**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of two residents reviewed for elopements. The facility failed to ensure Resident #1 received adequate supervision and remained in the facility's secured care unit, which resulted in her elopement from the facility on 10/04/2024. The facility failed to provide adequate supervision to Resident #1 to ensure Resident #2 did not facilitate Resident #1's elopement on 10/04/2024. The noncompliance was identified as PNC IJ. The noncompliance began and ended on 11/25/2024. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of injury and a decreased quality of life. Findings included: Record review of Resident #1's Face Sheet, dated 11/25/2024 at 9:40 AM, revealed she was a [AGE] year-old female admitted [DATE]. Relevant diagnoses included cerebral infarction (blood supply to the brain is blocked or reduced,) brain and lung cancer that had metastasized (spread,) and Neurocognitive disorder further detailed by unspecified symptoms and signs involving cognitive functions and awareness. She resided in the facility's secured unit. Record review of Resident #1's admission MDS dated [DATE] revealed she was admitted from home/community and had a severe cognitive impairment with BIMS score of 05. Resident #1's MDS stated she had recent wandering behavior. Resident #1 did not require any mobility aides for ambulation. Resident #1 required setup or clean-up assistance for most cares due to cognitive impairment and was occasionally incontinent of bowel and bladder. Record review of Resident #1's Wandering Assessment completed upon admission [DATE] revealed she was at risk for wandering/elopement and resided in facility's secured unit. Record review of Resident #1's Comprehensive Care Plan dated 11/20/2024 revealed she had neurocognitive disorder and resides in the secure unit due to her wandering and poor safety awareness. 10/04/2024 Resident observed by staff sitting outside on the bench. Interventions included: -Ensure resident was wearing proper fitting and appropriate footwear -To complete wander alert [documents] and place in elopement binder -Take picture of resident every quarter because I may have changed my appearance and/or weight -Elopement assessments to be completed upon admission, quarterly, and with any significant change of condition -To provide resident with redirection, comfort measures and address basic needs when wandering behavior is exhibited Record review of Resident #2's Face Sheet , dated 11/26/2024 at 1:38 PM, revealed he was [AGE] year-old admitted on [DATE]. Relevant diagnoses included cerebral infarction (blood supply to the brain is blocked or reduced,) and type 2 diabetes (insulin resistance.) Record review of Resident #2's admission MDS dated [DATE] revealed he was admitted from home/community and was cognitively intact with BIMS score of 15. Resident #2's MDS stated he did not have any recent wandering behavior but was resistive to cares recently. Resident #2 required a walker as a mobility aide. Resident #2 required setup or clean-up assistance or was independent for most cares and was occasionally incontinent of bowel and bladder. Record review of Resident #2's Comprehensive Care Plan dated 11/25/2024 revealed he enjoyed listening to country music, walks outside and playing cards. Additionally, Resident #2 was documented as resistive to cares at times. Interventions included: -Always ask for help if resident becomes abusive/resistive -Convey acceptance of resident during periods of inappropriate behavior -Encourage diversional activities -Keep environment calm and relaxed -Redirect resident as needed -Remove from public area when behavior is unacceptable -Staff to continue to educate resident on the importance of cares and interventions In interview and observation with Resident #1 on 11/21/2024 at 10:58 AM, she was in the facility's secured unit resting in her room on her bed. She was observed with proper fitting and appropriate footwear. She was clean, well dressed, and appeared to not be in any distress. She stated she recalled the elopement incident but did not remember the date, she denied she was injured because of the incident, and stated she went outside because she just wanted to get some sun. In interview and observation with Resident #1 on 11/26/2024 at 9:29 AM, she ambulated in the hallway of the facility's secured unit. She was observed with proper fitting and appropriate footwear. She was clean, well dressed, and appeared to not be in any distress. She reported she was having a good day and had no complaints. Record review of facility's Progress Note for Resident #1 by LVN A on 10/04/2024 at 3:44 PM revealed At about 1235, a resident alerted staff by yelling out that, this resident had exited the door and staff immediately chase after this resident while alerting other staff. A staff who was coming back from her break entered the building with the resident and said that, she saw this resident sitting outside on a chair near the main entrance to the facility. Head to toe assessment done and no injury noted. RP, DON, and MD made aware. Elopement watch initiated. Record review of Facility Event Summary with a look-back period of 10/01/2024-11/21/2024 revealed on 10/04/2024 at 12:54 PM, LVN A wrote [Resident #1] observed by staff sitting outside on the bench in front of the building. Head to toe assessment performed and no injuries noted. Resident stated she was 'getting some sun'. Resident [in] line of [sight] observation. Additional documented revealed the physician and RP were notified, and care plan reviewed. DON e-signed the incident status as closed on 10/09/2024. Interviews attempted with LVN A on 11/21/2024 2:44 PM and 11/25/2024 at 2:00 PM were unsuccessful. In interview with CNA C on 11/21/2024 at 11:10 AM revealed she was working the day of Resident #1's elopement, 10/04/2024, and around mid-day she at the facility's parking lot sitting in her car while on her lunch break. She stated she saw Resident #1 outside sitting on the bench near the front door. She stated she immediately went to Resident #1 and re-directed her back inside to her secured unit. CNA C stated Resident #1 was outside approximately 1.5 minutes. CNA C stated that Resident #1 told her upon her return to the facility that a gentleman opened the door, for her and that was how she got outside. In interview with Resident #2 on 11/25/2024 at 11:20 AM he stated he recalled the incident with Resident #1. Resident #2 stated he was watering the plants in the front of the building the day of the incident. He stated he saw the resident sitting on the bench located outside in the front of the facility building. He denied letting Resident #1 out of the building and stated she was not outside for very long. Resident #2 stated after Resident #1's elopement, he was educated by the Administrator and DON on the importance of not opening the facility front door for any residents. He stated at that time of Resident #1's elopement, he was aware of the facility's front door code, but declined to disclose how he obtained the code. He stated after Resident #1's elopement, the facility changed the front door code, and he did not know it currently. In interview with facility's Administrator on 11/25/2024 at 11:01 AM, he stated based on his investigation Resident #1 exited through the secured unit door. He was not able to determine how Resident #1 exited the secured unit; but he determined Resident #1 was let outside the facility's front door by Resident #2 while he was watering the plants in the front of the building. He stated Resident #2 was high functioning, had a BIMS score of 15, resided in an unsecured environment, and was able to sign himself in and out of the facility as he pleased. He stated there was not a way to disable the door alarms without the location/door specific code. He stated both the secured unit and the facility's doors were alarmed with a code that only facility staff had access to. The facility Administrator stated since Resident #1's elopement, all the door codes have been changed and a sign has been placed on the front door to not allow any residents out unassisted. He stated his expectations were for his residents in the secured unit to remain in the secured unit. He further stated it was the responsibility of facility staff to supervise and monitor the residents to identify and re-direct wandering behaviors. Finally, he stated it was nursing leadership's responsibility to ensure any additional and/or resident specific assessments and/or interventions were in place to prevent resident elopements. In interview with facility's DON on 11/26/2024 at 11:47 AM, she stated based on her investigation, CNA C reported to her that she saw Resident #1 outside while she was on her lunch break. DON stated she was not sure how Resident #1 exited the secured unit; but she concluded that Resident #2 let Resident #1 out of the facility's front door while he was watering the plants. She stated there was not a way to disable the door alarms without the location/door specific code and to her knowledge the doors did not malfunction. She stated both the secured unit and the facility's doors were alarmed with a code that only facility staff was permitted to have access to. DON further stated since Resident #1's elopement, all the door codes have been changed probably twice already. She stated after Resident #1's elopement, she ensured proper notification to Resident #1's provider and RP, that Resident #1 was assessed for injury/harm, that Resident #1's Comprehensive Care Plan was reviewed, that maintenance performed a facility-wide inspection of doors for functionality, she conducted a facility-wide elopement drill, and provided In-services to her staff specific to elopements and the prevention of any potential piggy-backing of residents that may get out of the secured unit without staff's awareness. She stated her expectations were for the residents in the secured unit to remain in the secured unit and it was facility staff's responsibility to monitor and supervise the residents. DON stated it was nursing leadership's responsibility to ensure the Elopement Binder was at the secured unit's nurses' station, the documents were completed and quarterly updated, and any other resident specific interventions were in place to prevent resident elopements. In interview with Resident #1's RP on 11/25/2024 at 10:07 AM, she stated she was Resident #1's RP and that her family member resides in the secured unit at [Facility.] She stated she was notified by LVN A on 10/04/2024 about Resident #1's elopement. Resident #1's RP denied any successful elopements from the facility prior to 10/04/2024, but stated she had elopements from home prior to her admission which necessitated her admission to the facility's secured unit. In interview with facility's Maintenance on 11/25/2024 at 9:30 AM revealed after Resident #1's elopement on 10/04/2024, he ensured all the doors at the facility were operating as required. In observation of facility's front door on 11/21/2024, 11/22/2024, 11/25/2024, and 11/26/2024 at approximately 9:00 AM revealed a sign posted on the front door that stated, Please do not let our residents out unassisted. In observation of facility's secured unit front and back doors and facility main entrance/exit door on 11/21/2024 at 9:29 AM and 2:00 PM, doors demonstrated appropriate function and were secured with a multi-digit code for entry and exit. In observation of facility's Elopement Binder located at the secured unit's nurses' station on 11/26/2024 at 9:26 AM, revealed Resident #1's Wander Alert documents with relevant identification and notification details in the binder with a recent, recognizable photograph of Resident #1. In interview with CNA C on 11/21/2024 at 11:10 AM she stated the importance of proper footwear for Resident #1, stated the location and purpose of the facility's Elopement Binder at the secured unit's nurses' station, and the importance of providing Resident #1 with redirection and comfort measures to address basic needs when wandering behavior is exhibited. In interview with CNA D on 11/26/2024 at 9:26 AM she stated the importance of proper footwear for Resident #1, the location and purpose of the facility's Elopement Binder at the secured unit's nurses' station, and the importance of providing Resident #1 with redirection and comfort measures to address basic needs when wandering behavior is exhibited. In interview with LVN B on 11/21/2024 at 11:15 AM he stated the importance of proper footwear for Resident #1, stated the location and purpose of the facility's Elopement Binder at the secured unit's nurses' station, the requirement of an accurate wandering/elopement assessment to be completed upon admission, quarterly, and upon a resident's change of condition, and the importance of providing Resident #1 with redirection and comfort measures to address basic needs when wandering behavior is exhibited. In interview with facility's DON on 11/26/2024 at 11:47 AM stated the importance of proper footwear for Resident #1, that the facility's Elopement Binder was located at the secured unit's nurses' station and was required to be created upon admission, updated quarterly, and/or upon a change of condition, and that she was responsible to ensure resident wandering/elopement assessments were completed upon admission, quarterly, and with any significant change in condition. DON stated the importance of all staff providing Resident #1 with redirection and comfort measures to address her basic needs when wandering behavior is exhibited as stated in her Comprehensive Care Plan. In interview with facility Administrator on 11/25/2024 at 11:01 AM he stated the importance of proper footwear for Resident #1, that the facility's Elopement Binder was located at the secured unit's nurses' station and both the Elopement Binder and wandering/elopement assessments were required to be updated upon a resident's admission, quarterly, and in response to a resident's change of condition. Administrator also stated the importance of his staff to provide Resident #1 with redirection and comfort measures to address her basic needs when wandering behavior is exhibited. Record review of Resident #1's Comprehensive Care Plan dated 11/20/2024, reviewed on 11/25/2024 at 9:00 AM revealed sufficient identification of Resident #1's wandering/elopement behaviors and detailed list of multiple interventions prior to investigation. Record review of Resident #1's Wandering Assessments reviewed on 11/25/2024 at 9:30 AM revealed sufficient assessment of Resident #1's risk for wandering/elopement that necessitated her need to reside in facility's secured unit. Record review of facility Inservice titled, Elopement/Wandering .Secured Unit/Missing Resident, dated 10/04/2024 conducted by facility's DON revealed facility policy, protocols, and procedures which specifically included to ensure no resident exits behind you when entering or exiting the secure unit. Please wait till the door is locked before walking away . Document revealed multiple staff signatures. Record review of facility document titled, Elopement Drill dated 10/10/2024 conducted by facility's DON revealed facility's elopement drill was completed. Document revealed multiple staff signatures. Record review of facility's Inservice titled, Elopement Drill dated 10/10/2024 conducted by facility's DON revealed facility's elopement policy, protocols, procedures, provided to staff. Document revealed multiple staff signatures. Record review of facility's documentation of Maintenance of the doors, dated 10/04/2024, revealed that he personally ensured all doors were operating as required. Review of facility policy, Wandering and Elopements, dated 09/01/2023 revealed The facility will ensure that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care . Monitoring and managing residents at risk for elopement or unsafe wandering . a person-centered care plan will be developed based on the risk factors identified in the risk assessment . adequate supervision will be provided to help prevent accidents or elopements . The noncompliance was identified as PNC IJ. The noncompliance began and ended on 11/25/2024. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for one (Resident #1) of six residents reviewed for Change in condition. LVN B failed to notify Resident #1's Doctor on 08/02/24 after CNA A asked her to assist with picking Resident #1 off the floormat and putting her back to bed. Subsequently, Resident #1 was sent to the hospital on [DATE] and currently at the hospital diagnosed with two fractures (Tibia and Fibula) of her left lower leg. An Immediate Jeopardy (IJ) was identified on 08/12/24. An IJ Template was provided to the facility on [DATE] at 12:10 pm. While the Immediate Jeopardy was removed on 08/12/24 at 7:50 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place all residents at risk of not being assessed and treated in a timely manner and appropriately, with Doctors interventions, which could result in a decline in their psycho-social well-being and health resulting in internal bleeding, pain when being moved causing further injury or death. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted [DATE] with a BIMS Staff Assessment score of 2 (Moderate impaired cognition), no speech, with a memory problem and severely impaired. She had upper extremity impairment on one side and lower extremity impairment of both sides. Her functioning abilities and goals: Self-care: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for all ADLs including (toileting, personal hygiene). Her functioning abilities and goals: Mobility: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for roll left and right and for chair/bed to chair transfer. She was always incontinent to bladder and bowel, has a progressive neurological conditions with diagnoses of hypertension. She had Multiple Sclerosis (nerve degeneration), Gastronomy status (feeding tube), Cardiac arrhythmia (irregular heartbeat), dysphagia (not able to swallow properly), muscle weakness, atrial fibrillation (irregular heartbeat), and lack of coordination. She was 5'6 and 132 pounds. Record review of Resident #1's August 2024 Order Summary Report revealed orders for: Eliquis (blood thinner) 5 mg, folic acid 1 mg. senna 8.6 mg. tramadol 50 mg. Enteral Feeding tube, Enteral stoma site care, NPO, Enteral formula pump administration. Record review of Resident #1's Care Plan printed 8/10/24 revealed, Multiple sclerosis: assist with ADL and comfort measures as needed, Abdominal binder: to keep G-tube in place keep head and bed elevated. Geri-chair: make as comfortable as possible, falls (Resident has a history of falling related to mobility due to Multiple Sclerosis): place resident in a fall prevention program. Multiple sclerosis at risk for a decline in current ADLs and injuries due to increased injuries and assist with ADL's and comfort measures as needed. Cognitive loss/dementia: allow time for task and responses. Communication has aphasia approach in calm manner. Falls - keep call light within reach, ADL Functional status: ambulation/transfers amount of assist: total x 2 non-ambulatory, bathing/hygiene assist: total x1, resident care as per policy, toileting amount of assist total x1. Record review of Resident #1's Progress notes reviewed from 08/02/24 to 08/09/24 did not reveal she had any falls or incidents. Record review of Resident #1's X-Ray results dated 08/08/24 at 8:03 p.m. revealed, Clinical information: Bruising, swelling, Test procedures: Left tibia and fibula, two views. Findings: Proximal tibial and fibular shafts fracture. No osteolytic or osteosclerotic lesions. No signs of bone infection. Impression:1. Proximal tibial and fibular shafts fracture. 