**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, closed record review, review of hospital records, review of a protective order, review of a police report, facility policy review and interview, the facility failed to provide adequate supervision and comprehensive individualized interventions to prevent an unauthorized leave of absence (LOA) for Resident #200, who was under adult protection services (APS) with a guardian and guardian directive which prohibited Resident #200's husband from taking the resident off facility premises or into his vehicle. This resulted in Immediate Jeopardy and actual harm/death beginning on [DATE] at approximately 6:00 P.M. when Resident #200's husband took the resident outside the facility and then left the facility grounds with the resident in his vehicle without staff knowledge. Resident #200 was found deceased by local police on [DATE] approximately 1.5 miles from the facility with a gunshot wound to the head. Resident #200's husband was also deceased with an apparent self-inflicted gunshot wound to the head. This affected one resident (#200) of one sampled resident with a protective order reviewed for safety/supervision. The facility identified that 24 residents (#1, #2, #4, #5, #11, #25, #26, #27, #29, #30, #31, #41, #45, #50, #63, #70, #72, #74, #77, #79, #82, #94, #98, and #100) who had guardians and no additional residents with protection orders in place. On [DATE] at 2:58 P.M. the Administrator, by [NAME] President of Operations (VPO) #303, [NAME] President of Clinicals (VPC) #304, and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 6:00 P.M. when staff failed to prevent Resident #200's husband from taking the resident off facility premises (as per a guardian directive). On [DATE] Resident #200 was found deceased by local police approximately 1.5 miles from the facility with a gunshot wound to the head. The Immediate Jeopardy was removed and the deficiency corrected on [DATE] when the facility implemented the following correction actions: • On [DATE] at 10:29 P.M. Licensed Practical Nurse (LPN) #300 notified the DON Resident #200 was not in the facility. The DON instructed LPN #300 to notify Physician #302 and Adult Protective Services (APS) Guardian #320. • On [DATE] at 10:53 P.M. LPN #300 notified Physician #302 and left a voicemail to return call to facility. • On [DATE] at 10:54 P.M. the DON attempted to contact Resident #200's husband and left a voicemail asking him to return the call as soon as possible. On [DATE] at 10:55 P.M. the DON attempted to contact Resident #200's husband again but did not leave a voice mail. • On [DATE] at 10:55 P.M. LPN #300 notified APS Guardian #320 that Resident #200 was not in facility. • On [DATE] at 11:20 P.M. the DON notified the local police department of an unauthorized LOA for Resident #200. • On [DATE] at 11:45 P.M. the DON arrived at facility and spoke with Police Officer (PO) #322 regarding the situation and supplied him with Resident #200's face sheet and diagnosis list. Officer #322 assigned report #24-33-628. • On [DATE] between 9:45 A.M. and 10:00 A.M. a root cause analysis was conducted by VPO #303, VPC #304, Regional Director of Operations (RDO) #305, Regional Director of Clinical Services (RDCS) #306, Administrator, and DON related to the incident. System failure was identified as failure to ensure LOA sign-out was monitored and failure to adequately supervise Resident #200's LOA. • On [DATE] at 10:05 A.M. VPCS #304 and VPO #303 educated the DON and Administrator on the facility adequate supervision of residents, LOA procedure, and facility abuse/neglect policy. • On [DATE] at 10:10 A.M. the DON spoke with PO #322 from the local police department and received an update that Resident #200 had expired. • On [DATE] at 10:25 A.M. the DON and Administrator educated all department heads on adequate supervision of residents, abuse/neglect policy and LOA procedure. The LOA procedure included that LOA books must be in secured location behind each nurse's station and the front desk, employee must verify LOA status via bed board (list of all residents by room number, payer and LOA status) resident or responsible party must sign out on the book with estimated return time. If the resident is not back by the estimated time, the facility will make contact and ask for an updated return time. • On [DATE] at 10:49 A.M. RDCS #306 reviewed all residents' medical records for guardian status, to ensure appropriate LOA orders and any protective orders were in place and care planned. The facility identified 24 Residents (#1, #2, #4, #5, #11, #25, #26, #27, #29, #30, #31, #41, #45, #50, #63, #70, #72, #74, #77, #79, #82, #94, #98, and #100) with guardians. There were no additional residents currently residing in the facility who had protection orders. • On [DATE] from 11:00 A.M. through 4:00 P.M. the DON, Assistant Director of Nursing (ADON) #308, LPN #309, Human Resource Director (HR) #310, Dietary Manager (DM) #311, Director of Rehabilitation (DOR) #312, Housekeeping Supervisor #313, Activities Director (AD) #314 educated their departments so that all staff were in-serviced on the facility adequate supervision of residents, LOA procedure, and facility abuse/neglect policy. Staff who were not in the building received a phone call with the information. • On [DATE] at 11:15 A.M. Admissions Director #315, reviewed and updated the facility bed board per LOA orders. • On [DATE] at 11:30 A.M. the DON updated the LOA sign-out books with a new form to include anticipated return time at all nurse's stations and the front desk. • On [DATE] at 11:45 A.M. LPN #309 updated and implemented the nurse report sheets at all nurse's stations. The nurse report was updated to include the report of residents on LOA. • On [DATE] at 2:33 P.M. Physician #303 was informed of the situation surrounding Resident #200's death by the DON. • On [DATE] at 2:41 P.M. Medical Director #316 was notified of Resident #200's death and a Quality Assurance and Performance Improvement (QAPI) meeting was held with the interdisciplinary team (IDT) including Medical Director #316, Physician #302, Administrator, DON , AD #314, HR #310, LPN #309, Maintenance Director #317, Admissions #315, and Maintenance Assistant #318 to review root cause analysis, facility interventions, facility policies, and facility response. The Administrator educated attendees on the policy if an order was obtained that allowed outside visits on facility property or with contingencies such as: not allowed to sit in car, the outside visit must occur during supervised smoke times so staff were still able to supervise that the order restrictions were being followed, the adequate supervision of residents with orders, LOA procedure, and facility abuse/neglect policy. Orders must be complete and thorough with details that the facility would be able to follow. If any orders were received that were unable to followed or that could not be met and managed, the facility must call the prescriber/person back and explain why the order could not be followed and get a new or updated order. All communication for clarifying orders must be documented in Point Click Care (PCC) (electronic medical record). If any order comes that the facility is questioning the manageability, a call must be placed to regional staff for review. This included all orders for medications, LOA, protective orders, treatments, etc. • On [DATE] at 3:55 P.M. APS Guardian #320 was notified by the DON of the situation surrounding the death of Resident #200. • On [DATE] at 4:00 P.M. LPN #319 reviewed LOA orders, protective orders and LOA care plans for accuracy and updated as necessary. No other residents currently had protective orders. • Audits were initiated the week of [DATE] for bed board completion and accuracy. Audits would be conducted five times a week for four weeks then weekly for four weeks and randomly thereafter by the Administrator or designee. • Audits were initiated the week of [DATE] for completion and accuracy of LOA books. Audits would be conducted five times a week for four weeks then weekly for four weeks and randomly thereafter by the Administrator or designee. • Audits were initiated the week of [DATE] for accuracy and completion of nursing report sheets. Audits would be conducted five times a week for four weeks then weekly for four weeks and randomly thereafter by the DON or designee. • Audits were initiated the week of [DATE] for new admission or existing residents for new or revised protective orders, guardian status, and updated LOA orders to reflect in the residents' care plans. Audits would be conducted five times a week for four weeks then weekly for four weeks and randomly thereafter by the Social Worker or designee. • Audits were initiated the week of [DATE] for new admission or existing residents with a mental health diagnosis to ensure they were offered psychological services. Audits would be conducted five times a week for four weeks then weekly for four weeks and randomly thereafter by the DON or designee. • Observational audits were initiated on [DATE] of ten residents who required supervision of care to ensure monitoring was effective. Audits would be conducted five times a week for four weeks then weekly for four weeks and randomly thereafter by the DON or designee. • Interviews on [DATE] and [DATE] at various times from 6:45 A.M. through 4:00 P.M. with Registered Nurse (RN) #569, Housekeeper #524, LPN #595, RN #557, Certified Nursing Assistant (C.N.A.) #571, C.N.A. #611, C.N.A. #588 and Receptionist #618 revealed that they were in-serviced on elopement, abuse, and visitation. • Review of signed in-service sheets dated [DATE] verified employees were in-serviced on resident supervision with all tasks according to their plan of care, missing residents' best practice, LOA books, and LOAs with restrictions. Findings include: Review of the closed medical record for Resident #200 revealed an admission date of [DATE] and a re-admission date of [DATE] with diagnoses including unspecified psychosis not due a substance, Crohn's disease, generalized anxiety disorder, depression, and delusional disorder. Based on review of a police report, Resident #200 was pronounced deceased on [DATE] as a result of a gunshot wound to the head. The circumstances surrounding Resident #200's death was not included as part of the resident's medical record. Review of Resident #200's hospital admitting paperwork dated [DATE] revealed the resident had been hospitalized for treatment of acute psychosis. Resident #200 was brought to the hospital emergency department on [DATE] from home as she reportedly been increasingly confused and paranoid. She presented it to the hospital after a stress-induced seizure after a fight with her husband. Resident #200 presented to her primary care provider (PCP) on [DATE] with a right arm injury stating her husband slammed a metal door on her arm and held it closed causing multiple abrasions. She declined hospital and police at that time and was returned home. She and her husband continued to argue, the police were notified by neighbors, and Resident #200 was brought to hospital. Resident #200 was a poor historian. She had multiple visits to the hospital with psychosis and paranoia (mostly regarding her husband). Adult Protective Services (APS) had been involved with Resident #200 since 2013 related to the resident's accusations of abuse from her husband. The resident lived with her husband for over 60 years, and police visited the home multiple times due to domestic complaints. Upon examination, Resident #200 appeared drowsy but does engage. She voiced fear and paranoia of her husband. