**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from neglect for two residents (#1 and #2) out of five residents identified by the facility at risk for elopement, to prevent elopement. Serious harm occurred on 4/19/25, when Resident #1 was allowed to walk away from the facility unnoticed, walk along high traffic streets for eight miles, and end up on an Interstate Highway where he was found by the [State Highway Patrol]. Resident #1 was taken to a higher level of care for evaluation and treatment of dehydration. On 3/25/25 Resident #2 exited the facility through an emergency exit door and was found 10 -15 feet from the door walking away from the facility. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/ or death to Resident #1 and resulted in the determination of Immediate Jeopardy occurring on 4/19/25. The findings of Immediate Jeopardy were determined to be removed on 4/30/25 and the scope and severity was reduced to D after verification of removal of immediacy of harm. Findings included: Review of the medical record revealed Resident #1 was admitted on [DATE], with diagnoses including other specified disorders of [the] brain, unspecified lack of expected normal physiological development in childhood, anemia, mood disorder due to known physiological condition with mixed features, major depressive disorder, recurrent, moderate, hypertension, psychotic disorder with delusions due to known physiological condition, pedestrian on foot injured in collision with motor vehicle in nontraffic accident, pelvis fracture, skull and facial bone fractures, and lung contusion. A review of Resident #1's physician order summary report, dated 4/01/2025-4/30/2025, revealed the following: - Divalproex 250 mg (milligrams) AM (morning) dose and Divalproex 500 mg at bedtime for unspecified mood disorder. -Mirtazapine 15 mg for major depressive disorder. -Risperidone 0.5 mg for psychotic disorder with delusions. Review of Resident #1's physician attestation of a resident incapacitated form, dated 7/31/24, revealed the resident is physically and cognitively unable to communicate a willful and knowing health decision. Review of Resident #1's Brief Interview for Mental Status (BIMS), dated 3/31/25, revealed a score of 0, indicating severe cognitive impairment. Review of Resident# 1's Activity Participation Note, dated 3/24/25, revealed He gets around on his own and enjoys sitting in the porch enjoying fresh air . Review of Resident# 1's Narrative Nurses Note, dated 3/29/25, revealed Resident has been up walking about facility. Staff on 100 unit didn't know him and they tried to tell him he couldn't go and to go back to his floor. He went down towards the porch where he sits. Review of Resident# 1's Narrative Nurses Note, dated 3/30/25, revealed Male resident on 400 stuck up his middle finger at Resident #1, he leaned towards the other resident and mumbles no giving him (other resident) the finger back. I redirected Resident #1 back towards his room. Review of the Resident# 1's eInteract SBAR (situation, background, assessment, recommendation) summary for a Provider Note, dated 3/30/25, showed the following: Nursing observations Resident alleged to have hit another resident, [MD] and family notified, Psych consult, Psychosocial monitoring q (every) shift x (for) 72 hours, Lab work, and enhanced monitoring x 72 hours. Resident is not easily understood, reminded not to touch other residents. Review of Resident #1's Interdisciplinary Team (IDT) Narrative Note, dated 3/31/25, showed Review of incident resident allegedly hit another resident on the back . BIMS 0, post allegation abuse protocol initiated. Review of Resident #1's Medication Administration Report (MAR), dated April 2024, behavior monitoring, either 0 indicating none or N/A is documented daily from 4/1/25 to 4/18/25. Review of Resident #1's laboratory results, reported on 3/5/25, showed Valproic Acid (Depakote) 32.4 L (low) (range 50-100). Review of Resident #1's laboratory results, reported on 4/4/25 showed Valproic Acid (Depakote) 39.3 L (range 50-100) and Ammonia 125 H (high) (range 27-102). Review of the Resident# 1's eInteract SBAR summary for a Provider Note, dated 4/19/25 at 9:39 P.M., showed, Resident visually observed while in back of law enforcement vehicle and during transfer from one law enforcement vehicle to another. At the time, there were no injuries or signs or symptoms of medical distress . Resident transported to the ED (emergency department) for further evaluation. Review of Resident #1's care plan showed the following: Focus area: initiated on 4/22/25, elopement risk/wanderer related to history of leaving the facility impaired safety awareness, wanders aimlessly. The interventions included the following: allow to wander safely on the secured unit, distract resident from wandering by offering pleasant diversions, structures activities, food, conversation, television, books; provide structured activities: .walking inside and outside . Review of Resident# 1's Psychiatric report, dated 3/31/25, revealed Per staff report, the resident was involved in an altercation with another resident ., the patient allegedly struck another resident on the back of the head. Primary concern: impulsivity and agitation in the context of severe cognitive impairment. Depakote and Ammonia level ordered. Monitoring: continue to assess behavioral changes and adjust interventions as needed. The mental status exam showed Resident #1's thought association was non intact. During an interview on 4/28/25 at 10:10 A.M. Staff J, LPN said Resident #1 mumbles and is hard to understand, Walks all over the building, mumbles a lot. She said they are often short and sometimes work 12-16-hour shifts. During an interview on 4/28/25 at 10:20 A.M. the Activities Director, (AD) said prior to 4/19/25 the door from the facility to the non-smoking patio was left unlocked and residents could enter the patio unsupervised. She said Resident #1 told her he Wanted to go home. During an observation and interview on 4/28/25 at 12:46 P.M., Resident #1 was sitting on the side of his bed eating lunch. Resident #1's speech was slurred and difficult to understand. He said he was walking to see mother when he was found on the Interstate. During an interview on 4/28/25 at 1:00 P.M. Staff C, LPN, Unit Manager (UM) said on 4/19/25 at approximately 7:20 P.M. she received a call from Staff B, RN, NS telling her an elopement drill had been started because they could not find [Resident #1]. She notified the Nursing Home Administrator (NHA) and the Risk Manager (RM) immediately. Staff C, LPN, UM said, at approximately 730 P.M. a group text was sent to all department heads to come to the facility. The exit doors were checked. Staff C, LPN UM said she did not participate in the elopement investigation. During an interview and observation on 4/28/25 at 1:10 P.M. with the Director of Maintenance (DOM) and the Regional Maintenance Director, the DOM said the maintenance staff checks all facility exit doors daily. The DOM said the exit doors have a magnetic lock, and the process is to push the door for 15 seconds to verify the latch and alarm works. He said when the latch is disengaged a secondary keyed alarm is activated. He said, in the screened patio area, the screen door to exit the building has a padlock which is checked daily. The DOM said doors are checked between 8:00 A.M. and 10:00 A.M., Monday through Thursday and around 3:00 P.M. on Friday. The DOM said he checked all the exit doors on 4/18/25. The DOM stated on 4/19/25 after Resident #1 eloped all doors were checked; no issues were identified. He said the secondary alarm batteries were changed as a preventative measure. He said on 4/19/25 the screen in the lower portion of the patio screen door was pushed out and the rubber tubing to hold the mesh in place was laying on the ground. On 4/28/25 at 1:10 P.M. during a tour of the screened patio, observation revealed the screen door was secure with a padlock. The screen on the lower portion of the door screen was intact and a silver metal grate was secured on the exterior. During an interview on 4/28/25 at 1:32 PM with Staff H, Licensed Practical Nurse (LPN), Minimum Data Set (MDS) Nurse said on 4/19/25 at about 7:30 P.M. he received a group text notification a resident was not in the building, with instructions to come and assist. When Staff H, LPN, MDS arrived at a 7:40 P.M., the local police department was on the scene, and he was the first manager to arrive, and he accompanied the officer to search the facility for Resident #1. Staff H, LPN, MDS said, Staff O, Certified Nursing Assistant (CNA), unlocked the door to search the immediate area. He said, In the 400-hall screened in area they observed the bottom screen broken, blowing in the wind. Staff H, LPN, MDS said at approximately 8:20 P.M. a police officer told him Resident #1 was found. Staff H, LPN, MDS said, when the State Highway Patrol arrived with Resident #1, he assisted the Director of Nursing (DON) to assess, check neuros. He said the facility staff asked a local police officer to transport Resident #1 to a local hospital, they felt it was a safe transfer, a courtesy, did not have to use other resources. Review of the [State Highway Patrol (SHP)] call history record revealed the following: On 4/19/25 at 6:38 P.M. a pedestrian [Resident #1]; was found sitting down on the side of the Interstate-4 (I-4), westbound at mile marker number thirty-seven. [The posted speed on I-4 is 70 MPH]. At 6:50 P.M. the SHP contacted EMS [Emergency Medical Services] to check subject out (Resident #1). At 6:54 PM pedestrian possible mental disability. At 6:55 P.M. attempted to call emergency . At 6:56 P.M. [Resident #1] is trying to get home in [city] to [address listed on an expired identification card]. At 7:20 P.M. dispatch to transport Resident #1 to [address], in a different county. At 8:08 P.M. the report revealed [Resident #1] doesn't live