**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who required dialysis services continued to receive those services in accordance with physician orders when the facility-based dialysis center closed on 8/12/2024 for 6 of 7 residents reviewed for dialysis services. (Resident D, E, F, R, S and V) This deficient practice resulted in Resident D and Resident E missing two dialysis treatments and required transfer to an acute care hospital for treatment of critical laboratory results and emergency dialysis treatments. The Immediate Jeopardy began on 8/12/24, when the facility failed to ensure the provision of dialysis services were continued for the residents who previously had an order for Dialysis on Monday-Friday until the facility-based dialysis unit closed on Friday, 8/10/24, without residents having arrangements in place for when their next dialysis treatment would occur, on Monday 8/12/2024. The Interim Administrator, Interim Director of Nursing and the Regional Nurse Consultant were notified of the Immediate Jeopardy (IJ) on 8/22/24 at 1:40 P.M. Findings include: The former in-house dialysis clinic provided a letter, sent to the facility and addressed to the previous Administrator, on 4/25/24, which indicated they were requesting repairs, due to the (Indiana) Department of Health (IDOH) had surveyed the den in May of 2023 and noted several deficiencies. The letter indicated, since the survey, the dialysis staff had asked former and current Administrators to make repairs via email, meetings and in-person conversations, but to date, the repairs had not been made. The letter indicated a failure to repair would result in termination of the in-house dialysis agreement due to unsafe conditions/violations deemed by the (I)DOH. A letter, dated 6/10/24, provided by the former in-house dialysis provider, indicated .effective July 10, 2024 (the Termination Date) due to breach of agreement for failure to make repairs in accordance with provision 21.C in the Long-Term Care Facility Renal Dialysis Affiliation Agreement. For clarification purposes, Wednesday, July 10, 2024, will be the final day [name of dialysis company] provides renal dialysis services at the SNF [Skilled Nursing Facility] An email notification, from the former dialysis in-house clinic/den, dated 7/5/24, indicated .We have extended our services by 30 days to help give you all more time to place the dialysis patients to outpatient clinics. Our new date we will be ceasing operation is August 9th During an interview, on 8/20/24 at 12:47 P.M., an emergency room (ER) Manager, from the local hospital, indicated Residents E and Resident D were both sent to the ER on [DATE]. They both required emergency dialysis treatment, while in the ER and were then admitted to the hospital. The hospital's concern was that the residents were not provided dialysis services at the facility and/or set up with dialysis times according to those residents after the in-house dialysis services ceased. ER Manager indicated Resident F, also from the facility, had been transported to the ER on [DATE], due to not having dialysis and was discharged from the hospital on 8/16/24. During an interview, on 8/19/24 at 1:05 P.M., Resident E's sister indicated Resident E was still at the hospital because the facility did not make arrangements for her to have dialysis when they knew the in-house dialysis was closing. She indicated the facility knew for 2 months they were going to close the unit. Resident E had her last had her last in-house dialysis on Friday the 9th. On Monday (8/12), she contacted the facility to find out when Resident E's next dialysis would be or where her sister would be going for dialysis, and they only told her not to worry. On 8/13/24, she was told her sister would be going somewhere in (neighboring city) to have her dialysis three times a week, however the facility would not be able to transport her. Then the facility said they would try a facility in [2 larger cities which were 2-3 hours away] to see if they would accept Resident E. On Wednesday (8/14), her sister indicated she was able to breath and was being sent to a local ER, where she required immediate dialysis and blood transfusion. 1. On 8/20/24 at 2:50 P.M., a review of the clinical record for Resident E was conducted. The resident's diagnoses included, but were not limited to: End Stage Renal Disease (ESRD), dependence on renal dialysis, congestive heart failure and respiratory failure. A Physician Order, dated 3/28/24, indicated, .Hemo-Dialysis 5 [five] times a week (Mondays, Tuesdays, Wednesdays Thursdays, Fridays). In house An Annual Minimum Data Set (MDS) assessment, dated 5/22/24, indicated the resident was alert and oriented, had no cognitive deficits, required dialysis and used oxygen. A current Care Plan, initiated on 5/25/23, and revised 6/2/24, indicated resident required Hemodialysis (in house) related to End Stage Renal Disease. The intervention included but were not limited to: .Dialysis Days: Mondays, Tuesdays, Wednesdays, Thursdays, Fridays . observe for signs of worsening renal insufficiency such as changes in level of consciousness .changes in heart and lung sounds .observe for symptoms of fluid volume excess such as edema, shortness of breath, crackles in lungs, weight gain or hypertension (sic) A current Care Plan, initiated on 5/25/23, and revised on 3/12/24, indicated the resident was at risk for fluid imbalance due to kidney failure, with refusal of dialysis or stopping dialysis early. The interventions included but were not limited to: .observe for signs of fluid overload: Anorexia, Anxiety, Mood/behavioral changes, Confusion, Edema, Nausea/vomiting, Shortness of breath, difficulty breathing (Dyspnea), Increased respirations (Tachypnea), Difficulty breathing when lying flat (Orthopnea), Congestion, Cough, Fatigue, Jugular Venous Distention (JVD), Sudden weight gain. Document and notify MD [Medical Doctor] of abnormal findings (sic) A electronic mail (email) communication , dated 8/12/24, between the previous Administrator and the Regional Director of Operations was provided, on 8/22/24, by the current Administrator. The email indicated chair times for Resident E were written on the email, but did not indicate at what facility she was to have her dialysis treatments. The nursing progress notes, dated 8/12/24 through 8/14/24, did not include documentation to indicate Resident E missed dialysis treatments, staff effectively assessed or monitored for fluid volume overload or for complications of not receiving dialysis in accordance with the physician's order. The notes did not include documentation to indicate staff attempted to secure dialysis services on 8/12/24 or 8/13/24 or to indicate the resident experienced a significant change in condition and was transferred to the hospital. A facility Dialysis Post Communication Record for Resident E, dated 8/14/24 at 4:18 A.M., indicated the resident was admitted to the hospital from dialysis. Addition information indicated .sent to [name of hospital] for abnormal labs (potassium hemoglobin) There were no lab documentation in the chart and Regional Nurse Consultant confirmed there were no lab draws for the resident from 8/12-8/14/24 and she did not know why the nurse completed a PostDialysis Communication Record for Resident E when there was no