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #200 was cognitively intact and required set up for activities of daily living. Resident #200 did use a wheelchair but could transfer herself. Review of a protective order dated [DATE] revealed Resident #200 needed protective services, was incapacitated and that there was no person authorized by law or court to give consent (for the resident). It was ordered that APS would be authorized by law or court to be able to give consent. It was further ordered that APS should have the authority to consent to medical treatment and nursing home admission. Review of a Social Service note dated [DATE] revealed Social Service Designee (SSD) #800 attempted to call APS Guardian #320 multiple times for discharge instructions for the resident. The note indicated this was an APS case, and the resident was not allowed to leave with her husband, but they were insisting on her leaving the facility and going home. A message was left with APS Guardian #320, and APS stated that he would reach out Friday or Monday. Review of the progress note dated [DATE] at 2:47 P.M. revealed the Administrator spoke to APS Guardian #320, (a temporary guardian), about Resident #200's husband being able to walk Resident #200 around the building. APS Guardian #320 stated that it was okay. They note indicated, per the APS Guardian, they were not allowed to leave the premises, but they could walk outside around the building. Review of a social services note dated [DATE] at 2:48 P.M. revealed Social Service Designee (SSD) #800 spoke with APS Guardian #320 regarding visitation by Resident #200's husband. The note revealed as of this date, Resident #200's husband was informed he was not allowed to sit in his car with his wife, and that they could just walk around the building. The note reflected third floor nursing (where the resident resided) and the front desk were notified. Review of Resident #200's medical record revealed no care plan was implemented for visitation, the resident's protection order and/or any restriction(s) on visitation with the resident's husband. In addition, there were no interventions initiated to ensure the resident was adequately supervised or her whereabouts monitored as it pertained to visitation with the resident's husband and per APS Guardian #320's directive. Review of the facility LOA logbook revealed on [DATE] Resident #200's husband signed in at 6:00 P.M. Record review revealed no nursing progress notes were written from [DATE] at 6:00 P.M. through [DATE] at 2:42 A.M. Review of a nursing progress note, created on [DATE] at 2:42 A.M. with an effective date of [DATE] at 9:28 P.M. (the police report below notes a time of 11:28 P.M.) authored by LPN #300 revealed she arrived to Resident #200's room and noticed Resident #200 wasn't in the room. The note indicated she looked in the bathroom and the resident was not there. Staff did a building search inside and outside. Resident #200's frequent visitor (identified to be her husband) was contacted with no answer. A voicemail was left. The nurse reached out to the DON, contacted the local police who arrived at the facility at 11:39 P.M., and a report was made. APS Guardian #320 was made aware of the situation. The note included will have dayshift follow up. Review of a police report (report #2024-00336281) dated [DATE] revealed the local police were called to the facility at 11:28 P.M. for a missing person [Resident #200]. Officer #322 spoke with LPN #300, who reported Resident #200 left the faciity on [DATE], between the approximate hours of 6:28 P.M. and 11:26 P.M. LPN #300 continued to state Resident #200 had a court ordered guardian [APS Guardian #320] and was not permitted to leave the property, without her guardian's permission. LPN #300 stated at approximately 11:26 P.M. she went to Resident 200's room to administer her night medications. It was at this time she realized Resident #200 was missing from her room. LPN #300 then stated that when she checked the visitor logbook, she observed that Resident #200's husband had signed the logbook as arrived for a visit. LPN #300 stated she then attempted to call the resident's husband by phone but received no response. She then proceeded outside and located Resident #200's wheelchair hidden behind bushes, in the rear parking lot of the facility. Officer #322 interviewed other staff members, and they believed the husband took Resident #200 in his car. Officer #322 drove by the husband's house and there was no activity. Officer #322 called the local medical examiner's office and was informed Resident #200 and her husband were found dead at a nearby golf course. The officer closed the report on [DATE] at 4:02 A.M. The report did not state the actual time Resident #200 and her husband her found deceased . Information provided by the facility during the investigation revealed on [DATE] between 9:45 A.M. and 10:00 A.M. a root cause analysis was conducted by VPO #303, VPC #304, Regional Director of Operations (RDO) #305, Regional Director of Clinical Services (RDCS) #306, the Administrator, and DON related to the incident. System failure was identified as failure to ensure LOA sign-out was monitored and failure to adequately supervise Resident #200's LOA. Interview on [DATE] at 8:15 A.M. with Receptionist #618 revealed the facility had a list of residents who could not go on LOAs. The list changed frequently. Receptionist #618 revealed Resident #200 was not allowed to go out on LOAs at first but then the resident's guardian allowed her to go outside the facility building with her husband if she did not get into the car or leave the premises. Receptionist #618 revealed the resident's husband would always park down on the right side (outside the facility), and she could not see the car. She stated she was not on duty on [DATE] at the time of the incident. During the interview, Receptionist #618 revealed she was responsible to ensure Resident #200 did not get in her husband's car when they were outside; however, she again reiterated she was not present in the facility at the time of the incident on [DATE]. Observation on [DATE] at 8:20 A.M. from front desk revealed no parked cars were visible from the front desk. Interview on [DATE] at 10:48 A.M., with the DON verified the content of the social service notes which directed (per the APS Guardian) that Resident #200 could not be in car with her husband. The DON stated the facility did not have a person assigned to supervise Resident #200 when she went outside. He stated the receptionist knew the husband should not have taken Resident #200 off the premises. Information from APS revealed Resident #200 had been an active client with APS as of [DATE]. An APS investigation validated physical abuse (with a history of domestic violence) and self-neglect involving Resident #200. This resulted in APS pursuing a Protective Service Order (PSO) which made APS the temporary decision maker for the client. The resident was subsequently placed at the facility while APS pursued getting the client a guardian. The resident's husband was not pleased with either the PSO or the decision to place the resident in the facility. Following admission and during the resident's stay in the facility, APS was in regular contact with the resident's husband and the facility concerning visitation issues. Resident #200's husband wanted to take the resident out and away from the facility, but he could not be trusted to return her, so eventually the facility was directed by APS that the husband could visit, but he was not allowed to take her away from the facility. Interview with APS Guardian #320 on [DATE] at 2:44 P.M. revealed APS the facility told him that they would watch Resident #200 on the grounds. He stated the facility told him that they try not to limit visitors. Interview on [DATE] at 3:42 P.M. with LPN #580 revealed Resident #200 did not say much but did go outside with her husband. LPN #580 stated Resident #200 was not supposed to leave the premises. The LPN provided no additional information as to how staff were to ensure the resident did not leave the premises with her husband or how staff monitored the resident's whereabouts when the husband was visiting with her, or they were outside. Interview on [DATE] at 3:18 P.M. with Certified Nursing Assistant (CAN) #571 revealed during the resident's admission, she had become more social and was starting to talk. CNA #571 was aware Resident #200's husband visited a lot, and that the resident did go outside with him. CNA #571 denied the resident having any other visitors besides her husband. The CNA stated she was aware Resident #200 was not supposed to leave the premises. The CNA provided no additional information as to how staff were to ensure the resident did not leave the premises with her husband or how staff monitored the resident's whereabouts when the husband was visiting with her, or they were outside Interview on [DATE] at 3:28 P.M. with CNA #611 revealed Resident #200 was very quiet and stayed in her room. CNA #611revealed the resident's husband did visit a lot and he took her off the floor. The CNA