at listed address any longer. At 8:10 P.M., Resident #1's family member told the police the name and address of the facility where Resident #1 lived. At 8:23 P.M. dispatch rerouted transport to the facility where Resident #1 lived. At 8:24 P.M. Local Police called to report subject missing At 8:26 P.M. trooper is returning subject to nursing home now and [local police] have officers at [the] nursing home now. At 8:31 P.M. [Resident #1] has been missing from nursing home all day had not reported it to [local police] yet. At 10:05 P.M. nursing home took custody. [local police] is transporting to [Local Hospital]. Review of the [Local Police] case report revealed the following: On 4/19/25 at 7:34 P.M. Resident #1, a missing, an endangered adult was reported. At 7:36 P.M. The local police department arrived at the facility upon arrival spoke with {Resident #1's nurse, Staff NN, Licensed Practical Nurse (LPN)}, who stated she last saw her patient {Resident #1} at 5:40 P.M., when he was walking towards the patio on the south side of the facility. {Staff NN, LPN} stated he usually walks the hallways or sits on the patio and looks outside. He {Resident #1} has been diagnosed with major depression, psychotic disorder, and brain disorders. There was a large hole in the patio screen door. I did not observe any footprints in the dirt near the door. {LPD} dispatch notified us that {SHP} located {Resident #1} near mile marker 37 on I-4 WB (westbound). Resident #1 was to walk to his former address { .Road}, {city}. {Resident #1} was returned to the facility by the State Highway Patrol. {Resident #1} was placed in a secure unit. The facility administrator was notified. {Resident #1} was taken to a local hospital for altered mental status. After arrival at the facility the local police responding officer received notification [Resident #1] had been located by the [SHP] The local police report showed transported to a local hospital for altered mental status. Review of Resident #1's local hospital records, showed the following: On 4/20/25 at 12:43 A.M. history and physical examination revealed the Chief Complaint was patient missing from {facility name} .found by law enforcement and brought to the ED patient non-verbal in triage. Patient is a {age} year old male with a history of unspecified brain disorders, prior skull fracture, and psychotic disorder, who is chronically housed at {name of facility}. Patient was reported missing and was found by the State Highway Patrol. He is difficult to obtain a reliable history due to significant dysarthria (motor speech disorder) and developmental delay, .he is intermittently redirectable and moderately communitive. {Resident #1's} laboratory testing was notable for Blood Urea Nitrogen (BUN) of 31 mg/dL (deciliter) (ref range 8-23), Creatinine of 2.09 mg/dL increased from 1.13 mg/dL baseline. (ref range 0.67-1.17), and Potassium of 5.2 mmol/L. (ref range 3.5-5.1) .Patient was admitted for further work up and management of AKI (acute kidney injury) and mild hyperkalemia (elevated potassium). Assessment and Plan: Acute kidney insufficiency, .dehydration, .acute kidney injury most likely secondary to volume depletion. Interventions included the following: monitor renal function , IV (intravenous) fluids, monitor intake and output, .Potassium 5.2 likely secondary to AKI. On 4/20/25 Resident #1's laboratory report revealed BUN 29 mg/dL, creatinine 1.47 mg/dL and potassium 4.7 mmol/L. On 4/21/25 Resident #1 was discharged from the local hospital and returned to the facility. Review Resident #1's Hospital to Nursing Home Medical Center Transfer Form (Form 5000-3008), dated 4/21/25, showed a primary diagnosis of dehydration. On 4/29/25 at 8:20 A.M. during an interview the Medical Records Director she said she interacts with Resident #1 on a regular basis, and they have a good rapport. She said Resident #1 usually saunters around the facility and does not bother anyone. She said Resident #1 normally sits in the nonsmoking (screened in) patio and prefers verbal redirection rather than being touched. She said prior to the incident on 4/19/25 Resident #1 stated he wanted to go home. On 4/29/25 at 8:52 A.M. during an interview and observation, with assistance of the Medical Records Director, Resident #1 said and gestured he left the facility from the non-smoking patio door. He said and gestured his removal of part of the screen on the patio door, crawling out to exit the facility. Resident #1 said he walked mile, mile (a long distance) and the police picked him up and took him to his former home in [city]. He said he did not have a key to open the door. Resident #1 said and gestured the police transported him back to the facility. Resident #1 was unable to communicate the time he exited the facility. Resident #1 was observed walking in a shuffle gait with tremors to bilateral upper extremities. On 4/29/25 at 9:09 A.M., during an interview Staff A, CNA said on 4/19/25 she was assigned to take care of Resident #1 during the 7:00 A.M. -3:00 P.M. and the 3:00 P.M. to 11:00 P.M. shifts. She stated before the incident Resident #1 did not have any behaviors, she said he normally walks down the 300 hall and sits in the screened patio area. Staff A, CNA said on 4/19/25 she went to the dining room around 5:00 P.M. and that was the last time I saw [Resident #1]. Staff A, CNA, said around 5:45 P.M. she went to Resident #1's room and noticed He had not touched his food. She said she went to check the screen patio where Resident #1 usually sits and the door [to enter from the hallway] was locked. Staff A, CNA notified Staff NN, Licensed Practical Nurse (LPN) to Call Code Amber (missing resident code) because she Knew the resident was not in the building because I looked in all the usual places the resident would have been. Staff A, said most of the staff began searching for Resident #1 and searched longer than we should have, there is a time limit for the {facility name} to search for a resident before they call the police, and they searched longer. Staff A, CNA said she did not see any damage to the door in the screened patio area, because the door from the hallway was locked. She said the hallway door was locked by someone in the activity department around 5:30 P.M. Staff A, CNA said Resident #1 was an elopement risk before this event but has never tried to leave. On 4/29/25 at 9:09 A.M. during an interview with Staff NN, Licensed Practical Nurse (LPN), said she was assigned to Resident #1 on 4/19/25 during the elopement. Staff NN said Resident #1 Likes to walk all over the facility. Staff NN, LPN said Staff A, CNA, told her Resident #1 had not eaten his dinner. Staff NN, LPN said she administered medications to Resident #1 at approximately 4:45 P.M. and the last time she saw the resident was around 5:00 P.M. Staff NN, LPN said Staff A, CNA Came up to me around 6:40 P.M. and asked if I had seen {Resident #1} because he had not touched his dinner. Staff NN, LPN said she told Staff A, CNA to check Resident #1's usual spots, In the green room on 400 Hall. Staff NN, LPN said she was not aware They locked the porch at a specific time, but she wanted Staff A, CNA to check All the areas the resident usually walks. Staff NN, LPN said Staff A, CNA told her Resident #1 was not on the porch. She said a Code [NAME] was called around 6:48 or 6:50 P.M. Staff NN, LPN said another nurse notified Staff B, Registered Nurse (RN) Nursing Supervisor (NS). Staff B, RN, NS notified the police and Resident #1's representative. Staff NN, LPN said when the police arrived an Activity person unlocked the green room, that's when I saw the screen was cut, the police put an alert out and they found the resident on I-4. Staff NN, LPN said they Only have 10 minutes to notify police during an elopement. On 4/29/25 at 11:01 A.M. during a telephone interview with Resident #1's Primary Care Physician (PCP) he stated he was notified of Resident #1's elopement and I was surprised to hear {Resident #1} got out. Resident #1's PCP said he did not have much information regarding recommendations because the facility had alarms on all their doors. The PCP said when Resident #1 returned from the hospital he was assigned to the 200 Hall, the locked unit, and now Resident #1 is back in his previous room. The PCP said, The facility should put Resident #1 back on the more secured unit, (200 hall) because it is safer for him, and he could be watched all the time. He said, It was very concerning when he was notified Resident #1 was found on I-4. On 4/29/25 at 11:15 A.M. during a telephone interview with the facility's Medical Director he said he was notified on 4/19/25 Resident #1 eloped from the facility and was found on I-4. He said Resident #1 is not his patient, but he has seen the resident walk all over the facility. The Medical Director said, the only recommendation is to have more monitoring for this patient. He said, I don't' think he would benefit from a locked unit because he likes to walk around. During an interview on 4/29/25 at 11:30 A.M. with Staff B, RN, NS she said on 4/19/25 she went to lunch about 7:09 P.M., while on lunch break she received a call from one of the nurses, telling her a resident [Resident #1] was missing. She said by the time she came back into the facility the code had been called, and she saw staff looking for {Resident #1}. Staff B RN, NS, said she notified the Director of Nursing (DON) and the Risk Manager (RM) to let them know the resident was missing. Then she contacted Resident #1's family member to see if {the family member} had picked up {Resident #1} from the facility. Staff B, RN, NS said she called the local police around 7:34 pm, 15 to 20 minutes after she was informed the resident was missing. She said she was familiar with Resident #1 because he walks all over the facility and the last time she saw the resident was in the morning. Staff B, RN, NS, said, As soon as management arrived at the