2. CT is recommended. Record review of Resident #1's Hospital Emergency Department Doctor's note dated 08/08/24 revealed, Chief complaint: Leg deformity: patient here from [Nursing Facility]. Left leg swelling noted and ecchymosis found this morning. On Eliquis .Patient is bed bound and nonverbal. Radiology: Tibia/fibula, left 2 views final result: Impression: Proximal left tibial and fibular fractures, negative left ankle and knee joint. Soft tissue swelling. Osteopenia. Record review of Resident #1's Progress note 08/02/2024 [Recorded as Late Entry on 08/09/2024 06:19 PM] by LVN B revealed, Events - fall: 11:06 PM On 2nd of August, CNA call attention to this nurse to room XXXX and reported to this nurse that she rolled resident down to the floor mat while giving care. Observed and assess resident on the floor mat., no apparent injury noted at that time. No S/S of pain noted at that time. Resident was helped back to bed with the help of the CNA. Record review of Resident #1's Incident/Accident Report completed date 08/09/24 at 6:08 p.m. by LVN B revealed, Event date 08/02/24 at 5:57 p.m., in resident room, yes fall was witnessed, no injury and no pain, ROM without pain/limitations, no rotation/deformity/shortening noted .notifications: Attending physician faxed: no, Physician notified: no, Resident Representative notified: no, care plan reviewed: no. Record review of Resident #1's Hospital Orthopedic Doctor note dated 08/09/24 revealed, Orthopedic diagnosis: Left Proximal tibia fracture. Orthopedic plan: Closed management of left proximal tibial fracture, knee immobilization, non-weight bearing. History of present illness: A [AGE] year-old female with multiple advance medical issues including MS, who is nonverbal at baseline .The patient is nonverbal, non-ambulatory. I do not think she would be a very good candidate for surgical intervention. I will plan for a knee immobilization and follow-up in the outpatient setting. Observation on 08/09/24 at 3:40 p.m., Resident #1's room revealed a thin blue floormat that was approximately two inches height and six feet in length on the left side of Resident #1's bed. Observation on 08/10/24 at 3:37 p.m., Resident #1 was at the hospital lying flat on her back, in bed watching television, she nodded yes to her name. She shook her head no she was not hurting. When asked had she fallen out of bed, she looked at her left leg and did not shake or nod her head. There was a G-tube next to her bed and she did not appear to be in pain. And her left leg was bent at a 45-degree angle with a knee immobilizer on it. Interview on 08/09/24 at 6:43 p.m., CNA A stated on 08/02/24 after dinner she checked Resident #1 and incontinent care was needed. She stated she was standing right in front of the window with the bed elevated and while caring for Resident #1, she turned her towards the door then towards her. She stated she put the bed linen on the floor then rolled her to the right to clean her and afterwards she tried to grab her bed sheets at the foot of her bed. She stated then Resident #1 started shaking and rolled off the bed so she went to get LVN B who came to assess the resident and made sure she was okay. She stated she and LVN B got Resident #1 back to bed and got her dressed then LVN B asked her what happened and she told her she was doing incontinent care and the resident rolled to the floor. She stated Resident #1 was nonverbal but did not appear to be in any pain and her leg was not swollen or in a weird position. She stated she was not sure if the nurse called to have any x-rays done and did not see anyone come out to do x-rays during her shift. She stated there was most likely no x-rays done because the resident was not crying because she checked on her frequently and changed her about four more times that night. Interview on 08/10/24 at 9:09 a.m., LVN B stated she worked the overnight shift and last took care of Resident #1 Last Friday 08/02/24, Tuesday 08/06/24 and Wednesday 08/07/24. She stated yesterday 08/09/24 she heard Resident #1 had a leg fracture. She stated she was very surprised Resident #1 was injured. She stated the DON spoke to her about what she knew about Resident #1's fall on 08/02/24 then the DON told her she should have completed an incident report and called her Doctor. She stated she did a late add nurses note and incident/accident report on 08/09/24 per the DON's request. She stated last Friday 08/02/24 after meal service, after 11:00 pm she was at the nurses' station and CNA A stood at Resident #1's room door calling her name out loud about needing help putting Resident #1 back to bed. She stated she saw Resident #1 in her room and her bed was in the lowest position and Resident #1 was on the left side of her bed on the floor. She stated Resident #1 was on her back and her left leg was turned to the left, and her head and buttocks was flat on the floormat, she was on her back. She stated her left leg was paralyzed and for her care they normally used a pillow to prop it in place. She stated when Resident #1 was on the floor her G-tube port was okay and the tubing was still connected to the g-tube pump. She stated there was no pillow under Resident #1's leg and the bed linen and pillow was on her bed. She stated she assessed Resident #1 and did not find anything wrong with her and she had no signs or symptoms of pain, then she CNA A put her back to bed. She stated when she asked CNA A why Resident #1 on the floor, CNA A said she rolled Resident #1 onto the floor to give her incontinent care. She stated CNA A did not say Resident #1 fell but said she guided her to the floormat. She stated if CNA A told her Resident #1 had fallen, she would have reported it to her Doctor. She stated she would have also documented it in Resident #1's nurses notes and completed an incident report and called her family. She stated she would have followed up with her to ensure she was fine and added Resident #1 was on scheduled Tramadol she received at 12:00 am and PRN Tylenol. She stated there was no increase in giving her more pain medications. She stated Resident #1's floor mat next was next to her bed 24/7 and Resident #1 normally did not get care on the floor mat that was why can questioned CNA A about it. She stated there was not anything propping her left leg, she checked on Resident #1 four or five times that night. She stated Resident #1 watched television and slept and she was given her Tramadol at midnight and she was asleep rest of the night. She stated she did not tell the oncoming nurse or the DON about her being on the floor because she got busy and did not suspect anything was wrong. She stated she got busy with taking care of other residents forgot to document at nurses note. She stated there was no swelling or redness of her legs during her 08/02/24 shift. She stated she returned to work Tuesday 08/06/24 the nurse reported Resident #1 had left leg swelling and her Doctor ordered for a doppler study for edema. She stated the doppler study result came back Wednesday 08/07/24 was negative and she faxed that result to her Doctor. She stated there were no new orders and she took a picture of Resident #1's left leg and sent it to her Doctor. She stated she got a call from the DON yesterday 08/09/24 around 4:00 pm and she returned the call around 4:49 pm and the DON told her to come to the facility. She stated a little after 5:00 pm she gave the DON her statement and completed Resident #1's incident report. The DON told her she should have reported this to her and called her Doctor and family. She stated she had the mind to call the DON but forgot and stated if a resident fell and the Doctor, DON or family was not notified could result in delayed injury. She stated that was why she always documented but she forgot to document Resident #1's fall and said after the DON spoke to her, she now knew why she should have completed a nurses note and reported it to her Doctor and family. She stated she thought it was odd Resident #1 was on the floormat. She stated Resident #1 was bed bound with left sided weakness, upper and lower and alert and oriented x1. She stated Resident #1 was not able to express her needs because she was aphasic and knew her name. She stated Resident #1 was able to gesture responses by nodding and shaking her head. She stated the nurses were responsible for ensuring the residents were getting proper care and cleaned and dry and checked every 2 hours. She stated the DON suspended her and CNA A pending the investigation of Resident #1. She stated not reporting something bad could cause the resident to get bruised, get skin tears or injured. Interview on 08/09/24 at 4:45 p.m., The Police Detective stated he visited Resident #1 at the hospital and gathered other information and opened a case to further investigate the circumstances involving Resident #1's leg injury. He stated he had spoken to CNA A who said on 08/02/24 she was cleaning Resident #1 and she turned around then the resident kept rolling and fell out of the bed. He stated CNA A said she asked LVN B to help get Resident #1 off of the floor then LVN B picked up Resident #1 and put her back onto her bed. Police Detective stated as of right now there was no documentation of the resident falling and no one knew what happened to her leg and the resident was not able to say what happened. He stated the Administrator and DON said they just discovered it from CNA A's statement. He stated Resident #1 sustained two fractures of her left tibia and left fibula that was approximately one inch below her knee. He stated Resident #1's roommate said she remembered a nurse and CNA coming in really fast one night but was not able to see or know what happened. He stated he was getting ready to interview LVN B to gather more information. Interview on 08/09/24 at 7:26 p m, the DON stated she received a report on 08/06/24 about Resident #1's left leg appearing shiny and red like she had irritated rash. She stated her Doctor ordered a doppler study of her left leg and the results came back negative. She stated the area on her leg started swelling up more and getting darker red and her Doctor diagnosed her with cellulitis and ordered antibiotics. She stated yesterday 08/08/24 her leg was still looking red and her Doctor ordered an X-ray and the result came back yesterday morning for two fractures of her left tibia and fibula. She stated she was just finding out today 08/09/24 around 4:30 pm Resident #1 fell Friday night on 08/02/24. She stated there were no notes in her medical records and no incident reports. She stated they were currently doing in-service trainings with all staff and doing skin and pain assessments of all the residents. She stated the staff trainings were on notifications to the resident's Doctor and did 1:1 trainings with LVN B and now they were training all staff. She stated it was too early in her investigation and was not sure if Resident #1 was a 1 or 2 person assist for ADL's but said she would follow-up with the surveyor. She stated CNA A said she was doing Resident #1's incontinent care and when she turned to get some linen, Resident #1 rolled out of her bed. She stated CNA A told her that LVN B was alerted and Resident #1 was assessed but there was not any documentation of a nurses note and no notifications to her Doctor. She stated LVN B confirmed everything that happened she went into the room the resident was on the floor, and CNA A explained she had guided the resident to the floor. She stated LVN B said she did a head-to-toe assessment and when asked why she did not document the assessment LVN B said it got so busy and she forgot. The DON stated today 08/09/24 she informed Resident #1's Doctor about Resident #1's fall with injury and he was upset because no one had called him 08/02/24. She stated the Doctor was at the facility visiting patients Monday 08/05/24 and no one told him about this until today. She stated ADON C assessed Resident #1 then she was transferred to the hospital. She stated she spoke to LVN B on 08/09/24 around 4:00 pm she confirmed Resident #1 had fallen on 08/02/24. She stated LVN #1 was suspended. She stated LVN B came to the facility to drop off her statement and said she had not worked in the past two days. She stated Resident #1 was not able to express her needs but was good at communicating by nodding and shaking her head. She stated Resident #1 required the use a wheelchair and was not sure if she could move her legs but was in the process of finding out more. She stated unreported and undocumented falls could have adverse effects because neuro checks needed to be done to monitor if they had a change of mental status, got injured or needed more pain medications. She stated Resident #1 had routine pain medication and since 08/02/24 and she had not had any increased pain. She stated after Resident #1 fell her Doctor should have been called and the fact that CNA A said the resident fell off the bed, LVN B should have called her Doctor for further instructions. She stated the last she heard the hospital were not going to do surgery to repair her left tibia and fibula because of her MS diagnosis. Interview on 08/09/24 at 8:21 p.m., the Administrator stated he found out Resident #1 fell 08/02/24 and they were currently doing their investigation. He stated today 08/09/24 CNA A said Resident #1 fell last Friday 08/02/24 and that she and LVN B got her back into bed and they suspended her. He stated they called LVN B to tell them her story and she was interviewed then they decided to suspend LVN B pending investigation for not following their events protocol procedure. He stated yesterday 08/08/24 Resident #1 was transferred to the hospital after her x-ray result showed she had fibula and tibia fractures of her left leg. He stated ever since then they were doing employee trainings on reporting events. He stated the DON and ADON were responsible for ensuring the nursing staff were following their protocols. He stated they reviewed all of Resident #1's documentation today and there was not any documentation about her falling. He stated unreported and undocumented falls could cause all kinds of things to happen such as pain, worsening condition, tons of things, no follow up on the resident's status. He stated they spoke to the Medical Director about Resident #1's fall with injury and they planned to continue to do trainings and get statements from the staff. He stated they were reviewing her documents and other residents to protect all the residents and to see if they could do something another way to communicate better. Interview on 08/10/24 at 11:00 a.m., with the Hospital RN stated Resident #1 admitted to the hospital because of a fractured tibia and fibula. She stated she was stable right now and was currently awake but nonverbal and just nodded in agreement to everything and was not good at following commands. She stated Resident #1 did not appear to be in any pain and no surgery was planned yet and they were doing conservative treatments on her. She stated there were no discharge plans at this time and her pain levels were fine but grimaced when providing care then but when still she had no signs or symptoms of pain. She stated she had not been given any pain medications since she admitted on [DATE] but had Doctor orders for Norco for moderate pain. She stated she Resident #1 has Doctor orders for Ativan for anxiety, morphine for severe pain and Tylenol for mild pain/headache. She stated Resident #1 had an immobilizer on her left leg and stated both her arms were contracted (right arm moved a little more and her left arm was more contracted). She stated her left leg was completed contracted and stated she was a 2 person assist because it was hard to turn her because she was very stiff. She stated Resident #1 was given 4 mg. of morphine on 8/8/24 at 10:15 pm in the ER via her G-tube. Interview on 08/11/24 at 1:45 p.m., the DON stated they updated the staff trainings that were conducted by herself and Nursing Supervisors RN G and LVN H. She stated they were reviewing the other resident's records to see if any other residents were affected no other residents were affected. She stated they started notification of changes trainings on 08/09/24. She stated she they started doing Resident's skin and pain assessments on Friday morning of 08/09/24. She stated LVN B said CNA A told her while giving Resident #1 incontinent care CNA A guide rolled the resident to the floor. Interview on 08/11/24 at 2:28 pm, ADON C stated last Tuesday 08/06/24 LVN D reported Resident #1 had redness of her left leg and her Doctor was called and he ordered for her to get a doppler study that came back negative. She stated on Thursday 08/08/24 LVN O reported something was going on with Resident #1's left leg was swollen and the color was reddish and greenish. She stated she assessed Resident #1's left leg and tried to move her leg but when she moved her leg back the resident flinched her leg back. She stated she asked her was she in pain and she moved head but it was not a distinct nod or shake. She stated she asked Resident #1 was her leg in pain and she gestured yes. She stated she was not crying or appeared to be in pain and noticed the upper part of chin had discoloration and swelling from under her kneecap to her lower leg. She stated she notified Resident #1's Doctor herself and he ordered doxycycline, x-ray and lab work and she contacted her FM. She stated when her x-ray results came back showing she had a fractured tibia and fractured fibula shaft, they sent her to the hospital. She stated Resident #1 was a Hoyer lift transfer resident and she was a 1-person physical assist for incontinent care/bed mobility. She stated Resident #1's legs were contracted and a draw pad was needed to reposition her and reason why she always asked for assistance when providing her care. She stated she was a G-tube resident also and normally another staff was needed for ensure the tubing to stayed intact. She stated Resident #1 fell on [DATE] and she did not find out about it until Friday 08/09/24. Interview on 08/11/24 at 4:13 pm, LVN D stated she worked on 08/06/24 around 10:00 am and Resident #1 was not able to speak but could follow verbal commands. She stated on 08/06/24 she was giving her medications through her g-tube and Resident #1 was different and her mood was flat and she asked Resident #1 was she good and she did not nod her head yes like she usually did and she was not her normal self. She stated when she flipped her blanket back, she noticed her knee looked different, both of her legs were contracted, but the lower part of her left knee was swollen and purplish and when she moved her left leg, she pulled it back and guarded with it. She stated Resident #1 was not her regular self she saw the left knee was a little swollen with a little purplish bruise, from her knee to her ankle. She stated she took a picture and sent it to her Doctor because she took Eliquis and was not sure if she had a blood clot of not. She stated her Doctor ordered a doppler study then when she returned to work on 08/09/24 she found Resident #1 was transferred to the hospital because her leg was getting bigger. She stated 911 was called and they took her to the hospital. She stated Resident #1 was supposed to be on her bed for all care needs. She stated if a resident was on the floor mat due to having a guided fall was the same as a fall and the Doctor needed to be called immediately. She stated the Doctor needed to be called for special instructions on what to do, and the nurses were supposed to assess the resident and know the residents blood pressure and vitals and do neuro checks for 72 hours and complete an incident report. She stated Resident #1 was a 2 person assist Hoyer lift resident and 1 person assist for bed mobility and ADL care. She stated Resident #1 used a Geri chair because she could not use a regular chair because she had a stroke affecting her left side and was not able to sit up in a wheelchair. She stated Resident #1 was good following commands but could not speak but she could look at their face and body language for signs of pain. She stated monitoring checks and notifying the next nurse to follow up on the resident monitoring was also needed. She stated if a resident had a fall and it was not reported or documented the resident could get injured more or lose their life. Interview on 08/12/24 at 12:53 pm, MDS Coordinator E, stated Resident #1's ADL status ranged and it depended on if she had any Muscle spasms related to her Multiple Sclerosis disease process. She stated Resident #1's status varied because on some days she was a little more rigid than other days. She stated it was reported