stated she was aware the resident was not supposed to leave the grounds with her husband. The CNA provided no additional information as to how staff were to ensure the resident did not leave the premises with her husband or how staff monitored the resident's whereabouts when the husband was visiting with her, or they were outside Interview on [DATE] at 3:33 P.M. with CNA #588 revealed Resident #200 was becoming more social and starting to talk. Resident #200's husband visited a lot, and she went outside with him. CNA #588 stated Resident #200 had no other visitors, and Resident #200 was not supposed to leave the premises. The CNA provided no additional information as to how staff were to ensure the resident did not leave the premises with her husband or how staff monitored the resident's whereabouts when the husband was visiting with her, or they were outside Review of the facility policy dated [DATE] titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, revealed the facility would not tolerate neglect of any resident. The definition of neglect was the failure of the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid harm, pain, mental anguish, or emotional distress. This deficiency represents non-compliance investigated under Master Complaint Number OH00160035 and Complaint Number OH00160019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of the facility investigation, hospital record review, review of the facility root cause analysis, review of facility policy and interviews, the facility failed to provide adequate supervision and monitor WanderGuard (wearable device to help keep residents at risk of wandering safe) functioning for Resident #69, a resident with a history of exit seeking behavior to prevent elopement. This resulted in Immediate Jeopardy and the potential for serious harm, injury and/or death on 10/08/24 at approximately 7:44 P.M. when Resident #69 eloped from the facility without staff knowledge, through a smoking patio exit door and traveled from Ohio (OH) to Wisconsin (WI), under unknown circumstances. Resident #69 was not seen by facility staff for nearly three hours before he was discovered missing at approximately 10:30 P.M. Resident #69 was missing from the facility for over two days when he was found on 10/11/24 by a university police department on a college campus in WI, approximately 425 miles away from the facility. Resident #69 was subsequently transported to a local hospital in WI for evaluation and treatment and then transferred back to the facility on [DATE]. During the time Resident #69 was missing, the resident missed hemodialysis (treatment that filters waste and excess fluid from the blood when the kidneys are unable to) treatment and several prescription medications including those to treat high blood pressure, angina (chest pain) and mental illness. This affected one resident (#69) of six residents reviewed for elopement. The facility census was 101. On 10/16/24 at 2:52 P.M. the Administrator, Regional Director of Operations (RDO) #800 and Regional Director of Clinical Services (RDCS) #801 were notified that Immediate Jeopardy began on 10/08/24 at approximately 7:44 P.M. when the facility failed to provide adequate supervision and ensure a functional WanderGuard for Resident #69. Resident #69 was able to exit the facility, without staff knowledge, through the smoking patio door and traveled out of state, approximately 425 miles away, under unknown circumstances. Resident #69 was placed at increased risk due to the unknown circumstances of his travel to WI and medical treatments, (including dialysis and medications) not being provided. Resident #69 was not located until 10/11/24, at which time he was transported to a local hospital in WI for evaluation, treatment and supervision until he was transported back to the facility on [DATE]. The Immediate Jeopardy was removed on 10/15/24 when the facility implemented the following corrective actions: · On 10/08/24 at 10:30 P.M., Registered Nurse (RN) #811 was unable to locate Resident #69 for medication administration and instructed State Tested Nursing Assistant (STNA) #823 and STNA #824 to search the unit. · On 10/08/24 at 10:45 P.M. RN #811 called a code and Licensed Practical Nurse (LPN) #825 and LPN #826 searched all facility floors and outside areas. · On 10/08/24 at 11:01 P.M., RN #827 notified the Director of Nursing (DON) that Resident #69 was missing. The DON instructed RN #811 to complete a resident head count of the entire facility and obtain witness statements from all staff present at that time. · On 10/09/24 at 12:00 A.M., Police Officer (PO) #834 arrived from the local police department and took a report from RN #811. RN #811 provided the officer with Resident #69's demographic information, the last time he was seen and a brief description of what he was wearing (blue jeans, a white and blue striped shirt and a navy-blue lightweight jacket) prior to the elopement. · On 10/09/24 at 6:00 A.M., a root cause analysis was conducted by RDO #800, RDCS #801, the Administrator and the DON. The root cause of Resident #69's elopement was determined to be a system failure to ensure the resident ' s WanderGuard was in place and/or functional and adequate supervision. · On 10/09/24 at 6:15 A.M., RDO #800 re-educated the DON and the Administrator on the facility's elopement policy and best practice, WanderGuard protocol, elopement risk assessments and interventions, door alarm response and adequate supervision of residents. · On 10/09/24 at 8:00 A. M., the DON initiated in-person education with all facility staff on the elopement policy and best practice, WanderGuard protocol, elopement risk assessments and interventions, door alarm response and adequate supervision of residents. Dietary Manager (DM) #828, Housekeeping Director (HD)#806, Activities Director (AD) #808 and Assistant Director of Nursing (ADON) #838 assisted with the education, after receiving the education from the DON and/or Administrator. By 4:30 P.M., 113 of 113 staff received the education. Education will be provided for all new employees during orientation. · On 10/09/24 from 10:30 A.M. to 1:30 P.M., ADON #838, Unit Manager (UM) #829 and Wound Nurse (WN) #830 re-assessed all residents for elopement and verified care plans were up to date. · On 10/09/24 at 10:15 A.M., Director of Maintenance (DOM) #804 checked all doors equipped with WanderGuard sensors to ensure functionality. · On 10/09/24 at 11:00 A.M., an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the root cause analysis, facility interventions, facility policies on wandering and elopement and facility response. In attendance were Medical Director (MD) #831, Primary Physician (PP) #802, the Administrator, the DON, AD #808, HD #806, Social Services Designee (SSD) #810, DM #828, Human Resources Director (HRD) #832, UM #829 and DOM #804. The Administrator re-educated attendees on the elopement policy, WanderGuard protocol, door alarm response and supervision of residents. · On 10/09/24 from 11:30 A.M. to 1:30 P.M., RDCS #801 reviewed residents with WanderGuard orders (Residents #20, #30, #31, #35, #39, #40, #44, #49 and #51) to ensure placement and functionality of the WanderGuards and the residents' care plans were accurate. All reviewed residents had functioning WanderGuards in place and care plans were updated. · On 10/09/24 from 1:00 P.M. to 4:00 P.M., Minimum Data Set Nurse (MDSN) #833 conducted a second review of all resident care plans and updated, as needed, to ensure all care plans accurately reflected elopement risk and WanderGuard use/interventions. · Beginning on 10/09/24, DOM #804, or designee, would conduct checks of doors equipped with WanderGuard sensors five times per week for two weeks then weekly until 11/06/24. · Beginning on 10/10/24, the DON, or designee, would audit nine WanderGuard placement and function three times weekly for four weeks then one time weekly for four weeks. · On 10/11/24 at 8:00 A.M., LPN #812 was notified by university police in Milwaukee, WI that Resident #69 was found on their campus. LPN #812 immediately notified ADON #838, who then immediately notified the DON and Administrator. · On 10/11/24 at 9:00 A.M., university police transported Resident #69 to an area hospital for further evaluation due to missed medications and hemodialysis treatments. · On 10/12/24 at 9:20 A.M., AD #839 and STNA #840 picked-up Resident #69 from the hospital in Milwaukee, WI and transported the resident back to the facility. · On 10/12/24 at 7:09 P.M., Resident #69 returned to the facility. LPN #814 assessed Resident #69 and the resident was placed on one-on-one supervision for safety. The resident's WanderGuard was replaced and tested to ensure it properly functioned. · On 10/12/24 at 8:00 P.M., RDCS #801 reviewed Resident #69's care plan for accuracy. · On 10/13/24 at 2:28 A.M., LPN #837 reassessed Resident #69 for elopement risk. Resident #69 was assessed to be at high risk for elopement. · On 10/14/24 at 6:00 P.M., DOM #804 conducted an elopement drill with no concerns identified with staff response. · On 10/15/24, MDSN #833 updated Resident #69's care plan to include updated elopement risk and interventions. Resident #69's physician orders were updated to check WanderGuard placement and function each shift. · On 10/15/24 at 4:00 P.M., DOM #804 placed an order for an additional WanderGuard testing device and WanderGuard bracelets to provide additional supplies. · Beginning on 10/14/24, DOM #804, or designee, would conduct elopement drills/resident supervision on each shift weekly for four weeks and then monthly indefinitely. · Beginning on 10/14/24, the DON or designee, would audit elopement assessments and interventions for accuracy and completeness weekly for four weeks. · Interviews on 10/15/24 from 8:51 A.M. to 3:56 P.M. and on 10/16/24 from 11:35 A.M. to 2:43 P.M. with LPN #813, LPN #814, STNA #815, STNA #816, STNA #817, STNA #818, STNA #819 and STNA #820 verified the facility provided education on the elopement policy and procedure, WanderGuard protocol, elopement risk assessments and interventions, door alarm response and adequate supervision of residents. · Review of the open medical records for five additional residents (#20. #35, #39, #40 and #49) revealed elopement assessments were completed, and care plans were reviewed and updated as needed. Although the Immediate Jeopardy was removed