facility, they took over the investigation. An interview was conducted on 04/29/25 at 3:00 P.M. with Staff BB, Activity Assistant (AA). Staff BB said the door from the hallway to the screened patio used to remain unlocked. Staff BB, AA, said she was working on 4/19/25 and arrived at work at 8:30 A.M. and did not leave the facility until 9:00 P.M. She said Resident #1 usually comes to the patio around 9:30 A.M. or 10:00 A.M. and after lunch he returns to the patio usually around 3:30 P.M. and stays until it is time to lock the door. Staff BB, AA said Resident #1 usually sits in a chair on the patio porch and looks out the door, and on 4/19/25 she did not see the Resident #1 all day. Staff BB, AA said, I think he wanted to go home for Easter. Staff BB, AA said she locked the door from the hallway to the patio around 5:15 P.M. A phone interview was conducted on 4/29/25 at 4:06 PM with Resident #1's representative. The Resident Representative (RR) said on 4/19/25 someone from the facility called to ask if he had checked the resident out from the facility. The RR said he told the facility around 6:00 P.M. or 7:00 P.M. a call was received from a State Trooper saying Resident #1 was found sitting on the side of I-4 and wanted a ride to his home. The RR said he informed the State Trooper Resident #1 does not live at the address and gave them the facility's name and address. The RR said he was concerned about a call he received from the facility today about finding another facility for Resident #1. The RR said the facility's Social Service said they would assist him with finding another facility, but he was concerned because, It was hard to get {Resident #1} admitted to the current facility, and he does not know how he will be able to find another facility. During an interview on 4/29/2025 at 4:45 P.M. with the NHA and the RM, the RM said elopement risk residents are identified before admission when a referral is received. After admission they use different tools such as the Hospital to Nursing Home Medical Center Transfer Form (Form 5000-3008), Preadmission and Resident Review (PASRR) forms, the history and physical, and the medication lists to determine if there are elopement concerns. She said nurses complete an elopement assessment on admission and the resident is given a score to indicate their elopement risk. She said if the resident has a score of 5 and above, they are at risk. The NHA said not all residents identified as an elopement risk are placed in the locked unit. There are different factors that could place a resident on the locked unit, such as preferences related to dementia care. The NHA said there are elopement books on every unit and the receptionist desk with pictures of residents identified as high risk for elopement. The NHA said information related to elopement risk is in the Electronic Health Record (EHR) on the resident profile. They said staff use care plans and Kardex for resident specific interventions. The NHA stated elopement risks are assessed on admission, quarterly and as needed. On 4/30/2025 at 11:38 A.M. an interview was conducted with the NHA and RM to review the facility's investigation of Resident #1's elopement on 4/19/25. They were notified Resident #1 was missing at approximately 7:21 P.M. by Staff C, LPN, UM. The NHA said a group message was sent to managers to report to the facility immediately. The NHA said the facility's investigation of the elopement on 4/19/25 showed the following: 4:53 P.M. Staff NN, LPN administered medication to Resident #1. 5:00 P.M. Staff A, CNA observed Resident #1 across the hall from the screened porch area. 6:00 PM Resident #1's meal was left in his room; 6:30 P.M. the State Highway Patrol found Resident #1 on I-4 and MM 37. 6:50 P.M. Staff A noticed the meal had not been eaten, 7:05 P.M. Code [NAME] was called, 7:21 P.M. Staff B, RN NS notified Staff C, LPN, UM; 7:25 P.M. Staff B, RN NS notified Resident #1's representative; 7:42 P. M. local police department arrived; 9:10 P.M. Resident #1 arrived to the facility. When Resident #1 said he wanted to go home, he was transported by the State Highway Patrol to an address listed on identification card for the resident. Resident #1 was taken to [city] approximately 45 minutes from the facility and the State Highway Patrol had to transport him back to the facility. The local police department transported Resident #1 to a local hospital. The NHA said the facility concluded that the door from the hallway to the screened patio was not secure and residents had unsupervised access. The NHA said there was a delay in notifying the local police department and they should have been notified after 10 minutes. A review of Resident #2's admission record revealed an admission date of 11/5/23 with the following diagnoses: Heredity and idiopathic neuropathy, asthma with status asthmaticus, protein calorie malnutrition, chronic obstructive pulmonary disease (COPD), mood disorder, major depressive disorder, and dementia. A Review of Resident #2's MDS, dated [DATE], Section C-Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of is 0 indicating severe cognitive impairment. A review of Section E-Behavior showed wandering behavior has occurred 1-3 days. A review of Resident #2's Care Plan, dated 4/21/25 showed the following: Focus area of elopement/wanderer r/t History of attempts to leave facility unattended, Impaired safety awareness with an initiated date of 4/21/25 and interventions for this focus area to include allow to wander safely on the secure unit. A review of Resident's #2 Narrative Nurses Note, dated 3/25/25, showed nurse heard alarm from side door on 300 hall door was open wide nurse observed {Resident #2} ambulating away from the building. {Resident #2} stated she was trying to leave. She was assisted to her room and placed on one-to-one observation. During a telephone interview on 4/29/25 at 11:15 A.M. the facility's Medical Director said he was not familiar with Resident #2. He stated he did not consider Resident #2 exiting the facility's locked door to be an elopement. He stated he does not have any concerns about the supervision of the residents. He stated he would be more concerned if these types of events happened more frequently. An interview was conducted on 4/30/25 at 2:26 P.M. with the NHA and the DON regarding the facility investigation of Resident #2's elopement on 3/25/25. They stated the investigation showed: At 6:45 Staff AA, LPN observed Resident #2 walking on 300 Hall At approximately 7:00 P.M. Staff AA, LPN heard the emergency exit door alarm, exited the medication room and observed Resident #2 walking away from the door, approximately 23 feet from the doorway. At 7:08 P.M. the NHA was notified of the elopement. The NHA said on 3/26/26 there was an Ad Hoc committee meeting held and after investigating the event the facility concluded Resident #2's elopement was an isolated event. The NHA said the facility provided a review of the Abuse, Neglect and Exploitation policy, wandering and elopement education, and increased the frequency of elopement drills. A review of the facility's policy titled Abuse, Neglect and Exploitation, revision date 4/2004, showed the following: Policy: It is the policy of this facility to provide protections for the health, welfare .and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect . Definitions: Neglect means failure of the 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. Policy Explanation and Compliance Guidelines: The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention; . Employee Training topics will include: 1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation; 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: .b wandering ort elopement-type behaviors Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect .G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur. Coordination with QAPI: The facility has written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI program. Review of the facility's policy titled Exit Doors, implementation date 9/1/23, showed the following: Definitions- Egress refers to the action of going out of or leaving a place. Policy Explanation and Compliance Guidelines: Check operation of magnetic door locks (if applicable) 1. Inspect door lock mounting and operation and inspect panic hardware .3. Any magnetically locked doors must automatically unlock during a fire alarm (verify this during your normal fire drill) .Check delayed egress operation (if applicable) 1. Push door release hard for a fraction of a second - door should not open and alarm should not sound 2. Apply pressure to the door release for the pre-determined nuisance period setting (normally 1-3 seconds) 3. Door should go into irreversible unlocking sequence 3 a. Door alarm will sound 3 b. Door will automatically open within 15 seconds . Ensure signs are placed on doors adjacent to the release device that read 'Push until alarm sounds. Door can be opened in 15 seconds Document results of inspection in logbook. Review of the facility's policy titled Elopements and Wandering, implementation date, [undated], showed the following: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit), or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Complia[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross Reference F921 Based on observations, interviews, and record review, the facility failed to provide supervision and failed to prevent accident hazards to prevent a fall with injury for one resident (#6) of 19 ambulatory residents in the memory care unit. The facility failed to replace a clean-out drain located in a high traffic area of the facility's memory care unit and failed to promptly and effectively address flooring issues, resulting in an unsafe walkway, where Resident #6 tripped and fell. On 1/20/2025, Resident #6 was ambulating in the hallway outside her room and suffered a fall significantly impairing the