**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and other facility documentation, it was determined that for two (R1and R2) out of three residents sampled for accidents, the facility failed to ensure that R1 and R2 received adequate supervision to prevent accidents. R1, a severely cognitively impaired resident, was able to elope from the building on 9/26/25 during the 11:00 PM to 7:00 AM shift. R1 was found on 9/26/25 at 8:38 AM, approximately 17-20 miles from the facility. This failure put R1 at immediate risk for severe injury or death due to exposure to traffic and environmental hazards while walking on the road unsupervised. An immediate jeopardy (IJ) was called at 12:30 PM on10/1/25. The facility abated the IJ on 10/2/25 at 3:00 PM. R2, a completely dependent resident, sustained a right femur fracture from a fall from the bed to the floor while a staff member was providing care and the resident rolled off the bed. Findings include: 12/4/23 - A facility document entitled, Elopement of Resident, documented, .The facility provides a safe environment and adequate supervision that respects the residents' dignity and minimizes the residents' risk for accidents or harm. Residents identified as at risk for elopement requires the vigilance of all staff. Residents identified as being at risk for elopement will have person- centered interventions to monitor and manage their risk as reflected in the care plan.1. Review of R1's clinical records revealed:10/24/24 - R1 was admitted to the secured unit of the facility with diagnoses including but not limited to mild cognitive impairment, major neurocognitive disorder and impaired decision making. R1's elopement assessment documented a score of 4, indicating a high risk for elopement.10/30/24 - R1's admission MDS assessment documented a BIMS score of 99, indicating the inability to conduct a cognitive interview. 10/31/24 (revised 1/29/25) - R1's elopement care plan documented, . Unaware of safety risk.at risk for wandering and eloping. want to return to the community. The interventions included, .Complete frequent face to face checks.1/22/25 7:33 AM - R1's clinical record documented, Resident was noted to be up at the nurses' station, fully dressed, with his shoes on. Resident repeatedly asked to leave his unit so he could walk to [previous place of residence] to get his hair cut. Resident informed that we could cut his hair but refused, insisted that he needs to go to [previous place of residence.] Resident remained near the nurses' station repeatedly asking people to let him out so he can walk to [previous place of residence].1/22/25 7:46 AM - R1's clinical record documented, Resident standing in front of the unit manager's office pleading with all the staff that passed by to let him out of the door.1/23/25 12:28 PM - R1's clinical record entitled Plan of Care Note, included, Risk for elopement due to recent talk of going to [name of recent place of residence.]1/23/25 2:54 PM - R1's clinical record documented, .Stated multiple times.been a year. want to go to [name of previous residence.] Please help [R1's name.]8/12/25 10:19 AM - R1's clinical record documented, Resident pacing up and down the hallway.8/15/25 4:44 PM - R1's clinical record documented, Resident was observed in the back hallway by the emergency exit door.9/4/25 12:02 PM - R1's clinical record documented, Resident expressed desire to leave the facility, per resident, it's been two years since he was taken to the hospital and then brought here. He stated, I am not sick, I want to go to [previous place of residence.]9/4/25 9:01 PM - R1's clinical record documented, Resident expressed desire to leave the facility to go [previous place of residence.]9/8/25 1:03 PM - R1's clinical record documented, Resident requested to speak with someone about getting out of this facility. Stated, I am not sick, I don't need to be here. Social Services came to speak with resident, reassured him that everything is being done to help him. Resident pulled out a piece of paper with his address written on it and stated, That's where I live. Resident spoke very clearly, explaining his experience in the hospital and how he got there and how he came to be at this facility. Resident expressed that he is very eager to get out of [name of current facility.]9/13/25 11:06 AM - R1's clinical record documented, Resident up out of his room, pacing around more than usual and expressing verbally the desire to leave, saying he's been here too long and wants to go back to where he used to live.9/14/25 8:53 PM - R1's clinical record documented, .Continues to stand in the hallway staring at the back and side doors.9/15/25 2:57 PM - R1's clinical record documented, Engaged in conversation with resident during which resident expressed his interest in going back to live the community.9/16/25 1:08 AM - R1's clinical record documented, . Ambulating back and forth in the hallway asking to go to [place of previous residence.]9/22/25 1:33 PM - R1's clinical record documented, . [R1] very vocal about his wants. Stated that he was brought to [name of facility] from the hospital and was supposed to stay here for a bit.9/23/25 - R1's annual MDS documented a BIMS score of 99, indicating the inability to conduct a cognitive interview.9/25/25 2:38 PM - R1's clinical record documented, Resident noted with slight agitation, kept saying he needs to get to [previous place of residence] to see his family. Redirected with little success. Noted to be standing by front doors of unit but no attempt to leave.9/26/25 6:00 AM - R1's clinical record documented, During unit rounds at 6:00 AM, resident was not noted to be in his usual sleeping position in his room. After a brief search of resident's room and his usual unit locations, still unable to locate resident, resident's window noted to be opened. 