**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from neglect to prevent a fall with major injury (#3); and neglected to implement care directives to promote safety during a transfer procedure, (#2), for 2 of 7 residents reviewed for mechanical lift use, out of a total sample of 8 residents. On 11/22/24 at approximately 5:00 PM, the facility failed to prevent resident #3, a vulnerable, physically impaired resident, from suffering a fall and fracture. The resident's plan of care indicated she required assistance from two staff members for transfers with a full body mechanical lift, but her assigned Certified Nursing Assistant (CNA) attempted the task single-handedly. During the transfer between the shower chair and her bed, one of the sling's loops detached from the lift while the resident was suspended in the air, and she fell to the floor. Resident #3 landed on her head and back, suffered excruciating pain, and was hospitalized with diagnoses of blunt head trauma and a fracture of the sacrum or tailbone. On re-admission to the facility, resident #3 complained of acute left hip pain, and after three weeks of persistent pain, she was subsequently diagnosed with a left hip fracture and required re-hospitalization. After the fall, resident #3 developed a fear of using the mechanical lift and chose to remain in bed, which affected her quality of life by limiting participation in her usual routine and activities of choice. On 12/10/24 at approximately 11:00 AM, the facility failed to ensure staff accessed and implemented the plan of care for resident #2, a physically impaired resident, to promote his safety during a mechanical lift transfer. The resident's assigned CNA neglected to review the CNA care plan or [NAME] prior to the procedure and attempted to transfer him from the bed to a chair with a sit-to stand lift, instead of a full body lift as required. Resident #2 had noticeable weakness and poor balance, but the CNA did not pause the transfer to validate his transfer status and thereby placed him at high risk for an adverse outcome as he was unable to stand. The facility's failure to provide appropriate care and services for mechanical lift transfers contributed to resident #3's fall and fracture and placed resident #2 and all 48 residents who required mechanical lifts for transfers at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy starting on 11/22/24. The facility's Director of Nursing and Regional Nurse Consultant were notified of the Immediate Jeopardy on 12/13/24 at 3:05 PM, and provided the Immediate Jeopardy templates. The Immediate Jeopardy was determined to be removed on 12/11/24 after verification of the immediate actions implemented by the facility. The scope and severity of the deficiencies was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy. The census at the start of the survey was 105. Findings: Cross reference F689 and F726. 1. Review of the medical record revealed resident #3, a [AGE] year-old female, was admitted to the facility on [DATE]. She was transferred to the hospital on [DATE], re-admitted on [DATE], and returned to the hospital on [DATE]. Her diagnoses included multiple sclerosis, breast cancer, secondary bone cancer, muscle contractures of her left hip, both knees, and right ankle, muscle wasting and atrophy of the shoulders, post-fall sacral fracture, and a left hip fracture. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 10/23/24 revealed resident #3 had functional limitation in range of motion due to impairment of all extremities and used a wheelchair for mobility. Resident #3 was dependent on staff for transfers between the chair and bed, and into and out of the shower. The MDS Discharge assessment-return anticipated, with ARD of 11/22/24, revealed resident #3 had an unplanned discharge to an acute care hospital on [DATE]. The MDS assessment indicated she had one fall since admission/entry, re-entry, or the prior assessment, which resulted in a major injury. Review of the medical record revealed resident #3 had a care plan for activities of daily living (ADL) self-care performance deficit related to multiple sclerosis, impaired mobility, and contractures. The document was created on 4/03/15 and revised on 2/23/24. The goal was resident #3 would have her ADL needs met by staff. The interventions included instructions for CNAs to perform chair/bed and shower transfers with a total body mechanical lift operated by two staff. A care plan for risk for complications of osteoporosis with a history of a fracture, initiated on 4/03/15 and revised on 11/28/24, revealed a goal that resident #3 would remain free of injury. The interventions included educate the resident and caregivers on safety measures needed to reduce the risk for falls and report signs of a fracture and pain to the physician. Review of the CNA care plan or [NAME] for resident #3 revealed instruction for two CNAs to perform transfers with a full body mechanical lift. On 12/10/24 at 3:02 PM, the facility's Administrator and Director of Nursing (DON) discussed resident #3's fall. The Administrator explained the incident investigation showed resident #3's assigned CNA performed a mechanical lift transfer without assistance, which was contrary to the facility's policy. The Administrator verified the facility therefore substantiated the incident as neglect. The DON stated she interviewed CNA A by telephone on the day of the incident and had her come into the building the following day to do a re-enactment and demonstrate how the resident fell. She stated CNA A confirmed she performed the mechanical lift transfer by herself and admitted to not following her training. On 12/10/24 at 10:10 AM, resident #3 verified she fell from the mechanical lift when her CNA attempted to transfer her from the shower chair to her bed. She stated the CNA was the only staff present at the time. Resident #3 said, It was not the first time that only one CNA picked me up in the lift. I did not realize it was wrong then, but now I know it is supposed to be two people. Resident #3 stated since the fall she was fearful of using the lift and now had significant left hip pain with movement. On 12/10/24 at 4:02 PM, CNA B stated she often assisted CNA A to transfer resident #3 with the mechanical lift on shower days. She recalled on the day the resident fell; she assisted CNA A to transfer her from the bed to the shower chair. CNA B stated she did not accompany them to the shower room, but told CNA A to call her when they were finished so she could assist with transferring resident #3 back to bed. CNA B stated she left to provide care for her assigned residents and when the dinner meal cart arrived, she started to distribute trays. She explained she did not see when CNA A and resident #3 returned from the shower room, and CNA A never asked her to help to transfer the resident back to bed. CNA B stated she was in the unit's day room when CNA A shouted her name three times from resident #3's doorway. She stated CNA A appeared very upset and when she ran to the room to check what happened, she saw resident #3 on the floor. CNA B stated all CNAs were aware a mechanical lift transfer required two people, but CNA A decided to do the wrong thing. In interviews on 12/10/24 at 10:00 AM, and 12/12/24 at 10:45 AM, the Cambridge Unit Manager (UM) confirmed resident #3 required a full body mechanical lift for transfers. She explained the resident fell from the lift on 11/22/24 when the assigned CNA performed a transfer by herself, although the task required two staff. The UM stated resident #3 was hospitalized after the fall, and was diagnosed with a sacral fracture. She confirmed the resident complained of increased pain since re-admission to the facility and now requested almost daily doses of the pain medication Oxycodone, a significant increase compared to before the fall. The UM stated x-rays done yesterday showed resident #3 had a left hip fracture so she was sent to the hospital this morning for evaluation. On 12/13/24 at 9:57 AM, in a telephone interview, resident #3's daughter confirmed since her mother fell during a mechanical lift transfer, she had been experiencing significant pain with movement, particularly when she rolled from side to side. The resident's daughter stated her mother was again in the hospital with a newly diagnosed left hip fracture that likely occurred at the time of the fall from the lift, although it was not diagnosed then. She explained her mother was not a good surgical candidate at this time as she was compromised by multiple clinical conditions including metastatic cancer and multiple sclerosis. Resident #3's daughter acknowledged the combination of the improbability of surgery, increased pain, and fear of using the lift would create limitations that negatively impacted her mother's quality of life. She said, I think they could have done a better job assessing her pain and addressing the cause. I am upset. 