ability to walk independently and complete Activities of Daily Living (ADLs) at her prior functional level. The resident suffered a significant change due to a fractured right femoral head requiring a surgical intervention of a right hip arthroplasty. The facility's failure to provide supervision and prevent accident hazards caused serious harm and injuries to Resident #6 and placed 18 additional ambulatory residents in the memory care unit at risk for serious injury, harm, and/or death. This failure resulted in the determination of Immediate Jeopardy on 1/20/25. The findings of Immediate Jeopardy were determined to be removed on 2/28/25 and the severity and scope was reduced to a D. Findings included: A review of Resident #6's admission record revealed the resident was [AGE] years old, originally admitted to the facility on [DATE], with a recent hospital stay from 1/20/25 to 1/26/25. The record showed diagnoses to include a displaced fracture of base of neck of right femur subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, difficulty in walking, presence of right artificial hip joint, and dementia and other diseases classified elsewhere unspecified severity with agitation. A review of the Situation, Background, Appearance, and Review (SBAR) Communication Form and Progress Note revealed Resident #6 had a change in condition of a fall on 1/20/25. The Situation section of the form documented status post fall, trip and fall in hallway, complaining of lower back and right leg pain. The Background section documented the resident has new pain with an intensity of 9 out of 10 (10 being the worst). The Appearance section documented status post fall in hallway, left in place due to pain on movement. 911 called. The Review and Notify section documented that the primary care clinician was notified on 1/20/2025 at 8:40 a.m. with recommendations to send to the emergency room (ER) for evaluation. The Family Member (FM) was notified on 1/20/2025 at 8:44 a.m. A review of Resident #6's hospital History and Physical Report, dated 1/20/25 at 12:59 p.m. revealed this [AGE] year-old female had a medical history of dementia, dyslipidemia, and COPD [chronic obstructive pulmonary disease]. The nursing home resident, presented to the hospital from the nursing home after a fall. The patient was found on the ground and complaining of right hip pain. The patient's baseline was confused, and she could only recognize her [FM]. The completed radiology imaging studies, on 1/20/25 at 10:44 a.m. showed a right femoral neck fracture. The Computed Tomography Scan (CT) of the pelvis without contrast, on 1/20/25 at 10:04 a.m., revealed impacted right femoral neck fracture with angulation and mild displacement. The X-ray results of the right femur and right hip with pelvis showed normal mineralization. A review of a hospital consultation note dated 1/20/25 at 6:04 p.m. showed the resident was complaining of right hip pain and the physical examination showed the right lower extremity was shortened and externally rotated. The assessment/plan showed resident would benefit from operative intervention of the right hip in order to provide stability to the fracture and promote satisfactory healing, to improve pain, to facilitate early motion and mobilization and to prevent complications associated with prolonged bedrest. The risks, benefits, complications, and alternatives treatments were explained to the patient and FM. This included the possibilities of infection, deep vein thrombosis, reaction to anesthesia, neurovascular compromise, death or dying on the table, incomplete relief of symptoms, and chronic pain or stiffness. A review of the operative report on 1/21/25 at 9:08 a.m., showed Resident #6 had undergone a right hip hemiarthroplasty. The post-operative X-ray results showed the prosthesis was well-seated with no evidence of hardware loosening or failure. A review of Resident #6's clinical record at the facility prior to the 1/20/25 fall with a fracture revealed a quarterly Minimum Data Set (MDS), dated [DATE]. The cognitive pattern (Section C) showed a Brief Interview of Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The functional abilities assessment (Section GG) revealed the resident was independent with eating, oral and toileting hygiene, and upper/lower body dressing. The resident required supervision with shower/bathing self, putting on/taking off footwear, and personal hygiene. The resident was independent with rolling left to right, sitting to lying, lying to sitting, sit to stand, transferring from chair/bed-to-chair, toilet transferring, walking 10 feet and walking 50 feet with two turns. The resident required partial assistance with tub/shower transfer, and supervision with walking 150 feet. The resident was always incontinent of bladder and frequently incontinent of bowel (Section H). The health conditions assessment (Section J) revealed the resident had no pain 5 days prior to the assessment, and had not fallen since admission/entry, reentry, or prior assessment. A review of Resident #6's last Physical Therapy (PT) Discharge Summary (prior to the 1/20/25 fall with a fracture) was dated 12/26/2024 and showed the resident was able to ambulate with no assistive device with modified independence (MI) for up to 300 ft. or as tolerated on level surface with verbal cues for directional changes. A review of Resident #6's last Fall Risk Evaluation (prior to the 1/20/25 fall with a fracture) was dated for a last known fall on 11/25/24 with a fall risk score of 9 (a score of 8 or higher indicates a fall risk). A review of a facility note dated 1/26/25 at 5:30 p.m., showed Resident #6 returned to the facility from the hospital following a right hip hemiarthroplasty (related to the fall on 1/20/25). The record showed the resident was in pain whenever touched. The resident had a surgical wound on the right thigh. A review of a Fall Risk Evaluation conducted on 1/26/2025 at 5:39 p.m. showed the last known fall was on 1/20/25. The resident's fall risk score was 17. A review of a PT Evaluation dated 1/27/2025 showed Resident #6's prior level of function (PLOF) for bed mobility and transfers was independent with a baseline on 1/27/2025 of total assistance. The PLOF for walking was supervision with rolling walker up to 200 feet with a baseline on 1/27/25 of unable. A review of Resident #6's 5-day MDS (post fall and hospitalization), dated 1/28/25, revealed the resident had a BIMS score of 00, indicating severe impairment. The functional abilities assessment showed the resident was dependent on eating, oral and toileting hygiene, shower/bathing, upper/lower body dressing, and putting on/taking off footwear. The resident was dependent for rolling left to right, sitting to lying, lying to sitting, sit to stand, transferring from chair/bed-to-chair, toilet transferring, car transferring, walking 10 feet, walking 50 feet with two turns, and walking 150 feet. The assessment showed the resident was using a manual wheelchair. The resident was incontinent of bowel and bladder. The health conditions revealed frequent pain, no falls in the last month prior to admission/entry or reentry, no fracture related to a fall in the 6 months prior to admission/entry or reentry and had major surgery during the 100 days prior to admission. A review of Resident #6's care plan initiated on 8/21/2024 and revised on 1/30/2025 revealed the resident was at risk for falls related to history of falls, poor safety awareness, incontinence, dementia, psychotropic medication use, and neuropathy. The interventions for the care plan included: Ensure resident has a safe environment: (Specify: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position; handrails on walls, personal items within reach) initiated on 8/21/2024. 1/20/2025 Keep environment/walkway free of trip hazards initiated on 1/20/25 and revised on 1/30/2025. 10/25/2024 Family to assist with decluttering room for safety initiated on 11/25/2024 and revised on 1/30/2025. 2/12/2025 Scoop mattress initiated on 2/13/2025. During a facility tour on 2/24/25 at 10:30 a.m. an area of rough and uneven concrete approximately 3ft (feet) x 2 ft in the middle of the corridor of the 200-hall located inside the memory care unit. The uneven concrete area had a drain cap located near the middle that was raised. The concrete area was a known high-traffic area, outside of the secured memory care dining room, the nurses' station, and just outside of Resident #6's room. A review of an electronic work order created on 12/18/24 at 6:31 p.m. by Staff G, Licensed Practical Nurse (LPN) revealed clean out cover missing, location 200 hallway, priority level medium, and a note/comment to repair drain on 200 hallway asap [as soon as possible]. The status of the order was updated by the Director of Maintenance (DOM) on 12/27/24 at 2:49 p.m. as Set to Completed. A Room Audit Form, for Project Clean OUT 200 Hall with a start date of 12/18/24 revealed daily notes monitoring the clean out cover area from 12/18/24 to 1/24/25 documented by the DOM. The first entry on the log, dated 12/18/2024, showed the (DOM) placed a metal sheet cover over the drain opening with tape. The entry on 12/27/24, the day the work order status was updated, showed a visual inspection was done in the morning and fresh tape was applied that evening. None of the entries between 12/18/24 and 12/27/24 showed any additional work outside of visual inspection and applications of fresh tape was completed. A review of the audit log revealed no documentation to show the area was visually inspected to ensure safety of residents, staff, and visitors on 12/21/24, 12/22/24, 12/25/24, 12/28/24, 12/29/24, 12/31/24, 1/4/25, 1/5/25, 1/10/25, 1/11/25, 1/12/25, 1/15/25, 1/16/25, 1/22/25, and 1/23/25. The log showed on 1/20/25 morning - Resident [#6] fall, fresh tape -plumber called -Received Quote & Sent. The log showed on 1/24/25 evening - Job completed. A review