9/26/25 8:38 AM - The facility's investigation documented, E5 (QA) successfully located [R1] walking on the road. E5 was trying to convince him to get into the vehicle and he went into the [NAME]. Later, more staff came from [the facility] including the police. We searched the [NAME] for approximately 45 minutes but could not locate him. After 45 minutes to one hour, a driver passing by stopped and asked if we were searching for someone. We said yes, and he described the person and said he fit the description of someone he had just passed about two miles down from the location where we were searching. We saw [R1] walking on the road.and he was brought back to the facility. An alarm was put on the window, and he was placed on 1:1 close supervision for safety.9/30/25 11:00 AM - The Surveyor observed that R1's bedroom window had a device that sounded an alarm when the window was opened. A check of the windows on the secured unit revealed that 8 out of 10 windows were unlocked and easily opened by the Surveyor. There was a total of 18 residents who resided on this secure unit. 9/30/25 12:00 PM - During an interview E1 (NHA) stated, We knew that the resident [R1] was an elopement risk on admission. He was placed in the secure unit for close monitoring. He placed on 1:1 supervision for 72 hours from 9/26/25 through 9/29/25 after the elopement, then hourly visual checks. Window limiters were approved by the fire marshal and will be installed on all the windows on [name of unit] upon delivery.9/30/25 12:30 PM - A review R1's clinical records from his admission to the date of the elopement lacked evidence of a person-centered care plan for elopement despite multiple episodes of exiting seeking and verbalization of wanting to leave the facility.9/30/25 1:00 PM - A review the facility's video recording from 9/26/25 at 12 midnight to 6:30 AM revealed:12:03 AM - R1 was observed exiting his room and entering the hallway.12:08 AM - R1 was observed returning to his room.12:21 AM - Staff member was observed walking past the resident's room, did not enter.12:25 AM - Staff member was observed looking at the resident's room from the end of the hallway.12:58 AM - Staff member was observed walking past the resident's room, did not enter.1:39 AM - Staff member was observed walking past the resident's room, did not enter.1:52 AM - Staff member was observed walking past the resident's room, did not enter.2:20 AM - Staff member was observed walking past the resident's room, did not enter.2:45 AM - Staff member was observed walking past the resident's room, did not enter.3:44 AM - Staff member was observed walking past the resident's room, did not enter.4:02 AM - Staff member was observed walking past the resident's room, did not enter.4:26 AM - Staff member was observed walking past the resident's room, did not enter.4:41 AM - Staff member was observed walking past the resident's room, did not enter.4:46 AM - Staff member was observed walking past the resident's room, did not enter.4:56 AM - Staff member was observed walking past the resident's room, did not enter.4:59 AM - Staff member was observed walking past the resident's room, did not enter.5:10 AM - Staff member was observed walking past the resident's room, did not enter.5:40 AM - Staff member was observed walking past the resident's room, did not enter.5:55 AM - Staff member was observed walking past the resident's room, did not enter.6:04 AM - Staff member was observed walking past the resident's room, did not enter.6:07 AM - New staff on the unit, entered, exited the resident's room and walked back to the nursing station.6:10 AM - Staff members entered the resident's room, other rooms, and checked the back doors.6:11 AM to 6:18 AM staff members were observed outside of the building. The staff failed to follow R1's care plan for visual check for 18 out of 20 opportunities.10/1/25 10:00 AM - During an interview E8 (CNA) stated, The last time I saw the resident in the hallway was around midnight. The Surveyor asked E8 whether R1 had verbalized that he wanted to leave the facility. E8 stated, Yes, all the time.10/1/25 10:10 AM - During an interview E7 (CNA) stated, He [R1] was independent with going to the bathroom so I did not know I have to do anything for him at night. I did not know he was an elopement risk and needed to be checked every hour. I now know that I must see him with my eyes every 30 minutes. The Surveyor asked E7 whether R1 had verbalized that he wanted to leave the facility. E7 stated, Yes, many times.10/1/25 10:30 AM - During an interview E13 (LPN) stated, I check on my residents when I come on shift. I went into the room around 6:10 AM but did not see the resident. I checked the bathroom and the closet but did not see him. I went outside and saw that the window was open. I went to the tell the supervisor right away.10/1/25 4:00 PM - The facility's abatement plan for the immediate jeopardy included:- All staff in the facility and staff reporting for scheduled shifts were in-serviced on the current elopement policy and face-to-face checks for residents at risk for elopement.- The facility reviewed all current residents and identified 8 residents deemed to be at higher risk for elopement. These residents were placed on every one-hour face-to-face checks.- The care plans were updated to reflect specific interventions for high elopement risks.