on 08/02/24 Resident #1 had a change in position and was assisted to the floor, which was still considered a fall. She stated, 'Oh definitely' LVN B should have called Resident #1's Doctor on 08/02/24, because the Doctor may have wanted to order x-rays and do a follow up visit. She stated the nurses needed to ensure the residents did not have any post injuries at that moment and further down the road. Interview on 08/12/24 at 2:33 pm, Medical Director/Resident #1's Doctor stated he had not received a call from anyone on 08/02/24 or from LVN A about Resident #1 falling. He stated LVN B should have called him for Resident #1's change in condition and completed an incident/accident report. He stated the first question on the incident/accident report asked had the Doctor been notified. He stated the facility wanted the Doctor called for any falls with or without injury, because there could be some reason why the resident fell. He stated if they had a seizure or became dizzy that might qualify for more investigation. He stated the DON notified him on 08/09/24 of Resident #1's fall on 08/02/24 that LVN B found her on the floor and put her back to bed and did not report it to anyone. He stated Resident #1 was bed bound and needed total assist and he wondered how this could have happened. He stated if CNA A and LVN B would have reported Resident #1's fall, she could have been assessed sooner and a follow up visit done with a full investigation of what caused it. He stated Resident #1 could not roll or turnover and had no muscular tone and not able to speak. He stated he wondered how Resident #1 could have fallen out of bed if she was total assist. He stated a guided fall was the same as a fall. He stated after finding out about Resident #1's fall they have had an Ad hoc QAPI Meeting on 08/12/24, to discuss their plan to prevent this from happening again. He stated they started re-educating the staff with various in-service trainings and continue to review their plan and make changes as needed and continue to discuss in their QA meetings. Review of the Facility's Provider Investigation Report dated 08/08/24 revealed on 08/02/24 at 8:00 pm. Alleged Perpetrators: CNA A and LVN B denied the allegation and no witnesses: Assessment: On 08/08/24 at2:11 p.m.by ADON C, indicated Resident #1 was assessed for an injury of unknown origin: Resident lying in bed with head above bed elevated, alert, and able to respond to questions by nodding. Left lower leg swollen warm and painful to touch, venous doppler negative, x-rays confirmed proximal tibial and fibula fracture of left leg. No treatment, resident transferred to the hospital. Provider response: RP, DON Physician notified, X-rays confirmed fracture resident transported to Hospital, satisfaction survey completed, Skin assessment completed on other residents, In services on transfers, bed mobility and Hoyer lifts. In- services on abuse and neglect. Interviews with staff. CNA A and LVN B suspended pending Investigations. Investigation Summary: On 8/2/24 in the PM. C.N.A. was providing incontinent care for Resident #1, Resident #1 rolled to the mat on the floor. C.N.A. notified LVN B. Nurse and C.N.A. assisted resident back to bed. No Documentation or Notification was given on 8/6/24 Nurse noted left leg swelling, Physician ordered a venous doppler. Doppler study had negative result. On 8/8/24 DR notified of doppler result and ordered x ray. X-rays confirmed proximal tibia and fibula shaft fracture. Administrator notified HHSC of injury of unknown origin Resident was transported to Hospital. In-services were started on Abuse, Neglect and Reporting, Transfer, Bed Mobility and Hoyer lifts. Event policy and notification. During interviews it was determined by CNA A, Resident #1 was picked up off the floor on 8/2/24. She stated that Nurse assisted her putting Resident #1 back to bed. LVN B confirmed that she assisted Resident #1 back to bed. LVN B and CNA A were suspended pending investigation. HHSC Investigator entered the building on 8/9/24 at 3:15 pm, HHSC reentered on 8/11/24 lJ was put in place at 5:30 pm. HHSC lowered the IJ 8/12/24 at 7:30 pm. Staff members LVN B and CNA A were terminated. Where others notified: Physician, RP, Ombudsman, Police, HHSC Facility investigation findings: Confirmed Provider action taken post investigation: HHSC onsite 8/09/24, 8/11/24, 8/12/24, Resident returned to facility 8/12/24, In-services on abuse neglect, reporting, Bed mobility and transfer, Events documentation and reporting to appropriate people with evidence based follow up. LVN B and CNA A were suspended and terminated. Record review of : Employee Statements dated 8/8/24, 8/9/24, Safe Survey Resident Interviews dated 8/9/24, Inservice trainings: Abuse and neglect definitions in-service dated 8/8/24, Check offs: Moving/positioning, assisting with dated 8/11/24, 8/12/24, Post Fall Physical Assessment Test dated 8/11/24, 8/12/24, Transfer training and bed mobility dated 8/9/24, Notification of change training dated 8/9/24, Employee Abuse investigation questionnaire dated 8/9/24, LVN B Employee Corrective Action Form suspended dated 8/9/24 and CNA A Employee Corrective Action Form suspended dated 8/9/24. [END] Record review of LVN B's Timesheet printed on 08/09/24 revealed she worked on: 08/02/24 5:45 pm - 7:40 am, 08/06/24 5:30 pm - 7:46 am, 08/07/24 5:26 pm - 7:51 am. Record review of an Article Tibia & Fibula Fracture (Broken Shinbone/Calf Bone) (clevelandclinic.org) last reviewed 06/01/23 revealed, Overview: What are tibia and fibula fractures? Tibia and fibula fractures are two broken bones in your lower leg. Your tibia is your shin bone. Your fibula is your calf bone. Because they're usually caused by major trauma like car accidents or falls, people often break both their tibia and fibula during the same injury. It's rare, but you can fracture one of your tibia or fibula without breaking the other. You might need surgery to repair your bones and physical therapy to regain your ability to move your leg. Record review of the facility's Change in condition policy revised 04/20/23 revealed, Policy statement: Our facility promptly notifies the resident, his or her attending physician, healthcare provider and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care .resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician, healthcare provider or physician on call when there has been a (an): a. accident or incident involving the resident . An Immediate Jeopardy (IJ) was identified on 08/12/24 at 12:10 pm. The Administrator was notified and the IJ Template was provided to the Administrator on 08/12/24 at 12:10 pm. The following Plan of Removal was accepted on 08/12/24 at 4:45 p.m., revealed the following: Plan of [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the resident had the right to be free from neglect as defined in this subpart for one (Resident #1) of six residents reviewed for Neglect. CNA A failed to ensure Resident #1 did not fall out of bed on 08/02/24 while she was providing incontinent care and LVN B failed to document assessing Resident #1's fall, LVN B failed to notify Resident #1's Doctor, LVN B failed to complete an incident report, and LVN B failed to notify the oncoming Nurse, DON, and Administrator about Resident #1's fall. Subsequently, Resident #1 was sent to the hospital 08/08/24 and was diagnosed with two fractures Tibia (Shinbone) and Fibula (Calf bone) of her left lower leg. An Immediate Jeopardy (IJ) was identified on 08/11/24. An IJ Template was provided to the facility on [DATE] at 3:38 pm. While the Immediate Jeopardy was removed on 08/12/24 at 7:50 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place all residents at risk of having increased distress and pain resulting in a decline in their psycho-social well-being and health resulting in internal bleeding, more injuries from being moved or death. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted [DATE] with a BIMS Staff Assessment score of 2 (Moderate impaired cognition), no speech, with a memory problem and severely impaired. She had upper extremity impairment on one side and lower extremity impairment of both sides. Her functioning abilities and goals: Self-care: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for all ADLs including (toileting, personal hygiene). Her functioning abilities and goals: Mobility: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for roll left and right and for chair/bed to chair transfer. She was always incontinent to bladder and bowel, has a progressive neurological conditions with diagnoses of hypertension. She had Multiple Sclerosis (nerve degeneration), Gastronomy status (feeding tube), Cardiac arrhythmia (arrhythmia (irregular heartbeat), dysphagia (not able to swallow properly), muscle weakness, atrial fibrillation (irregular heartbeat), and lack of coordination. She was 5'6 and 132 pounds. Record review of Resident #1's August 2024 Order Summary Report revealed orders for: Eliquis (blood thinner) 5 mg, folic acid 1 mg. senna 8.6 mg. tramadol 50 mg. Enteral Feeding tube, Enteral stoma site care, NPO, Enteral formula pump administration. Record review of Resident #1's Care Plan printed 8/10/24 revealed, Multiple sclerosis: assist with ADL and comfort measures as needed, Abdominal binder: to keep G-tube in place keep head and bed elevated. Geri-chair: make as comfortable as possible, falls (Resident has a history of falling related to mobility due to Multiple Sclerosis): place resident in a fall prevention program. Multiple sclerosis at risk for a decline in current ADLs and injuries due to increased injuries and assist with ADL's and comfort measures as needed. Cognitive loss/dementia: allow time for task and responses. Communication has aphasia approach in calm manner. Falls - keep call light within reach, ADL Functional status: ambulation/transfers amount of assist: total x 2 non-ambulatory, bathing/hygiene assist: total x1, resident care as per policy, toileting amount of assist total x1. Record review of Resident #1's Progress notes reviewed from 08/02/24 to 08/09/24 did not reveal she had any falls or incidents. Record review on Resident #1's Plan of care (POC) report dated 08/02/2024 at 7:06 pm revealed, CNA A provided Incontinent care. Record review of Resident #1 X-Ray results dated 08/08/24 at 8:03 pm revealed, Clinical information: Bruising, swelling, Test procedures: Left tibia and fibula, two views. Findings: Proximal tibial and fibular shafts fracture. No osteolytic or osteosclerotic lesions. No signs of bone infection. Impression:1. Proximal tibial and fibular shafts fracture. 2. CT is recommended. Record review of Resident #1's Hospital Emergency Department Doctor's note dated 08/08/24 revealed, Chief complaint: Leg deformity: patient here from [Nursing Facility]. Left leg swelling noted and ecchymosis found this morning. On Eliquis .Patient is bed bound and nonverbal. Radiology: Tibia/fibula, left 2 views final result: Impression: Proximal left tibial and fibular fractures, negative left ankle and knee joint. Soft tissue swelling. Osteopenia. Record review of Resident #1's Incident/Accident Report completed date 08/09/24 at 6:08 pm by LVN B revealed, Event date 08/02/24 at 5:57 pm, in resident room, yes fall was witnessed, no injury and no pain, ROM without pain/limitations, no rotation/deformity/shortening noted .notifications: Attending physician faxed: no, Physician notified: no, Resident Representative notified: no, care plan reviewed: no. Record review of Resident #1's Progress note 08/02/2024 [Recorded as Late Entry on 08/09/2024 06:19 PM] by LVN B revealed, Events - fall: 11:06PM On 2nd of August, CNA call attention to this nurse to room XXXX and reported to this nurse that she rolled resident down to the floor mat while giving care. Observed and assess resident on the floor mat., no apparent injury noted at that time. No S/S of pain noted at that time. Resident was helped back to bed with the help of the CNA. Record review of Resident #1's Hospital Orthopedic Doctor note dated 08/09/24 revealed, Orthopedic diagnosis: Left Proximal tibia fracture. Orthopedic plan: Closed management of left proximal tibial fracture, knee immobilization, non-weight bearing. History of present illness: A [AGE] year-old female with multiple advance medical issues including MS, who is nonverbal at baseline .The patient is nonverbal, non-ambulatory. I do not think she would be a very good candidate for surgical intervention. I will plan for a knee immobilization and follow-up in the outpatient setting. Observation on 08/09/24 at 3:40 pm, Resident #1's room revealed a thin blue floormat that was approximately two inches in height and six feet in length on the left side of Resident #1's bed. Observation on 08/10/24 at 3:37 pm, Resident #1 was at the hospital lying flat on her back, in bed watching Television, she nodded yes to her name. She shook her head no she was not hurting. When asked had she fallen out of bed, she looked at her left leg and did not shake or nod her head. There was a G-tube next to her bed she and she did not appear to be in pain. Her left leg was bent at a 45-degree angle with a knee immobilizer on it. Interview on 08/09/24 at 6:43 pm, CNA A stated on 08/02/24 after dinner she checked Resident #1 and incontinent care was needed. She stated she was standing right in front of the window with the bed elevated and while caring for Resident #1, she turned her towards the door then towards her. She stated she put the bed linen on the floor then rolled her to the right to clean her and afterwards she tried to grab her bed sheets at the foot of her bed. She stated then Resident #1 started shaking and rolled off the bed so she went to get LVN B who came to assess the resident and made sure she was okay. She stated she and LVN B got Resident #1 back to bed and got her dressed then LVN B asked her what happened and she told her she was doing incontinent care and the resident rolled to the floor. She stated Resident #1 was nonverbal but did not appear to be in any pain and her leg was not swollen or in a weird position. She stated she was not sure if the nurse called to have any x-rays done and did not see anyone come out to do x-rays during her shift. She stated there was most likely no x-rays done because the resident was not crying because she checked on her frequently and changed her about four more times that night. She stated typically they reported falls to the DON and from there the DON notified the Administrator. She stated she did not report this fall to the DON and Administrator because it was the weekend and the DON was not at the facility. She stated today 08/09/24 she came back to work and reviewed her assignment and did her walk through to get her eyes on the residents and noticed Resident #1 was not at the facility. She stated she asked Staffing Coordinator F what happened to Resident #1 and was told she went to the hospital with an injury unknown origin of her leg. She stated Staffing Coordinator F told her there was an investigation about Resident #1's injury and that she needed to talk to the Administrator. She stated on 08/09/24, she wrote up her statement and spoke to the DON about what happened on 08/02/24. She stated on 08/09/24 around 6:00 pm she was suspended and was told they would let her know more information later after they completed their investigation and would get back with her soon. She stated she did not ever want to step on anyone's toes when she told LVN B about what happened to Resident #1 and did not think to report it to the DON also. She stated in her eyes Resident #1 had a rollover onto the floor. She stated she received training today 08/09/24 on abuse and neglect and for if the resident's fall was guided, she was supposed to report it to their Administrator. She stated Resident #1 she believed was a 1 person assist for ADL care and for transfers was Hoyer 2 person assist. She stated she knew the resident's level of care by asking the nurse what the resident's transfer status and care needs were. She stated not being really sure on how to use the POC in the EMR system because when she clicked on that tab and it did not have the resident's mobility statuses in them. She stated the POC only had the resident's demographic info. She stated she should have reported this fall to the Administrator because there was a change in Resident #1's health. She stated if she would have reported it to the Administrator and DON, this whole situation would not have happened. She stated on Friday 08/02/24 she worked from 2:00 pm to 6:00 am then worked Sunday 08/04/24 from 2:00 pm - 6:00 am. She stated she also worked today 08/09/24 from 2:00 pm to 6:00 pm. She stated falls, including guided falls could cause death, injured bones, and internal bleeding. Interview on 08/10/24 at 9:09 am, LVN B stated she worked the overnight shift and last took care of Resident #1 Last Friday 08/02/24, Tuesday 08/06/24 and Wednesday 08/07/24. She stated yesterday 08/09/24 she heard Resident #1 had a leg fracture. She stated she was very surprised Resident #1 was injured. She stated the DON spoke to her about what she knew about Resident #1's fall on 08/02/24 then the DON told her she should have completed an incident report and called her Doctor. She stated she did a late add nurses note and incident/accident report on 08/09/24 per the DON's request. She stated last Friday 08/02/24 after meal service, after 11:00 pm she was at the nurses' station and CNA A stood at Resident #1's room door calling her name out loud about needing help putting Resident #1 back to bed. She stated she saw Resident #1 in her room and her bed was in the lowest position and Resident #1 was on the left side of her bed on the floor. She stated Resident #1 was on her back and her left leg was turned to the left, and her head and buttocks was flat on the floormat, she was on her back. She stated her left leg was paralyzed and for her care they normally used a pillow to prop it in place. She stated when Resident #1 was on the floor her Gtube port was okay and the tubing was still connected to the gtube pump. She stated there was no pillow under Resident #1's leg and the bed linen and pillow was on her bed. She stated she assessed Resident #1 and did not find anything wrong with her and she had no signs or symptoms of pain, then she and CNA A put her back to bed. She stated asking CNA A why Resident #1 on the floor and CNA A was said she rolled her onto the floor to give her incontinent care. She stated CNA A did not say Resident #1 fell but said she guided her to the floormat. She stated if CNA A told her Resident #1 had fallen, she would have reported it to her Doctor, the Administrator and DON. She stated she would have also documented it in Resident #1's nurses notes and completed an incident report and called her family. She stated she would have followed up with her to ensure she was fine and added Resident #1 was on scheduled Tramadol she received at 12:00 am and PRN Tylenol. She stated there was no increase in giving her more pain medications. She stated Resident #1's floor mat next was next to her bed 24/7 and Resident #1 normally did not get care on the floor mat that was why she questioned CNA A about it. She stated there was not anything propping her left leg, she checked on Resident #1 four or five times that night. She stated Resident #1 watched television and slept and she was given her Tramadol at midnight and she was asleep rest of the night. She stated she did not tell the oncoming nurse or the DON about her being on the floor because she got busy and did not suspect anything was wrong. She stated she got busy with taking care of other residents forgot to document at nurses note. She stated there was no swelling or redness of her legs during her 08/02/24 shift. She stated she returned to work Tuesday 08/06/24 the nurse reported Resident #1 had left leg swelling and her Doctor ordered for a doppler study for edema. She stated the doppler study result came back Wednesday 08/07/24 was negative and she faxed that result to her Doctor. She stated there were no new orders and she took a picture of Resident #1's left leg and sent it to her Doctor. She stated she got a call from the