**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interview and policy review, the facility failed to supervise residents at risk for elopement for 1 of 3 residents reviewed (Resident #9). This failure resulted in the resident eloping from the facility, his whereabouts unknown for approximately an hour and 30 minutes and sustaining fractures of five ribs, therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as ofMay 8, 2025, on August 18, 2025 at 1:15 PM. The Facility Staff removed theImmediate Jeopardy on August 20, 2025 through the following actions: Resident assessed and sent to the hospital 100% Headcount of all Residents on 6/4/2025 100% Elopement Risk assessment review completed by DON for accuracy and current on 6/5/2025. The three residents verified at risk for elopement, and wearing wanderguard devices, had all care plan interventions reviewed and confirmed in place for supervision on 6/5/2025. 100% Care plan, TAR, placement of device, elopement binder, and device functioning audit for all residents determined to be at risk for elopement completed by MDS on 6/5/2025 Facility conducted 100% audit of all external doors to ensure they are in proper working order and checked all windows for security on 6/4/2025 Facility conducted elopement drills x 3 shifts 6/5/2025-6/7/2025 Facility conducted Ad Hoc QAPI to address this alleged deficient practice on 6/5/2025 Elopement binder reviewed and noted as up-to-date on 6/5/2025 with reviews daily and weekly as part of our quality assurance program, 8/18/2025, and ongoing Staff in-service on Elopement Policy began 6/4/2025, to include, promptly answering sounding door alarms, not resetting alarm until the source of the alarm is discovered and/or 100% resident presence is verified Resident placed on 15-minute checks upon return from hospital and continued until discharged Current resident at risk for elopement, noted effective 3/21/2025, has a wanderguard in place on her ankle with every shift checks for placement and functioning, distract from wandering by offering pleasant diversions, structured activities, food, conversation, tv or book. Care plan revised and updated 5/29/2025, 8/18/2025 as part of our ongoing compliance. As of 6/5/25, and ongoing as part of our quality assurance, all current and new admissions to the facility have had and will continue to have an elopement risk assessment done on admission, quarterly and as needed. If determined to be at risk for elopement, the new resident's individualized care plan will be developed for safety based upon their preferences and routines related to ensuring adequate supervision for safety. New hire staff receive education upon hire related to elopement, and all direct care staff have access to the resident's Kardex/care plan and are expected to be familiar with individualized needs for supervision. The scope lowered from a J to D at the time of the survey after ensuring the facilityimplemented education and their policy and procedures. In addition, the facility failed to provide for safe transfer for Resident #10 by not using adequate staff during the transfer for 1 of 3 residents reviewed for transfer. The facility reported a census of 68 residents. Findings include: 1.The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #9 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The resident had diagnoses to include medically complex conditions, hyperlipidemia, Alzheimer's disease and anxiety disorder. The resident had wandering behavior that occurred 4 to 6 days, but less than daily, which significantly intruded on the privacy or activities of others. The Care Plan for Resident #9, with an initiation date of 4/24/25, included a focus area: potential for elopement risk/wanderer risk. The resident wanders aimlessly, WanderGuard bracelet (a wearable security device, worn by residents at risk of wandering that alerts staff when the resident approaches a monitored exit or enters an unauthorized area) in use for safety. The goal included: safety will be maintained through the review date and interventions included:Assess for elopement/wander risk (created 4/24/25)Observe location frequently. Document wandering behavior and attempted diversional interventions in behavior log (created 4/24/25) On 5/31/25 resident took his wander guard off his lower extremity in his room. WanderGuard (WG) replaced on right wrist hoping that resident might not be able to take it off with his left hand (created on 6/5/25) Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes (created 4/24/25)Every 15 minute safety/location checks upon readmission from hospital (created 6/13/25)Resident noted to remove wander guard bracelet-reapplied by staff (created 5/1/25)Room change upon readmission to new private room on different unit to decrease environmental stimuli (created 6/13/25)WG alert, replaced bracelet right wrist, expires 1/12/28 (created 4/24/25) Review of the Electronic Health