dialysis center and chair time set up for the resident for 8/14/2024. The next consecutive nursing progress note, dated 8/14/24 at 11:40 A.M., indicated the resident was away from the facility receiving dialysis. There were no nursing progress notes, dated 8/14/24 regarding transfer or discharge forms having been completed for Resident E. An ER Physician Report, dated 8/14/24 at 11:36 A.M., indicated Resident E complained of being short of breath and had missed two dialysis treatments since the previous Friday. Resident E told the physician she typically received dialysis Monday through Friday, however the nursing home where she resided was only able to provide dialysis until Friday (8/9) and she had not received dialysis since 8/12/24. Resident E reported the previous in-house dialysis service stopped and the facility did not ensure she continued receiving dialysis services. The report indicated Resident E suffered from fluid overload from lack of dialysis related to resident not receiving dialysis for five days. She was admitted to the hospital in guarded condition. Lab work at the hospital indicated critical levels of Potassium at 6.5, Creatinine at 10.4 [no normal ranges were provided] and hemoglobin at 6.4 with BUN (Blood Urea Nitrogen level) high at 83. The patient received a blood transfusion of one unit of packed red blood cells due to hemoglobin being less than 7. Hemoglobin is a value assigned to the number of red blood cells that carry oxygen. During an interview, on 8/19/2024 at 1:05 P.M., Resident E's sister indicated Resident E was still at the hospital because the facility did not make arrangements for her to have dialysis when they knew the in-house dialysis center was closing. She indicated the facility knew for two months they were going to close the in-house dialysis unit. Resident E has her last in-house dialysis treatment on 8/9/24. On Monday, 8/12/24, the family member indicated she contacted the facility to find out when Resident E's next dialysis would be or where her sister would be going for dialysis and the facility staff only told her not to worry. On 8/13/24, she was told her sister would be going somewhere in [neighboring city] to have her dialysis three times a week, however, the facility was not able to transport her. The the facility said they would try a facility in [two larger cities which were two - three hours away] to see if they would accept Resident E. On Wednesday (8/14/24) her sister indicated she was not able to breathe and was being sent to a local ER because she required immediate dialysis and a blood transfusion. During an interview, on 8/20/24 at 2:45 P.M., the interim Administrator indicated there were no dialysis centers within a forty-five mile radius, around the facility, that would accept Resident E. The only options suggested to her, were to have her transferred to a facility in [2 larger cities which were 2-3 hours away]. The interim Administrator indicated no documentation could be provided to indicate dialysis services had been secured for Resident E on 8/12/24, 8/13/24 and 8/14/2024. The resident required emergent transfer to the hospital on 8/14/24 During an interview on 8/21/24 at 10:15 A.M., Resident E indicated she had been in the hospital since last Wednesday (8/14/24) and her last day of dialysis, at the facility, was on 8/9/24. On the last day of her dialysis treatment, at the facility, the previous Administrator had told the resident the facility would have dialysis setup for her, by Monday 8/12/24. The Transportation person, Employee 7, had also told the resident the facility was going to make sure she received her dialysis treatment on Monday 8/12/24. On Monday 8/12/24, the resident indicated she did not receive her dialysis treatment and was told by the Interim Administrator they could not find anywhere to send her because she required a Hoyer lift for transport needs. The facility told her she could look for my own dialysis center, which made her angry and she was ready to give up. Resident E indicated she had never received any kind of nursing assessment on Saturday (8/10) through Wednesday (8/14). The resident indicated a nurse had listened to her lungs, on Wednesday, after she complained about not being able to breath and then the nurse decided to send her to the hospital. Resident E indicated she was admitted into the hospital because she needed dialysis. The resident was upset because she was then told she could not go back to the facility because she needed dialysis and the facility would not provide her transportation to a dialysis clinic, because she needed a Hoyer lift for transfers. However, the resident indicated she did not need a Hoyer lift for transfers and the resident indicated the Physical Therapist at the hospital also confirmed she did not require a Hoyer lift for transfer needs. During an interview, on 8/21/24 at 11:32 A.M., Transport Employee 7 indicated she had sent referrals [to local dialysis centers] for all dialysis residents approximately a month ago, prior to the in-facility dialysis center's closure date. However, the previous Administrator had informed Employee 7 she would be working on the referrals, so Employee 7 had no further involvement with the referrals. On Monday 8/12/24, the former Administrator was released from her duties at the facility and Transport Employee 7 was notified that day to start making transportation arrangements for all the residents in the building requiring dialysis. Resident D was referred to [2 different facilities over 1.5 hours away],a facility, both with in-house dialysis. It was Employee 7's understanding the facility would be providing transportation to one of these facilities. Resident E was scheduled to have dialysis on Monday, Wednesday and Friday at a local dialysis center and was scheduled to have her first dialysis treatment there on Wednesday 8/14/2024, however the dialysis center had called on Tuesday, 8/13/24, and informed Employee 7 they could not take Resident E due to her weight and there was no other treatments scheduled for Resident E. Employee 7 indicated no residents had started their dialysis treatments on Monday 8/12/24. Although Employee 7 indicated Resident E was scheduled to receive dialysis treatments 3 times a week, on Monday, Wednesday and Friday at a dialysis center for treatments, there was no physician's order provided to change Resident E's dialysis treatments from a 5 day Monday- Friday schedule to a 3x a week - Monday, Wednesday and Friday schedule. There was no documentation provided regarding to whom Employee 7 had communicated the issues with Resident E's dialysis treatments. During an interview, on 8/21/24 at 3:50 P.M., with alert and oriented Resident K indicated she had been roommates with Resident E for some time. Resident K indicated on Wednesday (8/14/24), last week, both her and Resident E were in the activity room when a staff member came in the room and told Resident E she was going to the ER. Resident K indicated Resident E kept telling her she did not feel well and was worried about not receiving her dialysis treatments due to transportation concerns. Nursing Progress Note for Resident E, dated 8/14/24 at 11:40 A.M., indicated LOA (Leave of Absence) at dialysis. There were no Nursing Notes indicating the resident had been transferred to a local hospital. During an interview, on 8/22/24 at 1:02 P.M., LPN 13 indicated he had written the Progress Note, dated 8/14/24 at 11:40 A.M He indicated he thought Resident E was at an outside dialysis center and when he heard she was in the hospital he assumed she went there from the dialysis center. He was not aware of when or where Resident E's dialysis days at an outside dialysis center had been scheduled. During a interview, on 8/23/24 at 1:33 P.M., an admission Coordinator (AC) for (multiple local dialysis centers) indicated the facility had contacted and started the admission process for Resident E was receive from the facility, on 7/19/2024. The AC indicated no documentation could be provided to determine dialysis services were scheduled on 8/12/24. In addition, the AC indicated she had never communicated to the facility the need for a bariatric chair for Resident E. The AC indicated no documentation could be provided to indicate communication with the facility occurred between 7/19/24 - 8/19/24 when a second request for dialysis services was received. 