- An alarm was placed on R1's window and all the windows on the units were checked and locked. When windows were found to be damaged, maintenance was called for immediate repair.- R1 was moved to another secure unit with alarm on the window and double locks on both entrances.- All the windows on the secure unit have hard wired alarms and were tested on this same day.- Window limiters were approved by the fire marshal and will be installed upon delivery.10/1/25 1:00 PM - Staff interviews conducted, and in-service education and training verified.10/2/25 2:45 PM - Staff training records reviewed and verified. The IJ was abated at 3:00 PM.10/2/25 3:30 PM - Findings were verified with E1 (NHA) and E2 (DON.) 2. Review of R2's clinical records revealed:4/7/20 - R2 was admitted to the facility with diagnoses including severe intellectual disability, cerebral palsy and morbid obesity12/4/23 - A facility document entitled, Fall Risk Prevention Policy, documented, .The facility will ensure that the resident environment is safe and free of hazards. That each resident receives adequate supervision and assistance to prevent falls or minimize the risk for fall related injuries.3/14/25 - R2's quarterly MDS documented a BIMS score of 00, indicating an inability to conduct a cognitive interview. R2 was non-ambulatory and completely dependent on staff for all activities of daily living.5/11/25 8:57 PM - A facility incident report submitted to the Division documented, Resident fell from the bed to the floor during care and sustained a right eyebrow cut/swollen and Rt [right] knee abrasion. Provider was notified and resident sent to the ER for evaluation.5/13/25 11:00 AM - R2's clinical record documented, Resident seen today for decreased ROM [range of motion] to right knee. Right knee noted with swelling and warm to touch. Resident moaned and grimaced when the right knee was touched. Right knee tender to touch, resident unable to flex knee to 90 degrees. X-ray of right knee ordered.5/13/25 8:40 PM - R2's clinical record documented, .Showed that the resident's right femur is fractured.Send the resident out via 911.5/16/25 11:35 AM - The facility's 5 day follow up report to the Division documented, .admitted for right knee surgery due to a right femur fracture. She [R2] had surgery and returned on 5/16/25.10/1/25 2:00 PM - The facility's post fall investigation documented, [R2] was not care planned for falls because she is unable to move herself. E6 (CNA) interview statement documented, .[R2] does not move at all and cannot scoot because she is heavy. E6 advised that she turned [R2] on her right side as she reached for a washcloth. Resident was being turned towards the window and as she reached for the washcloth R2 rolled off the bed. She fell face down on the floor.The facility failed to provide adequate supervision to prevent R2's fall with injury.10/2/25 1:30 PM - A review of the facility's actions after R2's fall revealed:- R2's care plan was revised and updated for 2 staff members assistance with bed mobility.- All nursing staff were trained on fall prevention during resident care. The training included not rolling the resident away from the staff's body. Ensure that the resident is in the middle of the bed before turning him/her away from your body (if you must turn the resident away from you.)- The certified nursing assistant (CNA) involved in the fall was required to re-take new hire orientation, which included shadowing another CNA before she could return to provide resident care independently.- The fall was discussed and reviewed at the fall committee meeting on 5/16/25 and at QAPI meetings 6/30/25 and 7/28/25.- A review of all falls since 5/11/25 during the fall committee meeting and QAPI meetings revealed no falls relating to resident's positioning in bed or during care.10/2/25 2:30 PM - Based on staff interviews and review of the above corrective actions, it was determined that this deficient practice was past non-compliance with an abatement date of 5/16/25 at 3:00 PM. 10/2/25 3:30 PM - During an interview, findings were confirmed with E2 (DON).10/3/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) at the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that for one (R1) out of three residents reviewed for accident hazards and falls, the facility failed to ensure that R1 received adequate hands-on assistance and supervision to prevent a fall to the extent possible. R1, a cognitively impaired and dependent resident sustained a fall on [DATE] when two staff members improberly used a mechanical lift to perform a transfer. The facility's failure caused R1 to suffer a subdural hematoma and two (2) lacerations to her scalp. R1 was sent emergently to the hospital. Due to this failure, an Immediate Jeopardy (IJ) was called at 10:30 AM on [DATE]. Findings include: The facility's fall policy dated 2023 and titled, Fall Prevention, included, .The facility will ensure that the resident environment is safe and free of hazards. That each resident receives adequate supervision to prevent falls or minimize the risk for fall related injuries . Review of R1's clinical record revealed: [DATE] - R1 was admitted to the facility with diagnoses including dementia, chronic kidney disease and weight loss. [DATE] - R1's fall care plan (revised [DATE]) documented, Transfer with the help of 2 people using a mechanical lift, using the appropriate size sling . [DATE] - R1's quarterly MDS documented a BIMS score of 00, indicating a severe cognitive impairment. R1's MDS also documented, Complete