Record (EHR) revealed Resident #9 scored at risk for elopement on Elopement Risk Evaluations completed on 4/24/25, 5/4/25, 6/5/25 and 6/12/25. Review of the EHR revealed Resident #9 admitted to the facility on [DATE]. The resident was placed in a room on Hall 6 (Ambassador). Review of the EHR for Resident #9 revealed Progress Notes which documented wandering behavior:Progress note dated 4/24/25 at 3:33PM, nurses note: resident noted to be wandering hallways looking for his wife. Easily directed. Spoke with wife in regards to safety and she gave permission to place WG on resident and will reevaluate as needed. Placed on RT(right) ankle.Progress note dated 4/24/25 at 3:455PM nurses note: resident was up to Royal walking down hall 2 looking to leave. assisted by 2 staff to return to ambassador. He did not want to go but after much talking from staff he did begin to walk with staff to ambassador.Progress note dated 4/24/25 at 4:52PM, nurses note: resident continues to walk up and down hallways and has been taken out of the therapy room [ROOM NUMBER] times and redirected. Spoke with DON was instructed to call wife and ask her to sit with him for awhile. Spoke with wife explained situation. Wife will be here at building in a few minutes.Progress note dated 4/25/25 at 4:49AM, nurses note: resident has been resting quietly in the lounge, at beginning of shift he was redirected multiple times from going in and out of other residents rooms and hallways he would go to his room and only stay in room for a very short time. Progress note dated 4/28/25 at 8:27PM nurses note: found resident coming out of room [ROOM NUMBER], resident in room [ROOM NUMBER] was yelling out help Walked resident back to Ambassador and gave him to staff. 10 minutes later resident was back looking in rooms on hall 2. Walked back to Ambassador again.Progress note dated 4/29/25 at 9:57AM nurses note: resident in and out of resident rooms on hall one. redirected back to his room.Progress note dated 4/29/25 at 12:42PM nurses note: found wandering around hallways on royal and into resident rooms. directed out and then stood at the front door. assisted by CNA back to ambassador.Progress note dated 4/29/25 at 2:30PM nurses note: resident has been on Royal side of building for the past couple hours walking up and down the hallways. He does attempt to open door but only tries once before moving on.Progress note dated 4/29/25 at 3:41PM nurses note: resident pushing on door until they sound. staff responded and redirected resident. He attempted this on 2 different doors.Progress note dated 4/30/25 at 12:35AM nurses note: resident on Royal side of the building wandering throughout the evening. Made several attempts to open the front door and doors at end of hallways. Wandered into other resident rooms several times. escorted back to his room by staff many times. Resident very pleasant with staff.Progress note dated 4/30/25 at 12:32PM nurses note: resident has been up and about wandering down all 3 halls standing and pushing on doors trying to go outside to get in his car. Staff have redirected him several times, I just walked him down to his room to rest resident is confused and disoriented of where he is.Progress note dated 5/1/25 at 3:03AM nurses note: resident is currently awake and wandering about ambassador side of building no set location or explanation as to where he is going is noted to become agitated with redirection as he has been trying to go in and out of other residents room Certified Nurses Aid (CNA) reports that he swung at her while trying to redirect him out of the therapy room this nurse was able to get resident back into his room.Progress note dated 5/1/25 at 9:33AM nurses note: resident noted to cut off WG this am with his butter knife. New WG put in place. DON made aware. Progress note dated 5/5/25 at 12:49PM Risk Note: IDT review of attempted elopement finds that all facility processes/systems working correctly. Resident was stopped at the base of the ramp outside the exit door by staff responding to alarm sounding. No injuries. He was able to be redirected back into the building. Wander guard bracelet remains in place to rt ankle et functioning properly. RCA: wanderer with dementia et confusion. Wander guard in place to rt ankle as ordered. Alarm systems working. Resident allowed staff to walk back into the building and enter through the patio door. Resident stated that the noises the alarms made needed to be fixed not to go off when he went out through doors. INTERVENTION: 15 minute safety checks implemented. Referrals already in progress for a dementia unit placement. N.O. for prn Xanax for increased anxiety from PCP. Psych provider referral requested 5/5/25.Progress note dated 5/8/25 at 12:21PM at 4:52PM nurses note: resident wandering up and down halls. easily redirected when attempting to go in others rooms or trying to push on doors.Progress note dated 5/8/25 at 12:28PM nurses note: resident tore of WG this am, was immediately replaced. Progress note dated 5/8/25 at 4:52PM nurses note: resident continues to wander trying to go out the doors. He is easily redirected. Progress note dated 5/9/25 at 8:17AM risk: IDT review of removal of wander guard 5/8 et fall notes 15 minute safety checks and alternative placement attempts con't. Wander guard in place to left ankle et functioning. No injuries r/t fall from side of bed, 72 hr fall f/u w/neuro checks in place. Staff are encouraging resident to lie down in bed or recliner when observing s/sx tiredness however res is resistive to this, wandering throughout facility continues. Progress note dated 5/10/25 at 9:24AM nurses note: resident wandering in and out of residents rooms. easily redirected but continues to do it over and over.Progress note dated 5/29/25 at 12:23PM risk: IDT review of care/needs notes COC (change of condition) for increased edema noted to BLEs this week. labs per NP w/visit. See orders. No c/o pain. No new falls. Res con't to wander throughout facility during waking hours. Does not comprehend/remember education/enc to sit et rest to elevate extremities r/t edema. Appetite poor today. Res noted to be unwilling to remain in dining room for meal at times et does not consume from room trays provided. Progress note dated 5/30/25 at 7:41PM nurses note: resident noted to be being aggressive with staff trying to hit and shove staff also noted to be trying to leave building spoke with PCP new order obtained for alprazolam 0.5 mg po q 8 hours prn mar updated pharmacy notified and wife aware.Progress note dated 5/31/25 at 2:21PM nurses note: resident roommate brought this resident leg-alarm to this nurse at the nurse's station and he said he observed this resident taking his leg alarm out with his right hand in their room. as such, the alarm is now placed on right wrist hoping that resident right might not be able to take it out with his left hand. Progress note dated 6/5/25 12:13AM nurses note: This writer asked at 9:44PM if anyone had seen Resident. This writer went to Residents room, then started a building search with ALL staff. When Resident was not found in the building outside search started 2 staff out front door, this nurse and CNA went out therapy door and started outside search. Resident was found at 9:40 pm sitting on his bottom, legs in front and left (Lt) arm leaning against cement wall in the back of building between hall 6 wing and assisted living. DON was called and notified of elopement. Asked Resident if he was ok, he stated his right (RT) ribs and RT hip hurt. Attempted to assist to his feet and Resident was unable to stand with assist of 2. Assistance was requested outside and wheelchair (W/C). 4 staff to assist Resident to W/C. Noted dirt to back RT shoulder, lifted shirt and noted light purple discoloration. Emergency Medical Services (EMS) was called for assistance. (late entry, incident occurred on the night of 6/4/25) During an interview 8/5/25 at 2:30 PM, Staff J, Licensed Practical Nurse (LPN), stated she was working the night of 6/4/25, the night of the incident with Resident #9. Staff J stated the night of the 4th of June was not the first time the resident was able to get out of the building, she thought it happened maybe two other times, however stated she was not working on the other occasion(s). Staff J stated Resident #9 admitted to the facility in April of 2025, he had a room on Hall 6. The therapy room is at the end of hall 6, and the resident liked to walk down to the end of that hall by the therapy room and open the door in the therapy room. He also liked to walk to the front of the building, by halls 1, 2 and 3 and spend time in that front dining hall. Staff J stated the resident walked around the building daily, he walked fast and did not use a walker or any device. He could present initially as though he was intact cognitively, he would talk often. The resident had taken his WG off, he took it off at least 2-3 x's prior to the night of June 4, 2025. Staff J stated she was working on the night of the 4th of June on the Ambassador halls, where Resident #9 had a room, starting at 6:00 pm. Staff J stated the door alarm did go off around 7 pm that night when the smokers went outside to smoke. Staff J stated she never heard another alarm go off that night. Staff J stated a staff member at the Assisted Living (AL), which is connected to their building by a passageway, down Hall 6 and Hall 5, past the nursing station, told Staff J she saw the resident outside smoking with an AL resident that night in the AL courtyard, in the evening, not sure what time exactly. Staff J stated on the night of the 4th she gave Resident #9 an as needed (PRN) anti-anxiety medication at around 6:30-7:00 PM due to agitated behaviors. He was ripping pictures off the wall and became aggressive with staff. Staff J stated she then went to check on the resident at 9:00 PM and could not