2. On 8/21/24 at 3:15 P.M., a review of the clinical record for Resident F was conducted. The resident's diagnoses included, but were not limited to: ESRD ,dependence on renal dialysis, diabetes and hypertension A Quarterly Minimum Data Set (MDS) assessment, dated 6/11/24, indicated the resident was cognitively intact and required dialysis treatments. A current Care Plan, initiated on 3/6/23 and revised on 1/17/24 indicated the resident required Dialysis related to ESRD. The interventions included, but were not limited to: .observe for symptoms of fluid volume excess such as edema, shortness of breath, crackles in lungs, weight gain or hypertension (sic) A current Care Plan, initiated on 3/23/24 and revised 1/17/24, indicated the resident was at risk for fluid imbalance due to ESRD. The interventions included, but were not limited to: .observe for signs of fluid overload: Anorexia, Anxiety, Mood/behavior changes, Confusion, Edema, Nausea/vomiting, Shortness of breath, difficulty breathing (Dyspnea), Increased respirations (Tachypnea), Difficulty breathing when lying flat (Orthopnea), Congestion, Cough, Fatigue, Jugular Venous Distention (JVD), Sudden weight gain. Document and notify MD of abnormal finding (sic) A Physician Order for Resident F, dated 3/27/24, indicated .Hemo-Dialysis five times a week (Mondays, Tuesdays, Wednesdays Thursdays, Fridays). In- house A electronic mail (email) communication , dated 8/12/24, between the previous Administrator and the Regional Director of Operations was provided, on 8/22/24, by the current Administrator. The email indicated chair times for Resident F were written on the email, but did not indicate at what facility he was to have his dialysis treatments A Nursing Progress Note, dated 8/12/24 at 11:00 A.M., indicated the resident was noted to have shortness of breath and an overall decline. The Nurse Practitioner was notified regarding the resident's change of condition and an order was received to send the resident to a local ER. Emergency Medical Staff (EMS) arrived and resident was transported to the ER via an ambulance. It was unclear why the nursing progress note, dated 8/12/24 for Resident F was not completed until 11:00 A.M., after he had been evaluated in the local ER. A un-timed Nurse Practioner (NP) Acute Note, dated 8/12/24, indicated Resident F was short of breath, had a cough, was drowsy and had labored respirations. The note indicated the resident, initially refused to be transferred to the hospital for evaluation of fluid volume overload and dialysis treatment, but then agreed. An ER Physician Report, dated 8/12/24 at 10:45 A.M., indicated Resident F had a medical history of ESRD, on dialysis with last dialysis on Friday (8/9/24) who presented to the Emergency Department with shortness of breath, some congestion, a cough and altered mental status. He was admitted to the hospital's Intensive Care Unit (ICU), in guarded condition with a nephrology consult. Lab work completed in the ER for Resident F included, but was not limited to: high potassium level at 5.4, high BUN at 76 with a critical Creatinine level at 9.42. A Physician's Order, dated 8/13/24, indicated .Dialysis M/W/F @ 11:45 AM [name and address of dialysis center]. Please have ready for transport @10:45 am, one time a day every, Mon, Wed, Fri The order was received while the resident was hospitalized . The resident was discharged from the hospital on 8/16/2024 and returned to the facility. The Physician's order changing the resident's dialysis treatments to three times a week was not received for Resident F until 8/13/24. During an interview on 8/21/24 at 11:47 A.M., Transport Employee 7 indicated Resident F had a medical issue and was sent the hospital. Transport Employee indicated Resident F had an appointment set up for dialysis treatments for Monday (8/12/24) at 11:50 A.M., at the dialysis center, but was sent to the hospital and was admitted on [DATE] prior to the 11:50 A.M. appointment. During an interview, on 8/22/24 at 10:43 A.M., Resident F indicated he was told about the in-house dialysis closure by an aide who worked for the company who provided his dialysis. He indicated arrangements for his dialysis was never done until after the closure. He indicated he went to the hospital on Monday, 8/12/24, and received dialysis while there, but he had no information, prior to his admission to the hospital, regarding an outside dialysis center nor when he would next go to dialysis. After his return from the hospital, he indicated he was informed he would be going to a dialysis center on Mondays, Wednesdays and Fridays for treatments. During an interview, on 8/22/24 at 1:54 P.M., the facility NP indicated the in-house dialysis center had not given the facility much of a notice, maybe two-four weeks prior to their closure. She indicated she had rounded on all the dialysis resident's due to problems with the facility setting up dialysis for those residents requiring dialysis, and would be missing their Monday dialysis. She had instructed Nurse Manager 12 to send residents to a local ER if they had no had dialysis by Wednesday the 14th. She indicated she was contacted about Resident F having some concerns which may or may not have been related to him not having dialysis on his regular scheduled Monday, and had ordered the nurses to send him to the ER on [DATE]. There was no documentation provided the NP had notified her supervising MD of the issues regarding missed and/or unscheduled dialysis treatments per orders. During an interview with the Admissions Coordinator (AC) for multiple, local dialysis clinics, on 8/23/2024 at 1:39 P.M. she indicated Resident F had an initial request for dialysis made on 7/19/2024 however, there was no chair time set up for him until after he was hospitalized . His first dialysis treatment at the center was on 8/19/24. 