of an email dated 2/25/25 confirmed the plumbing company had completed a repair of the area on the 200 hall on 1/24/25, 4 days after Resident #6 fell and 37 days after the original work order was created. An interview on 2/25/25 at 1:34 p.m. with Staff C, Certified Nursing Assistant (CNA) revealed she witnessed Resident #6's incident on 1/20/25. Staff C, CNA reported Resident #6 was in the hallway with her FM. The resident was attempting to detach herself from tape on the floor in the unrepaired plumbing area that was covered with concrete. The staff member stated the tape was not holding anything down. Staff C saw Resident #6 lose her balance and fall. Review of a written statement by Staff C, CNA dated 1/20/25 at 8:30 a.m. showed Staff C was coming down the hall with a breakfast tray and witnessed Resident #6 trip and fall over an area on the floor. The tape was coming up and Resident #6's foot got caught on it. On 2/25/25 at 9:45 a.m., an interview was conducted with the DOM. He stated on 200-hall, the memory care unit, a resident had pulled the clean-out cap off, on 12/18/24. The DOM reported roping the area off and cutting a metal piece to fit on top of the missing cap. He stated this was done after Resident #6 had fallen. The DOM stated the facility had plumbers come in on 1/24/25. The DOM stated from 12/18/24 to 1/24/25, he had put several patches on the area, and went back every day to make sure it was secure and safe. The DOM reported the plumbers removed the tile all the way around the clean out cap, leaving a cemented patch. On 2/25/25 at 10:46 a.m., the DOM observed the 200 hall and showed the area where Resident #6 had fallen in the hallway. The area was near the nursing station in the 200-hall and just outside of Resident 6's room at that time of the 1/20/25 incident. The DOM observed an additional area of missing floor tiles on the 200 hall and stated the facility had just received the diamond blades to smooth out the concrete. He stated the plumbers had to remove the tiles to fix a plumbing issue. During the time of this interview, the DOM confirmed the area where Resident #6 had fallen was still uneven due to the concrete patch left by the plumbers on 1/24/25. A follow-up interview on 2/26/25 beginning at 3:05 p.m. with the DOM revealed the rough concrete patch observed during the survey beginning on 2/24/25 was part of the repair. The DOM stated he had to research a replacement cap since the missing cover was so old. The DOM stated the plumber did not have a cap to fit the cast iron piping, so the plumber had to make the hole bigger and cut pipe to fix it. The DOM revealed this repair happened in the middle of January. The DOM stated he had put a metal plate on the area trying to save the company money in December 2024. The DOM reported he was researching it to try to fix it himself before calling the plumbers in, but after Resident #6's fall, he was done searching for the replacement and decided to get plumbers in. The DOM stated he felt the location where Resident #6 fell was safe and felt the [brand name] tape was a good tape to use as a temporary fix. The DOM reported the diamond grinding wheel, needed to smooth out concrete, had been back ordered and came in last week. The DOM said he had looked at local merchants for the grinding wheel, but they did not have the size needed in stock. The DOM stated the diamond wheel was delivered on 2/14/25, the day before he went on vacation. Review of the online merchant's receipt for the 4.5-inch diamond concrete grinding wheel showed the order was placed on 1/27/25 and shipped on 1/27/25. At the time of this interview, the area where Resident #6 fell was still not fully repaired leaving a rough and uneven flooring surface in this high traffic area. During an interview on 2/25/25 at 2:15 p.m., the Director of Nursing (DON) stated Resident #6 had been ambulating in the hallway with a family member and her foot kind of got stuck on tape. The DON reported the FM grabbed the resident had pulled her, then the resident lost her balance and fell. The DON stated the resident had a history of osteopenia and because of right hip pain the resident was left on floor. The DON stated she interviewed Staff B/CNA, Staff C/CNA, and Staff E, Licensed Practical Nurse (LPN). The DON stated Staff E, LPN was sitting at the desk and did not witness the fall, but heard the resident call out and saw her lying on the right side. The DON confirmed Resident #6 suffered a fall, was transferred out to the hospital, had surgery and came back to the facility. The DON stated Resident #6 had suffered a previous fall on 10/25/24. She stated the resident had a big chair in her room at the time so the family decluttered the room and when the resident started ambulating, the facility ensured the environment was free of clutter and slip hazards to prevent additional falls. An interview was conducted on 2/26/25 at 12:00 p.m. with Staff J, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member described the area of concrete as similar to other drains on unit, showing a circular drain with a square metal outer plate. Staff J, LPN/UM stated the residents on the unit like to pick at it and had pulled the square metal plate up. Staff J, LPN/UM stated maintenance had covered the area with a metal square that was approximately the same size as the missing plate and secured it to the floor with yellow and black striped industrial tape so it would be recognized as a caution area. Staff J, LPN/UM stated she doubted the residents in the memory care unit would have recognized the tape as a caution area. The staff member stated the concrete area was a high-traffic area as it was between the dining room, Resident #6's room, and the nursing station on the memory care unit. Staff J, LPN/UM stated they had a lot of residents wandering up and down the hallways due to dementia on the unit. Staff J, LPN/UM said she could only report it to maintenance, and then it was out of her hands. Staff J, LPN/UM stated the metal and tape was a hazard, and during the repair period, the area had become larger in size. A review of a work order dated 12/3/24 at 2:24 p.m. showed Staff J, LPN/UM reported missing tile on the floor of the 200 hallway with a medium priority level. The work order was acknowledged by the DOM on 12/27/24 at 3:30 p.m. with a status of Set to-In-Progress. The work order was updated on 2/26/25 at 2:17 p.m. by the DOM with a status of Set to completed. On 2/24/25 at 10:18 a.m., a second area in hall 200 towards the front of the facility, near the janitor supply closet #3 was observed with 12 missing tiles. The area was in the walking path of residents in the memory care unit. The area had a raised drain with a cap near the middle of it. An immediate interview was conducted with Staff B, Certified Nursing Assistant (CNA) who confirmed the area had been in disrepair for a long time and estimated it to be approximately 6 to 8 months. On 2/24/25 at 10:38 a.m., the entrance ramp to the 400-hall was observed missing five full carpet squares (approximately 2 ft x 2 ft) and 5 half carpet squares leaving exposed concrete with a raised drain that was not level to the concrete, and the carpet that remained was not level with the concrete. A yellow traffic cone was placed in the corner from the hallway to the ramp. This area was the inside entrance for residents, staff and visitors to access the 400-hall and used frequently by residents with ambulation devices and wheelchairs. On 2/27/25 at 2:04 p.m., the Regional DOM reported not being aware of the flooring issue. The Regional DOM stated depending on severity, if something could not be handled in-house the facility contacted vendors for repairs. The Regional DOM expected something to be implemented promptly, within one to two weeks for the safety of the residents. During a facility tour of the 200 hall on 02/27/2025 at 2:21 p.m. with the Nursing Home Administrator (NHA), revealed tiles that were popping up on the edges where the facility had replaced flooring using old tiles. The NHA confirmed the area was a hazard for someone with a shuffling gait. The NHA stated the tiles needed to be put down again and better. The NHA stated her expectation was an immediate fix for any hazard affecting residents. The NHA observed the area where Resident #6 fell and stated she expected the area to be safe for the residents. The NHA stated it was unacceptable to wait to repair the floors. Photographic evidence was obtained. Review of the Fall Prevention Program, implemented on 9/1/24, revealed Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy defined a fall as an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g. resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. The policy explanation and compliance guidelines showed the facility utilized a standardized risk assessment for determining a resident's fall risk. Low/moderate risk protocols include implementation of universal environmental interventions that decrease the risk of a resident falling, including, but not limited to: A clear pathway to the bathroom and bedroom doors. A review of the facility's immediate actions to remove the Immediate Jeopardy included: 1. Immediate Action: • Environmental rounds completed, identified areas of concern noted. • Summoned Corporate Plant Operations support team for assistance. • Quality review completed for all current residents sustaining a fall to ensure plan of care is in place in the past 6 months, no discrepancies noted. • Medical Record Review of all residents with falls with major injury in the past 6 months conducted; no discrepancies noted. • 99.5% of all facility staff were educated by 9:00 a.m. on 2/28/2025. • Initiated and assigned direct care staff member as Hallway Safety Monitor on secure unit (200 Hall) for additional supervision. Hallway Safety Monitor will be assigned for 24 hours a day X 7 days to establish a pattern of ambulatory residents. When pattern is established, Hallway Safety Monitor will be staffed from 0700 to 2300 daily X 14 days. Then, as pattern is further established, Hallway Safety Monitor will be staffed 12 hours daily X 30 days. Hallway Safety Monitor staffing hours will be adjusted as indicated. 