2. Review of the medical record revealed resident #2, a [AGE] year-old male, was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included seizures, muscle wasting and atrophy of both shoulders, unsteadiness on his feet, abnormal posture, and cervical spine fusion. Resident #2 had a nursing care plan created on 10/27/24 for ADL self-care performance deficit related to generalized weakness. An intervention dated 11/24/24 instructed CNAs to perform transfers between the bed and wheelchair and into and out of the shower with a total body mechanical lift operated by two staff. Review of the [NAME] for resident #2 revealed the instruction for two CNAs to transfer him between the bed and chair with a full body mechanical lift. On 12/10/24 at 9:50 AM, CNA C stated resident #2 was scheduled for a shower today and she would transfer him from his bed to the shower chair with a mechanical lift. A sit-to-stand lift was noted in the hallway near the resident's door. On 12/10/24 at 11:00 AM, CNA C stated she was ready to transfer resident #2 with assistance from CNA E. The sit-to-stand lift remained outside resident #2's door so CNA C was prompted to check the care directives regarding the resident's transfer needs. She reviewed the nursing care plan for risk for falls, but did not check the care plan for ADLs or view the [NAME] with specific transfer instructions. On 12/10/24 at 11:02 AM, CNA C placed the sit-to-stand lift at resident #2's bedside and CNA E assisted with positioning the resident into a seated position on the side of the bed. He was not able maintain an upright position and rocked backwards and fell to the side without CNA E's support. CNA C explained before the resident went to the hospital, he did not use a lift as he was able to stand for transfers with the assistance of two people. She stated since re-admission, he was much weaker and required a mechanical lift. CNA C stated this was her first attempt to get the resident out of bed since his return from the hospital. As CNA C continued to position resident #2 in the sit-to-stand lift for the transfer, CNA E expressed concern, pointed to the lift, and said, Maybe this is not good for him. Staff were aware of the resident's extreme weakness and obvious inability to even sit, and neither CNA stopped the procedure to verify his transfer requirements or report concerns to a nurse. The transfer with the sit-to-stand lift was averted when CNA C discovered the lift's battery was dead. On 12/11/24 at 9:56 AM, the Therapy Director was informed staff attempted to transfer resident #2 from his bed to the shower chair with a sit-to-stand mechanical lift. She reviewed his Physical Therapy notes and explained the resident required maximum assistance for transfers and it was determined that the full body mechanical lift was the appropriate type for CNAs to use. She was informed CNA C mentioned that prior to his hospitalization, the resident could do stand and pivot transfers with two staff. The Therapy Director reiterated resident #2 required maximum assistance for transfers and for the safety of staff and the resident, a full body mechanical lift was the only recommended transfer method. On 12/12/24 at 12:19 PM, the facility's Medical Director stated he was very familiar with resident #3's medical issues which included multiple sclerosis and breast cancer with bone metastasis. He explained recent diagnostic tests showed metastatic lesions in both hips. The Medical Director stated the CNA's decision to transfer the resident by herself was inexcusable as she was very frail and already at high risk for fractures due to her diagnoses. He stated his expectation was for all staff to handle resident #3 delicately, like an egg. The Medical Director confirmed he was made aware CNAs attempted to transfer resident #2 with the wrong type of mechanical lift a couple days ago, because they did not check the care directives. He stated he was dumbfounded as all staff were re-educated on transfers with mechanical lifts after resident #3 fell a few weeks ago. The Medical Director emphasized the importance of CNAs following care directives to ensure residents were transferred appropriately and safely. Review of the facility's policy and procedures for the prohibition of Abuse, Neglect and Exploitation, revised on 11/16/23, revealed the facility would protect the health, welfare, and rights of each resident. The policy defined neglect as 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. The document indicated the facility would provide ongoing oversight and supervision of staff to ensure the abuse and neglect prohibition policy was implemented. Review of the policy and procedures for Comprehensive Care Plans, revised on 7/27/22, revealed the facility would develop and implement a comprehensive care plan to meet residents' needs according to assessment findings and identify services to be furnished to attain the highest practicable well-being. Review of the facility's policy and procedures for Safe Resident Handling/Transfers, revised on 11/29/22, revealed the facility would ensure residents were handled and transferred safely to minimize risks for injury and promote a safe, secure and comfortable experience for the resident. The guidelines revealed the interdisciplinary team (IDT) would evaluate and assess each resident's mobility needs to determine the type of lifting equipment or other transferring/handling aids to be used. The document read, Two staff members must be utilized when transferring residents with a mechanical lift.Staff members are expected to maintain compliance with safe handling/transfer practices.Resident lifting and transferring will be performed according to the resident's individual plan of care. The resident sample was expanded to include five additional residents who required a full body mechanical lift for transfers. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 11/22/24, the evening shift Nursing Supervisor immediately placed the mechanical lift and sling out of service. * On 11/22/24, the CNA who failed to follow correct procedure for use of mechanical lift using two staff members was immediately suspended. * On 11/22/24, the Weekend Nursing Supervisor began education and skills validation with 13 of 24 CNAs duty on the day, evening and night shifts. * On 11/23/24, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the facility's Administrator, Director of Nursing, and Medical Director to review the initial incident. * On 11/24/24 through 11/25/24, the Therapy Director completed resident transfer status evaluations on current residents. Any updates were placed in the [NAME] and care plans. * On 11/24/24 through 11/25/24, the MDS coordinator completed care plan/[NAME] reviews to ensure appropriate transfer status was on care plan/[NAME] for current residents. * On 11/25/24, the MDS Coordinators completed a quality review of current residents for MDS accuracy related to transfer status. Corrections were made as identified. Quality reviews were then completed on current resident care plans and kardexes to ensure accurate transfer status were listed. Corrections were made when identified. * On 11/23/24, the Maintenance Director inspected all mechanical lifts and slings for any malfunctions and no concerns were identified. * On 11/23/24 through 11/27/24, current nursing staff were educated on mechanical lift usage and competencies were performed by the Director of Nursing, Staff Development Coordinator, and Nurse Managers. Occupational and Physical Therapy staff were educated on mechanical lift usage. Of 91 total nursing staff, 80 total current nursing staff received education, and 11 total nursing staff members were to receive education prior to next shift worked. Of 27 total Occupational and Physical Therapy staff, 26 