3. Resident D's record review was completed 8/21/2024 at 11:48 A.M. His diagnoses included, but were not limited to: end stage renal disease, dependence on renal dialysis, heart failure, anemia, depression, hemiplegia and hemiparesis. A Physician's order, dated 3/27/2024, indicated Resident D should receive in house dialysis 5 times a week on Monday, Tuesday, Wednesday, Thursday and Friday. A current Care Plan for Resident D, with a revision date of, 4/29/2024, indicated the resident required hemodialysis and at times may refuse dialysis. The goal for the Care Plan was to remain free of complications related to dialysis. Interventions to the Care Plan included, but were not limited to: - Dialysis Days: Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays revised on 4/29/2024. - Observe for symptoms of fluid volume deficit such as hypotension, postural changes in blood pressure, dizziness, thirst, dry oral mucosa, weight loss, nausea or muscle cramps 1/13/2022 - At times, resident will refuse dialysis. Staff to re-approach as needed. If resident continues to refuse, staff to offer education on importance of receiving dialysis as well as inform resident of potential adverse effects. (sic) A Social Services Note, dated 7/30/2024, indicated the Social Service Director had called Facility B, and left a voicemail inquiring about a fax number or email to send a referral for a resident transfer to be closer to his family and other potential dialysis centers. A Quarterly Minimum Data Set (MDS) assessment, dated, 8/1/2024, indicated Resident D had intact cognition, had received dialysis while at the facility and had not rejected any care during the previous seven days. A Social Services Note, dated 8/7/2024, indicated the interim Social Service Employee had sent a referral for Resident D to Facility B and was awaiting acceptance or denial. A Dialysis Hand Off Communication Report, dated 8/9/24, indicated resident had refused treatment from the in-house dialysis, provided at the facility. There was no documentation indicating Resident D had been dialyzed after 8/8/2024. An electronic mail (email) communication, dated 8/12/24, between the the previous Administrator and the Regional Director of Operations, was provided on 8/22/24 by the current Administrator. The email did not include documentation to indicated dialysis services were scheduled for Resident D on 8/12/24. An Acute Note from the Nurse Practitioner, dated 8/12/2024, indicated Resident D had outpatient hemodialysis arranged, and it was ok to wait another day for his outpatient dialysis A Nursing Progress Note, dated 8/14/2024 at 4:34 A.M., indicated Resident D returned from hospital because the hospital could not administer dialysis treatments at night and the resident was to return in the morning for dialysis. A Nursing Progress Note, dated 8/15/2024 at 5:40 A.M., indicated the resident was sent to the hospital for dialysis but was then admitted for pneumonia. An emergency room admission Note from the Physician on 8/14/2024, indicated Resident D was admitted to the hospital on [DATE] due to not receiving hemodialysis and having the following critical lab levels: -Blood Urea Nitrogen (BUN) 104 mg/dL (normal levels are 6-25 mg/dL) -Creatinine 21.5 mg/dL (normal levels are 0.6-1.5 mg/dL) -Potassium 6.5 mmol/L (normal levels are 3.5-5.2 mmol/L) Resident D's record lacked documentation the Physician had been notified about Resident D not having outpatient dialysis arranged for any future treatments and/or had missed any dialysis treatments. During an interview, on 8/21/24 at 11:32 A.M., Transport Employee 7 indicated Resident D was referred to (2 different facilities over 1.5 hours away) ,a facility, both with in-house dialysis clinics. It was her understanding the facility would be providing transportation to one of these facilities once the resident had been accepted for admission. She indicated no residents were scheduled to start their dialysis treatments on Monday 8/12/24. During an interview on 8/21/24 at 1:45 P.M., Resident D indicated he was sent to the ER because he had not received dialysis since 8/9/24. Resident D had critical BUN, Creatinine and Potassium levels and needed to be dialyzed immediately. The first day he went to the ER for dialysis was on 8/13/2024 and staff had only informed him he needed dialysis; they never told him he was being sent to the ER. The resident indicated he was not assessed on any day since his last dialysis treatment. He was notified at least 30 days in advance of the facility no longer offering dialysis in the facility. He believed the staff was looking for a new place for him to live and were setting up dialysis. Resident D was never made aware by any staff member that the facility was having a hard time finding somewhere for him to go. [name of skilled facility 1.5 hours away], contacted Resident D to inform him he was accepted but needed some papers from the facility. He had told the new Administrator, and she said she would take care of it. During an interview on 8/21/24 at 11:50 AM, an admission Director (AD) for Facility A indicated an admission referral for Resident D was received, the resident was approved for admission, and more information was requested from the previous Administrator for consideration to be admitted into the hemodialysis program on 8/12/24. The AD for Facility A indicated a response was not received even though her staff had made attempts to contact the resident's residing facility on 8/13/24 and 8/14/24, for additional information. During an interview on 8/21/2024 at 1:45 P.M., Admissions Director (AD) for Facility B (skilled facility approximately 2 hours away) indicated they had not received a referral for Resident D prior to 8/15/24. During an interview on 8/22/2024 10:35 A.M., the Business Office Manager indicated Facility A had called on 8/13/2024 and had inquired about family members' contact information for Resident D. Facility A called again on 8/14/2024 and requested clinical information and the call was transferred to the north nursing unit. During an interview, on 8/22/2024 at 11:23 A.M., QMA 3 indicated Resident D's face was swollen so he was sent out for dialysis because he had not been set up for outpatient dialysis treatments and had not been to dialysis. QMA 3 called a non-emergency transport for both him and Resident B and both residents were sent to the hospital for dialysis. During an interview on 8/22/2024 at 11:25 A.M., the Regional Nurse Consult indicated there was not any transfer or discharge paperwork completed for Resident D on 8/13 or 8/14/2024 when the resident was sent to the hospital for dialysis. During an interview on 8/22/2024 at 12:46 P.M., the Unit Manager indicated Resident D did not have outpatient dialysis setup to start on the week 8/12/2024. On 8/9/2024., the previous Administrator sent her a text message notifying her any resident who did not have a new dialysis center setup should be sent to the hospital on their next dialysis day. The Medical Director and Nurse Practitioner were told all residents had outpatient dialysis setup, but they did not. On 8/13/2024, when the Unit Manager returned to work after being off for 3 days, the Unit Manager was notified Resident D was not looking well. The UM indicated Resident D's face was swollen and it sounded like he had fluid on his lungs. The Nurse Practitioner was notified and gave an order to send Resident D to the hospital. Resident D has never refused dialysis, and she had never been notified he had refused his dialysis treatment. All refusals for any treatment should be documented in the chart and the provider notification of refusal should also be documented. She was not able to provide any notes of