on 10/15/24, the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #69 revealed an admission date of 09/13/23 with diagnoses including schizophrenia, bipolar disorder, anxiety disorder, end stage renal disease with dependence on renal dialysis, left below knee amputation, cirrhosis of the liver, type two diabetes mellitus and essential hypertension. Resident #69 had a legal guardian and resided on the facility third-floor, long-term care unit. Review of the Admit/Readmit Progress Note, dated 09/13/23, revealed Resident #69 admitted to the facility with episodes of delusions and hallucinations. Resident #69 had a WanderGuard applied to his wheelchair as the resident was known to exit seek and become combative. Resident #69 admitted to the facility under supervision of a legal guardian. Review of a physician's order, dated 09/14/23, revealed an order for WanderGuard check every shift for location of the device. There was no evidence of an order to check the WanderGuard functionality. Review of the Statement of Expert Evaluation for the local county probate court, dated 05/09/24, revealed Resident #69 had mental impairment related to mental illness of schizophrenia, major depressive disorder, anxiety disorder and bipolar disorder. Resident #69 lacked insight and judgement into mental health diagnoses and lacked proper decision-making skills. The physician noted Resident #69 was not mentally or physically capable of caring for himself and guardianship should be continued. Review of the Elopement Review assessment, dated 08/03/24, revealed Resident #69 was assessed to be low risk for elopement. The assessment indicated Resident #69 had no elopement attempts in the last three months, was cognitively intact and ambulatory with the use of a wheelchair. Review of Medicare Minimum Data Set (MDS) Annual assessment dated [DATE] revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. There were no noted wandering behaviors on the MDS assessment. Resident #69 was independent for dressing, bed mobility, wheelchair use, and transfers. Resident #69 used a wander or elopement alarm daily. The assessment revealed Resident #69 required dialysis. In addition, review of the active physician orders revealed Resident #69 received (hemo)dialysis three days a week. Resident #69 was ordered the following medications to treat high blood pressure and/or angina (chest pain): two 25 milligram (mg) tablets of Carvedilol two times per day, 100 mg tablet of Hydralazine three times per day, 30 mg tablet of Isosorbide Mononitrate in the evening, 60 mg tablet of Nifedipine two times per day, and 4 mg tablet of Doxazosin Mesylate one time per day. Additionally, Resident #69 was on 2.5 milliliters (ml) of 2 mg/ml Haldol by mouth three time per day and 25 mg intramuscular injection of Risperdal one time per day for control of symptoms associated with schizophrenia. Review of the treatment administration record (TAR) for September 2024 and October 2024 revealed Resident #69's WanderGuard was checked for placement, per the physician order at the time. Further review of the medical record revealed no evidence Resident #69 ' s WanderGuard was checked for functionality. Review of the psychiatric note, dated 09/20/24, revealed Resident #69 was guarded and evasive during the visit. Resident #69 denied having mental illness. Nursing reported Resident #69 had behaviors and refused medications at times. Resident #69's insight and judgement were poor as evidenced by self-defeating or endangering behaviors without regard to consequences. Review of nursing progress note dated 10/08/24 at 3:47 P.M. revealed Resident #69 had returned from dialysis treatment. It was noted Resident #69 was administered an injection of Risperdal. Review of the nursing progress note, dated 10/08/24, at 10:36 P.M., revealed the nurse (RN #811) witnessed Resident #69 get on the elevator and leave the third floor between 7:30 P.M. and 8:30 P.M. Resident #69 was not found in his room during medication pass. All staff began searching the facility and outside premises. Review of Elopement Incident Report, dated 10/08/24 at 11:01 P.M., revealed Resident #69 was missing from the facility. Search of the building and surrounding area did not locate Resident #69. The Administrator, DON and police were notified. Risk factors included end stage renal disease, impaired vision, taking psychoactive drugs, diabetes, non-compliance, amputation and active exit seeking. Resident #69's physician was notified on 10/08/24 at 11:10 P.M. and Resident #69's guardian notified on 10/08/24 at 11:20 P.M. Review of nursing progress note, dated 10/09/24 at 2:09 A.M., revealed Resident #69 was not located in the facility or outside premises. The DON was notified on 10/08/24 at 11:01 P.M. The nurse contacted the local hospital, local police and guardian. The local police arrived and took a report from the nurse. Review of the late entry admit/readmit progress note, dated 10/09/24 at 8:00 A.M., revealed the DON was notified Resident #69 was not located in the facility. A complete search of the facility and surrounding area was completed. The DON instructed nursing staff to notify the local police and fill out a missing person report. The local police arrived at the facility at approximately 12:00 A.M. on 10/09/24. The DON and Administrator came to the facility and another search of the facility and surrounding area was conducted. Review of the nursing progress note dated 10/09/24 at 10:39 A.M. revealed a follow up call was placed to Resident #69's guardian. The unit manager left a voicemail to contact facility for emergent notification. Review of the late entry social services progress note dated 10/09/24 at 11:32 A.M. revealed MD #831 was notified Resident #69 was not located in the facility. Review of the social services progress note dated 10/09/24 at 1:15 P.M. revealed Resident #69's guardian returned the phone call and was provided with an update on Resident #69. Review of the revised care plan, dated 10/09/24, revealed Resident #69 had history of cutting off the WanderGuard on 08/30/24. Further review of the medical record revealed no information related to events or occurrences of Resident #69 attempting to remove the WanderGuard. Review of the general progress note dated 10/11/24 at 8:02 A.M. revealed the nurse received a call from a police department in Milwaukee, Wisconsin. Resident #69 was at the police station. The nurse gave police officer information on Resident #69's medical history. Resident #69 was sent to a local hospital in Milwaukee. The nurse notified Resident #69's guardian, physician, and ADON. Review of hospital records revealed Resident #69 arrived at the emergency room (ER) on 10/11/24 at 8:01 A.M. via ambulance. The resident reported no symptoms and last had dialysis three days prior. Resident #69 had labs drawn, a chest x-ray and an electrocardiogram (EKG - measures electrical activity of the heart). The hospital nephrologist (kidney specialist) recommended 30 milligrams (mg) of Kayexalate (treats high levels of potassium in the blood) and no dialysis treatment. Social work was consulted related to legal guardianship in Ohio. The guardian reported to hospital staff Resident #69 was in a locked facility, managed to elope and used public transportation to get to WI. The social worker reached RDO #800 at the facility to arrange Resident #69 ' s return. Resident #69 was scheduled to be picked up in a facility van by two facility staff on 10/12/24 at 9:00 A.M. Review of Interdisciplinary Team (IDT) note dated 10/11/24 at 8:26 A.M. revealed the IDT reviewed the root cause of Resident #69 leaving the facility. Interventions upon Resident #69's return included one- on-one supervision and exit doors would be monitored for proper function of WanderGuard equipment. Review of the admit/readmit progress note dated 10/12/24 at 7:09 P.M. revealed Resident #69 readmitted to the facility in a wheelchair. Resident #69 was alert and oriented to person, place, and time. Resident #69 had no complaints of pain or discomfort. Resident #69 was placed on one-on-one supervision until further notice. Resident #69's guardian, ADON, unit manager, and nurse practitioner were notified of his return. Review of the late entry nursing progress note dated 10/12/24 at 7:47 P.M. revealed staff obtained Resident #69's weight, provided a shower, obtained vital signs and completed a skin assessment. Review of the revised care plan dated 10/15/24 revealed Resident #69 was at high risk for elopement related to diagnosis of schizophrenia, history of attempts to leave the facility unattended and impaired safety. Interventions included to distract resident from wandering with pleasant diversions, structured activities, food, conversation, television, or books; identify a pattern of wandering; divert wandering as needed; intervene as appropriate; monitor for fatigue or weight loss, and wander alert to resident's wheelchair. A telephone interview on 10/15/24 at 11:20 A.M. with Program Manager (PM) #822 with the volunteer guardian program revealed on 10/09/24, at approximately 2:00 A.M., they received a call indicating Resident #69 was missing from the facility. PM #822 stated the facility noticed Resident #69 was missing during the nighttime medication pass on 10/08/24. PM #822 reported they were informed Resident #69 left out of the smoking patio door and kept going. PM #822 indicated Resident #69 was in a wheelchair so she was unsure how Resident #69 could have gotten so far without anyone noticing. PM #822 stated on 10/11/24 they were notified Resident #69 was found in Milwaukee, WI, sitting on a bench on the university campus, by the university police. Resident #69 told the police he was waiting to meet with admissions about going to graduate school. PM #822 stated this was a common fixation for Resident #69. PM #822 explained Resident #69 was originally from New Jersey and traveled to Ohio under similar circumstances as his elopement to WI. While it was unknown how Resident #69 traveled to WI, it was believed he had been withdrawing money from his resident fund account and storing the funds prior to his elopement. PM #822 verified the facility Administrator reached out to her on 10/14/24 to discuss alternative placement for Resident #69. A telephone interview on 10/15/24 at 12:48 P.M. with Primary Physician (PP) #802 revealed he was notified immediately after