total current therapy staff received education, and 1 total therapy staff member was to receive education prior to next shift worked. There are no contracted licensed nurses or CNAs currently on staff. Any contracted nurses or CNAs who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet. * On 11/24/24 through 11/27/24, current facility staff were educated on abuse, neglect and exploitation by the Administrator, Director of Nursing, Staff Development Coordinator, and Nurse Managers. Of 171 total staff, 171 current staff received education. There are no staff members who require education prior to next shift worked, and no contracted licensed nurses or CNAs on staff. Any contracted nurses or CNAs who are placed at the facility on assignment in the future will receive the above education prior to starting their shift through an agency orientation packet. * On 11/23/24, an Ad Hoc QAPI meeting was completed with the Medical Director, Administrator, and DON. The topics of the incident, abuse and neglect, use of mechanical lifts, mechanical lift competencies, updating care plans/[NAME], and following care plans/[NAME] were discussed. * On 11/25/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, Staff Development Coordinator, IDT members, and Nurse Managers to review the 4-Point Plan and Investigation. * On 11/26/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT members to include the Director of Rehabilitation, to review the 4-Point Plan, Root Cause Analysis, and progression of investigation. * On 12/07/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT team to include the Director of Rehabilitation, to review the 4-Point Plan progress, quality reviews, and conclusion of investigation. * On 12/10/24, the Unit Manager corrected the assigned CNA on the proper way to transfer resident #2 and showed her the transfer status on the [NAME]. The CNA was suspended pending investigation and re-educated on checking the [NAME] prior to transfers. * On 12/10/24, nursing staff re-education on how to view [NAME] for transfer status was initiated with return demonstration required. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift. * On 12/10/24, nursing staff competencies were initiated by the Director of Nursing or designees. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift, by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift. * On 12/11/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to discuss areas of concern that were identified during the complaint survey that started on 12/10/24 and additional steps the facility is taking to re-educate staff. * On 12/12/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to go over [NAME] education, discuss quality monitoring tools, root cause of concerns, and clarify areas of concerns. Interviews conducted on 12/13/24 with 19 total facility staff who represented the nursing, therapy, and housekeeping departments revealed they were knowledgeable of the facility's policy and procedure to prohibit abuse and neglect. Interviews conducted with nursing staff, including 12 CNAs, two Registered Nurses, and two Licensed Practical Nurses, revealed they received education on the Safe Resident Handling/Transfers policy and procedures, and the requirement to access and review the nursing care plan or CNA [NAME] as appropriate, to identify the type of mechanical lift and number of staff required for transfers. Staff validated they performed return demonstrations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policies and procedures and accepted standards of practice to prevent an avoidable fall from a full body mechanical lift (#3); and ensure use of the appropriate type of mechanical lift to meet assessed needs (#2), for 2 of 7 residents reviewed for mechanical lift use, out of a total sample of 8 residents. On 11/22/24 at approximately 5:00 PM, the facility failed to prevent resident #3, a vulnerable, physically impaired resident, from suffering a fall and fracture. The resident's plan of care indicated she required assistance from two staff members for transfers with a full body mechanical lift, but her assigned Certified Nursing Assistant (CNA) attempted the task single-handedly. During the transfer between the shower chair and her bed, one of the sling's loops detached from the lift while the resident was suspended in the air, and she fell to the floor. Resident #3 landed on her head and back, suffered excruciating pain, and was hospitalized with diagnoses of blunt head trauma and a fracture of the sacrum or tailbone. On re-admission to the facility, resident #3 complained of acute left hip pain, and after three weeks of persistent pain, she was subsequently diagnosed with a left hip fracture and required re-hospitalization. After the fall, resident #3 developed a fear of using the mechanical lift and chose to remain in bed, which affected her quality of life by limiting participation in her usual routine and activities of choice. On 12/10/24 at approximately 11:00 AM, the facility failed to ensure staff accessed and implemented the plan of care for resident #2, a physically impaired resident, to promote his safety during a mechanical lift transfer. The resident's assigned CNA neglected to review the CNA care plan or [NAME] prior to the procedure and attempted to transfer him from the bed to a chair with a sit-to stand lift, instead of a full body lift as required. Resident #2 had noticeable weakness and poor balance, but the CNA did not pause to validate his transfer status which thereby placed him at high risk for an adverse outcome as he was unable to stand. The facility's failure to adhere to plans of care related to providing the required number of staff to operate a mechanical lift and failure to use the appropriate type of lift contributed to resident #3's fall and fracture, and placed resident #2 and all 48 residents who required mechanical lifts for transfers at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy starting on 11/22/24. The facility's Director of Nursing and Regional Nurse Consultant were notified of the Immediate Jeopardy on 12/13/24 at 3:05 PM, and provided the Immediate Jeopardy templates. The Immediate Jeopardy was determined to be removed on 12/11/24 after verification of the immediate actions implemented by the facility. The scope and severity of the deficiencies was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy. The census at the start of the survey was 105. Findings: Cross reference F600 and F726. 1. Review of the medical record revealed resident #3, a [AGE] year-old female, was admitted to the facility on [DATE]. She was transferred to the hospital on [DATE], re-admitted on [DATE], and returned to the hospital on [DATE]. Her diagnoses included multiple sclerosis, breast cancer, secondary bone cancer, muscle contractures of her left hip, both knees, and right ankle, muscle wasting and atrophy of the shoulders, post-fall sacral fracture, and a left hip fracture. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 10/23/24 revealed resident #3 had clear speech, was able to express her ideas and wants, and had no comprehension issues. The resident's Brief Interview for Mental Status (BIMS) score was 15/15 which indicated she was cognitively intact. The MDS assessment revealed resident #3 exhibited no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. She had functional limitation in range of motion due to impairment of all extremities and used a wheelchair for mobility. Resident #3 was dependent on staff for transfers between the chair and bed, and into and out of the shower. The MDS Discharge assessment-return anticipated, with ARD of 11/22/24, revealed resident #3 had an unplanned discharge to an acute care hospital on [DATE]. The MDS assessment indicated she had one fall since admission/entry, re-entry, or the prior assessment, which resulted in a major injury. Review of the medical record revealed resident #3 had a care plan for activities of daily living (ADL) self-care performance deficit related to multiple sclerosis, impaired mobility, and contractures. The document was created on 4/03/15 and revised on 2/23/24. The goal was resident #3 would have her ADL needs met by staff. The interventions included instructions for CNAs to perform chair/bed and shower transfers with a total body mechanical lift operated by two staff. A care plan for