why the resident was sent to the hospital in August. On 8/22/2024 at 1:45 P.M., the Regional Nurse Consultant provided a Dialysis Pre/Post Communication Record. The record indicated the resident had refused dialysis on 8/12/2024 at 4:36 A.M. and the Nurse Practitioner was notified. It was unclear why the form indicated the resident had refused a dialysis treatment on 8/12/2024 at 4:36 A.M. when there was no dialysis chair time or appointment set up for the resident on 8/12/2024. During an interview on 8/22/24 at 2:00 P.M., the Nurse Practitioner (NP) indicated Resident D did not have an appointment for dialysis on 8/12/24 because the facility requested she see Resident D due to not having a dialysis appointment on 8/12/24. The facility staff did not contact the NP on 8/9/24 notifying her Resident D refused dialysis. When the NP saw Resident D on 8/12/2024, she told the resident he could miss one more day of dialysis and the resident had no concerns or questions for the NP. During an interview with the Administrator, on 8/22/2024 at 2:12 P.M, from Facility B she denied ever receiving a voicemail referral inquiry or a faxed referral for Resident D from the facility. She indicated she received a referral inquiry for Resident D on 8/15/2024 but was uncertain if the inquiry was from the facility or the hospital During a interview, on 8/23/24 at 1:39 P.M., an admission Coordinator (AC) for the (multiple local dialysis centers) indicated the facility had contacted had a request for Resident D but it was deleted and another request for services came in on 8/22/24. 4. A record review for Resident R was completed, on 8/23/2024 at 11:12 A.M. Diagnoses included but were not limited to end stage renal disease, type 2 diabetes mellitus with neuropathy, and anemia in chronic kidney disease. A Physician Order,dated 3/28/24, indicated .Hemo-Dialysis 5 times a week (Mondays, Tuesdays, Wednesdays Thursdays, Fridays). In house A current Care Plan problem , initiated on 9/12/2022, indicated Resident R required hemodialysis. Interventions included, but were not limited to, -Dialysis days were Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays. -Observe for fluid volume excess such as edema, shortness of breath, crackles in lungs, weight gain or hypertension. (sic) A Nursing Progress Note, dated 8/12/24 at 8:53 A.M., indicated the resident would not receive dialysis services in accordance with physician orders, on 8/12/24, but dialysis services would [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) in accordance with the resident's advanced directives for 1 of 3 residents reviewed for facility discharge. (Resident D) This deficient practice resulted in CPR not being provided immediately when staff found the unresponsive resident and the resident died. The Immediate Jeopardy began, on 6/22/24 at 5:25 P.M., when staff identified Resident D was unresponsive and failed to immediately initiate CPR. The Administrator and the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/12/24 at 12:46 P.M. The Immediate Jeopardy was removed, on 7/13/24, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: On 7/11/24 at 11:13 A.M., a review of the clinical record for Resident D was conducted. The resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, necrotizing fasciitis (flesh eating disease) to a sacral wound, insulin dependent diabetes, End Stage Renal Disease requiring hemodialysis, and a history of a cardiac arrest. A Physician's Order, dated 3/12/24 at 1:45 P.M., indicated the resident was a Full Code (Medical personnel will do everything possible to save your life in a medical emergency including CPR. A Care Plan, dated 3/18/24, indicated the resident established advanced directives and wished to be a full code. The interventions included, but were not limited to, .Notify MD [Medical Doctor] and representative of changes in the resident condition/status A Care Plan, dated 3/18/24, indicated the resident was at risk for complications, related to medical conditions, medications and treatments. The interventions included, but were not limited to, observe for signs/symptoms of complications and assessments as indicated. An admission Minimum Data Set (MDS) Assessment, dated 3/19/24, indicated the resident was cognitively intact, had an unstageable wound, and did not have a condition which may have resulted in a life expectancy of less than six months. A MD/NP (Nurse Practitioner) Progress Note, dated 3/21/24 at 2:30 P.M., indicated the resident was sent to the emergency room (ER) for an evaluation due to persistent hyperkalemia (high potassium levels). The resident refused dialysis and was provided with education. The resident returned to the facility on 3/27/24. An Interdisciplinary Team (IDT) Progress Note, dated 4/18/24 at 12:07 P.M., indicated the resident was at risk for nutritional issues due to weight loss and a wound to her coccyx. The resident triggered for a significant weight loss in the past 30 days, upon return from the hospital, and her wound improved. The resident had been refused dialysis treatments and/or requesting shorter dialysis treatment times. The Medication Administration Record (MAR) for June 2024, indicated the resident was administered Reglan (used for GERD - gastroesophageal reflux disease) 5 mg (milligrams) before meals and at bedtime. The resident accepted the 8:00 A.M., 11:00 A.M and 5:00 P.M. doses, on 6/22/24. The resident did not have an order for anti-nausea medication on her MAR. A Nursing Progress Note, dated 6/3/24 5:03 P.M., indicated the resident was sent to the emergency room for an evaluation of a lesion near her dialysis port. She returned to the facility the same day. An IDT Progress Note, dated 6/4/24 at 2:22 P.M., indicated the IDT reviewed Resident D due to multiple lesions noted on her face and slightly above the dialysis port. The resident received topical and oral antibiotic due to cellulitis. The NP reviewed the resident's recent laboratory tests, noted the resident's WBCs (white blood cells) counts were elevated, and gave an order for the resident to be sent to the ER again. There was no nursing progress note to indicate the resident had returned to the facility; however, the resident's census documentation indicated the resident had returned from the hospital on 6/13/22. A Nursing Progress Note, dated 6/15/24 at 5:31 A.M., indicated the resident received IV antibiotic for an infection and did not experience any side effects from the medication. The note also indicated the resident's vital signs were within her normal limits. A Nursing Progress Note, dated 6/22/24 at 12:00 A.M., indicated the resident experienced an unwitnessed fall. The resident was assessed, the vital signs were checked, range of motion (ROM) was intact, and no injuries were noted. A Neurological Assessment check sheet was initiated. The resident denied pain or discomfort. The physician and the resident's family were notified of the fall. A Nursing Progress Note, dated 6/22/24 at 6:08 A.M., indicated the resident's vital signs were within normal limits and the resident denied any pain related to the fall and monitoring would continue. A form titled, Neurological Assessment for Resident D indicated the neurological assessments started on 6/21/2024 at 11:45 P.M. and continued until 6/22/24 at 6:00 A.M. The form indicated the resident did not have her neurological status assessed at 7:00 A.M., 8:00 A.M., 11:00 A.M. and 3:00 P.M., as scheduled for an unwitnessed fall. There were no additional Nursing Progress Notes, on 6/22/24 until 6:18 P.M., for Resident D. A Nursing Progress Note, dated 6/22/24 at 6:18 P.M., indicated the resident was found unresponsive at about 5:25 P.M., .by the aide while passing dinner trays. Sternal rub attempted. Res [resident] set on the floor, CPR initiated. 