Resident #69 was determined to be missing. PP #802 noted Resident #69 had schizophrenia and was always talking about going to a university. PP #802 was unaware if Resident #69 wore a WanderGuard but indicated he would suggest one. PP #802 noted Resident #69 would have missed dialysis and medications while in the community. Interview on 10/15/24 at 2:34 P.M. with LPN #812 revealed she worked from 7:00 A.M. until 7:00 P.M. on 10/08/24 and was assigned to Resident #69's unit. LPN #812 stated Resident #69 went to dialysis at approximately 8:00 A.M. that morning and returned at approximately 2:00 P.M. LPN #812 stated Resident #69 was agitated upon return from dialysis and had called 911, for unknown reasons, while he was at the dialysis clinic. LPN #812 stated Resident #69 was resting in bed when she completed rounds at the end of her shift. LPN #812 revealed she observed Resident #69's WanderGuard was in place. LPN #812 stated Resident #69's physician orders included checking placement of the WanderGuard; however, there was no order to ensure it was properly functioning. On 10/11/24, LPN #812 stated she received the phone call that Resident #69 was found in Milwaukee, WI. LPN #812 stated the police had picked the resident up when he was lingering around the police station and seemed off. LPN #812 stated she provided the police with the resident's medical and mental illness history and then she notified the unit manager of the phone call. A telephone interview on 10/15/24 at 2:53 P.M. with RN #811 revealed she was Resident #69's assigned nurse on 10/08/24 from 7:00 P.M. to 7:00 A.M. RN #811 stated she was told in report that Resident #69 had an incident at dialysis, received a Risperdal injection upon return to the facility and had been lying down for a few hours. At approximately 7:30 P.M., RN #811 stated she was standing at the medication cart when she saw Resident #69 in his wheelchair. RN #811 stated she asked the resident how he was doing and he indicated he was fine and proceeded down the hall to the elevator. RN #811 stated Resident #69 frequently utilized the elevator to go downstairs to the vending machines, so she was not concerned with his actions. At approximately 10:30 P.M., RN #811 stated she went to Resident #69's room to pass medications and he was not there. RN #811 indicated she asked other staff if they had seen him, without success. RN #811 was unable to locate Resident #69 and staff began searching the building, then searched outside the facility. At 11;01 P.M., when staff were unable to locate Resident #69, RN #811 called the DON. The DON instructed RN #811 to ensure a thorough search was completed and to call the police. The DON was going to call the guardian. RN #811 stated she gave report to the police, collected witness statements from staff and asked other residents if they had seen Resident #69. RN #811 confirmed Resident #69 wore a WanderGuard; however, she had not yet done her assessment to confirm placement. RN #811 stated she was unsure how the WanderGuard system worked as it did not alarm at the third-floor elevator. RN #811 indicated she did not check the functioning of Resident #69's WanderGuard, just the placement, and she did not know who was responsible for checking the functioning of his WanderGuard. RN #811 stated Resident #69's WanderGuard order was different than the other residents' because his asked about behaviors and not about functionality. Interview on 10/16/24 at 7:37 A.M. with the Administrator revealed he was notified Resident #69 was missing from the facility by the DON on 10/08/24. He was unable to recall the exact time of notification. The Administrator indicated he met the DON at the facility and drove around the community looking for Resident #69 until about 7:00 A.M. on 10/09/24. The Administrator indicated that he, and other facility management, continued to search the community for Resident #69 on 10/09/24 and 10/10/24. The Administrator stated there was camera footage on 10/08/24 at 7:44 P.M. of Resident #69 getting off the elevator and going in the direction of the smoking patio. The Administrator indicated the camera footage overwrites after a few days and the footage from the evening Resident #69 eloped had not been retained; however, it was unclear how Resident #69 exited the smoking patio door as there was no camera footage in that area. The Administrator confirmed the smoking patio door was equipped with a WanderGuard sensor and should have alarmed. Observation on 10/16/24 at 7:46 A.M. of the door leading to the outside smoking patio, with the Administrator, revealed a locked door with a keypad next to the door. The door was equipped with the WanderGuard system. The patio was not fully enclosed and led out to the back parking lot driveway. The smoking patio door was located in a room with several tables. The room was located on an administrative hallway, which included offices, laundry and the kitchen. Observation on 10/16/24 at 7:53 A.M. with DOM #804 and Maintenance Assistant (MA) #805 revealed the smoking patio door was locked. DOM #804 held a WanderGuard, and the keypad indicated the system was in working order. DOM #804 stated the smoking patio door was locked from 8:00 P.M. to 8:00 A.M. and demonstrated that pushing on the smoking patio door for 15 seconds, while locked, would set off an audible alarm prior to the door releasing and opening. From 8:00 A.M. to 8:00 P.M., DOM #804 stated the door was unlocked but a functional WanderGuard would set off an audible alarm. DOM #804 further explained a functional WanderGuard would trigger the door to lock and then alarm if the door was pushed on. Continued observation confirmed the audible alarm was loud enough for staff working in resident care areas on the first floor to hear the alarm in order to respond. Interview on 10/16/24 at 8:18 A.M. with RDO #800 revealed she was notified Resident #69 was missing by the Administrator on 10/08/24. RDO #800 indicated she arrived at the facility on the morning of 10/09/24 to assist with search efforts. RDO #800 reported interviews with staff revealed no evidence of Resident #69's WanderGuard system alarming. RDO #800 stated she assisted with trying to obtain information on where Resident #69 might have gone. RDO #800 reported she called Resident #69's guardian to find out if he had any local friends or family that could be contacted. RDO #800 found that Resident #69 had taken out 130 dollars from his funds account over the previous two weeks. RDO #800 stated Resident #69's room was searched, with no indication of where he may have gone, and it did not appear the resident had taken any of his personal belongings. RDO #800 stated medical documents were found from a previous facility indicating Resident #69 had taken a bus from New Jersey to Ohio and was found disoriented at a bus stop needing dialysis. RDO #800 noted Resident #69 had a history of paranoia and was fixated on not being in a facility and going back to college. When Resident #69 was found the morning of 10/11/24, she coordinated transportation for the resident to be returned to OH from WI. RDO #800 reported the resident's WanderGuard was still attached to his wheelchair upon his return. RDO #800 stated the facility determined Resident #69 was able to leave the facility undetected as his WanderGuard was not in working order and it was replaced upon his return. Additionally, RDO #800 stated Resident #69 was placed on one-on-one supervision. RDO #800 indicated there was no written policy for WanderGuard use but the protocol was to check placement and functioning every shift. Interview on 10/16/24 at 9:05 A.M. with Resident #69 revealed Resident #69 refused to answer questions about why he left the facility and how he traveled to Milwaukee, WI. Resident #69 indicated he felt safe while out of the facility and had his coat on. Resident #69 stated he did not like it at the facility and asked if surveyor was going to take him back to WI. Resident #69 ended the interview. Interview on 10/16/24 at 10:46 A.M. with the Administrator, RDO #800, and RDCS #801 revealed they believed the cause of Resident #69's elopement was failure of his WanderGuard functionality. Interview on 10/16/24 at 11:35 A.M. with STNA #816 revealed on 10/08/24 he supervised the nighttime smoke break, which occurred at approximately 8:00 P.M. that evening. STNA #816 reported there was no evidence of the smoking patio door alarming or having been tampered with. STNA #816 denied seeing Resident #69 during the smoke break. Interview on 10/16/24 at 2:43 P.M. with STNA #815 revealed on 10/08/24 she was assigned to Resident #69's unit from 3:00 P.M. to 11:00 P.M. STNA #815 stated, at the start of her shift, Resident #69 was agitated and combative with staff. STNA #815 stated Resident #69 received a shot and slept in his room until 5:30 P.M., when the resident exit his room and stated he was going to the dining room. STNA #815 indicated she remained busy with patient care and was notified by RN #811 that Resident #69 was missing. STNA #815 indicated she assumed Resident #69 was in the dining room and had not checked on him as he did not need care from her, adding the resident was independent with activities of daily living (ADLs). Review of the Resident Trust Funds Withdrawal Authorizations revealed Resident #69 withdrew 50 dollars on 09/20/24, 50 dollars on 09/27/24, and 30 dollars on 09/30/24. Review of the Root Cause Analysis dated 10/08/24 revealed staff failed to verify WanderGuard placement and function by root cause of inattention and knowledge deficit. Review of the facility policy titled Wandering, Unsafe Resident, revised August 2014, revealed residents would be evaluated for risk of unsafe wandering or elopement, at risk residents may wear a Secure Care or other such bracelet for additional security and prevention, and the care plan would identify a detailed monitoring plan to ensure safety. Review of facility policy, Elopements, dated December 2007, revealed if an employee observes a resident leaving the premises they should attempt to prevent departure in courteous manner, get help from other staff, and instruct other staff to inform Charge Nurse or DON. This deficiency represents non-compliance investigated under Complaint Number OH00158807.