**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of the facility policy, the facility staff failed to implement care plan interventions for two residents ((R) #33 and R#34) of 30 residents reviewed. Specifically, the care plan was not followed for R#34 resulting in elopement from the facility on two occasions. Additionally, on 12/30/24 R#33 sustained fractures of the distal left femur with mild comminution when staff transferred her without using appropriate number of staff and equipment. On March 11, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on March 11, 2025, at 9:55 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on February 2, 2025. At the time of exit on March 13, 2025, the Immediate Jeopardy remained ongoing. Findings include: 1. Record review indicated R#34 was admitted [DATE] and had diagnoses of Alzheimer's disease, generalized anxiety disorder, other depressive episodes, and generalized weakness. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/24, revealed R#34 had a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had a severe cognitive impairment. Review of records indicated R #34 had two facility reportable incidents for elopement that occurred on 5/20/24 and 2/2/25. Review of R #34's care plan documented a risk for elopement and wandering that was initiated 7/9/21. Care plan interventions initiated on 7/9/21 included, Staff to supervise resident as she moves on and off the unit. Following the 2/2/25 elopement, care plan interventions were updated as follows: 2/3/25 Resident in view of staff at all times within the facility for 3 days as ordered, Date Initiated 2/3/25 .Daily check on locked doors, Date Initiated 2/4/25, Staff education/Inservice as needed, Date Initiated 2/4/25. During an interview, on 3/6/25 at 12:17 p.m., the Director of Nursing (DON) reported that the resident had not had an elopement risk assessment since admission. The DON further stated that she did not know why the resident had not been escorted from the activity department to their unit per the care plan intervention of 2021. The DON stated they initiated door lock checks, but this was not placed on the care plan after the first elopement. During an interview, on 3/11/25 at 1:23 p.m., the DON stated that facility-wide changes were implemented to include census checks performed at 8:00 p.m. for all units and that the glass doors were locked after the first elopement. The DON further stated that care plan decisions are made during Interdisciplinary Team (IDT) meetings held daily at 9:00 a.m . 2. Review of the facility policy titled, IDT [Interdisciplinary Team]/Care Plan Activities, last revised 5/1/19 revealed Purpose: To evaluate, implement and maintain a thorough plan of care for each resident ensuring that he/she maintains the highest quality of life possible. Review of R#33's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, Alzheimer's Disease (admitting diagnosis), encounter for other orthopedic aftercare, fracture of lower end of left femur (12/31/24). Review of R#33's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was severely cognitively impaired and rarely/never understood. Further review of the MDS revealed the resident was dependent of staff and required two persons' physical assistance with transfers. Review of R#33's comprehensive care plan, initiated on 12/18/23, revealed Resident has a self-care deficit r/t [related to] impaired mobility and cognition. Care plan approaches included resident is dependent on staff for chair/bed transfers and resident is dependent on staff for transfers and a mechanical lift [Hoyer] is used by 2 [two] staff (initiated 2/28/25). Review of R#33's Monthly Nursing Summary, dated 12/4/24, revealed Resident required assistance of 2 [two] or more staff and Hoyer lift used for transfers .care needed for positioning required assistance of 1 [one] staff . Review of R#33's Progress Note dated 12/31/24 at 1:32 a.m. revealed At 2200 [10:00 p.m.] CNA [Certified Nursing Assistant] called nurse into room to see resident's leg. When CNA attempted to reposition resident, her left thigh was deformed and touching the leg it made a crunching sound and moved. Put the leg on the pillow to support it and notify the nurse manager. Sent resident to ER [Emergency Room] to be evaluated and treated. Notified family of situation . Review of the R#33's Hospital Discharge Summary revealed an x-ray that concluded R#33 had sustained fractures of the distal left femur with mild comminution and a few degrees of posterior angulation (a broken femur). Review of the facility's Investigation Report dated 1/7/25 revealed R#33 sustained a broken femur. Further review of the report revealed the facility was unable to substantiate the exact