2. Identification of others at risk was accomplished by: • On 2/26/25-2/27/25 The Director of Clinical Services (DCS) and designee(s) reassessed all residents residing in the facility for fall risk via Fall Risk Evaluation. • Facility implemented Activities Invitation Rounds for residents identified at risk for falls. Activities staff will encourage identified residents to attend activities of choice and document on log to establish a pattern of attendance/ preferences. • The Care Plan Coordinator(s) completed review of care plans to ensure all residents identified as at risk for falls (Fall Risk Score of 8 or higher) had safety measures, as well as resident specific interventions in place and to ensure the safety measures and resident specific interventions are also reflected on the [NAME] so that the CNA's have access to this information. • Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and fall hazards. • Identified environmental concerns addressed by priority level, initiated repairs and ongoing. • Record review of Resident #6 completed. Therapy screen completed on 1/22/2025; PT/OT services ongoing. Resident seen by psych provider. No changes in mood or mentation noted. Pain Management in place. Resident has orders for pharmacological pain intervention: Tylenol, Lidocaine External Patch, and Tramadol as of 2/27/25. Resident was previously on Norco, but medication was discontinued. 3.Actions to Prevent Occurrence/Recurrence: • NHA, DCS, and Plant Operations/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion. • Regional DCS educated the DCS on the facility's Fall Prevention Program, all facility fall related policies, how to conduct an RCA, and how to ensure incident investigations are timely and complete. • DCS/designee re-educated staff on facility Fall Prevention Program guidelines, following care plan/[NAME] interventions, as well as all facility fall related policies. • DCS/Designee re-educated staff on Abuse, Neglect, Exploitation Policy. • DCS/Designee re-educated staff on Residents' Rights. • DCS/Designee re-educated staff on Accidents and Supervision Policy. • DCS/Designee re-educated staff on Recognizing & Reporting Hazards. • DCS/Designee re-educated staff on Redirecting Residents with Cognitive Deficits from Environmental Hazards • DCS/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm. • The Director of Clinical Services/designee to conduct quality monitoring of new admission fall risk evaluation completion to ensure that risk factors, safety measures, and resident specific interventions are reflected on the care plan and [NAME] five times weekly x 8 weeks, three times weekly x 2 weeks; twice weekly x 2 weeks, then weekly and PRN (as needed) as indicated. • A Performance Improvement Plan (PIP) has been initiated to report on the above monitoring and auditing procedures. All finding from the PIP will be presented at the monthly Quality Assessment & Assurance (QAA) meeting. Monitoring/auditing and reporting will continue for a minimum of three months. 4. NHA/Plant Ops/Designee will round to ensure facility is free of hazards daily X 7 days, then daily X 5 days, then twice weekly x 8 weeks; then weekly and PRN as indicated. DON/designee will review all falls at the clinical meeting with the IDT (interdisciplinary) daily X 5 (Business Days) for 4 weeks to ensure appropriate fall interventions are implemented, the resident's care plan has been reviewed and revised, and the [NAME] has been update; then 3 x weekly X 4, then twice weekly x 4, then weekly x 4, then monthly x 3; and PRN as indicated. Regional DCS will review falls weekly for three months to ensure a RCA (root cause analysis) has been conducted and that resident specific interventions are reflected in the care plan as well as updated on the [NAME]. These audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee by the assigned auditors for three months. Verification of the facility's removal plan was conducted by the survey team on 2/28/25. On 2/28/25 observations were made to ensure the facility repaired the concrete area in the 200-hall to include level tiles and repaired the area at the end of the 200-hall to ensure the tiled area was level. The facility removed the carpet on the 400-ramp and replaced it with two pieces of rolled carpet. The facility educated 99% of their staff on notifying supervisors of accident hazards and to notify other management if the hazard was not repaired. Interviews were conducted with 77 staff members, which included the NHA, the DOM, 13 licensed nurses, 17 CNAs, and 45 other staff members across all shifts. The staff members were able to state that they had been trained and were knowledgeable about the new procedures. Interview with the NHA on 2/28/25 revealed a couple of the staff were not reachable, but a system was put into place for education prior to their next working day. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 2/28/25 and the non-compliance was reduced to a scope and severity of D.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross Reference F689 Based on observations, interviews and record reviews, the facility failed to provide a safe environment, free from flooring hazards for staff, the public, and 19 ambulatory residents in the facility's secure memory care unit. One (Resident #6) of the 19 ambulatory residents fell on 1/20/2025, sustained a fracture to the right femoral head (top of thigh bone), required a transfer to a higher level of care, and surgical intervention due to a floor repair that was not completed by the facility. The injuries to Resident #6 caused a significant decline in her ability to ambulate and complete activities of daily living (ADLs) at her prior functional level. The facility's failure to maintain a safe walking environment caused serious injury and harm to Resident #6 and placed 18 additional ambulatory memory care residents, staff, and visitors at risk for serious injury, harm, and/or death. This failure resulted in the determination of Immediate Jeopardy on 1/20/25. The findings of Immediate Jeopardy were determined to be removed on 2/28/25 and the severity and scope was reduced to a D. Findings included: A review of an electronic work order created on 12/18/24 at 6:31 p.m. by Staff G, Licensed Practical Nurse (LPN) revealed clean out cover missing, location 200 hallway, priority level medium, and a note/comment to repair drain on 200 hallway asap [as soon as possible]. The status of the order was updated by the Director of Maintenance (DOM) on 12/27/24 at 2:49 p.m. as Set to Completed. A Room Audit Form, for Project Clean OUT 200 Hall with a start date of 12/18/24 revealed daily notes monitoring the clean out cover area from 12/18/24 to 1/24/25 documented by the DOM. The first entry on the log, dated 12/18/2024, showed the (DOM) placed a metal sheet cover over the drain opening with tape. The entry on 12/27/24, the day the work order status was updated, showed a visual inspection was done in the morning and fresh tape was applied that evening. None of the entries between 12/18/24 and 12/27/24 showed any additional work outside of visual inspection and applications of fresh tape was completed. A review of the audit log revealed no documentation to show the area was visually inspected to ensure safety of residents, staff, and visitors on 12/21/24, 12/22/24, 12/25/24, 12/28/24, 12/29/24, 12/31/24, 1/4/25, 1/5/25, 1/10/25, 1/11/25, 1/12/25, 1/15/25, 1/16/25, 1/22/25, and 1/23/25. The log showed on 1/20/25 morning - Resident [#6] fall, fresh tape -plumber called -Received Quote & Sent. The log showed on 1/24/25 evening - Job completed. A review of an email dated 2/25/25 confirmed the plumbing company had completed a repair of the area on the 200 hall on 1/24/25, 4 days after Resident #6 fell and 37 days after the original work order was created. During a facility tour on 2/24/25 at 10:30 a.m. an area of rough and uneven concrete approximately 3ft (feet) x 2 ft in the middle of the corridor of the 200-hall located inside the memory care unit. The uneven concrete area had a drain cap located near the middle that was raised. The concrete area was a known high-traffic area, outside of the secured memory care dining room, the nurses' station, and just outside of Resident #6's room. A review of Resident #6's admission record revealed the resident was [AGE] years old, originally admitted to the facility on [DATE], with a recent hospital stay from 1/20/25 to 1/26/25. The record showed diagnoses to include a displaced fracture of base of neck of right femur subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, difficulty in walking, presence of right artificial hip joint, and dementia and other diseases classified elsewhere unspecified severity with agitation. A review of the Situation, Background, Appearance, and Review (SBAR) evaluation for Resident #6, dated 1/20/25, showed the resident tripped and fell in the hallway, complaining of lower back and right leg pain. The evaluation revealed new pain in the right thigh, lower back and right leg with an intensity score of 9 of 10. The documentation revealed the resident was left in place due to pain on movement, and the primary physician placed an order to send the resident to the emergency room (ER) for evaluation on 1/20/25 at 8:40 a.m. An interview on 2/25/25 at 1:34 p.m. with Staff C, Certified Nursing Assistant (CNA) revealed she witnessed Resident #6's incident on 1/20/25. Staff C, CNA reported Resident #6 was in the hallway with her Family Member (FM). The resident was attempting to detach herself from tape on the floor in the unrepaired plumbing area that was covered with