dependence on the staff for all activities of daily living, including eating, dressing and transfers. [DATE] - E5 (CNA) documented in a facility's investigative document titled and timed 12:30 PM, Employee Interview Statement, After I provided care for [R1] Me and the nurse (R4 LPN) were putting her [R1] in the chair, and she slid from her sling to the floor. [DATE] - E4 documented in a facility's investigative document titled and timed 12:30 PM, Employee Interview Statement, .I was in the room .and started (the roommate's) tube feeding. After starting the feeding, I noticed [R1's] CNA come with a lift to get her up for lunch. I told her that since I'm already in the room, I will watch her while she put [R1] in her wheelchair. I watched [E5] connect all 4 hooks to the Hoyer lift. Then she lifted her (R1) up. I saw both of [R1's] legs of out of the sling, and I told [E5] that I will hold both legs so that they don't hit the wheelchair. I was not able to get to them in time. I heard [R1] fall on the floor. I ran immediately and called the unit manager in the dayroom. [DATE] 1:30 PM - E6 (NP) documented in R1's clinical record, Resident fell from the Hoyer lift a few minutes before we were called to the unit staff reports the fall was due to slipping while being transferred. Resident has bleeding of head, left hand, left leg pain .she repeated mumbled in distress .limited exam to her head because of diffuse bleeding and need to apply pressure to the laceration . [DATE] 2:44 PM - E4 (LPN) documented in R1's nursing progress notes, Resident fell at 1244 [12:44 PM] during 2 people transfer from her bed to her chair. She was noted with blood on the back of her head and her right shin. She was alert, treatment was provided. 911 was activated and was sent to the hospital. Of note, both E5 and E6's investigative statements documented that the fall occured at 12:30 PM. [DATE] 12:15 PM - The facility's immediate action plan included training of E4 and E5 on the use of the mechanical lift. [DATE] 1:30 PM - During an interview, E5 (CNA) stated, The fall happened so sudden and fast. I provided her care, and she was ready to get up in the chair. The nurse (E4) was in the room was taking care of the other patient. The nurse said, I am already here, I will help you. The pad was under the resident [R1] and I hooked up the sling to the lift. The nurse was on the other side of bed. I raised the sling to get her [R1] off the bed and tried to straighten myself and it happened suddenly. I was behind the lift and tried to open the legs of the lift to put the resident above the chair. The nurse was around the side of the bed, but the resident slid out of the bed before she could reach her. The Surveyor asked E5 if the nurse Had hands on the resident while she was being lifted from the bed. E5 stated, The nurse was coming around the bed to reach the resident. It all happened so fast. [DATE] 12:30 PM - During an interview R4 (LPN) stated, I was putting the feeding up for the roommate and the aide [E5] was helping [R1] to get up for lunch. She finished getting her ready to get up and I told her that I would help her with the lift. I was on one side of the bed, and the aide was on the other side. She started to bring her around to the chair, and I saw her [R1's] legs hanging out of the sling. I said, Hold on, let me secure her legs so they don't hit the wheelchair. The resident was in the air already by the time I got around from the other side of the bed. And [E5] was backing up with the lift to put her in the chair. I came around to help put the resident in the chair, but she started to slide and fell before I could reach her. I did not get to reach her legs before she hit the floor. [DATE] 10:30 AM - An Immediate Jeopardy was called due to the seriousness of this incident. [DATE] 1:30 PM - A review of R1's hospital records revealed that she sustained the following: - An intra cranial traumatic hemorrhage, - A 9 cm. laceration to the mid- scalp, - A 5 cm. laceration to the back of her scalp. R1 was placed on comfort care and expired at the hospital. The facility failed to provide the recommended use of two persons hands on assistance for R1 during the transfer from the bed to the wheelchair with the use of a mechanical lift. R1 sustained a traumatic fall which resulted in head injuries and expired at the hospital. [DATE] 3:30 PM - The facility's abatement plan was accepted. The facility's action plan included: - All nursing staff will complete a mandatory in-service training on the proper use of mechanical lifts and the requirement for two-person assistance with hands on the resident while in the air when transferring residents. - A review of the facility protocols for safe transfers, including the use of mechanical lifts, a detailed explanation of the risks and potential injuries caused by improper transfers, emphasis on the importance of following the care plan for each resident and using the required number of staff for transfers; and hands-on resident training while in the air, on proper techniques and safety protocols for lifting and transferring residents while using mechanical lifts. - A full review of all residents' care plans requiring two-persons assistance for transfers. [DATE] 1:00 PM - Based on the Surveyor's review of the facility's investigation, documented response, completion of audits from [DATE] to [DATE], staff interviews and no further mechanical lift fall or injuries, the IJ was considered abated on [DATE] at 7:00 AM. [DATE] 3:00 PM - Findings were reviewed at the exit conference with E1 (NHA), and E2 (ADON.)