cause of the injury, however, it likely occurred during transfer to or from the shower chair due to age, immobility, contractures, and malnutrition. During an interview with R#33's Responsible Party (RP) on 3/5/25 at 10:10 a.m. via telephone, the RP revealed she was notified via telephone on 12/31/24 by facility staff that R#33 was transferred to the hospital and had sustained a broken femur. The RP revealed she was confused due to R#33 being incapable of moving without assistance from nurses. The RP revealed she had asked facility staff how it happened, and facility staff revealed they were unsure of how it occurred. The RP revealed she had spoken with the Administrator and Director of Nursing a couple of days later (was unsure of the exact date) and revealed the injury may have occurred during transferring the resident to the shower room. An interview with Certified Medication Aide (CMA)/CNA AA on 3/5/25 at 12:49 p.m. revealed on 12/30/24 she was passing medications during the day shift. CMA/CNA AA stated another CNA requested assistance with transferring R#33 from the bed to the shower chair. CMA/CNA AA revealed she was in the middle of passing medications to another resident and had to put away several items on the medication cart prior to assisting CNA DD with transferring R#33 to the shower chair. CMA/CNA AA revealed that when she entered R#33's room, R#33 was positioned on the edge of the bed with her legs crossed at the ankles. CMA/CNA AA revealed CNA DD was behind R#33 and held her up with both arms under the resident's arm for support. CMA/CNA AA revealed R#33 was unable to hold themselves up without assistance from staff. CMA/CNA AA revealed she assisted CNA DD with transferring R#33 from the bed to the shower chair. CMA/CNA AA revealed they did not use any equipment (gait belt or mechanical lift) to transfer the resident to the shower chair. CMA/CNA AA revealed she did not witness CNA DD assisting the resident to the edge of the bed. However, due to prior occasions, R#33 required more than one person to be transferred due to her physical and medical conditions. During an interview with CNA BB on 3/5/25 at 1:01 p.m., it was revealed that on 12/30/24, CNA DD assisted R#33 to the shower room. CNA BB revealed she showered the resident and during this time, CNA BB revealed she observed an open area on R#33's bottom (referring to the resident's buttocks). CNA BB revealed she reported the open area to the Nurse Manager. CNA BB revealed that after she showered R#33, she assisted the resident back to their room and put her in bed. CNA BB revealed that even though she was aware the resident required two staff with transfers, she did not request assistance from another staff member prior to transferring the resident back to bed. During an interview with CNA CC on 3/5/25 at 1:59 p.m., it was revealed she was working the day shift on 12/30/24. CNA CC revealed she was to the shower room to assess R#33 because another staff member revealed the resident's toes were bleeding. CNA CC revealed when she went to assess R#33, her toes were dry and she did not observe any blood. CNA CC revealed he/she left the shower room and did not provide any care to R#33 for the rest of the shift. An interview with CNA DD via telephone on 3/5/25 at 2:06 p.m. revealed on 12/30/24 she was assigned to provide care for R#33. CNA DD revealed she went to R#33's room to get the resident up for a shower. CNA DD revealed she requested assistance from another CNA to transfer the resident. CNA DD revealed she did not move the resident until CMA/CNA AA entered the room. CNA DD revealed they did not use any equipment to transfer the resident from the bed to the shower chair. CNA DD revealed R#33 was showered by another staff member, and when she went back to R#33's room, the resident was in bed resting. CNA DD revealed R#33 required two staff members for transfers due to the resident's immobility During an interview with the Director of Nurses (DON) on 3/6/25 at 11:56 a.m., the DON revealed the facility concluded that R#33 was transferred improperly. The DON revealed she expected staff to use a lift or gait belt when transferring residents. The DON also revealed she expected staff to follow care plan approaches with transfers and that R#33 should have been transferred by two staff members due to resident's condition. (Cross refer F689)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility policy titled, Safe Transfers - Hoyer Lift, last revised on 8/29/22, revealed All residents require handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Review of R#33's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to, Alzheimer's Disease (admitting diagnosis), encounter for other orthopedic aftercare, fracture