DON yesterday 08/09/24 around 4:00 pm and she returned the call around 4:49 pm and the DON told her to come to the facility. She stated a little after 5:00 pm she gave the DON her statement and completed Resident #1's incident report and completed in-service trainings on neglect/abuse, who was the abuse coordinator and the DON told her she should have reported this to her and called her Doctor and family. She stated she had the mind to call the DON but forgot and stated if a resident fell and the Doctor, DON or family was not notified could result in delayed injury. She stated that was why she always documented but she forgot to document Resident #1's fall and said after the DON spoke to her, she now knew why she should have completed a nurses note and reported it to her Doctor, DON, and family. She stated in general the residents were on the floor mat for care if they were uncooperative, but Resident #1 was never uncooperative and never on the floor for incontinent care. She stated she thought it was odd Resident #1 was on the floormat. She stated Resident #1 was a 1 person assist for incontinent care because she was not that heavy. heavy, but needed 2 person Hoyer assist for some care needs. She stated Resident #1 was bed bound with left sided weakness upper and lower and alert and oriented x1. She stated Resident #1 was not able to express her needs because she was aphasic and knew her name. She stated Resident #1 was able to gesture responses by nodding and shaking her head. She stated there was 1 nurse and 1 aide for on the norm for 21 residents. She stated she did not know Resident #1 was a 2 person assist for bed mobility but if a resident was skinny 1 person could do incontinent care on her. She stated only 1 CNA worked that side of the hall where Resident #1 was and CNA A never asked her for assistant with doing Resident #1's incontinent care. She stated she did not know Resident #1's MDS Assessment changed her bed mobility to 2-person assistance. She stated at night they had been 1 person assist with her incontinent care. She stated the nurses were responsible for ensuring the residents were getting proper care and cleaned and dry and checked every 2 hours. She stated she did not look at the Resident's Plan of Care to determine if they were 1 or 2 person assist by knowing the residents and going by the 24-hour report. She stated the DON suspended her and CNA A pending the investigation of Resident #1. She stated not reporting something bad could cause the resident to get bruised, skin tear or injured. Interview on 08/09/24 at 4:45 pm, the Police Detective stated he visited Resident #1 at the hospital and gathered other information and opened a case to further investigate the circumstances involving Resident #1's leg injury. He stated he had spoken to CNA A who said on 08/02/24 she was cleaning Resident #1 and she turned around then the resident kept rolling and fell out of the bed. He stated CNA A said she asked LVN B to help get Resident #1 off of the floor then LVN B picked up Resident #1 and put her back onto her bed. The Police Detective stated as of right now there was no documentation of the resident falling and no one knew what happened to her leg and the resident was not able to say what happened. He stated the Administrator and DON said they just discovered it from CNA A's statement. He stated Resident #1 sustained two fractures of her left tibia and left fibula that was approximately one inch below her knee. He stated Resident #1's roommate said she remembered a nurse and CNA coming in really fast one night but was not able to see or know what happened. He stated he was getting ready to interview LVN B to gather more information. Interview on 08/09/24 at 7:26 pm, the DON stated she received a report on 08/06/24 about Resident #1's left leg appearing shiny and red like she had irritated rash. She stated her Doctor ordered a doppler study of her left leg and the results came back negative. She stated the area on her leg started swelling up more and getting darker red and her Doctor diagnosed her with cellulitis and ordered antibiotics. She stated yesterday 08/08/24 her leg was still looking red and her Doctor ordered an X-ray and the result came back yesterday morning for two fractures of her left tibia and fibula. She stated they reported on 08/08/24 to HHSC of an injury of unknown origin because of the darkness of her leg that looked to be spreading to other areas of her leg. She stated she was just finding out today 08/09/24 around 4:30 pm Resident #1 fell Friday the night of 08/02/24. She stated there were no notes in her medical records and no incident reports. She stated Resident #1's fall should have been reported to her and the Administrator so they could have started investigating and reported this incident to HHSC. She stated had they had known sooner they would have reported this incident immediately. She stated they were currently doing in-service trainings with all staff, doing skin and pain assessment of all the residents. She stated they were doing a lot of trainings on abuse/neglect, notifications to the DON and Administrator. She stated the therapy staff were assisting with the trainings. She stated they were currently interviewing staff. She stated CNA A said she was doing Resident #1's incontinent care and when she turned to get some linen, Resident #1 rolled out of her bed. She stated CNA A told her that LVN B was alerted and Resident #1 was assessed but there was not any documentation of a nurses note, no notifications to her family, herself, or Administrator. She stated LVN B confirmed everything that happened she went into the room and the resident was on the floor, and CNA A explained she had guided the resident to the floor. She stated LVN B said she did a head-to-toe assessment and when asked why she did not document the assessment, LVN B said it got so busy and she forgot. The DON stated she informed Resident #1's Doctor today 08/09/24 about Resident #1's fall with injury and he was upset because no one had called him on 08/02/24. She stated the Doctor was at the facility visiting patients Monday 08/05/24 and no one told him about this. She stated ADON C assessed Resident #1 then she was transferred to the hospital. She stated she spoke to LVN B on 08/09/24 around 4:00 pm and she confirmed Resident #1 had fallen on 08/02/24. She stated LVN #1 was suspended. She stated she interviewed CNA A around 3:30 pm or 4:00 pm and CNA A was removed off the floor and interviewed with the Corporate Nurse Representative. She stated CNA A was sent to the conference room and until they received her statement. She stated she told CNA A she was suspended until they completed their investigation and sent her home. She stated LVN B came to the facility to drop off her statement and said she had not worked in the past two days. She stated the staff knew how to go into the EMR POC to review the resident's level of care and was not aware of any issues with that. She stated they were still investigating this incident and felt like the incident was not intentional and people just needed to think when they did resident care and thought about the processes beforehand. She stated from what she was told Resident #1's bed was at the level of CNA A's hips. She stated Resident #1 did have tremors and twitched a lot and said she was not sure if she was 1 or 2 person assist or Hoyer lift yet. She stated Resident #1 was not able to express her needs but was good at communicating by nodding and shaking her head. She stated Resident #1 required the use of a wheelchair and was not sure if she could move her legs but was in the process of finding out more. She stated unreported and undocumented falls could have adverse effects because neuro were checks needing to be done to monitor if they had a change of mental status, got injured and needed more pain medication and was a form of neglect. She stated Resident #1 had routine pain medication and since 08/02/24 she had not had any increased pain. She stated after Resident #1 fell her Doctor should have been called and the fact that CNA A said the resident fell off the bed, LVN B should have called her Doctor for further instructions. She stated the last she heard they were not going to do surgery to repair Resident #1's left tibia and fibula because of her MS diagnosis. Interview on 08/09/24 at 8:21 pm, the Administrator stated he found out Resident #1 fell on [DATE] and they were currently doing their investigation. He stated today 08/09/24 CNA A said Resident #1 fell last Friday 08/02/24 and that she and LVN B got her back into bed and they suspended her. He stated they called LVN B to tell them her story and she was interviewed then they decided to suspend LVN B pending investigation for not following their events protocol procedure. He stated they needed to ensure there was not anything missed and added up to the point they knew Resident #1 could not move and something was going on with her leg he reported this incident to HHSC. He stated yesterday 08/08/24 Resident #1 was transferred to the hospital after her x-ray result showed she had fibula and tibia fractures of her left leg. He stated ever since then they were doing employee trainings on abuse/neglect, resident transfer techniques, reporting events and change in condition. He stated the DON and ADON was responsible for ensuring the nursing staff were following their protocols. He stated they reviewed all of Resident #1's documentation today and there was not any documentation about her falling. He stated unreported and undocumented falls could cause all kinds of things could happen such as pain, worsening condition, tons of things, no follow up on the resident's status. He stated they spoke to the Medical Director about Resident #1's fall with injury and they planned to continue to do trainings and get statements from the staff. He stated they were reviewing her documents and other residents' documents to protect all the residents and to see if they could do something another way to communicate better. He stated Resident #1 was a 1 person ADL assist resident because she was able to assist with turning and a petite lady and it was easy to turn her one way from to the other. Interview on 08/10/24 at 11:00 a.m. with the Hospital RN stated Resident #1 admitted to the hospital because of a fractured tibia and fibula. She stated she was stable right now and was currently awake but nonverbal and just nodded in agreement to everything and was not good at following commands. She stated Resident #1 did not appear to be in any pain and no surgery was planned yet and they were doing conservative treatments on her. She stated there were no discharge plans at this time and her pain levels were fine but grimaced when providing care then but when still no signs or symptoms of pain. She stated she had not been given any pain medications since she admitted on [DATE] but had Doctor orders for Norco for moderate pain. She stated she Resident #1 has Doctor orders for Ativan for anxiety, morphine for severe pain and Tylenol for mild pain/headache. She stated Resident #1 had an immobilizer on her left leg and stated both her arms were contracted (right arm moved a little more and her left arm was more contracted). She stated her left leg was completed contracted and stated she was a 2 person assist because it was hard to turn her because she was very stiff. She stated Resident #1 was given 4 mg. of morphine on 8/8/24 at 10:15 pm in the ER via her G-tube. Interview on 08/11/24 at 2:28 pm, ADON C stated last Tuesday 08/06/24 LVN D reported Resident #1 had redness of her left leg and her Doctor was called and he ordered for her to get a doppler study that came back negative. She stated on Thursday 08/08/24 LVN O reported something was going on with Resident #1's left leg was swollen and the color was reddish and greenish. She stated she assessed Resident #1's left leg and tried to move her leg but when she moved her leg back the resident flinched her leg back. She stated she asked her was she in pain and she moved head but it was not a distinct nod or shake. She stated she asked Resident #1 was her leg in pain and she gestured yes. She stated she was not crying or appeared to be in pain and noticed the upper part of chin had discoloration and swelling from under her kneecap to her lower leg. She stated she notified Resident #1's Doctor herself and he ordered doxycycline, x-ray and lab work and she contacted her FM. She stated when her x-ray results came back showing she had a fractured tibia and fractured fibula shaft, they sent her to the hospital. She stated Resident #1 was a Hoyer lift transfer resident and she was a 1-person physical assist for incontinent care/bed mobility. She stated Resident #1's legs were contracted and a draw pad was needed to reposition her and reason why she always asked for assistance when providing her care. She stated she was a G-tube resident also and normally another staff was needed for ensure the tubing to stayed intact. She stated Resident #1 fell on [DATE] and she did not find out about it until Friday 08/09/24. She stated Oh yes if a resident had a guided fall or an assisted fall is a fall and a change in the resident's level of positioning. She stated Resident #1 had never been uncooperative with ADL care, but her legs were contracted and left hand was contracted. She stated she had never seen Resident #1 getting incontinent care on the floor mat and there were no reports of such. Interview on 08/11/24 at 4:13 pm, LVN D stated she worked on 08/06/24 around 10:00 am and Resident #1 was not able to speak but could follow verbal commands. She stated on 08/06/24 she was giving her medications through her g-tube and Resident #1 was different and her mood was flat and she asked Resident #1 was she good and she did not nod her head yes like she usually did and she was not her normal self. She stated when she flipped her blanket back, she noticed her knee looked different, both of her legs were contracted, but the lower part of her left knee was swollen and purplish and when she moved her left leg, she pulled it back and guarded with it. She stated Resident #1 was not her regular self she saw the left knee was a little swollen with a little purplish bruise, from her knee to her ankle. She stated she took a picture and sent it to her Doctor because she took Eliquis and was not sure if she had a blood clot of not. She stated her Doctor ordered a doppler study then when she returned to work on 08/09/24 she found Resident #1 was transferred to the hospital because her leg was getting bigger. She stated 911 was called and they took her to the hospital. She stated Resident #1 has never been non-compliant with care and had not ever seen her getting ADL care on her floor mat. She stated Resident #1 was supposed to be on her bed for all care needs. She stated if a resident was on the floor mat due to having a guided fall was the same as a fall and the Doctor needed to be called immediately. She stated the Doctor needed to be called for special instructions on what to do, and the nurses were supposed to assess the resident and know the residents blood pressure and vitals and do neuro checks for 72 hours and complete an incident report. She stated Resident #1 was a 2 person assist Hoyer lift resident and 1 person assist for bed mobility and ADL care. She stated Resident #1 used a Geri chair because she could not use a regular chair because she had a stroke affecting her left side and was not able to sit up in a wheelchair. She stated Resident # was good following commands but could not speak but she could look at their face and body language for signs of pain. She stated monitoring checks and notifying the next nurse to follow up on the resident monitoring was also needed. She stated if a resident had a fall and it was not reported or documented the resident could get injured more or lose their life. Interview on 08/12/24 at 12:53 pm, MDS Coordinator E, stated Resident #1's ADL status ranged and it depended on if she had any Muscle spasms related to her Multiple Sclerosis disease process. She stated Resident #1's status varied because on some days she was a little more rigid than other days. She stated Resident #1 was a 1 to 2 person assist for bed mobility and hygiene on the MDS Assessment and stated she believed her care plan had her as a 2 person assist for bed mobility. She stated she would have to review that and get back with the surveyor. She stated Resident #1 was no longer on hospice as of last month and stated the resident's MDS's should match what their Care Plans were. She stated Resident #1 was an extensive assist, Hoyer lift resident. She stated Resident #1 got out of bed rarely and when she did, they transferred her to a Geri-chair. She stated their interdisciplinary team updated the residents Care plans with an RN or DON verifying the information was accurate. She stated the Care plans showed each resident's proper level of care, detailed safety issues on how to care for the residents. She stated if the resident's care plans were inaccurate it could lead up to injury due to them not receiving the proper care. She stated the nurses and cna's used care plans to know how to take care of each of the residents and whatever data was on the resident's MDS Assessments were reflected on their care plans. She stated the DON was responsible for ensuring the Care Plans were accurate. She stated both of Resident #1's legs were both contracted. She stated she admitted with the leg contractures and was able to wiggle her legs with both of her legs bending at a 45-degree angle. She stated Resident #1 received most times received bed baths. She stated it was reported on 08/02/24 Resident #1 had a change in position and was assisted to the floor, which was still considered a fall. She stated, 'Oh definitely' LVN B should have called Resident #1's Doctor on 08/02/24, because the Doctor may have wanted to order x-rays and do a follow up visit. She stated the nurses needed to ensure the residents did not h[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #1) of six residents reviewed for Neglect. CNA A and LVN B failed to prevent neglect, such as ensuring Resident #1 received the necessary care and services to prevent harm and LVN B's failure to notify the oncoming Nurse, DON and Administrator about Resident #1's fall on 08/02/24. Subsequently Resident #1 sustained fractures of her Tibia (Shinbone) and Fibula (calf bone) of her left lower leg and was taken to the hospital on [DATE]. An Immediate Jeopardy (IJ) was identified on 08/11/24. An IJ Template was provided to the facility on [DATE] at 3:38 pm. While the Immediate Jeopardy was removed on 08/12/24 at 7:50 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place all residents at risk of not being assessed and treated in a timely manner and appropriately, with Doctors interventions, which could result in a decline in their psycho-social well-being and health resulting in internal bleeding or death. Findings included: Record review of the facility's Abuse and Neglect policy dated 10/2023 revealed, Policy Statement: The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Policy Interpretation and Implementation: 1. The facility will develop and implement written policies and procedures that: a. Prohibit abuse, neglect, and exploitation of residents and misappropriation of resident property . VI. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective all other required agencies (e.g., law enforcement when applicable) within specified timeframes. CMS Definition of neglect: Neglect is the failure of a facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted [DATE] with a BIMS Staff Assessment score of 2 (Moderate impaired cognition), no speech, with a memory problem and severely impaired. She had upper extremity impairment on one side and lower extremity impairment of both sides. Her functioning abilities and goals: Self-care: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for all ADLs including (toileting, personal hygiene). Her functioning abilities and goals: Mobility: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for roll left and right and for chair/bed to chair transfer. She was always incontinent to bladder and bowel, has a progressive neurological conditions with diagnoses of hypertension. She had Multiple Sclerosis (nerve degeneration), Gastronomy status (feeding tube), Cardiac arrhythmia (arrhythmia (irregular heartbeat), dysphagia (not able to swallow properly), muscle weakness, atrial fibrillation (irregular heartbeat), and lack of coordination. She was 5'6 and 132 pounds. Record review of Resident #1's August 2024 Order Summary Report revealed orders for: Eliquis 5 mg, folic acid 1 mg. senna 8.6 mg. tramadol 50 mg. Enteral Feeding tube, Enteral stoma site care, NPO, Enteral formula pump administration. Record review of Resident #1's Care Plan printed 8/10/24 revealed, Multiple sclerosis: assist with ADL and comfort measures as needed, Abdominal binder: to keep G-tube in place keep head and bed elevated. Geri-chair: make as comfortable as possible, falls (Resident has a history of falling related to mobility due to Multiple Sclerosis): place resident in a fall prevention program. Multiple sclerosis at risk for a decline in current ADLs and injuries due to increased injuries and assist with ADL's and comfort measures as needed. Cognitive loss/dementia: allow time for task and responses. Communication has aphasia approach in calm manner. Falls - keep call light within reach, ADL Functional status: ambulation/transfers amount of assist: total x 2 non-ambulatory, bathing/hygiene assist: total x1, resident care as per policy, toileting amount of assist total x1. Record review of Resident #1's Progress notes reviewed from 08/02/24 to 08/09/24 did not reveal she had any falls or incidents. Record review of Resident #1 X-Ray results dated 08/08/24 at 8:03 pm revealed, Clinical information: Bruising, swelling, Test procedures: Left tibia and fibula, two views. Findings: Proximal tibial and fibular shafts fracture. No osteolytic or osteosclerotic lesions. No signs of bone infection. Impression:1. Proximal tibial and fibular shafts fracture. 2. CT is recommended. Record review of Resident #1's Hospital Emergency Department Doctor's note dated 08/08/24 revealed, Chief complaint: Leg deformity: patient here from [Nursing Facility]. Left leg swelling noted and ecchymosis found this morning. On Eliquis .Patient is bed bound and nonverbal. Radiology: Tibia/fibula, left 2 views final result: Impression: Proximal left tibial and fibular fractures, negative left ankle and knee joint. Soft tissue swelling. Osteopenia. Record review of Resident #1's Progress note 08/02/2024 [Recorded as Late Entry on 08/09/2024 06:19 PM] by LVN B revealed, Events - fall: 11:06PM On 2nd of August, CNA call attention to this nurse to room [ROOM NUMBER]B and reported to this nurse that she rolled resident down to the floor mat while giving care. Observed and assess resident on the floor mat., no apparent injury noted at that time. No S/S of pain noted at that time. Resident was helped back to bed with the help of the CNA. Record review of Resident #1's Incident/Accident Report completed date 08/09/24 at 6:08 pm by LVN B revealed, Event date 08/02/24 at 5:57 pm, in resident room, yes fall was witnessed, no injury and no pain, ROM without pain/limitations, no rotation/deformity/shortening noted .notifications: Attending physician faxed: no, Physician notified: no, Resident Representative notified: no, care plan reviewed: no. Record review of Resident #1's Hospital Orthopedic Doctor note dated 08/09/24 revealed, Orthopedic diagnosis: Left Proximal tibia fracture. Orthopedic plan: Closed management of left proximal tibial fracture, knee immobilization, non-weight bearing. History of present illness: A [AGE] year-old female with multiple advance medical issues including MS, who is nonverbal at baseline .The patient is nonverbal, non-ambulatory. I do not think she would be a very good candidate for surgical intervention. I will plan for a knee immobilization and follow-up in the outpatient setting. Observation on 08/09/24 at 3:40 pm, Resident #1's room revealed a thin blue floormat that was approximately two inches height and six feet in length on the left side of Resident #1's bed. Observation on 08/10/24 at 3:37 pm, Resident #1 was at the hospital lying flat on her back, in bed watching Television, she nodded yes to her name. She shook her head no she was not hurting. When asked had she fallen out of bed, she looked at her left leg and did not shake or nod her head. There was a G-tube next to her bed she and she did not appear to be in pain. Her left leg was bent at a 45-degree angle with a knee immobilizer on it. Interview on 08/09/24 at 6:43 pm, CNA A stated on 08/02/24 after dinner she checked Resident #1 and incontinent care was needed. She stated she was standing right in front of the window with the bed elevated and while caring for Resident #1, she turned her towards the door then towards her. She stated she put the bed linen on the floor then rolled her to the right to clean her and afterwards she tried to grab her bed sheets at the foot of her bed. She stated then Resident #1 started shaking and rolled off the bed so she went to get LVN B who came to assess the resident and made sure she was okay. She stated she and LVN B got Resident #1 back to bed and got her dressed then LVN B asked her what happened and she told her she was doing incontinent care and the resident rolled to the floor. She stated Resident #1 was nonverbal but did not appear to be in any pain and her leg was not swollen or in a weird position. She stated she was not sure if the nurse called to have any x-rays done and did not see anyone come out to do x-rays during her shift. She stated there was most likely no x-rays done because the resident was not crying because she checked on her frequently and changed her about four more times that night. She stated typically they reported falls to the DON and from there the DON notified the Administrator. She stated she did not report this fall to the DON and Administrator because it was the weekend and the DON was not at the facility. She stated today 08/09/24 she came back to work and reviewed her assignment and did her walk through to get her eyes on the residents and noticed Resident #1 was not at the facility. She stated she asked Staffing Coordinator F what happened to Resident #1 and was told she went to the hospital with an injury unknown origin of her leg. She stated Staffing Coordinator F told her there was an investigation about Resident #1's injury and that she needed to talk to the Administrator. She stated on 08/09/24, she wrote up her statement and spoke to the DON about what happened on 08/02/24. She stated on 08/09/24 around 6:00 pm she was suspended and was told they would let her know more information later after they completed their investigation and would get back with her soon. She stated she did not ever want to step on anyone's toes when she told LVN B about what happened to Resident #1 and did not think to report it to the DON also. She stated in her eyes Resident #1 had a rollover onto the floor. She stated she received training today 08/09/24 on abuse and neglect and for if the resident's fall was guided, she was supposed to report it to their Administrator. She stated Resident #1 she believed was a 1 person assist for ADL care and for transfers was Hoyer 2 person assist. She stated she knew the resident's level of care by asking the nurse what the resident's transfer status and care needs were. She stated not being really sure on how to use the POC in the EMR system because when she clicked on that tab it did not have the resident's mobility statuses in them. She stated the POC only had the resident's demographic info. She stated she should have reported this fall to the Administrator because there was a change in Resident #1's health. She stated if she would have reported it to the Administrator and DON, this whole situation would not have happened. She stated on Friday 08/02/24 she worked from 2:00 pm to 6:00 am then worked Sunday 08/04/24 from 2:00 pm - 6:00 am. She stated she also worked today 08/09/24 from 2:00 pm to 6:00 pm. She stated falls, including guided falls could cause death, injured bones, and internal bleeding. Interview on 08/10/24 at 9:09 am, LVN B stated she worked the overnight shift and last took care of Resident #1 Last Friday 08/02/24, Tuesday 08/06/24 and Wednesday 08/07/24. She stated yesterday 08/09/24 she heard Resident #1 had a leg fracture. She stated she was very surprised Resident #1 was injured. She stated the DON spoke to her about what she knew about Resident #1's fall on 08/02/24 then the DON told her she should have completed an incident report and called her Doctor. She stated she did a late add nurses note and incident/accident report on 08/09/24 per the DON's request. She stated last Friday 08/02/24 after meal service, after 11:00 pm she was at the nurses' station and CNA A stood at Resident #1's room door calling her name out loud about needing help putting Resident #1 back to bed. She stated she saw Resident #1 in her room and her bed was in the lowest position and Resident #1 was on the left side of her bed on the floor. She stated Resident #1 was on her back and her left leg was turned to the left, and her head and buttocks was flat on the floormat, she was on her back. She stated her left leg was paralyzed and for her care they normally used a pillow to prop it in place. She stated when Resident #1 was on the floor her Gtube port was okay and the tubing was still connected to the gtube pump. She stated there was no pillow under Resident #1's leg and the bed linen and pillow was on her bed. She stated she assessed Resident #1 and did not find anything wrong with her and she had no signs or symptoms of pain, then she and CNA A put her back to bed. She stated asking CNA A why Resident #1 on the floor and CNA A was said she rolled her onto the floor to give her incontinent care. She stated CNA A did not say Resident #1 fell but said she guided her to the floormat. She stated if CNA A told her Resident #1 had fallen, she would have reported it to her Doctor, the Administrator and DON. She stated she would have also documented it in Resident #1's nurses notes and completed an incident report and called her family. She stated she would have followed up with her to ensure she was fine and added Resident #1 was on scheduled Tramadol she received at 12:00 am and PRN Tylenol. She stated there was no increase in giving her more pain medications. She stated Resident #1's floor mat next was next to her bed 24/7 and Resident #1 normally did not get care on the floor mat that was why she questioned CNA A about it. She stated there was not anything propping her left leg, she checked on Resident #1 four or five times that night. She stated Resident #1 watched television and slept and she was given her Tramadol at midnight and she was asleep rest of the night. She stated she did not tell the oncoming nurse or the DON about her being on the floor because she got busy and did not suspect anything was wrong. She stated she got busy with taking care of other residents forgot to document at nurses note. She stated there was no swelling or redness of her legs during her 08/02/24 shift. She stated she returned to work Tuesday 08/06/24 the nurse reported Resident #1 had left leg swelling and her Doctor ordered for a doppler study for edema. She stated the doppler study result came back Wednesday 08/07/24 was negative and she faxed that result to her Doctor. She stated there were no new orders and she took a picture of Resident #1's left leg and sent it to her Doctor. She stated she got a call from the DON yesterday 08/09/24 around 4:00 pm and she returned the call around 4:49 pm and the DON told her to come to the facility. She stated a little after 5:00 pm she gave the DON her statement and completed Resident #1's incident report and completed in-service trainings on neglect/abuse, who was the abuse coordinator and the DON told her she should have reported this to her and called her Doctor and family. She stated she had the mind to call the DON but forgot and stated if a resident fell and the Doctor, DON or family was not notified could result in delayed injury. She stated that was why she always documented but she forgot to document Resident #1's fall and said after the DON spoke to her, she now knew why she should have completed a nurses note and reported it to her Doctor, DON, and family. She stated in general the residents were on the floor mat for care if they were uncooperative, but Resident #1 was never uncooperative and never on the floor for incontinent care. She stated she thought it was odd Resident #1 was on the floormat. She stated Resident #1 was a 1 person assist for incontinent care because she was not that heavy. heavy, but needed 2 person Hoyer assist for some care needs. She stated Resident #1 was bed bound with left sided weakness upper and lower and alert and oriented x1. She stated Resident #1 was not able to express her needs because she was aphasic and knew her name. She stated Resident #1 was able to gesture responses by nodding and shaking her head. She stated there was 1 nurse and 1 aide for on the norm for 21 residents. She stated she did not know Resident #1 was a 2 person assist for bed mobility but if a resident was skinny 1 person could do incontinent care on her. She stated only 1 CNA worked that side of the hall where Resident #1 was and CNA A never asked her for assistant with doing Resident #1's incontinent care. She stated she did not know Resident #1's MDS Assessment changed her bed mobility to 2-person assistance. She stated at night they had been 1 person assist with her incontinent care. She stated the nurses were responsible for ensuring the residents were getting proper care and cleaned and dry and checked every 2 hours. She stated she did not look at the Resident's Plan of Care to determine if they were 1 or 2 person assist by knowing the residents and going by the 24-hour report. She stated the DON suspended her and CNA A pending the investigation of Resident #1. She stated not reporting something bad could cause the resident to get bruised, skin tear or injured. Interview on 08/09/24 at 4:45 pm, the Police Detective stated he visited Resident #1 at the hospital and gathered other information and opened a case to further investigate the circumstances involving Resident #1's leg injury. He stated he had spoken to CNA A who said on 08/02/24 she was cleaning Resident #1 and she turned around then the resident kept rolling and fell out of the bed. He stated CNA A said she asked LVN B to help get Resident #1 off of the floor then LVN B picked up Resident #1 and put her back onto her bed. The Police Detective stated as of right now there was no documentation of the resident falling and no one knew what happened to her leg and the resident was not able to say what happened. He stated the Administrator and DON said they just discovered it from CNA A's statement. He stated Resident #1 sustained two fractures of her left tibia and left fibula that was approximately one inch below her knee. He stated Resident #1's roommate said she remembered a nurse and CNA coming in really fast one night but was not able to see or know what happened. He stated he was getting ready to interview LVN B to gather more information. Interview on 08/09/24 at 7:26 pm, the DON stated she received a report on 08/06/24 about Resident #1's left leg appearing shiny and red like she had irritated rash. She stated her Doctor ordered a doppler study of her left leg and the results came back negative. She stated the area on her leg started swelling up more and getting darker red and her Doctor diagnosed her with cellulitis and ordered antibiotics. She stated yesterday 08/08/24 her leg was still looking red and her Doctor ordered an X-ray and the result came back yesterday morning for two fractures of her left tibia and fibula. She stated they reported 08/08/24 to HHSC and an injury of unknown origin because of the darkness of her leg that looked to be spreading to other areas of her leg. She stated she was just finding out today 08/09/24 around 4:30 pm Resident #1 fell Friday night of 08/02/24. She stated there were no notes in her medical records and no incident reports. She stated Resident #1's fall should have been reported to her and the Administrator to they could have started investigating and reported this incident to HHSC. She stated had they had known soon they would have reported this incident immediately. She stated they were currently doing in-service trainings with all staff, doing skin and pain assessment of all the residents. She stated they were doing a lot of trainings on abuse/neglect, notification to the resident's Doctor, DON and Administrator and did 1:1 trainings with LVN B and now they were training all staff. She stated the therapy staff were assisting with the trainings. She stated it was too early in her investigation and was not sure if Resident #1 was a 1 or 2 person assist for ADL's but said she would follow-up with surveyor. She stated CNA A said she was doing Resident #1's incontinent care and when she turned to get some linen, Resident #1 rolled out of her bed. She stated CNA A told her that LVN B was alerted and Resident #1 was assessed but there was not any documentation of a nurses note, no notifications to her Doctor, family, herself, or Administrator. She stated LVN B confirmed everything that happened she went into the room the resident was on the floor, and CNA A explained she had guided the resident to the floor. She stated LVN B said she did a head-to-toe assessment and when asked why she not documented the assessment LVN B said it got so busy and she forgot. The DON stated she informed Resident #1's Doctor about Resident #1's fall with injury and he was upset because no one had called him 08/02/24. She stated the Doctor was at the facility visiting patients Monday 08/05/24 and no one told him about this until today 08/09/24 around 4:30 pm. She stated particularly concerning was CNA A said she noticed Resident #1's left leg was swollen on Sunday 08/04/24 and did not report it to anyone assuming the nurses were aware of it. She stated ADON C assessed Resident #1 then she was transferred to the hospital. She stated she spoke to LVN B on 08/09/24 around 4:00 pm she confirmed Resident #1 had fallen on 08/02/24. She stated LVN #1 was suspended. She stated she interviewed CNA A around 3:30 pm or 4:00 pm and CNA A was removed off the floor and interviewed with the Corporate Nurse Representative. She stated CNA A was sent to the conference room and until they received her statement. She stated she told CNA A she was suspended until they completed their investigation and sent her home. She stated LVN B came to the facility to drop off her statement and said she had not worked in the past two days. She stated the staff knew how to go into the EMR POC to review the resident's level of care and was not aware of any issues with that. She stated they were still investigating this incident and felt like the incident was not intentional and people just needed to think when they did resident care and thought about the processes beforehand. She stated from what she was told Resident #1's bed was at the level of CNA's hips. She stated Resident #1 did have tremors and twitched a lot and said she was not sure if she was 1 or 2 or Hoyer lift yet. She stated Resident #1 was not able to express her needs but was good at communicating by nodding and shaking her head. She stated Resident #1 required the use of a wheelchair and was not sure if she could move her legs but was in the process of finding out more. She stated unreported and undocumented falls could have adverse effects because neuro checks needed to be done to monitor if they have a change of mental status, get injured need more pain and was a form of neglect. She stated Resident #1 has routine pain medication and since 08/02/24 she had not had any increased pain. She stated after Resident #1 fell her Doctor should have been called and the fact that CNA A said the resident fell off the bed LVN B should have called her Doctor for further instructions. She stated the last she heard they were not