risk for complications of osteoporosis with a history of a fracture, initiated on 4/03/15 and revised on 11/28/24, revealed a goal that resident #3 would remain free of injury. The interventions included educate the resident and caregivers on safety measures needed to reduce the risk for falls and report signs of a fracture and pain to the physician. Review of the CNA care plan or [NAME] for resident #3 revealed the instruction for two CNAs to perform transfers with a full body mechanical lift. Review of the Physical Therapy Plan of Care dated 9/25/24 revealed resident #3 was referred for therapy services to address further deterioration in range of motion of her hips, knees, and ankles. The document indicated she required total assistance for transfers and got out of bed three times weekly to a high-back recliner wheelchair. The Initial Physical Therapy assessment showed resident #3 was dependent on staff for transfers and read, Resident does none of the effort to complete the activity.assistance of 2 or more helpers is required for the resident to complete the activity. A Situation, Background, Appearance, Review and Notify (SBAR) Communication Form dated 11/22/24 revealed resident #3 had a fall and complained of level 10/10 pain in the back of her head. The document indicated RN D notified the resident's primary care clinician and her daughter of the accident. Review of a Narrative Note written on 11/22/24 by Registered Nurse (RN) D, the 3:00 PM to 11:00 PM Nursing Supervisor, revealed resident #3 fell while being transferred from the chair to her bed with a full body mechanical lift, and was sent to the hospital. Review of the Order Recap Report for November and December 2024 revealed resident #3 had a physician order with an effective date of 11/22/24, to send her to the Emergency Department for evaluation after a fall. Review of the hospital record revealed resident #3 had computed tomography (CT) scans of her head, neck, and spine on 11/22/24 for complaints of a headache and neck pain after a she fell out of [mechanical] lift. The result showed no acute intracranial abnormality, but the resident had a small scalp contusion on the left side of the back of her head. A CT scan of the lumbar spine, dated 11/22/24, was done for a complaint of back pain, and the result showed resident #3 sustained an acute fracture along the anterior sacrum at the S2 level. An x-ray of her pelvis done on 11/22/24 was described as a significantly limited evaluation that could not exclude an acute impacted left hip femoral neck fracture. A follow-up CT scan for further evaluation was recommended by the radiologist. Review of the CT scan of the resident' pelvis dated 11/22/24 showed no acute abnormality. The hospital record included resident #3's History & Physical dated 11/23/24, which showed assessment findings including fall from a mechanical lift, lower back pain, headache, blunt head trauma, and acute closed fracture of the anterior sacrum. Review of the Admit/Readmit Screener & Baseline Care Plan dated 11/27/24 revealed on re-admission to the facility from the hospital, resident #3 was alert and oriented to person, place, time, and situation. The document showed resident #3 reported she had experienced frequent, moderate left hip pain over the last five days and the nurse noted the resident said, My left hip hurts. The document revealed the resident described her hip pain as worse with movement and alleviated by the pain medication Oxycodone. The Order Recap Report for November and December 2024 included orders dated 11/27/24 to re-admit resident #3 for long term care services and observe for pain every shift. Resident #3 had physician orders dated 11/28/24 for two tablets of Acetaminophen (pain reliever) 325 milligrams (mg) every four hours as needed for mild pain, Baclofen (muscle relaxer) 10 mg once daily for back pain, and Oxycodone (Opioid pain reliever) 5 mg as needed for pain. Review of a Health Note dated 11/28/24 revealed resident #3 was assessed by a clinical provider on re-admission to the facility. The note indicated she had acute pain due to trauma and complained of left hip pain with movement. A Skin/Wound Note dated 12/02/24 revealed resident #3 continued to complain of pain with left hip movement. Review of the medical record revealed a physician order dated 12/10/24 for diagnostic x-rays of the resident's left ankle, and both femurs (thigh bones) for report of pain. A Radiology Results Report dated 12/11/24 revealed resident #3 had x-rays of her left ankle, left hip, and right hip. Interpretation of the x-rays showed the resident had a fracture at the upper end of her left femur. Review of an SBAR Communication Form revealed resident #3's primary care clinician was notified of her left hip fracture on 12/12/24 at 6:20 AM. The form indicated the facility received an order to send the resident to the hospital Emergency Department via emergency medical services. On 12/10/24 at 10:00 AM, the Cambridge Unit Manager (UM) confirmed resident #3 fell from the full body mechanical lift and sustained a sacral fracture. She stated after completing the resident's shower, CNA A transported her back to her room in the shower chair. The UM explained CNA A used the mechanical lift to transfer the resident from the chair to her bed, noted one of the straps on the sling came loose, and had to lower her to the ground. The UM confirmed transfers with full body mechanical lifts required two staff members to be present. On 12/10/24 at 10:10 AM, resident #3 verified she fell from the mechanical lift during a transfer between the shower chair and her bed. She stated the CNA was the only staff member in the room at the time. Resident #3 used her hand to demonstrate that she was above the current height of the bed. She said, I was up in the air. I suddenly, quickly fell flat to the floor. I hit the back of my head and back. I was shocked. I did not realize what happened because it was so fast. She stated she felt as if she slipped out of the sling. The resident stated she was in a lot of pain after she landed on the floor. She explained she still had pain whenever she rolled from one side to another, especially on the left side. Resident #3 expressed fear of using the mechanical lift since the incident and stated in the three weeks since her fall, she got out of bed only once with assistance from two or three strong men, who transported her to a doctor's appointment. She confirmed she had not been transferred by CNAs since she fell. The resident stated before the incident, she enjoyed getting out of bed on some days, just to get into her wheelchair and move around the room. On 12/10/24 at 10:48 AM, Physical Therapy Assistant (PTA) F explained resident #3 was going to be transferred from her bed to the wheelchair for the first time since re-admission. She stated she would be present to reassure resident #3 during the procedure. PTA F confirmed resident #3 complained of pain in her left hip during morning care, and she positioned her legs with a pillow to relieve the pain. On 12/10/24 at 10:52 AM, CNAs C and E placed the sling underneath resident #3 in bed and attached the loops to the spreader bar of the full body mechanical lift. During the transfer procedure, the resident complained of left hip pain and had an apprehensive expression. When resident #3 was seated in the wheelchair, CNA E repositioned her left leg and foot and the resident cried out, grimaced, and continued to tell staff her left hip hurt. On 12/10/24 at 3:02 PM, the Administrator confirmed the facility's incident investigation showed resident #3 fell during a mechanical lift transfer performed by CNA A. She verified CNA A did not follow the facility's policy and procedures for mechanical lift transfers which indicated these types of transfers always required two staff members. On 12/10/24 at 3:37 PM, RN D verified she was the evening shift Nursing Supervisor on 11/22/24. She recalled she was on the Bristol unit at about 5:00 PM when someone urgently grabbed her and said she was needed on the Cambridge unit. RN D stated she rushed to the room as directed and saw resident #3 on the floor near the foot of her bed. She stated the mechanical lift was at the foot of the roommate's bed and the shower chair was close to the door. RN D explained it appeared as if CNA A had rolled the lift across the room with