concrete. The staff member stated the tape was not holding anything down. Staff C saw Resident #6 lose her balance and fall. Review of a written statement by Staff C, CNA dated 1/20/25 at 8:30 a.m. showed Staff C was coming down the hall with a breakfast tray and witnessed Resident #6 trip and fall over an area on the floor. The tape was coming up and Resident #6's foot got caught on it. A review of Resident #6's hospital History and Physical Report, dated 1/20/25 at 12:59 p.m. revealed This is a [AGE] year-old female with medical history of dementia, dyslipidemia, COPD [chronic obstructive pulmonary disease], nursing home resident, presented to hospital for [sic] facility after a fall. Patient was found on the ground and complaining of right hip pain, patient's baseline is confused, only be able to recognize her [FM], but nobody else, be able to eat by herself. When I saw the patient, her [FM] at bedside, provided all the history. The completed radiology imaging studies, on 1/20/25 at 10:44 a.m. showed a right femoral neck fracture. The Computed Tomography Scan (CT) of the pelvis without contrast, on 1/20/25 at 10:04 a.m., revealed impacted right femoral neck fracture with angulation and mild displacement. The X-ray results of the right femur and right hip with pelvis showed normal mineralization. A review of a hospital consultation note dated 1/20/25 at 6:04 p.m. showed the resident was complaining of right hip pain and the physical examination showed the right lower extremity was shortened and externally rotated. The assessment/plan showed resident would benefit from operative intervention of the right hip in order to provide stability to the fracture and promote satisfactory healing, to improve pain, to facilitate early motion and mobilization and to prevent complications associated with prolonged bedrest. The risks, benefits, complications, and alternatives treatments were explained to the patient and FM. This included the possibilities of infection, deep vein thrombosis, reaction to anesthesia, neurovascular compromise, death or dying on the table, incomplete relief of symptoms, and chronic pain or stiffness. A review of the operative report on 1/21/25 at 9:08 a.m., showed Resident #6 had undergone a right hip hemiarthroplasty. The post-operative X-ray results showed the prosthesis was well-seated with no evidence of hardware loosening or failure. A review of the hospital Physical Therapy (PT) evaluation dated 1/22/25 at 9:38 a.m., revealed the FM had reported a prior functioning of being able to mobilize with a walker. The PT assessment showed Impairments/Limitations: Ambulation deficits, Bed mobility deficits, Cognitive deficits, Range of motion deficits, Safety awareness deficits, Transfer deficits, Transition deficits Barriers to Safe discharge: Insight into deficits, Needs Assist for Mobility, Needs Assist for Transfer, Safety awareness Summary of Findings: Pt. [patient] very confused, unable to follow commands, dep[endent] for all mobility. A review of a facility note dated 1/26/25 at 5:30 p.m., showed Resident #6 returned to the facility from the hospital following a right hip hemiarthroplasty. The record showed the resident was in pain whenever touched. The resident had a surgical wound on right thigh and staff recommended rehab unit for the resident. During an interview on 2/25/25 at 2:15 p.m., the Director of Nursing (DON) stated Resident #6 had been ambulating in the hallway with a family member and her foot kind of got stuck on tape. The DON reported the FM grabbed the resident had pulled her, then the resident lost her balance and fell. The DON stated the resident had a history of osteopenia and because of right hip pain the resident was left on floor. The DON stated she interviewed Staff B/CNA, Staff C/CNA, and Staff E, Licensed Practical Nurse (LPN). The DON stated Staff E, LPN was sitting at the desk and did not witness the fall, but heard the resident call out and saw her lying on the right side. The DON confirmed Resident #6 suffered a fall, was transferred out to the hospital, had surgery and came back to the facility. The DON stated Resident #6 had suffered a previous fall on 10/25/24. She stated the resident had a big chair in her room at the time so the family decluttered the room and when the resident started ambulating, the facility ensured the environment was free of clutter and slip hazards to prevent additional falls. On 2/25/25 at 9:45 a.m., an interview was conducted with the DOM. He stated on 200-hall, the memory care unit, a resident had pulled the clean-out cap off, on 12/18/24. The DOM reported roping the area off and cutting a metal piece to fit on top of the missing cap. He stated this was done after Resident #6 had fallen. The DOM stated the facility had plumbers come in on 1/24/25. The DOM stated from 12/18/24 to 1/24/25, he had put several patches on the area, and went back every day to make sure it was secure and safe. The DOM reported the plumbers removed the tile all the way around the clean out cap, leaving a cemented patch. On 2/25/25 at 10:46 a.m., the DOM observed the 200 hall and showed the area where Resident #6 had fallen in the hallway. The area was near the nursing station in the 200-hall and just outside of Resident 6's room at that time of the 1/20/25 incident. The DOM observed an additional area of missing floor tiles on the 200 hall and stated the facility had just received the diamond blades to smooth out the concrete. He stated the plumbers had to remove the tiles to fix a plumbing issue. During the time of this interview, the DOM confirmed the area where Resident #6 had fallen was still uneven due to the concrete patch left by the plumbers on 1/24/25. An interview was conducted on 2/26/25 at 12:00 p.m. with Staff J, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member described the area of concrete as similar to other drains on unit, showing a circular drain with a square metal outer plate. Staff J, LPN/UM stated the residents on the unit like to pick at it and had pulled the square metal plate up. Staff J, LPN/UM stated maintenance had covered the area with a metal square that was approximately the same size as the missing plate and secured it to the floor with yellow and black striped industrial tape so it would be recognized as a caution area. Staff J, LPN/UM stated she doubted the residents in the memory care unit would have recognized the tape as a caution area. The staff member stated the concrete area was a high-traffic area as it was between the dining room, Resident #6's room, and the nursing station on the memory care unit. Staff J, LPN/UM stated they had a lot of residents wandering up and down the hallways due to dementia on the unit. Staff J, LPN/UM said she could only report it to maintenance, and then it was out of her hands. Staff J, LPN/UM stated the metal and tape was a hazard, and during the repair period, the area had become larger in size. A follow-up interview on 2/26/25 beginning at 3:05 p.m. with the DOM revealed the rough concrete patch observed during the survey beginning on 2/24/25 was part of the repair. The DOM stated he had to research a replacement cap since the missing cover was so old. The DOM stated the plumber did not have a cap to fit the cast iron piping, so the plumber had to make the hole bigger and cut pipe to fix it. The DOM revealed this repair happened in the middle of January. The DOM stated he had put a metal plate on the area trying to save the company money in December 2024. The DOM reported he was researching it to try to fix it himself before calling the plumbers in, but after Resident #6's fall, he was done searching for the replacement and decided to get plumbers in. The DOM stated he felt the location where Resident #6 fell was safe and felt the [brand name] tape was a good tape to use as a temporary fix. The DOM reported the diamond grinding wheel, needed to smooth out concrete, had been back ordered and came in last week. The DOM said he had looked at local merchants for the grinding wheel, but they did not have the size needed in stock. The DOM stated the diamond wheel was delivered on 2/14/25, the day before he went on vacation. Review of the online merchant's receipt for the 4.5-inch diamond concrete grinding wheel showed the order was placed on 1/27/25 and shipped on 1/27/25. At the time of this interview, the area where Resident #6 fell was still not fully repaired leaving a rough and uneven flooring surface in this high traffic area. On 2/27/25 at 2:04 p.m., the Regional DOM reported not being aware of the flooring issue. The Regional DOM stated depending on severity, if something could not be handled in-house the facility contacted vendors for repairs. The Regional DOM expected something to be implemented promptly, within one to two weeks for the safety of the residents. On 2/24/25 at 10:18 a.m., a second area in hall 200 towards the front of the facility, near the janitor supply closet #3 was observed with 12 missing tiles. The area was in the walking path of residents in the memory care unit. The area had a raised drain with a cap near the middle of it. An immediate interview was conducted with Staff B, Certified Nursing Assistant (CNA) who confirmed the area had been in disrepair for a long time and estimated it to be approximately 6 to 8 months. A review of a work order dated 12/3/24 at 2:24 p.m. showed Staff J, LPN/UM reported missing tile on the floor of the 200 hallway with a medium priority level. The work order was acknowledged by the DOM on 12/27/24 at 3:30 p.m. with a status of Set to-In-Progress. The work order was updated on 2/26/25 at 2:17 p.m. by the DOM with a status of Set to completed. On 2/24/25 at 10:38 a.m., the entrance ramp to the 400-hall was observed missing five full carpet squares (approximately 2 ft x 2 ft) and 5 half carpet squares leaving exposed concrete with a raised drain that was not level to the concrete, and the carpet that