of lower end of left femur (12/31/24). Review of R#33's significant change in status the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was severely cognitively impaired and rarely/never understood. Further review of the MDS revealed the resident was dependent of staff and required two persons for physical assistance with transfers. Review of R#33's comprehensive care plan, initiated on 12/18/23, revealed Resident has a self-care deficit r/t [related to] impaired mobility and cognition. Care plan approaches included resident is dependent on staff for chair/bed transfers and resident is dependent on staff for transfers and a mechanical lift [Hoyer] is used by 2 staff (initiated 2/28/25). Review of R#33's Monthly Nursing Summary, dated 12/4/24, revealed Resident required assistance of 2 [two] or more staff and Hoyer lift used for transfers .care needed for positioning required assistance of 1 [one] staff . Review of R#33's Progress Note dated 12/31/24 at 1:32 a.m. revealed At 2200 [10:00 p.m.] CNA (Certified Nursing Assistant) called nurse into room to see resident's leg. When CNA attempted to reposition the resident, her left thigh was deformed, and when touching the leg, it made a crunching sound and moved. Put the leg on the pillow to support it and notify the nurse manager. Sent resident to ER [Emergency Room] to be evaluated and treated. Notified family of the situation . Review of the R#33's Hospital Discharge Summary revealed an x-ray that concluded R#33 had sustained fractures of the distal left femur with mild comminution and a few degrees of posterior angulation [a broken femur]. Review of the facility's Investigation Report dated 1/7/25 revealed that R#33 sustained a broken femur. Further review of the report revealed that the facility was unable to substantiate the exact cause of the injury; however, it likely occurred during transfer to or from the shower chair due to age, immobility, contractures, and malnutrition. During an interview with R#33's responsible party (RP) on 3/5/25 at 10:10 a.m. via telephone, the RP revealed he was notified via telephone on 12/31/24 by facility staff that R#33 was transferred to the hospital and had sustained a broken femur. The RP revealed he was confused due to Resident #33 being incapable of moving without assistance from the nurses. The RP revealed he/she asked facility staff how it happened, and the facility staff revealed they were unsure of how it occurred. The RP revealed he/she spoke with the Administrator and Director of Nursing a couple of days later (was unsure of the exact date) and revealed the injury may have occurred during transferring the resident to the shower room. An interview with Certified Medication Aide (CMA)/CNA AA on 3/5/25 at 12:49 p.m., revealed on 12/30/24 she was passing medications during the day shift. CMA/CNA AA stated another CNA requested assistance with transferring R#33 from the bed to the shower chair. CMA/CNA AA revealed she was in the middle of passing medications to another resident and had to put away several items on the medication cart prior to assisting CNA DD with transferring R#33 to the shower chair. CNA AA revealed when she entered R#33's room, R#33 was positioned on the edge of the bed with her legs crossed at the ankles. CNA AA revealed CNA DD was behind R#33 and holding her up with both arms under the resident's arms for support. CNA AA revealed R#33 was unable to hold themselves up without assistance from staff. CNA AA revealed she assisted CNA DD with transferring R#33 from the bed to the shower chair. CNA AA revealed they did not use any equipment (gait belt or mechanical lift) to transfer the resident to the shower chair. CNA AA revealed she did not witness CNA DD assisting the resident to the edge of the bed. However, based on prior occasions, R#33 required more than one person to be transferred due to her physical and medical conditions. An interview with CNA BB on 3/5/25 at 1:01 p.m., revealed on 12/30/24, CNA DD assisted R#33 to the shower room. CNA BB revealed she showered the resident and during this time, CNA BB revealed she observed an open area on R#33's bottom (referring to the resident's buttocks). CNA BB revealed he/she reported the open area to the nurse manager. CNA BB revealed after she showered R#33 she assisted the resident back to their room and put her in bed. CNA BB revealed that even though she was aware the resident required two (2) staff with transfers, he/she did not request assistance from another staff member prior to transferring the resident back to bed. During an interview with CNA CC on 3/5/25 at 1:59 p.m. it was revealed she was working the day shift on 12/30/24. CNA CC revealed she went to the shower room to assess R#33 