the resident in it. She stated the sling was on the floor under the resident who still had towels wrapped around her body. RN D stated she assessed resident #3, noted she was in pain, and discovered a lump on the back of her head. She confirmed she arranged for the resident to go to the hospital for further evaluation. On 12/11/24 at 10:27 AM, the Therapy Director validated for at least the last three years, resident #3 was dependent on two staff for transfers as she required a full body mechanical lift. The Therapy Director stated the resident enjoyed therapy sessions and usually came to the gym. She was informed resident #3 was now fearful of the mechanical lift and chose to remain in bed. The Therapy Director reviewed resident #3's treatment notes and confirmed she did not see documentation regarding any treatments in the gym since the fall. The Therapy Director confirmed resident #3 sometimes liked to get out of bed and propel herself in the wheelchair in her room. On 12/12/24 at 10:45 AM, the Cambridge UM explained prior to her fall from the mechanical lift, resident #3 had chronic pain issues related to her metastatic cancer, but her pain levels worsened after the fall. The UM reviewed the resident's Medication Administration Record (MAR) for October through December 2024 and confirmed the document showed increasing pain levels and more frequent use of Oxycodone for pain management. She verified prior to the fall from the mechanical lift, resident #3 requested only one dose of Oxycodone 5 mg in October 2024 and three doses in November 2024. The UM stated after the fall, the resident received Oxycodone on 11/30/24 for a pain level of 8. She verified the MAR showed in December 2024 resident #3 received Oxycodone 5 mg almost daily, as eight doses were administered over a 10-day period for pain levels that ranged from 4 to 8 on a 0 to 10 scale. On 12/12/24 at 12:19 PM, the facility's Medical Director stated the Administrator and Director of Nursing (DON) informed him of resident #3's fall from the mechanical lift. He described the CNA's decision to utilize the mechanical lift without assistance as inexcusable since she was frail and already at high risk for fractures due to her diagnosis of metastatic bone cancer. On 12/13/24 at 9:57 AM, in a telephone interview, resident #3's daughter stated during the weeks since re-admission from the hospital her mother experienced significant pain. She explained every time staff rolled her mother from side to side, she screamed or cried out in audible distress. The resident's daughter stated the facility eventually did x-rays and discovered her mother had a left hip fracture. She stated she visited her mother in the hospital early this morning and the orthopedic surgeon explained hip replacement/repair surgery was the solution, but not currently a realistic option, due to her mother's multiple health issues. The resident's daughter said, She's fine if she's not rolling or they're not transferring her, but that would make her be in bed all the time, and mostly in the same position. She is very nervous about the lift now.combination of fear and pain. She explained before the fall, her mother did things around her room, went to the therapy gym, and occasionally attended bingo with her roommate. The daughter acknowledged there would be restrictions on her mother's usual activities if she could not have surgery and had to remain in bed. She acknowledged her mother's contractures made positioning for diagnostic tests challenging, and the orthopedic surgeon felt the left hip fracture was related to the fall from the mechanical lift on 11/22/24 but was not diagnosed at that time. 2. Review of the medical record revealed resident #2, a [AGE] year-old male, was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included seizures, muscle wasting and atrophy of both shoulders, unsteadiness on his feet, abnormal posture, and cervical spine fusion. Review of the MDS Medicare 5-day assessment with ARD of 11/25/24 revealed resident #2 had functional limitation in range of motion due to impairment of one lower extremity. The MDS assessment indicated the resident was dependent on staff for transfers between the bed and wheelchair. Resident #2 had a nursing care plan created on 10/27/24 for ADL self-care performance deficit related to generalized weakness. An intervention dated 11/24/24 instructed CNAs to perform transfers between the bed and wheelchair and into and out of the shower with a total body mechanical lift operated by two staff. A care plan for risk for falls and fall related injury, created on 10/27/24 had the goal that resident #2's risk for falls and injuries would be minimized. The interventions included assist with transfers as needed, cue for safety awareness, and encourage use of the call light for assistance with standing/transferring. Review of the [NAME] for resident #2 revealed the instruction for two CNAs to perform transfers with a full body mechanical lift was noted in the section for ADL Level of Assistance. Review of the Physical Therapy Evaluation & Plan of Treatment dated 12/03/24 revealed at baseline, resident #2 required maximum assistance from two staff for transfers. He was referred to physical therapy due to exacerbation of decreased strength, functional mobility, and transfer ability, and reduced ADL participation. The document indicated his static sitting balance was poor and he was unable to maintain balance without moderate to maximal assistance. The evaluation showed the resident had intermittent, aching right knee pain, at a level 5/10. Review of the Occupational Therapy Evaluation & Plan of Treatment dated 12/03/24 revealed resident #2 had reduced bilateral upper extremity strength, reduced safety awareness, and decreased activity tolerance. The evaluation indicated the resident had poor sitting balance at baseline. On 12/10/24 at 11:00 AM, CNA C stated she was ready to get resident #2 out of bed and into the shower chair to transport him to the shower room. A sit-to-stand lift, instead of the full body lift noted in the medical record, was in the hallway outside the resident's room. CNA C was prompted to check the electronic [NAME] regarding the resident's transfer status. She accessed the nursing care plan instead of the [NAME] and reviewed an intervention for fall prevention related to encouraging the resident to use his call light to obtain assistance with standing and transferring. After reading the nursing care plan, CNA C stated the resident was able to stand for transfers. A few minutes later on 12/10/24 at 11:02 AM, CNA C placed the sit-to-stand lift at resident #2's bedside and assisted by CNA E, she initiated the transfer procedure. With substantial effort, both CNAs assisted resident #2 to sit on the side of his bed with his feet dangling above the base of the lift. The resident exhibited extreme weakness and poor balance as he repeatedly rocked backwards and from side to side. Due to his poor trunk control, CNA E had to keep her left hand and arm on or around the resident's shoulders to prevent him from falling as he could not support himself in a sitting position. CNA C explained resident #2 was weaker since his recent re-admission from the hospital. Next, she placed the sling behind the resident's upper back and under his arms and attached it to the lift. CNA E positioned the resident's arms and hands to hold on to the frame of the lift while CNA C instructed him to position his feet on the platform in preparation to stand. The resident attempted to follow the instruction but as he gripped the lift tightly with both hands, he continued to sway backwards and to the side. CNA E expressed concern, pointed to the lift, and said, Maybe this is not good for him. However, CNA C persevered. She pressed the button on the remote to lift resident #2 from his seated position but was not able to perform the transfer with the inappropriate lift as the battery was dead. CNA C left the room to retrieve another battery while CNA E returned resident #2 to a supine position in bed. A couple minutes later, CNA C stood at the nurses' station while the Cambridge UM looked at the computer screen. On 12/10/24 at 11:08 AM, CNA C walked towards resident #2's room with a full body mechanical lift. The Cambridge UM was informed CNAs C and E had been about to transfer resident with the wrong type