find him. She did not see him in between giving him his medication at around 6:30-7:00 PM until she went to check on him at 9:00 PM. She started looking for him at 9:00 PM, then included the whole building in the search for him. They searched the entire building until 9:30 PM, then they went outside to look for him, she went outside to look for him with another staff member, a CNA. They found him at 9:40 PM. He was outside sitting on the ground, in a grassy area in between the back of Hall 6 and the AL building. He was sitting next to a cement wall, with his left arm leaning on the cement wall. He was wearing a plaid shirt, a bluish colored ball cap, sweat pants and tennis shoes. They tried to get him to stand up, he yelled out in pain so they got a wheelchair and assisted him up with a gait belt. Staff J stated she raised up the resident's shirt and noted purple colored bruising to the left side of his back. He yelled out in pain when they moved him but he could not say what happened or what was hurting him. Staff J stated prior to finding the resident, they were outside yelling his name, he did not respond to this. It was dark outside, they used their flashlights on their phones while looking for him outside. They called the physician and got an order to take him to the hospital. Staff J stated she talked to all of the staff working that night and no one saw him since around 7:00 PM. Staff J stated the resident was not on 15 minute checks and staff were supposed to know of his location frequently. No staff stated they heard the WG alarm go off that night. Staff J stated the smokers went outside at around 7:00 PM to 7:20 PM and the door alarm went off at that time. Staff J stated the resident had his wander guard on when they found him outside. Staff J had checked his wander guard earlier due to him being so agitated. Staff J stated the resident did go to the doors often, especially the therapy door at the end of hall 6. Staff J stated the door to get to the AL side is not alarmed. It has a code box, but no alarm. Staff J stated they did have an oxygen tank delivery that day (unsure of the exact time), the delivery guy went from their side to the AL side through the door at the back of Ambassador (halls 4, 5 and 6). Staff J stated the resident was an independent walker and would talk to people, he could present as though he was not a resident. Staff J wonders if the delivery guy let him through the AL doors, which take you into the dining room of AL and then through there there are doors to take you outside, one of the doors leads to the area where the resident was found. During an observation 8/5/25, beginning at 3:00 PM, with the Administrator present, observed the area where Resident #9 was found outside on the night of 6/4/25. Going out the door the smokers used to go outside to smoke, by the dining room, this leads to a courtyard that is not fenced in, there is a sidewalk that leads to a side parking lot and a ramp that goes up to the door leading to hall 6 by the therapy rooms. The courtyard where residents smoke is not enclosed. Walking around the ramp on the grass, down the side of the building by hall 6, going to the back of the building there is a short (approximately 3 feet tall cement wall). There is a grassy area in between the back of Hall 6 and the AL portion, with a door to the basement of the SNF building. The resident was found in this grassy area between the back of Hall 6 and the AL building. There was a door at the back of the AL building that was an exit door, out this door there is a sidewalk then a steeper grassy hill, which is connected to the area where the resident was found. With the Administrator present, the door alarms were tested in the SNF building. Each door is alarmed to go off if the door is opened more than 15 seconds, the doors are not locked, other than the front door which has a key pad. The doors sounded an alarm when pushed open more than 15 seconds. A WG was then tested on the doors, when the door was opened holding the WG the alarm went off immediately, this was the same alarm sound as the door alarm, however it went off immediately when the door was opened. The alarms are turned off by a key pad next to the doors, which also resets the alarms, including the WG alarm. The WG alarm is the exact same sound as the door alarm. While testing the alarms, observed AL residents going from the SNF over to AL through a door with a key pad, the door is at the back of the Ambassador hall. With the Administrator present, walked to the AL side, going through a door which connects their SNF with AL, at the back of Ambassador hall (halls 4, 5 and 6). This door is accessible to all of the residents, it is locked with a key pad next to the door. There is no alarm on this door, and the door is accessible from the SNF side by walking down a short hallway off the living room and nurses station of the Ambassador side. Once going through