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, video footage with audio review, emergency medical services (EMS) run sheet review, hospital record review, interviews, and review of the facility's Change in a Residents' Condition or Status policy and procedure and Abuse, Neglect, Exploitation and Misappropriation policy and procedure, the facility failed to provide adequate and necessary care and services to prevent neglect involving Resident #101. This resulted in Immediate Jeopardy, including actual harm and subsequent death beginning on [DATE] at 7:03 P.M. when an incident of neglect occurred when the facility failed to prevent a fall with injury (rib fracture), to ensure timely and appropriate treatment was provided immediately post fall, to timely identify an acute change in condition and obtain immediate medical care. Review of video footage with audio dated [DATE] timed 7:03 P.M. revealed Resident #101, who was dependent on staff for personal care including bed mobility, was lying naked on her right side at the edge of her bed which was in high position as one State Tested Nursing Assistant (STNA), STNA #400, who was standing behind Resident #101, was placing a fitted sheet on the bed. Resident #101 asked STNA #400 are you going to pull me back, and STNA #400 responded Honey, I'm trying to fix your bed today as she continued to place the fitted sheet on the bed. Resident #101 then stated, Well I'm about to fall on the floor and then yelled out I'm falling as she fell from the bed face down. As Resident #101 was lying face down on the floor with her left leg resting on the side of the bed, STNA #400 walked around the bed, pushed the bed away from the resident causing Resident #101's left leg to drop to the floor with a thud. STNA #400 exclaimed damn (name of resident) and exited the room without speaking to Resident #101. Resident #101 was heard crying and yelling out help me, help me . is anybody going to get me up? Resident #101 was subsequently transferred to the hospital. Resident #101 returned to the facility on [DATE] sometime between 11:00 P.M. and 12:00 A.M. with a diagnosis of a closed rib fracture. After her return to the facility on [DATE] the facility failed to complete neurological (neuro) checks and timely identify an acute change in condition and obtain immediate medical care resulting in an emergent transfer to the hospital on [DATE]. Emergency Medical Services (EMS) were called on [DATE] at 6:31 A.M. The resident was transported to the hospital where she subsequently expired at 7:49 A.M. This affected one resident (#101) of four sampled residents and one of seven residents (Residents #3, #33, #39, #50, #60, #71, and #78) identified as requiring two-person (staff) assistance with care. Facility census was 99. On [DATE] at 4:55 P.M. the Administrator and Regional Nursing Home Administrator were notified Immediate Jeopardy began on [DATE] at 7:03 P.M. when Resident #101 who had diagnoses of right leg amputation, diabetes, chronic kidney disease and congestive heart failure, and required two staff members for all care, was receiving care by one staff member (STNA #400) and fell out of bed landing on the floor face down requiring emergent transport to the hospital where she was diagnosed with a rib fracture. On [DATE] at 2:39 P.M. the Administrator and Regional Director of Clinical Services (RDCS) #401 were notified upon further review of hospital records, additional video footage and follow-up interviews the Immediate Jeopardy encompassed neglect related to failing to prevent the fall with injury, failing to provide timely and appropriate treatment immediately post fall, ensuring timely identification of an acute change in condition, and obtaining immediate medical care which resulted in the death of Resident #101 on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: · On [DATE] at 11:30 A.M., RDCS #401 met with the Interdisciplinary Team (IDT) team including the Director of Nursing (DON), Assistant Director of Nursing (ADON), Administrator, and Unit Manager (UM) #171 to complete a root cause analysis. The IDT identified a system failure because STNA #400 provided care alone for Resident #101 who required a two person assist and did not follow facility policy for rolling and supervision of resident. The facility also identified Resident #101 was not monitored per protocol, specifically the completion of neuro checks for 72 hours post-fall, upon readmission to facility. · On [DATE] from 11:40 A.M. to 12:00 P.M., RDCS #401 educated the Administrator, DON, ADON and UM #171 on post fall monitoring including skilled charting, vital signs every shift for 72 hours, neuro checks for all unwitnessed falls or witnessed falls with head injury per neuro check form for 72 hours, and two-person assist for care. · On [DATE] from 12:45 P.M. to 1:15 P.M. a Quality Assurance Performance Improvement (QAPI) meeting was held with the medical director, Administrator, RDCS #401, DON, ADON, UM #171, Human Resources (HR) #252, Business Office Manager (BOM) #110, Dietary Manager (DM) #180, Admissions Director (AD) #152, Housekeeping Supervisor (HS) #199, Medical Records (MR) #232, and Licensed Social Worker (LSW) #134 to review the root cause analysis. All agreed that the root cause was a system failure as STNA #400 provided care alone for Resident #101 who required a two person assist and did not follow facility policy for rolling and supervision of resident. The QAPI team also identified Resident #101 was not monitored per protocol, specifically the completion of neuro checks for 72 hours post-fall, upon readmission to facility. RDCS #401 provided education to team including post fall monitoring including skilled charting and vital signs every shift for 72 hours and neuro checks for all unwitnessed falls or witnessed falls with head injury per neuro check form for 72 hours, two person assist for care, and checking binder at nurse's station for number of persons required to assist with resident care at the start of nursing shift. · On [DATE] between 2:30 P.M. and 5:30 P.M. the Administrator, DON, ADON, UM #171, DM #180, HS #199, and BOM #110 educated all facility staff on post fall monitoring including skilled charting, vital signs every shift for 72 hour, neuro checks for all unwitnessed falls or witnessed falls with head injury per neuro check form for 72 hours, two person assist for care, and checking the binder at nurse's station for two person assist for resident care at the start of nursing shift. Staff hired after [DATE] would be educated on the above information during new hire orientation. · On [DATE] at 6:00 P.M., UM #171 reviewed fall investigations for past 30 days to ensure interventions, including but not limited to fall mats, enabler bars, proper positioning, visual reminders, therapy evaluations, and assistive devices were in place and appropriate care plans were in place for all residents. No additional issues were identified. · On [DATE] at 7:00 P.M. the DON and Minimum Data Set (MDS) Nurse #251 audited care plans, Kardex (brand name for system that staff use to quickly reference resident information and care plans) and physician orders for all residents to ensure all assistance orders were in place and care planned appropriately. · On [DATE] at 7:00 P.M. the ADON and UM #171 created a binder for each nurse's station that contained the number of persons required to provide resident care. · On [DATE] at 3:15 P.M. the Regional Director of Operations (RDO) met with the IDT including the DON, ADON, Administrator, and UM #171 to complete an additional root cause analysis. The IDT identified a system failure as Licensed Practical Nurse (LPN) #150 failed to identify Resident #101's change in condition and provide timely intervention. LPN #150 failed to assess Resident #101 and identify a change in condition of mental status and did not obtain any vital signs or blood sugar checks. · On [DATE] between 3:40 P.M. and 4:00 P.M. a QAPI meeting was held with the Medical Director, Administrator, DON, ADON, UM #171, BOM #110, DM #180, AD #152, HS #199, MR #232, Social Service Designee (SSD) #202, and Central Supply #107 to review the root cause analysis. All agreed that the root cause was a system failure as LPN #150 failed to identify resident change in condition and provide timely intervention. The RDO provided education to the team on abuse and neglect policy and acute change in condition policy to include changes in mental status, vital signs or blood sugar. · On [DATE] Between 4:00 P.M. and 4:45 P.M. Maintenance Director (MD)#104, HS #199, BOM #110, DM #180, MR #232 and SSD #202 interviewed residents with a Brief Interview of Mental Status (BIMS) score of 13 or greater (BIMS score of 13 and above indicates cognition is intact) to ensure no further instances of neglect or change in condition without identification/intervention with no negative findings. · On [DATE] between 4:00 P.M. and 7:00 P.M. the RDO provided education to the IDT team on abuse and neglect policy and acute change in condition policy to include changes in mental status, vital signs or blood sugar. The Administrator, DON, ADON, UM #171, DM #180, HS #199, and BOM #110 then educated all facility staff on the facility abuse and neglect policy and acute change in condition policy. Staff hired after [DATE] would be educated on the above information during new hire orientation. · On [DATE] at 4:30 P.M., UM #171 assessed residents with a BIMS score of 12 or lower (moderate to severe cognitive impairment) to ensure further instances of neglect or change in condition without identification/intervention. No negative findings. · On [DATE] at 4:30 P.M. the DON reviewed the 72- hour report to ensure there were no residents with identified change in condition without appropriate follow-up. No negative findings were noted. · On [DATE] at 4:45 P.M. the DON reviewed change of condition assessments from [DATE] to present to ensure appropriate interventions. No negative findings were noted. · On [DATE], LPN #150 was suspending pending an investigation for resident neglect. · On [DATE] at 8:44 P.M. the RDO submitted a Self-Reported Incident (SRI) for neglect related to Resident #101. · The facility implemented a plan for audits to be completed by the DON/designee for every fall occurrence to ensure appropriate post fall monitoring including skilled charting, vital signs, and neuro checks as indicated for eight weeks beginning [DATE] and ending [DATE]. · The facility implemented a plan for audits to