911 called did CPR on the patient for about 25 minutes no pulse or breathing post CPR. EMS did stop CPR, pronounced dead (sic) The resident's family member was present at the time of death. During an interview, on 7/11/24 at 1:15 P.M., QMA 2 indicated Resident D resided on the North unit. QMA 2 indicated she was assigned to the North unit, on 6/22/24, during the evening shift. QMA 2 indicated she reported to RN 3 that Resident D complained of stomach pain, vomited phlegm throughout the day, and wanted to go the ER. QMA 2 indicated the resident yelled out most of the day for assistance with the phone and frequent position changes. QMA 2 indicated RN 3 was the only licensed nurse in the facility and was assigned to another unit on 6/22/24. QMA 2 indicated RN 3 advised her to administer nausea medication and monitor the resident's response. QMA 2 indicated she checked on Resident D at an unknown time and the resident seemed fine. QMA 2 indicated she overheard the resident say she wanted to wait to go to the ER. QMA 2 indicated the resident's family was updated during the afternoon that the resident's stomach pain continued, the resident asked to be transferred to the ER, and family member wanted staff to wait until their arrival at the facility to send the resident. QMA 2 indicated CNA 4 was passing supper trays and alerted QMA 2 to the resident's yelling. QMA 2 indicated she instructed CNA 4 to continue passing supper trays and QMA 2 would check on Resident D. QMA 2 indicated the resident's family member and QMA 2 entered the resident's room at the same time and found the resident sitting on the side of bed and observed the resident was not breathing. QMA 2 indicated she ran to the nurse's station to determine the resident's code status, instructed CNA 4 to start CPR, and left the North unit to get RN 3 from the South unit. QMA 2 indicated upon her return to the North unit she observed Resident D lying on the floor and CNA 5 was performing CPR. QMA 2 indicated Emergency Medical Services (EMS) staff arrived, the EMS staff took over CPR, and eventually pronounced Resident D deceased . QMA 2 indicated she could not provide a specific timeline of events. During an interview, on 7/11/24 at 3:17 P.M., RN 3 indicated she was the only licensed nurse in the facility on 6/22/24. RN 3 was going about her duties when QMA 2 came to her unit, stating she had called a code. RN 3 indicated she took off running down to the other unit. When she arrived at the resident's room, Resident D was in a sitting position on her bed, without respirations/pulse and had not been receiving CPR. Another staff member helped her position Resident D on the floor so CPR could be initiated. QMA 2 grabbed the crash cart on her way back to the unit. RN 3 indicated QMA 2 told her the resident requested to be sent to ER earlier, but indicated the resident did not exhibit any new symptoms. RN 3 indicated she observed the resident several times throughout the day. RN 3 was told the resident had been visiting with her grandparents and after their visit, was asking again to go to ER. It was RN 3's understanding a non-emergent local transport ambulance and the resident's family member was called. RN3 indicated the resident's family member was in the room when she entered and assessed the resident, brought resident to the floor and had a staff member start CPR. Although RN 3 indicated she observed Resident D several times throughout the day, there was no documentation to support her statement. During an interview, on 7/11/24 at 3:55 P.M., the Maintenance Director indicated he measured the distance between the North and South nursing station to be 240 feet. During an interview, on 7/12/24 at 10:14 A.M., CNA 5 indicated he worked the day Resident D passed away but had clocked out for the day at approximately 3:00 P.M. and was not on duty during the evening meal. He indicated the resident told him before lunch she was not feeling well and wanted to go to the ER. He communicated the resident's request to QMA 2. CNA 5 indicated the resident was not using her call light that day and would just call out QMA 2's name repeatedly. He assisted the resident with numerous things during the day. Resident D told CNA 5 she thought the dialysis treatments were making her sick. During an interview, on 7/12/24 at 10:19 A.M., the Nurse Practitioner indicated she received three phone calls from the facility, on 6/22/24 regarding Resident D. The NP indicated she was notified of the resident's unwitnessed fall without injury just after midnight, of normal neurologic assessmetns throughout the night at 6:00 A.M., and of the resident's death during the evening. The Nurse Practitioner indicated the facility did not notify that the resident requested to go to the hospital on 6/22/24. The Nurse Practitioner indicated Resident D was usually very resistant to go to the hospital. The facility did nott request an order to send the resident to the hospital on 6/22/24. During an interview, on 7/12/24 at 10:32 A.M., CNA 4 indicated she worked, on 6/22/24 from 7:00 A.M. to 10:00 P.M., on the North unit. Resident D called out several times for assistance and told her she wanted to go to the ER sometime before lunch. CNA 4 indicated she told QMA 2 of the resident's request. Sometime after lunch, the resident's grandparents visited and brought the resident food; however, the resident did not eat much of it. During the evening, while CNA 4 was passing the supper trays, Resident D was yelling out again for assistance. QMA 2 instructed her to continue to pass the meal trays, as QMA 2 would be going into the resident's room shortly. Then CNA 4 observed QMA 2 running out of Resident D's room and told her to call a code blue. CNA 4 indicated she thought she was supposed to call for hel from the other unit because Resident D needed CPR. CNA 4 called the code on the facility overhead paging system, as QMA 2 ran down the hallway towards the South nursing unit. CNA 4 indicated she did not start CPR but followed all the other staff members, when they arrived on the North unit. CNA 4 entered the resident's room, and assisted other staff members to transfer the resident from her bed to the floor to start CPR. She was unable to name the staff member who started CPR. She indicated the ambulance service was at the facility shortly after and they took over CPR on the resident. CNA 4 left the room to continue passing the evening meal trays. During an interview, on 7/12/24 at 10:42 A.M., the local non-emergency EMS service staff indicated their service received a call, from the facility for an ambulance at 7:11 P.M. The EMS service indicated their dispatcher advised the facility to call 911 for immediate service, and they did not go to the facility on 6/22/24. During an interview, on 7/12/24 at 12:56 P.M., the Interim Director of Nursing (DON) indicated