the door, there was a short hallway into the AL side, going through another door which was not locked or alarmed, this entered into the dining room of AL. The Administrator stated the exit doors on the AL side have alarms, however they only sound at the nurses station, there is one nurses station in AL. Going down the hallway to the left of the dining room, there is an exit door at the end of the hallway, this exit door was the door closest to where Resident #9 was found. We opened the door, it was not locked, an alarm did not sound. Going to the nurses station, AL Staff K, Certified Medical Assistant (CMA) was sitting at the nurses station and said an alarm did not go off. Staff K stated an AL resident just came back from the SNF side after playing Bingo on the SNF side. The Administrator stated they encourage AL residents to go to the SNF side for activities and they can come and go as they please, they all have the code to get back into AL from the SNF side. The Administrator opened another door in AL, the door closest to the nurses station, and the alarm did not sound. The Administrator opened another door to the back of the nurses station, and the alarm did not sound. Staff K stated the alarms should sound at the nurses station when an exit door is opened, other than the door to the SNF side, and the front entry door and side door by the nurses station. The side and front entry door are not alarmed, they get locked at 10 PM every night. Staff K stated he is not sure why the alarms did not sound today when the other doors were pushed open. Staff K checked a panel on the wall and noted the alarms had been turned off, he said they should never be turned off. Staff K turned the alarm on from the panel and the Administrator opened an exit door, the alarm did sound at the nurses station. During an interview on 8/5/25 at 3:30 PM, Staff K stated he was working at AL on the night of the 4th of June, 2025. Staff K recalled seeing a person he did not know outside in the courtyard with an AL resident who was in the courtyard smoking. Staff K described what the person he did not know was wearing, stated the person had on a gray/blue colored ball cap, a plaid shirt and sweat pants. Staff K believed this was around 5:30 PM. He did not see this person again. Staff K stated he worked until 10 PM on the night of the 4th of June. He stated no one told him they were looking for a resident who was missing from the SNF side. Staff K stated they did have a delivery person who came over to the AL side from the SNF side on the 4th of June, he thought this was around 4 pm or so. During an interview 8/5/25 at 3:45 PM, the Administrator stated they followed up with AL regarding the visitor Staff K saw in the courtyard that day, and they do not believe it was Resident #9 as Staff K was shown a picture of the resident and he did not believe it was him. An AL resident did have a visitor that day. The Administrator stated all of the door alarms on the SNF were working the night of the 4th of June, she had the Assistant Director of Nursing (ADON) check and had her check the windows. They completed a facility investigation with interviews of staff working that day. Staff stated they did not believe a door alarm went off again that night other than the alarm for the smokers when they went out to smoke. The Administrator stated if a door alarm goes off, it has to be turned off and reset at that door, staff cannot turn off the door alarm from another door. They began education that night on elopement procedures and did elopement drills after the incident on the 4th. During an interview 8/6/25 at 10:45 AM, Staff L, Certified Medication Aid (CMA), stated she recalled the day of June 4th, she worked a day shift, leaving at 6:00 PM. Staff L stated Resident #9 was initially on Hall 6, then he moved to Hall 3 after getting back from the hospital. Staff L stated Resident #9 was a wanderer, and he loved to talk and joke around. The resident liked to walk around the facility. He would walk around at all times of the day and he was an independent walker before that night, he was not after he returned from the hospital right away, he used a walker. Staff L stated Resident #9 did try to open the doors to go outside and they would redirect him. The resident was always looking for his white SUV in the parking lot, from the front dining room. He would punch in random codes in the front door, however he never got out the front door. He would try to get out the door by the front dining room, the door off the side of the dining room. This door was alarmed. Staff L stated the resident never got out when she was working. Staff L stated the resident was not overly agitated that day, before she left he was not agitated, but he was going to the doors. During an interview 8/6/25 at 11:00 AM, Staff M, CMA, stated she recalled Resident #9. He was a resident who liked to wander and he would go to the doors and try to open