be completed to ensure the appropriate number of staff were providing care per identified needs would be completed by DON/designee on five random residents throughout all units five times weekly for eight weeks beginning [DATE] and ending [DATE]. · The facility implemented a plan for audits to be completed to ensure the person assist binders were accurate and up to date would be completed by DON/designee five times weekly for eight weeks beginning [DATE] and ending [DATE]. · The DON/designee would complete random staff interviews on all shifts to ensure binders were reviewed at start of shift. Two staff members to be interviewed five times weekly for eight weeks beginning [DATE] and ending [DATE]. · All new physician orders related to transfer status would be audited by DON/designee five times a weekly for eight weeks beginning [DATE] and ending [DATE]. · The DON/designee would observe 10 random residents a day five times a week for four weeks, then 10 random residents a week for four weeks, and randomly thereafter to ensure no change in condition without assessment and intervention and no signs of abuse or neglect beginning [DATE] and ending [DATE]. · The DON/designee would interview five random residents a day five times a week four weeks, then five random residents a week for four weeks to ensure no allegations of abuse or neglect beginning [DATE] and ending [DATE]. · The DON/designee would randomly review charting five times a week for four weeks to ensure no change in condition without assessment and intervention beginning [DATE] and ending [DATE]. · All audits would be reviewed during monthly QAPI meetings, and any identified concerns addressed immediately by QAPI committee. · Review of in-service sign-in sheets confirmed most facility staff received the training/education. Staff who did not attend would receive the training/education at the start of their next shift. Although the Immediate Jeopardy was removed on [DATE] the deficiency remained at Severity Level II (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as staff in-servicing and auditing to ensure continued compliance was still in process. Findings include: Review of the closed medical records for Resident #101 revealed an admission date of [DATE] and a discharge and deceased date of [DATE]. Resident #101 had diagnoses including right leg amputation, diabetes, chronic kidney disease and congestive heart failure. Review of the care plan dated [DATE] revealed Resident #101 required one person assist with bed mobility, toileting, transfers and personal hygiene. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 had intact cognition, required substantial/maximal assistance from staff for toileting and was dependent with rolling, bathing and personal hygiene. Review of current physician orders for [DATE] revealed Resident #101 was ordered two persons with all care. Resident #101 was ordered Plavix (antiplatelet) 75 milligram once daily with a start date of [DATE]. Review of the progress note dated [DATE] timed 9:57 P.M. authored by LPN #205 revealed a STNA reported Resident #101 was on the floor. Upon entering Resident #101's room the resident was observed lying face down on the floor. Resident #101 was assisted back into bed via a Hoyer (mechanical) lift and assessed. Resident #101 stated she hit her head, and a small amount of emesis was observed on Resident #101's face and on the floor. Resident #101's vital signs were stable. EMS was called and transferred Resident #101 to the hospital. Resident #101's daughter was notified via a Bluetooth device in the resident's room. The DON was also notified. Review of the progress note dated [DATE] timed 11:45 P.M. authored by LPN #214 revealed Resident #101 was returned from the hospital. The note indicated the resident was negative for any abnormalities. The note also indicated Resident #101 was non-compliant with obtaining a head-to-toe assessment and vital signs. Review of the progress note dated [DATE] timed 12:09 P.M. authored by LPN #208 revealed Resident #101 was alert and oriented and able to make her needs known, vital signs and neuro checks were within normal limits. The progress note did not include the vital signs. Review of the progress note dated [DATE] timed 2:01 P.M. authored by Social Services (SS) #134 revealed Resident #101 had a camera in her room and the fall had been recorded on video. SS #134 placed a call to Resident #101's daughter requesting a copy of the video for review and was awaiting receipt of video. The progress note indicated Resident #101's daughter requested half rails be placed on Resident #101's bed. The progress note also indicated the DON would interview the staff member that had been present at the time of the fall and all STNAs would be educated on proper positioning and a new bed with rails had been provided. Review of the progress note dated [DATE] timed 4:49 P.M. authored by LPN #404 revealed Resident #101's vital signs were blood pressure 132/65, heart rate 82, and oxygen saturation was 94% (normal 95-100%). Review of a progress note dated [DATE] timed 9:43 P.M. and authored by LPN #150 documented Resident #101 was arousable to verbal stimuli, resident sleeping, and medications were held. There was no additional information as to why the resident's medications were held at this time. Review of a progress note dated [DATE] timed 12:10 A.M. and authored by LPN #150 documented Resident #101 remained asleep, no distress. Review of a progress note dated [DATE] timed 3:55 A.M. and authored by LPN #150 documented Resident #101 continued to rest with no distress noted. Review of the progress note dated [DATE] timed 5:30 A.M. authored by LPN #150 revealed Resident #101 was arousable to verbal stimuli and pain, dressing was changed without incidence with no distress noted. Review of the progress note dated [DATE] timed 7:35 A.M. authored by LPN #150 revealed Resident #101 had a change in condition with altered mental status. Blood pressure was 62/28, heart rate 76, and oxygen saturation was 97% on room air. Review of the progress note dated [DATE] time 8:03 A.M. authored by LPN #150 revealed Resident #101 was noted to have increased drowsiness throughout the evening with a change in mental status as Resident #101 was not at her baseline. Resident #101 responded to pain but was not answering questions appropriately. Resident #101's vital signs were fluctuating. Emergency Services were called, and Resident #101 was transported out of the facility. The ADON was notified. Review of the EMS run report dated [DATE] revealed a call was received at 6:31 A.M. and EMS were in route at 6:35 A.M., on scene at 6:38 A.M. and at Resident #101 at 6:39 A.M. The report indicated Resident #101 was unresponsive with altered mental status for two days. Blood pressure taken at 6:53 A.M. was 68/58, heart rate was 86 and weak, oxygen was 96% on room air and blood sugar was 40 (normal 60-100), skin was cool and pale. Upon arrival Resident #101 was in a reclining chair and was slow to respond only responding to painful stimuli. The EMS report indicated Resident #101 was last seen normal yesterday ([DATE]) and normal mental status was alert and oriented. Review of hospital documentation dated [DATE] revealed Resident #101 presented with altered mental status along with low blood pressure and low blood sugar. Resident #101 was last known well sometime yesterday ([DATE]). Resident #101 was declared deceased on [DATE] at 7:49 A.M. Review of Resident #101's recorded vital signs revealed on [DATE] at 9:18 P.M. staff documented her blood pressure was 104/64, on [DATE] at 10:45 A.M. her blood pressure was 120/68 and on [DATE] at 7:36 A.M. her blood pressure was 62/28. Review of Resident #101's closed medical record including the hard/paper chart revealed no documented evidence of any type of neurological checks were completed following the resident's fall. Review of the facility progress note dated [DATE] timed 10:20 A.M. and authored by SS #134 revealed Resident #101 expired on [DATE] at 8:24 A.M. Review of video footage with audio provided by Resident #101's daughter, dated [DATE] timed 7:03 P.M., revealed Resident #101 lying naked on her right side at the edge of her bed which was in high position without siderails as STNA #400, who was standing behind Resident #101, was placing a fitted sheet on the bed. Resident #101 asked STNA #400 are you going to pull me back, and STNA #400 responded Honey, I'm trying to fix your bed today as she continued to place the fitted sheet on the bed. Resident #101 then stated, Well I'm about to fall on the floor and then yelled out I'm falling as she fell from the bed face down. As Resident #101 was lying face down on the floor with her left leg resting on the side of the bed, STNA #400 walked around the bed, pushed the bed away from the resident causing Resident #101's left leg to drop to the floor with a thud. STNA #400 exclaimed damn (name of resident) and exited the room without speaking to Resident #101. Resident #101 was heard crying and yelling out help me, help me . is anybody going to get me up? Video footage timed 7:06 P.M. revealed STNA #400 re-entering Resident #101's room with three additional staff members. Resident #101 remained on the floor yelling out help me and she let me fall on the floor. The staff members were observed placing a Hoyer pad underneath Resident #101 and applying a gown. Resident #101's daughter could be heard asking staff what happened. STNA #400 responded I was putting the sheet on the bed and instead of her holding on to the bed, she was digging in her nose. Resident #101 stated I was holding on to the bed. STNA #400 began to argue stating No you weren't you were digging in your nose. Resident #101 said STNA #400 was lying and STNA #400 stated Girl bye. Video footage timed 7:10 P.M. revealed staff assisting Resident #101 back into bed via a Hoyer lift. An unidentified staff member asked Resident #101 if she was having pain and Resident #101 replied all over. Video footage timed 7:12 P.M. revealed staff placed an incontinence brief on Resident #101. No physical assessment was completed, and vital signs were not obtained. Video footage timed 7:14 P.M. revealed Resident #101 stating I can't believe she let me hit the floor. The staff members present in the room did not respond. Video footage timed 7:30 P.M. revealed EMS arrived. Resident #101 stated I don't