of lift as the staff did not check the [NAME] for instructions prior to the task. On 12/11/24 at 2:46 PM, the Clinical Reimbursement Director confirmed it was very important for CNAs to follow the care directives developed by members of the interdisciplinary team (IDT) based on their assessment findings. She verified on admission on [DATE], resident #2's baseline care plan showed he was not able to stand. The Clinical Reimbursement Director reviewed the resident's comprehensive care plan and [NAME] and validated both documents showed the intervention for two staff to transfer him with a total mechanical lift. She stated resident #2 was never assessed as appropriate for sit-to-stand lift transfers. On 12/11/24 at 9:56 AM, the Therapy Director stated resident #2's re-admission evaluation by Physical Therapy on 12/02/24 showed he still required maximum assistance for transfers. She explained through a collaborative process, it was determined that CNAs should use the full body mechanical lift to transfer resident #2. The Therapy Director validated use of a sit-to-stand lift was not an appropriate choice for this resident. She explained the facility's goal was to promote safety for residents and staff, and the transfer attempted by CNAs C and E would not have been safe for resident #2 or the CNAs. On 12/12/24 at 12:19 PM, the Medical Director was informed of concerns related to the likelihood of an adverse outcome for resident #2 when staff attempted a mechanical lift transfer without accessing care directives and selected the wrong type of lift. The Medical Director confirmed the resident's attending physician had already made him aware of the issue and he was dumbfounded. Review of the facility's policy and procedures for Safe Resident Handling/Transfers, revised on 11/29/22, revealed the facility would ensure residents were handled and transferred safely to minimize risks for injury and promote a safe, secure and comfortable experience for the resident. The document indicated mechanical lifts were a safer alternative to manual lifting for staff and residents. The guidelines revealed the IDT would evaluate and assess each resident's mobility needs to determine the type of lifting equipment or other transferring/handling aids to be used. The document read, Two staff members must be utilized when transferring residents with a mechanical lift.Resident lifting and transferring will be performed according to the resident's individual plan of care. Review of the Facility Assessment Tool, dated 7/29/24, revealed facility staff would provide general care and services such as assistance with mobility and fall prevention. The document indicated the facility would offer specific care including bathing, showers, and transfers, and person-centered care such as the prevention of abuse and neglect and identification of risks and hazards. The resident sample was expanded to include five additional residents who required a full body mechanical lift for transfers. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 11/22/24, the evening shift Nursing Supervisor immediately placed the mechanical lift and sling out of service. * On 11/22/24, the CNA who failed to follow correct procedure for use of mechanical lift using two staff members was immediately suspended. * On 11/22/24, the Weekend Nursing Supervisor began education and skills validation with 13 of 24 CNAs duty on the day, evening and night shifts. * On 11/23/24, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the facility Administrator, Director of Nursing, and Medical Director to review the initial incident. * On 11/24/24 through 11/25/24, the Therapy Director completed resident transfer status evaluations on current residents. Any updates were placed in the [NAME] and care plans. * On 11/24/24 through 11/25/24, the MDS coordinator completed care plan/[NAME] reviews to ensure appropriate transfer status was on care plan/[NAME] for current residents. * On 11/25/24, the MDS Coordinators completed a quality review of current residents for MDS accuracy related to transfer status. Corrections were made as identified. Quality reviews were then completed on current resident care plans and kardexes to ensure accurate transfer status were listed. Corrections were made when identified. * On 11/23/24, the Maintenance Director inspected all mechanical lifts and slings for any malfunctions and no concerns were identified. * On 11/23/24 through 11/27/24, current nursing staff were educated on mechanical lift usage and competencies were performed by the Director of Nursing, Staff Development Coordinator, and Nurse Managers. Occupational and Physical Therapy staff were educated on mechanical lift usage. Of 91 total nursing staff, 80 total current nursing staff received education, and 11 total nursing staff members were to receive education prior to next shift worked. Of 27 total Occupational and Physical Therapy staff, 26 total current therapy staff received education, and 1 total therapy staff member was to receive education prior to next shift worked. There are no contracted licensed nurses or CNAs currently on staff. Any contracted nurses or CNAs who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet. * On 11/24/24 through 11/27/24, current facility staff were educated on abuse, neglect and exploitation by the Administrator, Director of Nursing, Staff Development Coordinator, and Nurse Managers. Of 171 total staff, 171 current staff received education. There are no staff members who require education prior to next shift worked, and no contracted licensed nurses or CNAs on staff. Any contracted nurses or CNAs who are placed at the facility on assignment in the future will receive the above education prior to starting their shift through an agency orientation packet. * On 11/23/24, an Ad Hoc QAPI meeting was completed with the Medical Director, Administrator, and DON. The topics of the incident, abuse and neglect, use of mechanical lifts, mechanical lift competencies, updating care plans/[NAME], and following care plans/[NAME] were discussed. * On 11/25/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, Staff Development Coordinator, IDT members, and Nurse Managers to review the 4-Point Plan and Investigation. * On 11/26/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT members to include the Director of Rehabilitation, to review the 4-Point Plan, Root Cause Analysis, and progression of investigation. * On 12/07/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT team to include the Director of Rehabilitation, to review the 4-Point Plan progress, quality reviews, and conclusion of investigation. * On 12/10/24, the Unit Manager corrected the assigned CNA on the proper way to transfer resident #2 and showed her the transfer status on the [NAME]. The CNA was suspended pending investigation and re-educated on checking the [NAME] prior to transfers. * On 12/10/24, nursing staff re-education on how to view [NAME] for transfer status was initiated with return demonstration required. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift. * On 12/10/24, nursing staff competencies were initiated by the Director of Nursing or designees. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift, by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift. * On 12/11/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to discuss areas of concern that were identified during the complaint survey that started on 12/10/24 and additional steps the facility is taking to re-educate staff. * On 12/12/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to go over [NAME] education, discuss quality monitoring tools, root cause of concerns, and clarify areas of concerns. Interviews conducted on 12/13/24 with 16 facility staff including 12 CNAs, two Registered Nurses, and two Licensed Practical Nurses who represented all shifts revealed they were knowledgeable of the facility's mechanical lift transfer policy and the requirement to access and review the nursing care plan or CNA [NAME] as appropriate, to identify the type of mechanical lift and number of staff required for transfers. Staff validated they performed return demonstrations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision to maintain a secure environment to ensure vulnerable residents did not exit the facility without supervision and failed to respond appropriately to a door alarm for 1 of 15 residents reviewed for elopement, of a total sample of 15 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was reasonable likelihood he could have fallen, become lost, been accosted/harmed by a stranger or been hit by a car. On 7/25/24 at approximately 5:15 AM, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. The facility was unaware of resident #1's whereabouts until staff located him across from an assisted living facility (ALF) approximately 0.2 miles away at 5:53 AM. The facility failed to ensure resident #1 was adequately supervised and failed to monitor the front lobby door to ensure vulnerable residents did not exit the facility without knowledge. There was a total of 15 residents who were identified as at risk for elopement. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy. The Immediate Jeopardy began on 7/25/24 and was removed on 7/26/24. The scope and severity of the deficiency was decreased to a D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings: Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses t included encephalopathy, unspecified dementia, heart failure, type 2 diabetes mellitus, adult failure to thrive and depression. Review of the Minimum Data Set quarterly assessment with assessment reference date of 7/07/24 revealed resident #1 had a Brief Interview for Mental Status score of 03/15 which indicated he had severe cognitive impairment. The document indicated resident #1 used a wheelchair for mobility and was able to propel his self independently. The assessment did not indicate resident #1 wandered or exhibited other behaviors during the look-back period but used a wander/elopement alarm daily. Review of physician orders revealed a current active order for electronic wander bracelet dated 11/20/23. Review of the psychiatric progress notes revealed resident #1 was recently seen by the provider on 4/03/24, 4/24/24, 5/29/24, 6/19/24 and 7/03/24. Each progress note indicated resident #1 had a history of exit-seeking behavior, was cognitively impaired with poor long-term and short-term memory, lacked insight concerning matters of self and lacked judgement regarding everyday activities. Review of the medical record revealed elopement risk evaluations dated 11/20/23, 12/04/23, 12/11/23, 12/20/23 and 3/04/24 indicated resident #1 was at risk for elopement. An elopement risk evaluation dated 5/03/24 indicated resident #1 was not at risk for elopement. Review of progress notes revealed resident #1 was considered to be at high risk for elopement on 11/20/23 and a wander bracelet was placed on his right arm. A progress noted dated 5/03/24 read, Resident elopement risk performed, no longer risk for elopement. [Electronic wander bracelet] removed. A care plan for elopement risk initiated 11/20/23 indicated resident #1 was at risk for elopement. Interventions included use of wander bracelet, check placement every shift, place resident information in elopement risk notebook, monitor for exit seeking behaviors and use verbal cues to redirect. The care plan was resolved on 5/03/24, when the electronic wander bracelet was removed and was reinitiated 7/25/24. Review of the Treatment Administration Record for May, June and July 2024 revealed staff continued to document on placement and function of the electronic wander alarm bracelet even though it had been removed on 5/03/24. In a phone interview on 8/07/24 at 6:23 AM, Certified Nursing Assistant (CNA) F verified resident #1 was on her assignment on 7/25/24. She recalled providing care to resident #1 with the assistance of another CNA between 4:00 and 4:30 AM. CNA F stated she then went to get another resident dressed for an appointment. She recalled as she escorted the other resident to the transportation pick-up area, Licensed Practical Nurse (LPN) D told her, Make sure you close that door so he [resident #1] can't get out. CNA F stated she closed the door and proceeded to the transportation area. On 8/06/24 at 5:37 AM, CNA B confirmed she assisted CNA F with providing care for resident #1 and then went back to her assignment. She recalled as she came out of a resident room around 5:00 AM, she saw resident #1 at the nurse's station with CNA A. CNA A informed her resident #1 was walking in the hallway without his wheelchair. CNA B stated she stayed with resident #1 while CNA A retrieved a wheelchair from the dayroom. She stated she went back to her assignment and did not see resident #1 again until after the event. She stated she did not hear an alarm go off and did not know the resident was missing until LPN D asked her to look for him. On 8/06/24 at 5:28 AM, CNA A stated she was not assigned to resident #1 but she saw him standing at the nurse's station. She asked CNA B to help her locate a wheelchair for resident #1. She explained she located a wheelchair in the day room, and they assisted the resident to sit in the chair. CNA A then went back to her assignment. She recalled LPN D later asked her if she knew where resident #1 was, so she started looking for him. She went up front and saw one of his shirts on the ground outside. She went back into the building and headed toward the back to see if she could find him. On 8/06/24 at 11:16 AM, LPN D - stated she saw resident #1 at the nurse's station between 5:00 - 5:10 AM. She recalled CNA F needed to escort another resident to the transportation area and asked LPN D if resident #1 was going somewhere as he was not usually up so early. LPN D stated she told CNA F to just close the doors when she went through, and LPN D continued her rounds. LPN D recalled at approximately 5:30 AM she came out of a resident's room and no longer saw resident #1 at the nurse's station. She stated she started looking around the unit for him and asked other staff to assist. LPN D reported Registered Nurse (RN) C called her and told her about the shirt found outside. LPN D stated she went outside with RN C and RN E to search for resident #1. She explained RN E located him between the two parking lots at the adjacent assisted living facility and they escorted him back into the facility through the back entrance. On 8/06/24 at 11:45 AM, RN E stated she was doing rounds and went to the unit resident #1 was on at approximately 5:00 AM on 7/25/24. She recalled seeing him in a wheelchair in front of the nurse's station. RN E reported she sat at the nurse's station to complete some documentation. She explained she left the unit at approximately 5:20 AM to go to the other unit but could not recall whether resident #1 was still near the nurse's station. She stated LPN D called her a short time later and asked if resident #1 followed her to the other unit. RN E informed LPN D he had not followed her and was not on that unit. RN E stated she told the staff to search for resident #1 and a code for missing resident was paged overhead. She recalled hearing the front door alarm as she was headed back to resident #1's unit. RN E stated when she entered the front lobby she saw RN C at the front door. RN C informed her resident #1 may have gone outside because they found a shirt on the ground that belonged to him. RN E stated she proceeded out the front door and walked down the pathway to the parking lot to search for resident #1. She recalled LPN D was ahead of her and when they reached the employee parking lot, RN E stated she got in her car to drive up toward the ALF to see if he was further up the road. She stated she saw resident #1 his wheelchair under a lamp post across from the ALF parking lot next to the enclosed retention pond. RN E stopped her car and called LPN D as she wheeled resident #1 back toward the facility. RN E reported RN C and LPN D took the resident back inside the facility as she retrieved her car. She explained he was placed on one-to-one supervision, and she applied a wander alarm bracelet on his ankle. RN E could not recall if resident #1 had a wander alarm bracelet previously. During a phone interview on 8/06/24 at 9:09 AM, RN C stated she was at the nurse's station around 5:00 AM the morning of 7/25/24. She recalled resident #1 wanted to use the phone. RN C asked resident #1 if he could make his call a little later and he agreed. She stated she left to use the restroom before she began to pass medications. RN C recalled LPN D was near resident #1 when she left. As she returned down the