them. Staff M stated the resident would try all the doors, he never got out up front that she is aware of, on the Royal side. Staff M stated Resident #9 would walk up to the doors on Royal, there are doors at the end of each hallway and the front door and the dining room door, however the resident never got out these doors, he would push on them and they would redirect him. Staff M stated on the 4th of June, she worked 6:00 PM to 6:00 AM, on the Royal side. Staff M stated she only saw the resident once, around dinner time, he was up here just briefly, then he went back to his hallway and she did not see him again. Staff M stated when the smokers go out to smoke, the door alarm does go off sometimes, when they hold the door open. Staff M stated she never heard the wander guard alarm go off, ever, that night, or any door alarms. Staff M stated staff up front on the Royal side were told that Resident #9 was missing and to search for him in the building. This was later at night, she was not sure what time, it was dark outside. Staff M stated all of the staff checked the rooms and the resident was not located anywhere on the Royal side. During an interview 8/6/25 at 11:20 PM, staff H, Certified Nursing Assistant (CNA), stated she did work the day of the 4th of June, from 2:00 PM to 6:00 PM, on the Royal side. Staff H recalled Resident #9, he was pleasant to be around. Staff H stated the resident would look for his wife and wander around routinely. Staff H stated the resident had a WG on. He was independent with walking. Staff H stated he was on hall 6 when he admitted in April of 2025. The resident would try to get out the doors often, especially the door at the end of hall 6, by the therapy room. The resident also liked to come up to the front and sit in the dining room. He would sometimes get agitated when he was redirected, but more frustrated than aggressive. Staff H stated she did not remember any alarms going off on the 4th of June. Staff H stated the door alarms do sound when they go out to smoke sometimes, she stated the door alarm sound is the same as the WG alarm sound. Staff H stated she did not recall any time the resident set off the door alarms or the WG alarm. During an interview 8/6/25 at 12:19 PM, Staff N, CNA, stated she worked on the 4th of June, 2025. Staff N stated she recalled Resident #9, he was a resident that liked to walk around the building. There were a few times he was violent with other CNA's, however he was never with her. He would get frustrated during redirection, but not physically aggressive toward her. Resident #9 liked to walk around and would walk to doors, they would redirect him. The resident wore a WG. He would try to take it off sometimes. Staff N stated they would always be sure the resident had his WG on. Staff N stated she worked from 2:00 PM to 10:00 PM on the 4th of June, on the Ambassador side. Staff N stated the last time she recalled seeing the resident that day was around supper time in the dining hall. Staff N stated she does not recall an alarm sounding that night. There have been times when she has worked that the door alarm has gone off when the smokers go outside. She cannot recall if the door alarm went off that night when the smokers went outside. Staff N stated she does not recall seeing the resident after supper that night. Staff N did not recall the resident trying to get out that night or trying to push a door open. He did like to go to the doors, especially in hall 6, at the end, by the therapy room. Staff N was told later that night on the 4th, before 10 pm, that the resident was missing. They all started looking for him, they looked all over in the building. After looking in the building, she is not sure for how long and not finding him, she and Staff J went outside to look for him. She and Staff J found him outside, he was found in the grass, in between the back of Hall 6 side and AL. He was awake, he said he could not stand on his own because he was in pain. Staff N stated it was dark outside, the resident was fully dressed. The resident did have some scrapes/marks on his back and rib area. He had on a flannel/plaid shirt and pants. His shoes were not on his feet, they were near him on the ground. The Administrator had them check every window and door alarm and review the elopement book for residents who were an elopement risk. During an interview 8/6/25 at 12:55 PM, Staff O, Licensed Practical Nurse (LPN), stated she works on the Royal side normally. Staff O stated she was aware Resident #9 had a WG and he liked to wander the building. Staff O stated he liked to go to the doors, and he would be redirected when he went to a door. On the night of the 4th of June, 2025, Staff O stated she worked, her shift began at 6:00 PM, on the Royal side. She did not recall seeing the resident at all that night. She recalled at around 9:00 PM being told that the resident was missing. They looked for the resident