going to do surgery to repair her left tibia and fibula because of her MS diagnosis. Interview on 08/09/24 at 8:21 pm, the Administrator stated he found out Resident #1 fell 08/02/24 and they were currently doing their investigation. He stated today 08/09/24 CNA A said Resident #1 fell last Friday 08/02/24 and that she and LVN B got her back into bed and they suspended her. He stated they called LVN B to tell them her story and she was interviewed then they decided to suspend LVN B pending investigation for not following their events protocol procedure. He stated they needed to ensure there was not anything missed and added up to the point they knew Resident #1 could not move and something was going on with her leg so he reported this incident to HHSC. He stated yesterday 08/08/24 Resident #1 was transferred to the hospital after her x-ray result showed she had fibula and tibia fractures of her left leg. He stated ever since then they were doing employee trainings on abuse/neglect, resident transfer techniques, reporting events and change in condition. He stated the DON and ADON was responsible for ensuring the nursing staff were following their protocols. He stated they reviewed all of Resident #1's documentation today and there was not any documentation about her falling. He stated unreported and undocumented falls could cause all kinds of things could happen such as pain, worsening condition, tons of things, no follow up on the resident's status. He stated they spoke to the Medical Director about Resident #1's fall with injury and they planned to continue to do trainings, getting statements for the staff. He stated they were reviewing her documents and other residents to protect all the residents and to see if they could do something another way, communicate better. He stated Resident #1 was a 1 person ADL assist resident because she was able to assist with turning and a petite lady and it was easy to turn her one way from to the other. Interview on 08/10/24 at 11:00 am with the Hospital RN stated Resident #1 admitted to the hospital because of a fractured tibia and fibula. She stated she was stable right now and was currently awake but nonverbal and just nodded in agreement to everything and was not good at following commands. She stated Resident #1 did not appear to be in any pain and no surgery was planned yet and they were doing conservative treatments on her. She stated there were no discharge plans at this time and her pain levels were fine but grimaced when providing care then but when still no signs or symptoms of pain. She stated she had not been given any pain medications since she admitted on [DATE] but had Doctor orders for Norco for moderate pain. She stated she Resident #1 has Doctor orders for Ativan for anxiety, morphine for severe pain and Tylenol for mild pain/headache. She stated Resident #1 had an immobilizer on her left leg and stated both her arms were contracted (right arm moved a little more and her left arm was more contracted). She stated her left leg was completed contracted and stated she was a 2 person assist because it was hard to turn her because she was very stiff. She stated Resident #1 was given 4 mg. of morphine on 8/8/24 at 10:15 pm in the ER via her G-tube. Interview on 08/11/24 at 2:28 pm, ADON C stated last Tuesday 08/06/24 LVN D reported Resident #1 had redness of her left leg and her Doctor was called and he ordered for her to get a doppler study that came back negative. She stated on Thursday 08/08/24 LVN O reported something was going on with Resident #1's left leg was swollen and the color was reddish and greenish. She stated she assessed Resident #1's left leg and tried to move her leg but when she moved her leg back the resident flinched her leg back. She stated she asked her was she in pain and she moved head but it was not a distinct nod or shake. She stated she asked Resident #1 was her leg in pain and she gestured yes. She stated she was not crying or appeared to be in pain and noticed the upper part of chin had discoloration and swelling from under her kneecap to her lower leg. She stated she notified Resident #1's Doctor herself and he ordered doxycycline, x-ray and lab work and she contacted her FM. She stated when her x-ray results came back showing she had a fractured tibia and fractured fibula shaft, they sent her to the hospital. She stated Resident #1 was a Hoyer lift transfer resident and she was a 1-person physical assist for incontinent care/bed mobility. She stated Resident #1's legs were contracted and a draw pad was needed to reposition her and reason why she always asked for assistance when providing her care. She stated she was a G-tube resident also and normally another staff was needed for ensure the tubing to stayed intact. She stated Resident #1 fell on [DATE] and she did not find out about it until Friday 08/09/24. She stated Oh yes if a resident had a guided fall or an assisted fall is a fall and a change in the resident's level of positioning. She stated Resident #1 had never been uncooperative with ADL care, but her legs were contracted and left hand was contracted. She stated she had never seen Resident #1 getting incontinent care on the floor mat and there were no reports of such. Interview on 08/11/24 at 4:13 pm, LVN D stated she worked on 08/06/24 around 10:00 am and Resident #1 was not able to speak but could follow verbal commands. She stated on 08/06/24 she was giving her medications through her g-tube and Resident #1 was different and her mood was flat and she asked Resident #1 was she good and she did not nod her head yes like she usually did and she was not her normal self. She stated when she flipped her blanket back, she noticed her knee looked different, both of her legs were contracted, but the lower part of her left knee was swollen and purplish and when she moved her left leg, she pulled it back and guarded with it. She stated Resident #1 was not her regular self she saw the left knee was a little swollen with a little purplish bruise, from her knee to her ankle. She stated she took a picture and sent it to her Doctor because she took Eliquis and was not sure if she had a blood clot of not. She stated her Doctor ordered a doppler study then when she returned to work on 08/09/24 she found Resident #1 was transferred to the hospital because her leg was getting bigger. She stated 911 was called and they took her to the hospital. She stated Resident #1 has never been non-compliant with care and had not ever seen her getting ADL care on her floor mat. She stated Resident #1 was supposed to be on her bed for all care needs. She stated if a resident was on the floor mat due to having a guided fall was the same as a fall and the Doctor needed to be called immediately. She stated the Doctor needed to be called for special instructions on what to do, and the nurses were supposed to assess the resident and know the residents blood pressure and vitals and do neuro checks for 72 hours and complete an incident report. She stated Resident #1 was a 2 person assist Hoyer lift resident and 1 person assist for bed mobility and ADL care. She stated Resident #1 used a Geri chair because she could not use a regular chair because she had a stroke affecting her left side and was not able to sit up in a wheelchair. She stated Resident #1 was good following commands but could not speak but she could look at their face and body language for signs of pain. She stated monitoring checks and notifying the next nurse to follow up on the resident monitoring was also needed. She stated if a resident had a fall and it was not reported or documented the resident could get injured more or lose their life. Interview on 08/12/24 at 12:53 pm, MDS Coordinator E, stated Resident #1's ADL status ranged and it depended on if she had any Muscle spasms related to her Multiple Sclerosis disease process. She stated Resident #1's status varied because on some days she was a little more rigid than other days. She stated Resident #1 was a 1 to 2 person assist for bed mobility and hygiene on the MDS Assessment and stated she believed her care plan had her as a 2 person assist for bed mobility. She stated she would have to review that and get back with the surveyor. She stated Resident #1 was no longer on hospice as of last month and stated the resident's MDS's should match what their Care Plans were. She stated Resident #1 was an extensive assist, Hoyer lift resident. She stated both of Resident #1's legs were both contracted. She stated she admitted with the leg contractures and was able to wiggle her legs with both of her legs bending at a 45-degree angle. She stated Resident [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1 ) of six residents reviewed for Quality of Care. CNA A failed to provide incontinent care with a second staff member assisting, which resulted in Resident #1 falling out of bed. And LVN B failed to notify Resident #1's Doctor on 08/02/24 after CNA reported Resident #1 on the floor and assisted with getting Resident #1 on the floor. LVN B did not complete and document doing a head to toe assessment and incident report and did not monitor the resident or do neuro checks and notify other nursing staff to continue monitoring the resident. Subsequently, Resident #1 was sent to the hospital on [DATE] and was currently at the hospital diagnosed with two fractures, a Tibia (Shinbone) and Fibula (Calf bone) of her left lower leg. After administrative review, an IJ was identified on 08/28/24. The Administrator was notified and an IJ template was provided on 08/28/24 at 12:57 pm. While the IJ was removed on 08/12/24 at 7:50 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place all residents at risk of not being assessed and treated in a timely manner and appropriately, with Doctors interventions, which could result in a decline in their psycho-social well-being and health resulting in internal bleeding, pain when being moved causing further injury or death. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted [DATE] with a BIMS Staff Assessment score of 2 (Moderate impaired cognition), no speech, with a memory problem and severely impaired. She had upper extremity impairment on one side and lower extremity impairment of both sides. Her functioning abilities and goals: Self-care: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for all ADLs including (toileting, personal hygiene). Her functioning abilities and goals: Mobility: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for roll left and right and for chair/bed to chair transfer. She was always incontinent to bladder and bowel, has a progressive neurological conditions with diagnoses of hypertension. She had Multiple Sclerosis (nerve degeneration), Gastronomy status (feeding tube), Cardiac arrhythmia (irregular heartbeat), dysphagia (not able to swallow properly), muscle weakness, atrial fibrillation (irregular heartbeat), and lack of coordination. She was 5'6 and 132 pounds. Record review of Resident #1's August 2024 Order Summary Report revealed orders for: Eliquis (blood thinner) 5 mg, folic acid 1 mg. senna 8.6 mg. tramadol 50 mg. Enteral Feeding tube, Enteral stoma site care, NPO, Enteral formula pump administration. Record review of Resident #1's Care Plan printed 8/10/24 revealed, Multiple sclerosis: assist with ADL and comfort measures as needed, Abdominal binder: to keep G-tube in place keep head and bed elevated. Geri-chair: make as comfortable as possible, falls (Resident has a history of falling related to mobility due to Multiple Sclerosis): place resident in a fall prevention program. Multiple sclerosis at risk for a decline in current ADLs and injuries due to increased injuries and assist with ADL's and comfort measures as needed. Cognitive loss/dementia: allow time for task and responses. Communication has aphasia approach in calm manner. Falls - keep call light within reach, ADL Functional status: ambulation/transfers amount of assist: total x 2 non-ambulatory, bathing/hygiene assist: total x1, resident care as per policy, toileting amount of assist total x1. Record review of Resident #1's Progress notes reviewed from 08/02/24 to 08/09/24 did not reveal she had any falls or incidents. Record review of Resident #1's X-Ray results dated 08/08/24 at 8:03 p.m. revealed, Clinical information: Bruising, swelling, Test procedures: Left tibia and fibula, two views. Findings: Proximal tibial and fibular shafts fracture. No osteolytic or osteosclerotic lesions. No signs of bone infection. Impression:1. Proximal tibial and fibular shafts fracture. 2. CT is recommended. Record review of Resident #1's Hospital Emergency Department Doctor's note dated 08/08/24 revealed, Chief complaint: Leg deformity: patient here from [Nursing Facility]. Left leg swelling noted and ecchymosis found this morning. On Eliquis .Patient is bed bound and nonverbal. Radiology: Tibia/fibula, left 2 views final result: Impression: Proximal left tibial and fibular fractures, negative left ankle and knee joint. Soft tissue swelling. Osteopenia. Record review of Resident #1's Progress note 08/02/2024 [Recorded as Late Entry on 08/09/2024 06:19 PM] by LVN B revealed, Events - fall: 11:06 PM On 2nd of August, CNA call attention to this nurse to room XXXX and reported to this nurse that she rolled resident down to the floor mat while giving care. Observed and assess resident on the floor mat., no apparent injury noted at that time. No S/S of pain noted at that time. Resident was helped back to bed with the help of the CNA. Record review of Resident #1's Incident/Accident Report completed date 08/09/24 at 6:08 p.m. by LVN B revealed, Event date 08/02/24 at 5:57 p.m., in resident room, yes fall was witnessed, no injury and no pain, ROM without pain/limitations, no rotation/deformity/shortening noted .notifications: Attending physician faxed: no, Physician notified: no, Resident Representative notified: no, care plan reviewed: no. Record review of Resident #1's Hospital Orthopedic Doctor note dated 08/09/24 revealed, Orthopedic diagnosis: Left Proximal tibia fracture. Orthopedic plan: Closed management of left proximal tibial fracture, knee immobilization, non-weight bearing. History of present illness: A [AGE] year-old female with multiple advance medical issues including MS, who is nonverbal at baseline .The patient is nonverbal, non-ambulatory. I do not think she would be a very good candidate for surgical intervention. I will plan for a knee immobilization and follow-up in the outpatient setting. Observation on 08/09/24 at 3:40 p.m., Resident #1's room revealed a thin blue floormat that was approximately two inches height and six feet in length on the left side of Resident #1's bed. Observation on 08/10/24 at 3:37 p.m., Resident #1 was at the hospital lying flat on her back, in bed watching television, she nodded yes to her name. She shook her head no she was not hurting. When asked had she fallen out of bed, she looked at her left leg and did not shake or nod her head. There was a G-tube next to her bed and she did not appear to be in pain. And her left leg was bent at a 45-degree angle with a knee immobilizer on it. Interview on 08/09/24 at 6:43 p.m., CNA A stated on 08/02/24 after dinner she checked Resident #1 and incontinent care was needed. She stated she was standing right in front of the window with the bed elevated and while caring for Resident #1, she turned her towards the door then towards her. She stated she put the bed linen on the floor then rolled her to the right to clean her and afterwards she tried to grab her bed sheets at the foot of her bed. She stated then Resident #1 started shaking and rolled off the bed so she went to get LVN B who came to assess the resident and made sure she was okay. She stated she and LVN B got Resident #1 back to bed and got her dressed then LVN B asked her what happened and she told her she was doing incontinent care and the resident rolled to the floor. She stated Resident #1 was nonverbal but did not appear to be in any pain and her leg was not swollen or in a weird position. She stated she was not sure if the nurse called to have any x-rays done and did not see anyone come out to do x-rays during her shift. She stated there was most likely no x-rays done because the resident was not crying because she checked on her frequently and changed her about four more times that night. Interview on 08/10/24 at 9:09 a.m., LVN B stated she worked the overnight shift and last took care of Resident #1 Last Friday 08/02/24, Tuesday 08/06/24 and Wednesday 08/07/24. She stated yesterday 08/09/24 she heard Resident #1 had a leg fracture. She stated she was very surprised Resident #1 was injured. She stated the DON spoke to her about what she knew about Resident #1's fall on 08/02/24 then the DON told her she should have completed an incident report and called her Doctor. She stated she did a late add nurses note and incident/accident report on 08/09/24 per the DON's request. She stated last Friday 08/02/24 after meal service, after 11:00 pm she was at the nurses' station and CNA A stood at Resident #1's room door calling her name out loud about needing help putting Resident #1 back to bed. She stated she saw Resident #1 in her room and her bed was in the lowest position and Resident #1 was on the left side of her bed on the floor. She stated Resident #1 was on her back and her left leg was turned to the left, and her head and buttocks was flat on the floormat, she was on her back. She stated her left leg was paralyzed and for her care they normally used a pillow to prop it in place. She stated when Resident #1 was on the floor her G-tube port was okay and the tubing was still connected to the g-tube pump. She stated there was no pillow under Resident #1's leg and the bed linen and pillow was on her bed. She stated she assessed Resident #1 and did not find anything wrong with her and she had no signs or symptoms of pain, then she CNA A put her back to bed. She stated when she asked CNA A why Resident #1 on the floor, CNA A said she rolled Resident #1 onto the floor to give her incontinent care. She stated CNA A did not say Resident #1 fell but said she guided her to the floormat. She stated if CNA A told her Resident #1 had fallen, she would have reported it to her Doctor. She stated she would have also documented it in Resident #1's nurses notes and completed an incident report and called her family. She stated she would have followed up with her to ensure she was fine and added Resident #1 was on scheduled Tramadol she received at 12:00 am and PRN Tylenol. She stated there was no increase in giving her more pain medications. She stated Resident #1's floor mat next was next to her bed 24/7 and Resident #1 normally did not get care on the floor mat that was why can questioned CNA A about it. She stated there was not anything propping her left leg, she checked on Resident #1 four or five times that night. She stated Resident #1 watched television and slept and she was given her Tramadol at midnight and she was asleep rest of the night. She stated she did not tell the oncoming nurse or the DON about her being on the floor because she got busy and did not suspect anything was wrong. She stated she got busy with taking care of other residents forgot to document at nurses note. She stated there was no swelling or redness of her legs during her 08/02/24 shift. She stated she returned to work Tuesday 08/06/24 the nurse reported Resident #1 had left leg swelling and her Doctor ordered for a doppler study for edema. She stated the doppler study result came back Wednesday 08/07/24 was negative and she faxed that result to her Doctor. She stated there were no new orders and she took a picture of Resident #1's left leg and sent it to her Doctor. She stated she got a call from the DON yesterday 08/09/24 around 4:00 pm and she returned the call around 4:49 pm and the DON told her to come to the facility. She stated a little after 5:00 pm she gave the DON her statement and completed Resident #1's incident report. The DON told her she should have reported this to her and called her Doctor and family. She stated she had the mind to call the DON but forgot and stated if a resident fell and the Doctor, DON or family was not