because another staff member revealed the resident's toes were bleeding. CNA CC revealed when she went to assess R#33, R#33's toes were dry, and she did not observe any blood. CNA CC revealed she left the shower room and did not provide any care to R#33 for the rest of the shift. During an interview with CNA DD via telephone on 3/5/25 at 2:06 p.m. it was revealed on 12/30/24 she was assigned to provide care for R#33. CNA DD revealed she went to R#33's room to get the resident up for a shower. CNA DD revealed she requested assistance from another CNA with transferring the resident. CNA DD stated she did not move the resident until CNA AA entered the room. CNA DD revealed they did not use any equipment to transfer the resident from the bed to the shower chair. CNA DD revealed R#33 was showered by another staff member and when she went back to R#33's room, the resident was in bed resting. CNA DD revealed R#33 required two staff members for transfers due to the resident's immobility. During an interview with the Director of Nursing (DON) on 3/6/25 at 11:56 a.m., the DON revealed the facility concluded that R#33 was transferred improperly. The DON revealed she expected staff to use a lift or gait belt when transferring residents. The DON also revealed she expected staff to follow care plan approaches with transfers and that R#33 should have been transferred by two staff members due to resident's condition. (Cross refer F656) Based on interviews, record review, and review of the facility policy titled Elopement and Wandering Residents and Safe Transfers - Hoyer Lift, the facility failed to ensure one resident (Resident #34) of two residents reviewed for elopement, did not leave the facility without the nursing staff being aware. This failure led to Resident (R) #34 eloping on 2/2/25 for a second time, which could have caused harm or death. The facility also failed to provide one of two residents reviewed the appropriate interventions when transferring (Resident (R) #33). Additionally, on 12/20/24, actual harm was experienced when R#33 sustained fractures of the distal left femur with mild comminution and was transferred to the hospital for further medical treatment. The failure to use appropriate facility equipment and follow care plan approaches resulted in the resident sustaining an avoidable injury. On March 11, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on March 11, 2025, at 9:55 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on February 2, 2025. At the time of exit on March 13, 2025, the Immediate Jeopardy remained ongoing. Findings include: 1. Review of the facility's policy titled, Elopement and Wandering Residents, dated 2/27/19, specified, .ensure residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents .PROCEDURE: .c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. PROCEDURE POST ELOPMENT: . g. Documentation in the medical record will include findings from social and nursing service assessments, physician/family notification, care plan discussions, and consultant notes as applicable. A record review indicated R #34 was admitted to the facility on [DATE] and had diagnoses of Alzheimer's disease, generalized anxiety disorder, other depressive episodes, and generalized weakness. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/5/24, revealed R #34 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The resident utilized a wheelchair independently for locomotion. Review of a nursing progress note, dated 5/20/24 at 2:34 a.m., documented that R #34 was found outside, had sustained a small skin tear to the top of the left foot, and was unable to answer questions. A review of R#34's In-service for Elopement and Reportable Incidents, held 5/20/24 through 5/27/24, documented that an elopement occurred on 5/20/24 at 1:30 a.m. The in-service documented, CONCLUSION: R #34 exited the facility without staff knowledge through a door that had not been reset to alarm. Review of R #34's care plan documented a risk for elopement and wandering, initiated on 7/9/21, with an intervention for Staff to supervise resident as she moves on and off the unit. Further record review documented that R #34 had a second elopement, which occurred on 2/2/25. A review of a facility incident report, dated 2/2/25, indicated R#34 was observed outside the building by a staff member at approximately 3:10 p.m. rolling down the sidewalk in her wheelchair. The report documented, INTERVENTIONS: Exit doors checked for locked/secured. The final report documented a review of inside and outside cameras determined the resident exited the dining area door at approximately 3:05 p.m. The surveyor requested to view the inside and outside cameras but was denied access. Review of R#34's care