inside and could not find him on the Royal side. Other staff went outside to look for him and he was later sent out by ambulance. Staff O stated she does not recall any alarms going off that night. During an interview 8/6/25 at 4:00 PM, Staff P, CNA, stated she recalled working on the 4th of June, 20205. She worked on the Ambassador side, on hall 5, the 2:00 PM to 10:00 PM shift. Staff P recalled Resident #9 had wandering behaviors that day, as he did every day. He would wander the halls and would go in and out of resident rooms. He would be redirected during these times. At times, he would become aggressive or agitated when redirected. Resident #9 would walk up and down the halls and go to doors. Staff P stated the resident never went out a door when she was working, she heard he did get out a door one other time, but she was not working then and only heard that he did. On the 4th of June, she believed she last saw Resident #9 at around 7:00 or 7:30 PM, he was in the 5 hallway, walking. Staff P recalled hearing a door alarm at around 7:00 PM, she thought this was the smokers going out or coming in. When she heard the door alarm, she checked the door at the end of hall 5 and by the AL entryway, and did not see any residents, the alarm was shut off, not by her. Staff P stated she was told at around 9:00 PM that the resident was missing. They looked all through the building for approximately 30 minutes and then staff went outside to look for him. He was found outside in between AL and the back of hall 6. Staff P stated she does not know how the resident got outside. Staff P stated the resident liked to go to the door at the end of hall 6, through the therapy room. She believed the door at the end of hall 6 is coded and not alarmed. During an observation 8/6/25 at 4:20 PM, observed the door at the end of hall 6, the door was alarmed. The door is located through the therapy room, at the back of the therapy room.During an interview 8/11/25 at 6:50 AM, Staff Q, LPN, stated she did work the night of 6/4/25, from 6:00 PM to 6:00 AM. She worked on the Ambassador side, the back halls. Staff Q stated Resident #9 was a resident who wandered, he would wander through the building the majority of the day. He was not aggressive, but he would get frustrated when redirected and would be verbally aggressive. He would wander into other resident's rooms and up and down the hallways, he would go to the doors to try to get outside. There were numerous times he would go into the therapy room at the end of hall 6 and try to get out the door in the ther[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The MDS assessment tool for Resident #5 dated 2/24/23 revealed residents BIMS score of 14 which indicated cognition intact. Diagnosis included coronary artery disease, peripheral vascular disease, heart failure, diabetes mellitus and localized edema. The Treatment Administration Record (TAR) for Resident #5 dated April 2023 directed staff to apply ace wraps to bilateral extremities. A check mark and Staff #C initials on 4/6/23 indicated the treatment was completed when TAR was reviewed on 4/6/23 at 1:50 PM. Record review of Resident #5 [NAME] (a note system for the nursing assistants directing care) dated as of 4/10/23 did not address ace wraps. During interview/observation on 4/6/23 at 2:00 PM Resident #5, voiced I need help to get my legs wrapped. Observed no wrapping to the lower legs that were edematous (meaning swollen related to excess fluid). Resident #5 relayed my legs are supposed to be wrapped every day, I cannot do it myself. I do not always get them wrapped, some days it is very late, as late as 4:00 PM and some days not at all. Interview on 4/6/23 at 2:10 PM with Registered Nurse (RN), Staff C reported on her process,Staff C stated she signed all treatments and wrote down the treatments to later ensure during the shift. All treatments were signed as completed at this time. Staff C relayed she trusts the nursing assistants to do non-medicated treatments, within their scope and she had signed completed. Staff C relayed the nursing assistants know the treatments to do since is listed on the [NAME] . Staff C stated she did not need to follow up since she trusts the nursing aid staff. Requested to review the nursing assistant [NAME] that did not list Resident #5 ace wrap treatment. Staff C acknowledged initialing as completed even though was not completed. During interview on 4/6/23 at 2:35PM the facility Administrator acknowledged a nurse should not sign off on a procedure including a medication or a treatment should not be signed as being completed before it is done. Interview with Director of Nursing (DON) on 4/10/23 at 11:50 AM confirmed a nurse should not sign ahead for any treatment, medication or procedure. DON acknowleged should not sign if did not complete. The DON stated the nurse should ensure the treatment and ideally at that time a nurse assesses for changes and reports