she was the DON, on 6/22/24, and was on call for any questions/concerns the staff might have. The Interim DON indicated she received a call from RN 3 at 7:21 A.M., indicating Resident D was requesting to go to the ER. The Interim DON indicated she told RN 3 to send the resident to the ER if that was what the resident requested. The Interim DON indicated she did not hear anything further from RN 3, until RN 3 contacted her to tell her they were performing CPR on Resident D. CPR Facts & Stats article was retrieved, on 7/11/24, from the American Heart Association website at www.cpr.heart.org. The article indicated .CPR is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances for survival On 7/11/24 the Administrator provided a form titled, An Indiana State Department of Health Certificate of Death The form indicated the date of Resident D's death on 6/22/24 at 6:00 P.M., and the cause of death was pulseless electrical activity. On 7/11/24 at 3:28 P.M., the DON provided a policy titled, Cardiopulmonary Resuscitation (CPR), dated July 2020, and indicated the policy was the one currently used by the facility. The policy indicated Purpose: to ensure the facility provides emergency basic life support immediately when indicated The Immediate Jeopardy that began, on 6/22/24, was removed, on 7/13/24, when the facility completed nursing staff education/in-service on CPR-,basic process with emphasis on immediately implementing CPR, in accordance with resident's advanced directive, with one staff member calling the code, while another staff member dials 911 and another staff member documenting code process, mock codes completed for each shift, resident code status and Care plans updated, The Immediate Jeopardy was removed on 7/13/24, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because not all staff had been educated on CPR audits were ongoing to review Progress Notes for a change of condition and/or requests to be sent to ER. This citation relates to Complaint IN00437316. 3.1-13(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to supervise a resident, with severe cognitive deficits and wandering behaviors, from exiting the facility resulting in the elopement of Resident J. The immediate jeopardy began on 10/3/23 when the facility failed to ensure supervision was provided to Resident J, who was deemed high risk for an elopement, had a diagnosis of Alzheimer's disease and displayed exit seeking behaviors. As a result, the resident was able to exit the facility unattended. The Interim Administrator, Director of Nursing Services, and Regional Nurses were notified of the immediate jeopardy, at 12:21 P.M. on 10/11/23. The immediate jeopardy was removed, and the deficient practice corrected, on 10/4/23, prior to the start of the survey and was therefore Past Noncompliance Finding includes: On 10/10/23 at 11:21 A.M., a review of the clinical record for Resident J was conducted. The resident's diagnoses included, but were not limited to: Alzheimer's Disease, schizoaffective disorder, anxiety and seizure disorder. An Annual MDS (Minimal Data Set) assessment, dated 9/18/23, indicated the resident had severe dementia, used a wheelchair and no motion sensor or wander elopement alarm. A Quarterly Wandering/Elopement Risk Assessment, dated 8/2/23, indicated the resident's score was 13. A score of 11 or higher indicated resident was a high risk for an elopement. A Psychiatrist Progress Note, dated 8/31/23, indicated the psychiatrist observed the following .adaptive weaknesses, distressing delusions of persecution, e.g., someone is coming to get her, she is pregnant, a significant other is dead, President [NAME] is to blame, etc. Ongoing, agitation, cursing, shouting at staff or reticent to speak, aggression, anxiety, and irritability/lability. At previous placement, resident physical aggression has been reported to cause $20K for repair in destruction of equipment and facility property. At the present encounter, writer observed resident while waiting for lunch as guarded, reactive and defensive, inquired, ?who are you? before writer began introduction. Stated, ?I don?t talk to psychologist! Bye!? Showed oriented to person . Mental status is severely impaired A care plan, dated 4/5/23 and last updated on 7/13/23, indicated the resident had behavioral symptoms of wondering and exit seeking. The interventions included, but were not limited to: identify behavior triggers, reduce exposure to triggers, maintain a safe environment and offer diversional activity. Another care plan, dated 10/20/21 and revised on 7/13/23, indicated the resident exhibited signs of cognitive impairment due to diagnosis of Alzheimer's and Dementia. Interventions included, but were not limited to: provide resident with cues-reminders to assist with decision making and recall. Be alert to non-verbal cues of problems or unmet needs. A Behavior Monitoring form indicated the resident was having Behavior Symptoms of wandering, on 9/9, 9/10, 9/11, 9/24 and 10/3/23 at 10:12 A.M. A self-reported incident #331, dated 10/3/23, regarding Resident J indicated .On 10.3 at approximately 4:00 pm resident wheelchair was observed by staff in the front of the lobby without the resident. Staff member notified the Nurses and a Code Walker was initiated. Staff Notified the ED/DNS [Executive Director/Director of Nursing Services] and continued search inside the facility, ED /DNS immediately arrived at the facility and notified police and continues search on the parameter of the facility. The weather outside was clear and warm. The outside search continued without results. A headcount revealed that all residents were accounted for except [name of resident]. [Name of Resident] has last been observed by DNS and Activity Director at 330 pm. She had been sitting outside for fresh air which was her typical behavior. Staff notified ED and DNS an interview with another resident revealed that the resident was observed getting into a Cab and was informed that the resident was taken to the store .3 miles from the facility. The DNS, ED and Activity Director took picture of the resident to the store and the clerk verified that the resident had been at the store. While at the store the DNS received a call from the police that the resident was picked up at the store and taken by EMS to [name of hospital]. ED spoke to nurse at the ER [Emergency Room] and the resident was there and had no signs of physical injury after assessment by ER staff. Resident was returned to the facility A typed statement, dated 10/4/23 at 2:48 P.M., signed by the Social Service Director (SSD) indicated she had observed the resident sitting in her wheelchair, outside, and had refused to return, inside the facility. A written statement, undated, by Administrative Assistant, who sits at the main entrance, indicated .On [DATE]rd around lunch time Resident [name of resident] was sitting up here at the desk/lobby area for a hour or 2. She asked to go out, and I nicely told her that I couldn't let her out. She got mad and held the door for 15 secs [seconds] and walked out and went to the sitting area. She was outside for a while and then came back in for her wheelchair. [Name of Resident] then proceeded to go back outside with her wheelchair and sat back down A typed statement by the Director of Nursing Services (DNS), dated 