hallway approximately 10 minutes later, she heard a door alarm coming from the front lobby. RN C explained she entered the lobby and went to the front door. She recalled she pulled the door toward herself to ensure it was engaged and looked out the glass door. RN C stated it was dark outside and she did not see anyone, so she turned off the alarm and returned to her work station. She explained she did not think about the alarm again until later when LPN D came to her and asked if she had seen resident #1. She then remembered the front door alarm and went back to the front lobby with CNA A. RN C stated she held the front door open while CNA A went outside. She recalled the CNA found a shirt on the ground which she recognized as the shirt resident #1 had on his lap in the wheelchair. RN C stated she told the CNA to come back inside and she paged overhead for LPN D and RN E to come to the front lobby. She explained the three of them went out together to search for resident #1. She reported that RN E located him and returned him to facility through the back entrance. RN C expressed she felt CNA F and LPN D should have provided closer supervision for resident #1. She explained CNA F told LPN D to watch resident #1 while she escorted a resident to the transportation area. RN C stated LPN D told CNA F to just shut the doors to the unit when she went out. RN C acknowledged when she heard the door alarm, she did not go outside to search, nor did she notify any other staff of the alarm and instead she turned it off and returned to her duties. On 8/06/24, resident #1's wife confirmed she was notified her husband eloped from the facility. She stated she was not sure how he managed to get outside. She explained they had been married for 63 years and had always been together. Resident #1's wife stated she was concerned he got out of the facility unsupervised, but she was looking forward to taking him home. On 8/06/24 at 12:06 PM, the Director of Nursing (DON) acknowledged resident #1 had history of elopement but had a decline in mobility in May 2024. She explained he was assessed at that time and was not considered an elopement risk. She clarified the wander/elopement alarm bracelet was removed and the care plan was resolved at that time. The DON recalled he progressed approximately 4-6 weeks later with improved mobility but did not exhibit any exit-seeking behaviors. She explained resident #1 regularly accompanied his wife to the front door, kissed her before she left and returned to his room without incident. The DON reported she was not aware of any exit-seeking behavior. In a meeting with the Administrator, DON and Regional Nurse Consultant (RNC) on 8/07/24 at 10:58 AM, the Administrator stated the Quality Assurance and Performance Improvement (QAPI) Committee met and reviewed the event and investigation. She stated the committee identified RN C should have opened the door and looked outside when she responded to the door alarm and should have notified staff of the alarm. The Administrator acknowledged staff should have been more aware of resident #1's movement through the facility. She stated the committee noted several areas of opportunity for improvement and began education on several topics which included abuse and neglect, elopement standards and guidelines, accuracy of documentation, increased supervision and appropriate response to door alarms. The Administrator stated the QAPI Committee conducted a root cause analysis and determined the facility failed to respond appropriately to a door alarm and failed to provide appropriate supervision. Review of the policy and procedure Elopements and Wandering Residents revised 3/16/23 revealed an elopement occurred when a resident left the premises or a safe area without authorization and/or necessary supervision to do so. The document indicated that alarms were not a replacement for necessary supervision. Staff were directed to be vigilant in responding to alarms in a timely manner. On 8/07/24, resident #1's likely elopement route was retraced. He exited the facility's front lobby door and wheeled himself in the dark along an uneven sidewalk with four-inch curbs, from the front door to the parking lot. Resident #1 proceeded through the parking lot and down a paved driveway approximately 0.2 miles to an adjacent ALF. He was located under a lamp post across the street from the ALF's front parking lot next to a fenced retention pond. Along the route, he passed several metal drainage grates, a drainage ditch with water, a downed lamp post with exposed wires and two parking lots with dumpsters and electrical equipment. Historical weather data revealed on the morning resident #1 eloped, 7/25/24, the temperature at 5:53 AM was 78 degrees Fahrenheit and mostly cloudy. Sunrise occurred at 6:44 AM, (retrieved on 8/07/24 from www.wunderground.com). Review of the Facility Assessment Tool revealed the facility accepted and could care for residents with psychiatric and mood disorders including psychosis, impaired cognition, depression, anxiety, and behaviors that needed intervention. The document indicated the facility provided person-centered care which included identifying and implementing interventions to help support individuals with cognitive impairment. Review of corrective measures to remove Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 7/25/24 at 5:30 AM, resident #1 was discovered to be missing and the facility implemented its elopement policy and procedures. *On 7/25/24 at 5:53 AM, resident #1 returned to the facility with facility staff. He was assessed on return to the facility and had no injuries. A head count was conducted to verify the safety of all residents. The required notifications were made to the physician and family. Resident #1 was placed on 1:1 supervision. *On 7/25/24, resident #1 was re-evaluated for elopement risk and the elopement risk care plan was re-initiated due to his increased risk. *On 7/25/24, the facility re-evaluated all residents' elopement risk and identified a total of 15 residents as at risk for elopement. The elopement risk binders were reviewed to ensure they contained photos and demographic information for all identified residents. *On 7/25/24, electronic wander alarm bracelets were checked for all residents identified as at risk for elopement. *On 7/25/24, the Maintenance Director checked all doors and alarms center wide for proper functioning. No issues were identified. *From 7/25/24 to 7/26/24, all staff were re-educated on the elopement policy to include elopement standards and guidelines, providing appropriate supervision for residents with wandering or exit seeking behaviors, appropriate response to door alarms and elopement risk binders. Staff were also educated on entering/exiting the facility through designated doors. As of 7/30/24, 100% of staff members received elopement education and participated in elopement drills. *From 7/25/24 to 7/26/24, the facility completed 6 elopement drills to cover all 3 shifts with satisfactory staff response documented on elopement drill worksheets. *On 7/26/24 at 8:50 AM, the facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting and conducted a root cause analysis. The committee reviewed recommendations to develop a plan for correction to include education, post-testing, drills and audits. The ad hoc QAPI committee including the Medical Director (via telephone) approved the recommendations. *On 7/26/24 at 5:00 PM, the facility held an ad hoc QAPI meeting to evaluate the actions taken which included education, elopement drills and increasing volume on alarm annunciators. The ad hoc QAPI committee including the Medical Director approved the current plan and recommendations for continued education and auditing. Interviews were conducted from 8/06/24 to 8/08/24 with 23 staff members (9 CNAs representing all shifts, 1 receptionist, 1 RN, 5 LPNs representing all shifts, 1 therapist, 3 environmental services staff and 3 dietary staff). Staff interviews revealed they were knowledgeable of the elopement policy and procedures, appropriate response to alarms and supervision of all residents to include those at risk for elopement. The resident sample was expanded during the survey to include 12 additional residents. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations, care plans and physician orders for residents #4 through #15.