believe that girl let me fall out of this bed. Review of the facility's fall investigation with an initiation date of [DATE] revealed a statement authored by STNA #400. The statement indicated STNA #400 placed Resident #101 in bed at approximately 7:00 P.M., while placing a fitted sheet on Resident #101's bed the resident was digging in her nose and tried to throw away a tissue in the trash and while reaching for the trash Resident #101's body went over the edge of the bed. Review of the facility investigation revealed no evidence a second staff person was in the room to assist with the resident's transfer to bed or to assist with personal care/bed mobility. Further review of the investigation revealed no documentation neuro checks were completed. The investigation indicated Resident #101 was transferred out of the facility. The investigation included hospital paperwork dated [DATE] that indicated Resident #101 had a CT scan and a chest x-ray. The hospital paperwork indicated Resident #101 had a closed left sided rib fracture. The results of the CT were not included with the paperwork. Telephone interview on [DATE] at 7:30 A.M. with Resident #101's daughter revealed on [DATE] she received a call from Resident #101 via an electronic device. Resident #101 told her she had fallen out of bed, and she was lying on the floor. Resident #101's daughter stated Resident #101 told her she was hurting all over. Resident #101 was transported to the hospital after the fall and was returned to the facility shortly after. Resident #101's daughter had concerns about Resident #101 being returned to the facility so quickly especially since she was on blood thinners. Resident #101's daughter stated she had spoken with the nurse (couldn't recall name) and asked that thestaff check on her mother more frequently. The daughter stated the nurse informed her Resident #101's CT scan was negative, and that Resident #101 had a rib fracture. Resident #101's daughter went to the facility on [DATE] and spoke with SS #134 and showed him the video footage of the fall; she also sent the link to view the video via text message to SS #134. Resident #101's daughter stated SS #134 did not say much about the video, but she was told the facility would begin an investigation. Resident #101's daughter further stated she reviewed additional camera footage and on the evening of [DATE] the camera, which was motion activated had not detected anyone entering Resident #101's room; the camera did not detect anyone from the evening of [DATE] until the morning of [DATE] at 5:30 A.M. At 5:30 A.M. a nurse entered to change Resident 101's wound dressing. The camera footage also showed staff placing Resident #101 into a dialysis chair and Resident #101 appeared to be unresponsive at that time. Resident #101's daughter was told Resident #101 was taken to the hospital and on the way to the hospital she crashed. The daughter was told by hospital staff Resident #101's blood pressure and blood sugar were low and she became unresponsive on the way to the hospital and passed away sometime after arriving to the hospital. Telephone interview on [DATE] at 11:48 A.M. with LPN #205 revealed on [DATE] shortly after 7:00 P.M. STNA #400 informed her Resident #101 was on the floor. STNA #400 did not provide any specific details of the fall. LPN #205 and three other staff members entered Resident #101's room and she observed Resident #101 was face down on the floor by her bed and was complaining of pain all over. LPN #205 stated she did not observe any obvious injuries. Resident #101 told her she had told STNA #400 she was falling out of bed. LPN #205 assisted with getting Resident #101 back into bed and then called EMS (911). LPN #205 stated Resident #101's daughter was notified of the fall via an electronic device located in the room at the time of the fall. LPN #205 stated Resident #101 required two person staff assistance for all care. LPN #205 had collected STNA #400's statement and STNA #400 told her as she was assisting Resident #101 with a bed change, Resident #101 was digging in her nose and had not been holding onto the bed. Resident #101 returned to the facility sometime between 11:00 P.M. and 12:00 A.M. and another nurse had taken over care of Resident #101 after her return. LPN #205 did not care for Resident #101 after her return from the hospital. Telephone interview on [DATE] at 12:12 P.M. with LPN #150 revealed she had cared for Resident #101 on the evening of [DATE] from 7:00 P.M. to [DATE] at 7:00 A.M. LPN #150 stated she entered Resident #101's room around 9:30 P.M. to administer Resident #101's evening medications and Resident #101 was sleepy but had spoken. Resident #101 appeared to be too sleepy to give her the medications and so she had not administered the medications. LPN #150 stated she entered Resident #101's to check on her a few times throughout the evening and she continued to sleep. When LPN #150 entered Resident #101's room on the morning of [DATE] at approximately 5:30 A.M. to complete her wound care, Resident #101 was sleepier than she had been earlier. Resident #101 was not easily arousable and was not responding appropriately. LPN #150 said she took Resident #101's blood pressure and it was low. LPN #150 called the physician and received orders to call 911. LPN #150 called 911 between 7:00 A.M. and 7:30 A.M. and Resident #101 was transported to the hospital. LPN #150 continued to get Resident #101 ready for dialysis and out of bed and took her from her room to the hall before calling 911 because she stated she felt the condition the resident was displaying was somewhat normal for her. The hospital called about an hour later and reported Resident #101 had passed away. Interview on [DATE] at 12:57 P.M. with Registered Nurse (RN) #185 revealed she had responded and assisted with Resident #101's fall on [DATE]. When RN #185 entered Resident #101's room she observed Resident #101 face down on the floor and Resident #101 was yelling out in pain. RN #185 was not aware how the fall occurred and stated Resident #101's assigned nurse (LPN #205) had called 911 and Resident #101 was transported to the hospital. RN #185 did not care for Resident #101 after her return from the hospital. Interview on [DATE] at 1:07 P.M. with STNA #103 revealed she was not present when Resident #101 fell out of bed, however she cared for her the next morning after her return from the hospital. STNA #103 stated Resident #101 usually used her call light early in the morning for assistance out of bed, but that morning Resident #101 did not use her call light or ask to get out of bed. When STNA #103 entered Resident #101's room that morning (could not recall time) Resident #101 appeared to be more tired than normal and did not want to get up. Interview on [DATE] 1:54 P.M. with RDCS #401 and the ADON revealed they completed an investigation into Resident #101's fall. RDSC #401 stated STNA #400 was terminated because she did not follow Resident #101's plan of care regarding the number of staff required when providing care. RDCS #401 stated Resident #101 was transported to the hospital after the fall and returned shortly after. RDSC #401 stated the hospital paperwork did not include results of the CT scan, but the hospital called and informed the nurse of the results being negative. RDCS #401 stated neurological (neuro) checks were not completed because the resident's CT scan was negative. Interview on [DATE] at 8:54 A.M. with the DON revealed she received a call on the evening of [DATE] from LPN #205 informing her Resident #101 had a fall and was being transported to the hospital. LPN #205 had not provided specific information regarding how the fall occurred. The DON stated Resident #101 was transported to the hospital and returned shortly after. The DON was surprised Resident #101 had returned so quickly. The hospital gave the discharge paperwork to Resident #101. The DON asked Resident #101 for the hospital paperwork the following morning. The hospital paperwork indicated Resident #101 had a rib fracture. The paperwork did not include the results of the CT scan. The DON confirmed neuro checks were not completed upon Resident #101's return and said they were not completed because the CT results were reported as being negative. Resident #101's daughter was present at the facility on [DATE] and she had video footage of Resident #101's fall. Resident #101's daughter played the video; however, the DON did not see the video she only heard the audio. The DON asked Resident #101's daughter to send the actual video because she was unable to open the link to view. The DON stated when she listened to the audio of the video, she heard Resident #101 ask to be pulled back and she heard the crash. The facility initiated an investigation on [DATE] which included Resident #101 was a two person assist with care and during the investigation she educated STNA #400 regarding following proper resident care and fall protocol that included not leaving a resident who was on the floor. The DON reviewed STNA #400's statement regarding the fall and stated STNA #400's statement was not truthful based on what she had heard on the video. The DON viewed the video footage the morning of [DATE] which was the morning she was notified Resident #101 had been lethargic and had low blood pressure and was being sent to the hospital. Upon review of the video footage STNA #400 was terminated. Interview on [DATE] at 12:54 P.M. with RDCS #401 revealed she was aware video footage existed regarding Resident #101's fall but she had not viewed the video until [DATE]. Telephone interview on [DATE] at 3:36 P.M. with STNA #400 revealed she cared for Resident #101 on multiple occasions, and she was aware Resident #101 required two-person assistance with care. STNA #400 stated she had often cared for Resident #101 by herself and on the evening of [DATE] Resident #101 requested to be put into bed and she had used the Hoyer lift by herself to place Resident #101 into bed. STNA #400 stated she gave Resident #101 a bed bath and began placing the fitted sheet on the resident's bed. Resident #101 was up on her side in bed and STNA #400 had a hand on Resident #101 the whole time and she told Resident #101 to hold on to the bed. STNA #400 stated Resident #101 had not held on to the bed, rolled out of the bed and fell to the floor. STNA #400 left the room to go get[TRUNCATED]