10/3/23 at 5:30 P.M., indicated .Name of Resident J] walked through front after holding door for 15 sec [seconds] sat at the sitting area outside the facility about 11am. This writer and SS [Social Services] attempted to redirect Resident to back in facility Resident declined stating I am trying to get fresh air .Resident continue sitting outside for the rest of the time. At 3:30pm this writer again noted this Resident sitting outside at the same spot During an interview, on 10/10/23 at 11:30 P.M., the Psychiatric Services Nurse Practitioner (NP) indicated she had seen the resident approximately every 2 weeks since July of 2023. She indicated the resident usually sat in a wheelchair, but could walk when she wanted to. The NP indicated the resident sat at the front entrance but had never communicated to her, she wanted to leave the facility. The NP indicated the resident would not have been safe left unattended and by herself outside of the community. The NP indicated the resident had delusions, stating she was seeing people and hearing voices. NP indicated she had to be sent to a psychiatric hospital due to her psychotic state, for stabilization after the elopement incident. During an interview, on 10/10/23 at 1:17 P.M., the SSD, indicated she was with the Resident J while she was sitting outside, in a sitting area, for approximately 1.5 hours. The Front Desk Receptionist sat with the resident afterward. The SSD explained she left the building, at approximately 2:45 P.M., and observed the resident, sitting outside, with the Front Desk Receptionist. As the SSD was leaving the facility the DNS was approaching the area, where the resident was sitting. During an interview, on 10/10/23 at 1:28 P.M., the DNS indicated the resident had exited out of the building, by holding onto the exit door for 15 seconds and the locked door released. The DNS had observed the resident leave the facility. The DNS indicated she, along with the Marketing/admission Coordinator and the SSD had tried to get the resident to return inside the facility, but the resident declined and went to an area, outside the facility where there were chairs and a table with an umbrella. The DNS indicated she instructed the Marketing/admission Coordinator to stay with the resident. She had observed the resident, again through the glass door at approximately 3:30 P.M. but didn't notice if anyone was with her. She left the facility at approximately 3:45 P.M., and noticed an empty wheelchair where the resident had been sitting and assumed Resident J had returned inside of the facility. During an interview, on 10/10/23 at 1:42 P.M., the Front desk Receptionist/Administrative Assistance indicated the resident had been sitting at the front entrance for approximately 1-1.5 hours around noon time. The resident then asked to go outside, however she explained to the resident she could not allow her out, so the resident pushed on the door, the alarm sounded, and the door then opened (had an emergency unlock after 15 seconds of pressure on exit door) and the resident wheeled herself out the door. At that time she verbally told the SSD and she went outside with the resident. On 10/10/23 at 1:59 P.M., an interview was conducted with the Administrator, the DNS, the SSD, the Activity Director and the Marketing/admission Director. The Marketing/admission Director indicated she went outside to relieve the SSD and sat with the resident for approximately 30 minutes, when the resident was persuaded to return inside the facility for a drink. The Marketing/admission Director indicated the resident was in her wheelchair and was last observed heading toward the dining room, at approximately 3:00 P.M. The Administrator indicated he was never outside with the resident and was not involved prior to discovery of elopement. The Activity Director indicated, at approximately 3:00 P.M., she had observed the resident, through a glass window, sitting in her wheelchair, at another area, near the gazebo. None of those present, during the interview, had any idea how the resident got out of the facility the second time. During an interview, on 10/10/23 at 2:46 P.M., the Front desk Receptionist/Administrative Assistant indicated she was the person who worked the front desk on 10/3/23 from 8 A.M. through 4:00 P.M. and had not observed the resident and/or Marketing/admission Director return inside the facility, nor did she observe or hear an alarm indicating the resident had left the building after 3:00 P.M. The SSD indicated, on 10/10/23 at 3:06 P.M., if there were wander seeking behavior notes, they would be in the Progress Notes. She indicated she had not written a progress note regarding the resident's exit seeking behavior that day. During an interview, on 10/10/23 at 3:35 P.M., LPN 2, who worked the resident's unit, indicated she was not aware of Resident J being outside for several hours and not wanting to return to the unit, until the staff were notified of the elopement. During an interview on 10/11/23 at 10:05 A.M., the Administrator indicated the cab company was called and indicated they left the Resident J at the store. The resident told the cab driver she would pay for the cab fare once she got to the store and used an ATM machine. The cab company indicated the resident ran into the store and would not pay the cab fare, so they left her there. He indicated the police notified him the resident had been picked up, at the store, and taken to a local emergency room. An emergency room (ER) Report, dated 10/3/23 at 4:04 P.M., indicated the resident presented to the emergency department with aggressive behavior. Report indicated the resident was found, on the floor, at a smoke shop and 911 was called. The medics evaluated the resident and chose to bring her to the ER for an evaluation. An ER Medical Decision Making Note indicated .Patient presented to the ED [Emergency Department] for an evaluation. She arrived via EMS. It turns out that she resides in a place called [name of facility]. We were able to contact them and they indicated she had eloped from their facility earlier in the day. Apparently she walked from there to a liquor store and the liquor store called 911 and she was subsequently brought in by EMS. In the ED she required sedation .The patient will be transferred back to her facility by the medics On 10/12/23 at 10:27 A.M., the Administrator provided a policy titled, Elopements and Wandering Residents, dated 4/6/19 and revised 9/23, and indicated the policy was the one currently used by the facility. The policy indicated .Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement .4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering .d. Adequate supervision will be provided to help prevent accidents accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly The past noncompliance immediate jeopardy began on 10/3/23. The immediate jeopardy was removed and the deficient practice corrected by 10/4/23 after the facility implemented a systemic plan that included the following actions: all current residents elopement evaluation scores were reviewed, care plans updated, elopement binder reviewed/updated, doors codes changed, wanderguard systems tested, elopement drills and all staff educated on the elopement policy. This Federal tag relates to complaint IN00419004. 3.1-45(a)(2)