. Resident #3 Review of the electronic heath record revealed resident #3 was readmitted to the facility on [DATE]. Further review revealed the resident's diagnoses included, in part: wheezing, unspecified dementia, unspecified severity with other behavioral disturbance, mild, with anxiety, and respiratory syncytial virus causing diseases. Review of the quarterly Minimum Data Set, dated [DATE] revealed resident #3 had a brief interview for mental status of 13 which indicated that resident #3 was cognitively intact with daily decision making. Further review revealed that resident #3 had a function limitation in range of motion. Review of the 5 day minimum data set assessment dated [DATE] revealed resident #3 had a brief interview for mental status score of 10. Further review revealed resident #3 was dependent on staff assistance with toileting, she required partial/moderate assistance with roll left and right, sit to lying, and was dependent with chair-to-bed transfer. Review of the [DATE] physician's orders for resident #3 revealed an order date [DATE]: May assist to turn and reposition every two hours and as needed. Review of resident #3's care plan revealed, in part an onset date of [DATE]: Resident #3 was totally incontinent of bowel and bladder with a history of urinary tract infection, she required one person extensive assistance with bed mobility, she required staff assistance with ADLs, and was at risk for harm due to may require two person assistance with transfers with a two person assistance with turning, repositioning, and transfer. Documented approaches included, in part: provide perineal care after each incontinent episode; require extensive to total dependent with all transfers, she required one person extensive assistance with bed mobility, and may assist to turn and reposition every two hours and as needed. Review of AM/PM Care Roster revealed documentation of resident #3 being incontinent of urine and he had voided three time [DATE] at 11:19 p.m. Further review revealed he was incontinent of bowel, he had two soft consistency medium bowel movements, his skin was checked with no new skin concerns on [DATE]/23 at 11:20 p.m. During the telephone interview on [DATE] at 8:13 p.m., S4CNA was notified of the findings regarding her documentation on the AM/PM Care Roster of care being provided for resident #3 on [DATE] at 11:19 p.m. and 11:20 p.m. S4CNA reported that she had documented the ADLs for resident #3. S4CNA confirmed that she had not checked on resident #3 at any time during her shift on [DATE] from 11:00 p.m. - 7:00 a.m. During an interview on [DATE] at 12:23 p.m., S2DON was notified of the interview with S4CNA confirming that she had documented ADLs tasks as being provided on the AM/PM Care Roster at the beginning of her shift. S2DON was further notified of S4CNA confirming the tasks not been completed, as she had not performed rounds on residents #1, #2 and #3 during her shift on [DATE] from 11:00 p.m. to 7:00 a.m. on [DATE]. S2DON confirmed that S4CNA had not performed the ADL tasks as per a review of the facility's video camera footage and per S4CNA's confirmation interview with S2DON on [DATE]. An interview with S1Administrator on [DATE] at 1:15 p.m. revealed that S3LPN and S4CNA had not rounded on residents #1, #2, and #3 every two hours on [DATE] - [DATE] in accordance with the facility's expectations and in accordance with the residents' plan of care. During the survey, multiple observations were made of staff rounding on residents, resident and staff interviews were conducted, in-service records, and QA (Quality Assurance) monitoring records were reviewed, and it was determined that the facility had implemented the following actions to correct the deficient practice: On [DATE] it was discovered that S3LPN and S4CNA had not been performing routine rounds during the night shift on [DATE] - [DATE]. They were both placed on suspension pending the investigation and later terminated when it was determined by the facility that the two staff members had not performed the necessary every two hour checks on three of their assigned residents (#1, #2, and #3), per the resident's individual plans of care. A state generated report was opened and staff education was initiated on performing routine care rounds for each resident with nurses to complete rounds on odd hours and CNAs on even hours. S1Administrator and S2DON initiated a new QA monitoring plan to ensure that routine care rounds were being provided with focus on nights and weekends via remote access at a minimum of 5 times per week for at least 8 weeks and then as needed. Resident care interviews were reviewed in the morning QA meetings along with the corrective action. The MDS (Minimum Data Set) nurse and ICP (Infection Control Preventionist) nurse were assigned to continue interviews and follow-up; and to provide staff education to the nurses at the beginning of each shift with no concerns reported. The corrective action with documenting and monitoring care rounds (nurse and aides) daily will continue until further notice from S2DON or S1Administrator. The completing, addressing, and documenting resident interviews weekly will continue until further notice and QA for care rounds for all shifts for at least 5 times per week for 8 weeks continued. The MDS and ICP nurses completed resident interviews with all residents who were interviewable in order to continue to identify any care issues. No additional complaints have been noted. Staff education was provided on abuse and neglect, reporting, investigating, immediate action, notification requirements to the state regulatory agency, licensing/Certification boards, and law enforcement per the ICP Nurse. The Louisiana State Board of Nurse Examiners was notified of the findings and the CNA Registry was contacted and stated that the State agency would notify the Registry of any negative findings. Education was provided to the LPNs and CNAs regarding timely, accurate, and complete documentation for resident care including voiding, intake, meal consumption, bowel movements, etc. During an interview on [DATE] at 4:33 p.m., S1 Administrator reported the deficient practice had been corrected with a completion date of [DATE].