plan following the second elopement, documented the following approaches: 2/3/25 Resident in view of staff at all times within the facility for 3 days as ordered, Date initiated 2/3/25 .Daily check on locked doors, Date initiated 2/4/25, Staff education/inservice as needed, Date initiated 2/4/25. A review of the Emergency Door Log Checks for A, B, and C halls initiated on 2/4/25 following the 2/2/25 elopement revealed the log had been signed daily from 2/1/25 through 2/28/25 for Units A and B, and signed from 3/1/25 through 3/27/25 for Unit C. The facility was not able to provide logs prior to February 2025. During an interview, on 3/6/25 at 12:17 p.m., the Director of Nursing (DON) reported that the resident had not had an elopement risk assessment completed since admission. The DON further stated that she did not know why the resident had not been escorted from the activity department to their unit per the care plan intervention of 2021. The DON stated they initiated door lock checks, but this was not placed on the care plan after the first elopement. On 3/7/25, at approximately 12:15 p.m., the DON provided documentation to indicate staff had participated in training and discussion of elopement. The DON provided a Daily Stand-up Meeting Sign-in Sheet, dated 1/4/25. Handwritten in the left margin revealed, QAPI committee met and discussed elopement event on 2/2/25 RE: R #34. During an interview, on 3/11/25 at 1:24 p.m., the DON stated she did not know why the resident's care plan was not updated following the May 2024 incident, but that facility-wide changes were implemented to include census checks performed at 8:00 p.m. for all units and that the glass doors were locked. The DON further stated that care plan decisions are made during Interdisciplinary Team (IDT) meetings held daily at 9:00 a.m.

Based on interviews and record reviews, the facility's Administration failed to ensure it administered in a manner that enabled it to use its resources effectively and efficiently to prevent residents from elopement. This resulted in a lack of supervision and processes, which placed residents at risk for multiple elopements and at risk for serious adverse outcomes. This failure resulted in resident (R)#34 eloping from the facility twice. The census was 81. On March 11, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on March 11, 2025, at 9:55 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on February 2, 2025. At the time of exit on March 13, 2025, the Immediate Jeopardy remained ongoing. Findings include: Review of a nursing progress note, dated 5/20/24 at 2:34 a.m., documented that R #34 was found outside, had sustained a small skin tear to the top of the left foot, and was unable to answer questions. A review of R#34's In-service for Elopement and Reportable Incidents, held 5/20/24 through 5/27/24, documented an elopement occurred on 5/20/24 at 1:30 a.m. The in-service documented, CONCLUSION: R #34 exited the facility without staff knowledge through a door that had not been reset to alarm. Review of a facility reported incident revealed a resident eloped from the facility on 2/2/25. The investigation concluded that the exit door, which the resident went out of, did not alarm and staff were not notified that the resident left the building unattended, without staff knowledge. During an interview with the Administrator on 3/13/25 at 11:49 a.m., the Administrator revealed she was aware of the resident's elopement on 2/2/25. The Administrator revealed after the resident's elopement; the Interdisciplinary Team (IDT) met the next day to discuss additional interventions for the resident who eloped. The Administrator revealed the IDT did not discuss any other residents who had the potential to elope. The Administrator revealed at the time, all of the residents were at risk for elopement and the facility should have conducted risk assessments on the residents who were at high risk for elopement. The Administrator revealed door checks were also implemented, however; they were not implemented on all shifts and were implemented just on the day shift. The Administrator revealed a resident could have eloped at any time of the day and that the facility failed to implement door checks on every shift to hold staff accountable and residents safe. The Administrator revealed there were several key areas of concern the facility staff had addressed, however, they failed to implement those interventions until the situation resulted in an IJ. The Administrator revealed moving forward she expected IDT members to discuss any areas of concern in QAPI (Quality Assurance Performance Improvement) meetings to identify care areas of concern and initiate appropriate interventions immediately.