notified could result in delayed injury. She stated that was why she always documented but she forgot to document Resident #1's fall and said after the DON spoke to her, she now knew why she should have completed a nurses note and reported it to her Doctor and family. She stated she thought it was odd Resident #1 was on the floormat. She stated Resident #1 was bed bound with left sided weakness, upper and lower and alert and oriented x1. She stated Resident #1 was not able to express her needs because she was aphasic and knew her name. She stated Resident #1 was able to gesture responses by nodding and shaking her head. She stated the nurses were responsible for ensuring the residents were getting proper care and cleaned and dry and checked every 2 hours. She stated the DON suspended her and CNA A pending the investigation of Resident #1. She stated not reporting something bad could cause the resident to get bruised, get skin tears or injured. Interview on 08/09/24 at 4:45 p.m., The Police Detective stated he visited Resident #1 at the hospital and gathered other information and opened a case to further investigate the circumstances involving Resident #1's leg injury. He stated he had spoken to CNA A who said on 08/02/24 she was cleaning Resident #1 and she turned around then the resident kept rolling and fell out of the bed. He stated CNA A said she asked LVN B to help get Resident #1 off of the floor then LVN B picked up Resident #1 and put her back onto her bed. Police Detective stated as of right now there was no documentation of the resident falling and no one knew what happened to her leg and the resident was not able to say what happened. He stated the Administrator and DON said they just discovered it from CNA A's statement. He stated Resident #1 sustained two fractures of her left tibia and left fibula that was approximately one inch below her knee. He stated Resident #1's roommate said she remembered a nurse and CNA coming in really fast one night but was not able to see or know what happened. He stated he was getting ready to interview LVN B to gather more information. Interview on 08/09/24 at 7:26 p m, the DON stated she received a report on 08/06/24 about Resident #1's left leg appearing shiny and red like she had irritated rash. She stated her Doctor ordered a doppler study of her left leg and the results came back negative. She stated the area on her leg started swelling up more and getting darker red and her Doctor diagnosed her with cellulitis and ordered antibiotics. She stated yesterday 08/08/24 her leg was still looking red and her Doctor ordered an X-ray and the result came back yesterday morning for two fractures of her left tibia and fibula. She stated she was just finding out today 08/09/24 around 4:30 pm Resident #1 fell Friday night on 08/02/24. She stated there were no notes in her medical records and no incident reports. She stated they were currently doing in-service trainings with all staff and doing skin and pain assessments of all the residents. She stated the staff trainings were on notifications to the resident's Doctor and did 1:1 trainings with LVN B and now they were training all staff. She stated it was too early in her investigation and was not sure if Resident #1 was a 1 or 2 person assist for ADL's but said she would follow-up with the surveyor. She stated CNA A said she was doing Resident #1's incontinent care and when she turned to get some linen, Resident #1 rolled out of her bed. She stated CNA A told her that LVN B was alerted and Resident #1 was assessed but there was not any documentation of a nurses note and no notifications to her Doctor. She stated LVN B confirmed everything that happened she went into the room the resident was on the floor, and CNA A explained she had guided the resident to the floor. She stated LVN B said she did a head-to-toe assessment and when asked why she did not document the assessment LVN B said it got so busy and she forgot. The DON stated today 08/09/24 she informed Resident #1's Doctor about Resident #1's fall with injury and he was upset because no one had called him 08/02/24. She stated the Doctor was at the facility visiting patients Monday 08/05/24 and no one told him about this until today. She stated ADON C assessed Resident #1 then she was transferred to the hospital. She stated she spoke to LVN B on 08/09/24 around 4:00 pm she confirmed Resident #1 had fallen on 08/02/24. She stated LVN #1 was suspended. She stated LVN B came to the facility to drop off her statement and said she had not worked in the past two days. She stated Resident #1 was not able to express her needs but was good at communicating by nodding and shaking her head. She stated Resident #1 required the use a wheelchair and was not sure if she could move her legs but was in the process of finding out more. She stated unreported and undocumented falls could have adverse effects because neuro checks needed to be done to monitor if they had a change of mental status, got injured or needed more pain medications. She stated Resident #1 had routine pain medication and since 08/02/24 and she had not had any increased pain. She stated after Resident #1 fell her Doctor should have been called and the fact that CNA A said the resident fell off the bed, LVN B should have called her Doctor for further instructions. She stated the last she heard the hospital were not going to do surgery to repair her left tibia and fibula because of her MS diagnosis. Interview on 08/09/24 at 8:21 p.m., the Administrator stated he found out Resident #1 fell 08/02/24 and they were currently doing their investigation. He stated today 08/09/24 CNA A said Resident #1 fell last Friday 08/02/24 and that she and LVN B got her back into bed and they suspended her. He stated they called LVN B to tell them her story and she was interviewed then they decided to suspend LVN B pending investigation for not following their events protocol procedure. He stated yesterday 08/08/24 Resident #1 was transferred to the hospital after her x-ray result showed she had fibula and tibia fractures of her left leg. He stated ever since then they were doing employee trainings on reporting events. He stated the DON and ADON were responsible for ensuring the nursing staff were following their protocols. He stated they reviewed all of Resident #1's documentation today and there was not any documentation about her falling. He stated unreported and undocumented falls could cause all kinds of things to happen such as pain, worsening condition, tons of things, no follow up on the resident's status. He stated they spoke to the Medical Director about Resident #1's fall with injury and they planned to continue to do trainings and get statements from the staff. He stated they were reviewing her documents and other residents to protect all the residents and to see if they could do something another way to communicate better. Interview on 08/10/24 at 11:00 a.m., with the Hospital RN stated Resident #1 admitted to the hospital because of a fractured tibia and fibula. She stated she was stable right now and was currently awake but nonverbal and just nodded in agreement to everything and was not good at following commands. She stated Resident #1 did not appear to be in any pain and no surgery was planned yet and they were doing conservative treatments on her. She stated there were no discharge plans at this time and her pain levels were fine but grimaced when providing care then but when still she had no signs or symptoms of pain. She stated she had not been given any pain medications since she admitted on [DATE] but had Doctor orders for Norco for moderate pain. She stated she Resident #1 has Doctor orders for Ativan for anxiety, morphine for severe pain and Tylenol for mild pain/headache. She stated Resident #1 had an immobilizer on her left leg and stated both her arms were contracted (right arm moved a little more and her left arm was more contracted). She stated her left leg was completed contracted and stated she was a 2 person assist because it was hard to turn her because she was very stiff. She stated Resident #1 was given 4 mg. of morphine on 8/8/24 at 10:15 pm in the ER via her G-tube. Interview on 08/11/24 at 1:45 p.m., the DON stated they updated the staff trainings that were conducted by herself and Nursing Supervisors RN G and LVN H. She stated they were reviewing the other resident's records to see if any other residents were affected no other residents were affected. She stated they started notification of changes trainings on 08/09/24. She stated she they started doing Resident's skin and pain assessments on Friday morning of 08/09/24. She stated LVN B said CNA A told her while giving Resident #1 incontinent care CNA A guide rolled the resident to the floor. Interview on 08/11/24 at 2:28 pm, ADON C stated last Tuesday 08/06/24 LVN D reported Resident #1 had redness of her left leg and her Doctor was called and he ordered for her to get a doppler study that came back negative. She stated on Thursday 08/08/24 LVN O reported something was going on with Resident #1's left leg was swollen and the color was reddish and greenish. She stated she assessed Resident #1's left leg and tried to move her leg but when she moved her leg back the resident flinched her leg back. She stated she asked her was she in pain and she moved head but it was not a distinct nod or shake. She stated she asked Resident #1 was her leg in pain and she gestured yes. She stated she was not crying or appeared to be in pain and noticed the upper part of chin had discoloration and swelling from under her kneecap to her lower leg. She stated she notified Resident #1's Doctor herself and he ordered doxycycline, x-ray and lab work and she contacted her FM. She stated when her x-ray results came back showing she had a fractured tibia and fractured fibula shaft, they sent her to the hospital. She stated Resident #1 was a Hoyer lift transfer resident and she was a 1-person physical assist for incontinent care/bed mobility. She stated Resident #1's legs were contracted and a draw pad was needed to reposition her and reason why she always asked for assistance when providing her care. She stated she was a G-tube resident also and normally another staff was needed for ensure the tubing to stayed intact. She stated Resident #1 fell on [DATE] and she did not find out about it until Friday 08/09/24. Interview on 08/11/24 at 4:13 pm, LVN D stated she worked on 08/06/24 around 10:00 am and Resident #1 was not able to speak but could follow verbal commands. She stated on 08/06/24 she was giving her medications through her g-tube and Resident #1 was different and her mood was flat and she asked Resident #1 was she good and she did not nod her head yes like she usually did and she was not her normal self. She stated when she flipped her blanket back, she noticed her knee looked different, both of her legs were contracted, but the lower part of her left knee was swollen and purplish and when she moved her left leg, she pulled it back and guarded with it. She stated Resident #1 was not her regular self she saw the left knee was a little swollen with a little purplish bruise, from her knee to her ankle. She stated she took a picture and sent it to her Doctor because she took Eliquis and was not sure if she had a blood clot of not. She stated her Doctor ordered a doppler study then when she returned to work on 08/09/24 she found Resident #1 was transferred to the hospital because her leg was getting bigger. She stated 911 was called and they took her to the hospital. She stated Resident #1 was supposed to be on her bed for all care needs. She stated if a resident was on the floor mat due to having a guided fall was the same as a fall and the Doctor needed to be called immediately. She stated the Doctor needed to be called for special instructions on what to do, and the nurses were supposed to assess the resident and know the residents blood pressure and vitals and do neuro checks for 72 hours and complete an incident report. She stated Resident #1 was a 2 person assist Hoyer lift resident and 1 person assist for bed mobility and ADL care. She stated Resident #1 used a Geri chair because she could not use a regular chair because she had a stroke affecting her left side and was not able to sit up in a wheelchair. She stated Resident #1 was good following commands but could not speak but she could look at their face and body language for signs of pain. She stated monitoring checks and notifying the next nurse to follow up on the resident monitoring was also needed. She stated if a resident had a fall and it was not reported or documented the resident could get injured more or lose their life. Interview on 08/12/24 at 12:53 pm, MDS Coordinator E, stated Resident #1's ADL status ranged and it depended on if she had any Muscle spasms related to her Multiple Sclerosis disease process. She stated Resident #1's status varied because on some days she was a little more rigid than other days. She stated it was reported on 08/02/24 Resident #1 had a change in position and was assisted to the floor, which was still considered a fall. She stated, 'Oh definitely' LVN B should have called Resident #1's Doctor on 08/02/24, because the Doctor may have wanted to order x-rays and do a follow up visit. She stated the nurses needed to ensure the residents did not have any post injuries at that moment and further down the road. Interview on 08/12/24 at 2:33 pm, Medical Director/Resident #1's Doctor stated he had not received a call from anyone on 08/02/24 or from LVN A about Resident #1 falling. He stated LVN B should have called him for Resident #1's change in condition and completed an incident/accident report. He stated the first question on the incident/accident report asked had the Doctor been notified. He stated the facility wanted the Doctor called for any falls with or without injury, because there could be some reason why the resident fell. He stated if they had a seizure or became dizzy that might qualify for more investigation. He stated the DON notified him on 08/09/24 of Resident #1's fall on 08/02/24 that LVN B found her on the floor and put her back to bed and did not report it to anyone. He stated Resident #1 was bed bound and needed total assist and he wondered how this could have happened. He stated if CNA A and LVN B would have reported Resident #1's fall, she could have been assessed sooner and a follow up visit done with a full investigation of what caused it. He stated Resident #1 could not roll or turnover and had no muscular tone and not able to speak. He stated he wondered how Resident #1 could have fallen out of bed if she was total assist. He stated a guided fall was the same as a fall. He stated after finding out about Resident #1's fall they have had an Ad hoc QAPI Meeting on 08/12/24, to discuss their plan to prevent this from happening again. He stated they started re-educating the staff with various in-service trainings and continue to review their plan and make changes as needed and continue to discuss in their QA meetings. Review of the Facility's Provider Investigation Report dated 08/08/24 revealed on 08/02/24 at 8:00 pm. Alleged Perpetrators: CNA A and LVN B denied the allegation and no witnesses: Assessment: On 08/08/24 at2:11 p.m.by ADON C, indicated Resident #1 was assessed for an injury of unknown origin: Resident lying in bed with head above bed elevated, alert, and able to respond to questions by nodding. Left lower leg swollen warm and painful to touch, venous doppler negative, x-rays confirmed proximal tibial and fibula fracture of left leg. No treatment, resident transferred to the hospital. Provider response: RP, DON Physician notified, X-rays confirmed fracture resident transported to Hospital, satisfaction survey completed, Skin assessment completed on other residents, In services on transfers, bed mobility and Hoyer lifts. In- services on abuse and neglect. Interviews with staff. CNA A and LVN B suspended pending Investigations. Investigation Summary: On 8/2/24 in the PM. C.N.A. was providing incontinent care for Resident #1, Resident #1 rolled to the mat on the floor. C.N.A. notified LVN B. Nurse and C.N.A. assisted resident back to bed. No Documentation or Notification was given on 8/6/24 Nurse noted left leg swelling, Physician ordered a venous doppler. Doppler study had negative result. On 8/8/24 DR notified of doppler result and ordered x ray. X-rays confirmed proximal tibia and fibula shaft fracture. Administrator notified HHSC of injury of unknown origin Resident was transported to Hospital. In-services were started on Abuse, Neglect and Reporting, Transfer, Bed Mobility and Hoyer lifts. Event policy and notification. During interviews it was determined by CNA A, Resident #1 was picked up off the floor on 8/2/24. She stated that Nurse assisted her putting Resident #1 back to bed. LVN B confirmed that she assisted Resident #1 back to bed. LVN B and CNA A were suspended pending investigation. HHSC Investigator entered the building on 8/9/24 at 3:15 pm, HHSC reentered on 8/11/24 lJ was put in place at 5:30 pm. HHSC lowered the IJ 8/12/24 at 7:30 pm. Staff members LVN B and CNA A were terminated. Where others notified: Physician, RP, Ombudsman, Police, HHSC Facility investigation findings: Confirmed Provider action taken post investigation: HHSC onsite 8/09/24, 8/11/24, 8/12/24, Resident returned to facility 8/12/24, In-services on abuse neglect, reporting, Bed mobility and transfer, Events documentation and reporting to appropriate people with evidence based follow up. LVN B and CNA A were suspended and terminated. Record review of : Employee Statements dated 8/8/24, 8/9/24, Safe Survey Resident Interviews dated 8/9/24, Inservice trainings: Abuse and neglect definitions in-service dated 8/8/24, Check offs: Moving/positioning, assisting with dated 8/11/24, 8/12/24, Post Fall Physical Assessment Test dated 8/11/24, 8/12/24, Transfer training and bed mobility dated 8/9/24, Notification of change training dated 8/9/24, Employee Abuse investigation questionnaire dated 8/9/24, LVN B Employee Corrective Action Form suspended dated 8/9/24 and CNA A Employee Corrective Action Form suspended dated 8/9/24. [END] Record review of LVN B's Timesheet printed on 08/09/24 revealed she worked on: 08/02/24 5:45 pm - 7:40 am, 08/06/24 5:30 pm - 7:46 am, 08/07/24 5:26 pm - 7:51 am. Record review of an Article Tibia & Fibula Fracture (Broken Shinbone/Calf Bone) (clevelandclinic.org) last reviewed 06/01/23 revealed, Overview: What are tibia and fibula fractures? Tibia and fibula fractures are two broken bones in your lower leg. Your tibia is your shin bone. Your fibula is your calf bone. Because they're usually caused by major trauma like car accidents or falls, people often break both their tibia and fibula during the same injury. It's rare, but you can fracture one of your tibia or fibula without breaking the other. You might need surgery to repair your bones and physical therapy to regain your ability to move your leg. Record review of the facility's Incident/Accident policy revised July 2017 revealed, Policy statement: All accidents or incidents involving residents .ocurring on our premises shall be investigateed and reported to the Administrator. Policy: 1. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promply initiate and document investigation of teh accident or incident. The following data , as applicable, shall be included on the Report of Incident/Accident form: a The date and time the incident took place .5. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall co[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Residents #1) of four residents reviewed for elopement. 1. The facility failed to ensure Resident #1who had severe cognitive impairment and lacked safety awareness eloped from the facility on 10/22/23 at 5:53 p.m. and was located by police on 10/24/23 at an unknown location and taken to the hospital for evaluation. 2. The facility failed to assess Resident #1's risk for elopement quarterly according to their policy/procedure. 