remained was not level with the concrete. A yellow traffic cone was placed in the corner from the hallway to the ramp. This area was the inside entrance for residents, staff and visitors to access the 400-hall and used frequently by residents with ambulation devices and wheelchairs. During a facility tour of the 200 hall on 02/27/2025 at 2:21 p.m. with the Nursing Home Administrator (NHA), revealed tiles that were popping up on the edges where the facility had replaced flooring using old tiles. The NHA confirmed the area was a hazard for someone with a shuffling gait. The NHA stated the tiles needed to be put down again and better. The NHA stated her expectation was an immediate fix for any hazard affecting residents. The NHA observed the area where Resident #6 fell and stated she expected the area to be safe for the residents. The NHA stated it was unacceptable to wait to repair the floors. Photographic evidence was obtained. A review of the Maintenance Director's job description signed on 10/24/24 by the DOM revealed: Position Purpose: Directs the day-to-day activities of the maintenance department in accordance with current federal, state, and local standards, guidelines and regulations governing the facility, and to ensure the facility is maintained in a safe and comfortable manner. The major duties and responsibilities included: Plans, develops, organizes, implements, evaluates, and directs the Maintenance Department, its programs and activities. Ensures the facility remains in compliance with all federal, state, and local regulations for life safety code compliance. Reviews the department's policies, procedure manuals, job descriptions, etc., at least annually for revisions and makes recommendations to the Assistant Administrator/Administrator. Prepares operating and staffing budgets for maintenance and monitors monthly. Ensures maintenance staff are properly trained on safety policies and procedures as well as monitors compliance. Ensures proper planning, direction, participation, and supervision of both preventative and unplanned maintenance and repair activities in the facility, which includes painting, plumbing, carpentry, HVAC, and electrical work. Purchases within budgetary responsibilities [sic] the general maintenance tools, supplies and equipment, safety equipment, and trains others in their appropriate use. Ensures that services performed by outside vendors are properly completed/supervised in accordance with contracts/work orders . Ensures facility's compliance with multiple OSHA standards . Develops and implements preventative maintenance tasks, document instructions and procedures for the preventative maintenance of facility and utility components and office equipment, as well as, mechanical, air conditioning, heating, and electrical systems, etc. Schedules department work hours (including vacation and holiday schedules), personnel, work assignments, etc., to expedite work . Ensures the facility's compliance with the law and other regulatory terms such as safety and building codes . Runs, operates, and assesses technical aspects of facility machinery, equipment, and buildings. A review of the Job Description for the Administrator signed on 1/9/24 revealed: Position Purpose: Leads, guides, and directs the operations of the health care facility in accordance with local, state, and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. The major duties and responsibilities included: Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. Plans, develops, organizes, implements, evaluates, and directs the facility's programs and activities in accordance with guidelines issued by the governing body. Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators. Establishes an ongoing system to monitor these key indicators such as the Quality Assurance and Performance Improvement process throughout the facility . Leads and coordinates daily, weekly, bi-monthly or monthly management team meetings to discuss priorities and develop solutions with facility leaders such as census, collections, clinical health, survey readiness, customer service satisfaction, activity participation, etc . Evaluates work performance of department heads and maintains accountability across all departments in concert with Human Resources for expected performance outcomes in each respective department . Knows and understands .Code of Federal Regulations, Appendix PP State Operations Manual .Life Safety Code regulations .and all other regulatory entities that may apply . Performs rounds to observe residents and ensure overall needs are being met. Knows residents by name and sight. Practices management by walking around. Makes himself/herself available to employees at all levels by practicing an open-door policy. A review of the policy titled, Safe and Homelike Environment, implemented 9/1/23, revealed: In accordance with resident's rights, the facility will provide a safe, clean, comfortable, and home like environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Definitions included: Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas; Orderly is defined as an uncluttered physical environment that is neat and well-kept. Policy explanation and compliance guidelines: Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. General Considerations: Report any unresolved environmental concerns to the Administrator. A review of the facility's immediate actions to remove the Immediate Jeopardy included: 1. Immediate Action: • NHA and Plant Operations Director performed environmental rounds on 2/26/2025, identified areas of concern noted and reported in the electronic maintenance records system. Work orders started in order of priority for hazards causing uneven surfaces, fall risk hazards, and items with potential to risk resident safety. • Summoned Corporate Plant Operations support team for assistance on 2/26/2025 • Initiated repairs of identified areas of concern on 2/26/2025 • Tiles in high traffic area of secure unit (200 Hall, outside room [ROOM NUMBER]) repaired on 2/26/2025, part of repaired tiles began to shift, tiles replaced again on 2/27/2025. • Tiles in high traffic area of secure unit (200 Hall, outside room [ROOM NUMBER]) repaired on 2/26/2025 • 400 Hall ramp missing carpet tiles replaced on 2/26/2025, carpet tile surface continues to be uneven, all carpet tiles were removed from ramp and replaced with one solid carpet piece. • On 2/27/2025 surveyors and NHA completed environmental rounds of the facility noting areas of continued concern. • List compiled of concerns from environmental tour, all items entered in the electronic maintenance records system. • 300 Hall clean out with uneven surface repaired. • 99.5% of all facility staff were educated by 9:00 a.m. on 2/28/2025. • Initiated and assigned direct care staff member as Hallway Safety Monitor on secure unit (200 Hall) for additional supervision. Hallway Safety Monitor will be assigned 24 hours a day X 7 days to establish a pattern of ambulatory residents. When pattern is established, Hallway Safety Monitor will be staffed from 0700 to 2300 daily X 14 days. Then, as pattern is further established, Hallway Safety Monitor will be staffed 12 hours daily X 30 days. Hallway Safety Monitor staffing hours will be adjusted as indicated. 2. Identification of others at risk was accomplished by: • Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and fall hazards. • NHA/Designee rounded facility to survey for environmental hazards. • Identified environmental concerns reported via electronic maintenance records system, addressed by priority level, and repairs initiated and will be ongoing 3. Actions to Prevent Occurrence/Recurrence: • NHA, DCS (Director of Clinical Services), and Plant Operations/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion. • DCS/Designee re-educated staff on Accidents and Supervision Policy. • DCS/Designee re-educated staff on Recognizing & Reporting Hazards. • DCS/Designee re-educated staff on Redirecting Residents with Cognitive Deficits from Environmental Hazards. • DCS/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm. • Initiation and Assignment of direct care staff member as Hallway Safety Monitor for secure unit (200 Hall) for additional supervision and hazard identification. • A Performance Improvement Plan (PIP) has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly Quality Assessment & Assurance (QAA) meeting. Monitoring/auditing and reporting will continue for a minimum of three months or until substantial compliance is determined. 4. NHA/Plant Ops/Designee will round to ensure facility is free of hazards daily X 7 days, then daily X 5 days, then twice weekly x 8 weeks; then weekly and PRN (as needed) as indicated. These audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee by the assigned auditors for three months. Verification of the facility's removal plan was conducted by the survey team on 2/28/25. On 2/28/25 observations were made to ensure the facility repaired the concrete area in the 200-hall to include level tiles and repaired the area at the end of the 200-hall to ensure the tiled area was level. The facility removed the carpet on the 400-ramp and replaced it with two pieces of rolled carpet. The facility educated 99% of their staff on notifying supervisors of accident hazards and to notify other management if the hazard was not repaired. Interviews were conducted with 77 staff members, which included the NHA, the DOM, 13 licensed nurses, 17 CNAs, and 45 other staff members across all shifts. The staff members were able to state that they had been trained and were knowledgeable about the new procedures. Interview with the NHA on 2/28/25 revealed a couple of the staff were not reachable, but a system was put into place for education prior to their next working day. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 2/28/25 and the non-compliance was reduced to a scope and severity of D.