3. The facility failed to ensure staff were trained and able to demonstrate competency in elopement and supervision. An Immediate Jeopardy was identified on 10/24/23 at 4:02 p.m. While the Immediate Jeopardy was removed on 10/25/23 at 3:45 p.m., the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for severe injury and/or death. Findings included: Review of Resident #1's annual MDS assessment, dated 10/02/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included intracerebral hemorrhage in brain stem (bleeding within the brain a life-threatening type of stroke), seizure disorder, heart failure and encephalopathy (Encephalopathy-a group of conditions that cause brain dysfunction that can appear as confusion, memory loss, and personality changes). The MDS reflected the resident had a BIMS of 3 indicating severe cognitive impairment, occasionally incontinent of bowel/blader, required physical assistance and/or supervision of staff for eating, dressing, personal hygiene, and toileting. Review of Resident #1's care plan edited on 10/06/23 revealed the resident's risk for elopement, was addressed due to new environment, ambulation status, dementia, wandering and a history of elopement on 03/31/23 and 05/10/23 when he exited a window into the fenced and secured courtyard. The care plan addressed the resident's diagnoses of encephalopathy and residing in the Secure Unit due to wandering and poor safety awareness. Interventions included monitoring the resident closely, performing elopement assessments quarterly, quarterly reviews for continued placement on the Secure Unit and reporting exit seeking behaviors to the Administrator, DON, physician, and responsible party. Care plan goals were Resident #1 would not elope from the secured unit and would be safe in the secured unit due to wandering and poor safety awareness. Review of Resident #1's most recent Elopement Evaluations, dated 05/10/23, and 10/09/23 revealed the resident was ambulatory, cognitively impaired, with poor decision-making skills and made statements that he was leaving. The evaluation dated 05/10/23 reflected Resident #1 had broken and climbed out of a window. The evaluations further reflected the resident was at risk for elopement. There was no evidence of a quarterly evaluation being completed in 08/2023. Review of Resident #1's Secure Unit Evaluation dated 03/13/2023 revealed the resident was independently ambulatory, exhibited wandering behavior, had long/short-term memory loss, and cognitive skills for daily decision making were moderately impaired. There were no other Secure Unit Evaluations available. Review of in-service training dated 06/28/23, revealed staff received training related to showers and restroom doors. The training reflected in part All unit doors, outside exit door, outside gates and interior entrance/exit doors should never be left open for any reason except in the case of emergency evacuations. When entering and exiting the unit staff will monitor that no resident leaves unaccompanied and the maglock are energized, and all doors are properly locked. The training did not address exit seeking behaviors, elopement prevention or training to ensure staff were able to demonstrate competency in elopement and supervision. Review of in-service training dated 07/14/23, revealed staff received training related to dementia, with aggressive behaviors. The training did not address exit seeking behaviors, elopement prevention or training to ensure staff were able to demonstrate competency in elopement and supervision. Interview with the Administrator on 10/24/23 at 10:00 a.m., he stated Resident #1 resided on the Secure unit, eloped on the evening of 10/22/23 after dinner and was still missing. The facility's missing resident procedure was implemented and the entire facility inside and outside was searched. Staff also searched the surrounding neighborhood, and the police were notified. The Administrator stated the nurse on duty during the evening of 10/22/23 was passing medications and thought Resident #1 was in the bathroom. Later when she was unable to locate the resident, she contacted the DON and the facility's missing resident procedure was implemented. He stated he theorized Resident #1 exited the secure unit behind a staff who was taking a cart of dirty trays out and the staff did not notice the resident. He stated sometime in May 2023 the resident broke a window on the secure unit, exited the window into the fenced and locked courtyard and was immediately retrieved and brought back inside. The Administrator stated the resident made verbal statements about wanting to leave to the physician, but he had not been aware of the resident making the statements until yesterday (10/23/23) when the physician told him. He further stated staff had reported Resident #1 had exhibited no exiting seeking behaviors. Additionally, the Administrator stated he had verbally instructed staff that there should always be at least one staff in the front area of the Secure Unit (desk or day area close to door) to monitor residents. Interview on 10/24/23 at 10:10 a.m. the SW stated after Resident #1's attempted elopement in May 2023 she attempted to have the resident admitted /evaluated at an in-patient psychiatric setting, but she was not able to because the facility she contacted was full. She stated she had checked on the resident daily but did not say how long the daily checks lasted. The SW stated the resident had been stable and had made no other attempts to elope from the facility prior to 10/22/23. Interview on 10/24/23 at 10:13 a.m. the DON stated after Resident #1 attempted to elopement in May 2023, the resident was placed on every 15-miniute checks for a few days until the facility was comfortable the resident would not attempt to elope. The DON stated there had been no formal training provided related to one staff staying in the front area, near the exit doors in the secure unit and she did not have any documentation of the verbal instructions provided to staff. The DON stated she would check for any documented training related to elopement prevention. The DON further stated in-service training had been in progress since Monday but not all staff had received the training yet. Observation on 10/24/23 at 10:30 a.m., revealed staff on the Secure Unit consisted of one licensed nurse and two CNAs who were all in the front area of the unit interacting with five residents. Interview with LVN A on 10/24/23 at 10:30 a.m., revealed the nurse was not on duty when Resident #1 eloped. LVN A stated he recalled receiving some type of in-service training approximately one year ago related to not providing the door code to anyone who did not work at the facility, making sure the door closed/locked when entering/exiting the unit and making sure no residents followed him out. He stated he was aware that there should always be at least one staff in the front area of the unit, at the desk or in day area near the exit doors at all times. LVN A stated he was not aware of Resident #1 exhibiting any exit seeking behaviors, but the resident would wander around on the unit. He never heard the resident say anything about leaving. Interview on 10/24/23 at 10:34 a.m. CNA B stated she was not on duty when Resident #1 eloped. She stated she recalled receiving training related to not providing the door code to anyone who did not work at the facility, making sure the door closed/locked when entering/exiting the unit and making sure no residents followed her out. CNA B was unable to recall when she had received the training. She was not aware of Resident #1 exhibiting any exit seeking behaviors, but he did wander around the unit. Interview on 10/24/23 at 10:38 a.m., CNA C stated she was not on duty when Resident #1 eloped. She stated she recalled receiving training related to not providing the door code to anyone who did not work at the facility, making sure the door closed/locked when entering/exiting the unit and making sure no residents followed her out. CNA C was unable to recall when she had received the training. She stated she was not aware of Resident #1 exhibiting any exit seeking behaviors, but he did wander around on the unit. Interview on 10/24/23 at 11:05 a.m., the Administrator stated he had reviewed the camera footage and observed Resident #1 exiting the front door of the facility at 5:53 p.m. He stated he did not see the resident cross the street (a busy 4 lane road). He stated the front door to the facility and back door to smoking area are not locked. Interview on 10/24/23 at 11:44 a.m., the DON stated nurses were responsible for completing quarterly elopement evaluations. She stated she had a main screen on her computer that let her know what elopement evaluations were coming due and which ones were overdue. The DON stated she was in the process of rescheduling and completing assessments as they had not been scheduled appropriately. She further stated she had overlooked Resident #1's overdue quarterly elopement evaluation. Interview on 10/24/23 at 12:15 p.m. the Administrator stated the delay on the Secure Unit door lock had a 5 second delay on exiting and a 3 second delay on entering and that may have contributed to Resident #1's elopement. He stated the delay had been reset so that the lock delay was 3 seconds on entering and exiting. Interview on 10/24/23 at 12:26 p.m., the DON stated interventions to address Resident #1's elopement included staff performing a head count on the Secure Unit three times a day, after each meal and at midnight. Interview on 10/24/23 at 1:30 p.m. CNA D stated she was on duty during the evening shift on 10/22/23 when Resident #1 eloped. She stated the last time she recalled seeing the resident was at approximately 5:00 p.m. eating dinner in the day area. She stated sometime after dinner she took the cart (she was unable to recall what time) with dirty dinner trays out of the unit. She stated she usually checked the door to make sure it locked or listened for the latch to lock when she exited. CNA D stated she did not do either on the evening of 10/22/23 and does not know why, she just forgot. She did not see the resident after she returned from dropping off the tray cart. Sometime after LVN F arrived on duty at approximately 7:40 p.m. the nurse told her she was unable to find Resident #1 and all staff began a search. She further stated the resident would occasionally stand near the exit door but was easily redirected. CNA D stated she did not know if any staff had been in the front area of the Secure Unit during the time she left with the trays. Additionally, she stated she had received training related to working on the unit but was unable to recall when she received the training. Interview on 10/24/23 at 1:56 p.m., LVN E stated when Resident #1 eloped on 10/22/23 she was scheduled to work the day shift from 6:00 a.m. to 6:00 p.m. but stayed late to cover for the oncoming nurse (LVN F) who arrived late at approximately 7:30 p.m. She was dancing with Resident #1 after dinner at approximately 5:45 p.m. and did not recall seeing CNA D leave the unit with the tray cart. The last time she saw the resident was shortly after dancing with him and he was going down the hallway away from the exit door. She stated she then went to assist another resident in their room and recalled Hospitality Aide G was in the day area with other residents. LVN E stated she was aware and had received training in the past that there must be someone in the front area of the secure unit at all times. She further stated Resident #1 had exhibited no exit seeking behaviors. Interview on 10/24/23 at 2:19 p.m., LVN F stated she did not normally work on the Secure Unit, and when Resident #1 eloped on 10/22/23 she was the night shift nurse scheduled to work from 6:00 p.m. to 6:00 a.m. She arrived late to work at approximately 7:40 p.m. and after receiving report she was immediately on the floor making rounds and passing medications. She stated she noticed Resident #1 was not in his room for medications and assumed he was in the bathroom. After completing the medication pass, she returned to the resident's room and discovered she was unable to locate him. The nurse checked with the CNA and Hospitality Aide to see if they were providing the resident with a shower, and they told her no shower was being provided. The nurse stated after she was unable to locate the resident, she called LVN E to see if Resident #1 had gone out with family. LVN E told her the resident had not gone out and was on the unit. LVN F stated she followed the facility's missing resident protocol to include notifying the DON, police, and family. Facility staff searched inside, outside and in the surrounding vicinity but were unable to locate Resident #1. LVN F stated she had not observed the resident exhibit any exit seeking behaviors. She stated she had received training related to working in the secured unit and had worked in many secured units during her career. She was aware not to share the code to the secure unit door, check the surrounding environment when entering and exiting the unit to see if a resident was close by. Interview on 10/24/23 at 2:35 p.m., Hospitality Aide G stated she was on duty 10/22/23 during the evening shift when Resident #1 eloped. She stated she was assigned to the resident and the last time she saw him was at approximately 5:45 p.m. in the day area with LVN E. After that she was assisting another resident in their room. At approximately 8:00 p.m. CNA D asked her if she had seen the resident they began searching for the resident and was unable to locate him. She stated Resident #1 liked to stand next to the door, but she would talk to him and get him to do something else. She stated she had received training about always checking to make sure no resident was behind her when leaving the unit, someone should always be in the front area near the door and not all staff in resident rooms at same time. Hospitality Aide G was unable to recall when she had received the training. Interview on 10/25/23 at 9:40 a.m. the Administrator stated Resident #1 had been located by police on 10/24/23. He did not know any specifics but stated the resident was not harmed or injured and had been taken to the hospital by police as a precaution. He further stated the DON was out for the day. Interview on 10/25/23 at 11:28 a.m. the facility's Clinical Resource Nurse stated Secure Unit Evaluations were to be completed quarterly and along with elopement evaluations helped determine a resident's risk for elopement. All residents in the Secure Unit had updated and current Secure Unit evaluations completed since the facility's policy was to complete the evaluations on admission and quarterly. She stated the Secure Unit evaluations had not been consistently completed for residents in the unit. She further stated the DON had been in the process of completing/updating the evaluations possibly because she (the DON) had determined they had not been done. Interview on 10/25/23 at 11:41 a.m. the ADON stated she was only able to locate one Secure Unit Evaluation for Resident #1 dated 03/13/23. She stated nurses were responsible for completing the evaluations quarterly. Interview on 10/25/23 at 11:58 a.m., Resident #1's physician stated Resident #1's verbalizations related to going home were episodic and not necessarily a threat to elope, but just a statement that he wanted to be with his family. The physician stated he was not aware of the resident exhibiting any exit seeking behaviors. Interventions to address a resident with exit seeking behaviors could include redirection and psychiatric evaluations. His expectation would be that staff made room checks throughout their shifts. Interview on 10/25/23 at 3:54 p.m. the Administrator stated it was important to address exiting seeking behaviors to ensure residents received appropriate care that could include medication adjustments and/or psychiatric evaluations. The Administrator stated cognitive residents at risk for elopement could elope and get hurt. Review of the facility's P/P entitled Wandering and Elopements revised 05/15/23 revealed Policy Statement: The center will identify residents who are at risk for unsafe wandering and/or elopement. The center will strive to prevent harm while maintaining the least restrictive environment for residents. Review of the facility's P/P entitled Secure Unit Overview revised 03/18/23 revealed Purpose: The Secure Unit is designed to provide a holistic approach of care for the resident with cognitive impairment and with exit-seeking behaviors. The P/P reflected Resident assessments would be completed by the interdisciplinary team prior to admission to the Secured Unit, quarterly and with significant change in condition. An Immediate Jeopardy was identified on 10/24/23 at 4:02 p.m. and the Administrator was informed of an IJ in the area of accidents/supervision. The IJ template was provided via email on 10/24/23 at 4:02 p.m. The facility's Plan of Removal was accepted on 10/25/23 at 11:18 a.m. and reflected: Plan of Removal: 689: Free of Accidents Hazards, and Supervision/Devices (Immediate) Action: Searched for Resident # I inside and outside the building. Called a Code Pink. Notified the Administrator, Police, Notified MD, and Responsible Party. Continue to search for the missing resident and work with the local police department (called local hospitals/ERs/bus station/ homeless [NAME]/ gas stations and businesses around [NAME] Nursing and Rehab). Checked all doors/gates for the secured unit and ensured they were secured. Person(s) Responsible: Charge Nurse, Director of Nursing, and Administrator Date: 10/22/2023 by 10PM (Identification) Action: Resident head count performed with all residents residing at [NAME] Nursing and Rehabilitation. No other missing residents identified. Person(s) Responsible: Charge Nurse Date: I0/22/2023 by 10PM (Identification) Action: Elopement assessment performed on all residents at [Facility Name] Any residents residing on the secured unit have elopement assessment, secured unit assessment, orders, consent and care plans in place. Person(s) Responsible: Director of Nursing Date: 10/23/2023 by 10PM (Prevention) Action: Education provided to all staff including-Elopement & Missing Resident Policy Ensuring the secured unit door is shut and latched prior to walking away from the unit doors. Reporting residents voicing ·'they want to leave to Charge Nurse and Administrator. All staff will be educated prior to working their next shift. All new staff will be educated prior to working their first shift. Person(s) Responsible: Administrator, Director of Nursing, and /or Designee Date: I 0 /23 /2023 by 10PM (Prevention) Action: Maintenance Director worked with the door latch to ensure it ''latches quickly enough (3 seconds) and stays secured'' once shut. Sign placed on unit doors (coming in and going out) stating-Please ensure the door latches prior to walking away. Person(s): Maintenance Director Date: l 0/23/2023 by 4:45PM Action: Ad Hoc QAPl performed by center IDT and Medical Director to inform him of the incident and our plan in place. Person(s) Responsible: Administrator Date: 10/23/2023 by 2PM. Review of in-service training records to include attendance records, instruction topics and competency questions dated 10/22/23 and 10/23/23 revealed education included performing head counts, checking to ensure Secure Unit door latched after exiting and before walking away, three second door lock delay, being aware of surroundings at all times, reporting resident verbalizations of wanting to leave. Interviews were conducted with facility staff across multiple shifts on 10/25/23 from 12:44 p.m. to 1:25 p.m. and form 2:39 p.m. to 3:43 p.m. Staff interviewed were Housekeeping Staff H, Housekeeping Staff I, Activity Director, LVN A, CNA B, LVN F, CNA J, CNA K, CNA L, Dietary Staff M, LVN N, CNA O, CNA P, CNA Q and Dietary Manager. Staff verbalized comprehension of the in-service training provided to include monitoring the Secure Unit door when entering/exiting, ensuring at least one staff remains in front area of unit at all times and reporting to Administrator and/or DON of residents exhibiting exit seeking behaviors. The Administrator was notified on 10/25/23 at 3:45 p.m. that the Immediate Jeopardy was removed. However, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.