to the doctor if needed. Confidential interview on 4/12/2023 at 9:50 AM with another family member, daughter of a resident stated to surveyors in conference room visit of repeated notifications needed to staff that her family member is suppose to have specialized hose on daily for treatment of edema , relayed is repeatedly missed. Facility policy provided titled Medication Administration, Preparation and General Guidelines section 7.2, Part D, 1. revealed recording of the process directly is after completion. Based on observations, interviews and record review the facility failed to accurately assess and intervene in a timely manner for resident with change in condition for 3 of 3 residents reviewed, (Resident #82, #83 and #5). On December 4, 2022, Resident #82 was experiencing shortness of breath and coughing symptoms, nursing staff failed to provide timely assessments and on December 5th the resident passed away with cause of death being respiratory failure. This failure resulted in the death of one resident, therefore causing an Immediate Jeopardy (IJ) to the health, safety, and security of the resident. Resident #83 had an unwitnessed fall and staff failed to provide neurological assessments and Resident #5 had edema and an order for daily leg wraps, staff failed to apply the wraps. The facility reported a census of 75 residents. The State Agency informed the facility of the IJ that began as of December 4, 2022, on April 13, 2023 at 9:45 AM. The facility staff removed the Immediate Jeopardy on April 13, 2023 through the following actions: a. Completed 100% audit on change of condition 4/13/23. b. Completed 100% audit on neuro check completed per policy on 4/13/23. c. Completed the following in-service with licensed nursing on 4/13/23; 1. Change in Condition, nursing assessments. 2. Notification of Change in condition policy. 3. Neuro checks completed per policy. d. Facility Nurse Practitioner evaluated residents with change in condition on 4/13/23. e. The facility will monitor the following through the facility audit tool 5x a week for 4 weeks then monthly; 1. Resident with change in condition for assessment and intervention. 2. Neuro check completed per policy. f. Education will be incorporated in orientation of new hire during on boarding effective 4/13/23; 1. Change in condition, nurse assessment and intervention, 2. Notification of change policy, 3. Neuro check per policy. The scope was lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #82 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). The resident required extensive assistance with the help of two staff for bed mobility, transfers, dressing and toileting. A Care Plan initiated on 10/5/22 showed that Resident #82 had a self-care performance deficit and required assistance of one staff with walker and noncompliant with asking for assistance. The resident had a history of falls and fall with fracture on 9/6/22. The resident stated that he would not ask for assistance if he didn't feel that he needed help. Observe for new onset of signs and symptoms of Covid-19 infection and communicate with the physician. Monitor for pocketing choking coughing, monitor for malnutrition, Resident was on diuretics increased risk of falls and report pertinent lab results. Diagnosis reflux, repeated falls chronic kidney disease chronic bronchitis, cognitive communication deficit, muscle wasting. According to an Incident Report dated 12/4/22 at 9:07 AM Resident #82 was found in front of his bathroom door with the wheel chair in front of him and the wheels were not locked. The resident stated that he was trying to go the bathroom and slid out of the wheel chair. The nursing note indicated that immediate action had been taken that included neurological evaluation per protocol. A Neurological (Neuro) Check List Form found in the electronic chart under the Assessments tab included the following vital signs that were taken on 12/4/22 at 9:31 AM; Temperature 97.8, Heart Rate, 116 beats per minute, Respirations of 18 per minute and a Blood Pressure of 98/78. a. 1st Neuro check times 6:36 AM and signed on 12/4/22 at 1:37 PM b. 2nd Neuro check timed 6:40 AM and signed at 1:38 PM c. 3rd Neuro check timed 7:00 AM and signed at 1:39 PM d. 4th Neuro check timed 7:00 AM and signed at 1:40 PM e. 5th Neuro check timed 8:00 AM and signed at 1:40 PM f. 6th Neuro check timed 9:00 AM and signed at 1:40 PM g. 7th Neuro check timed 9:32 AM and signed at 9:35 AM h. 8th Neuro check timed 10:06 AM and signed at 1:41 PM i. 9th Neuro check timed 11:00 AM and signed at 1:42 PM The following documentation was found in the Nursing Notes: a. On 12/1/22 at 11:15 PM resident complaining of nausea with dry heaves and given as needed Zofran medication b. On 12/2/22 11:05 PM physician note the resident had complaints of nausea with temperature of 97.5 and heart rate of 68 beats per minute. c. On 12/3/22 at 10:33 PM [NAME] emesis and Zofran given. d. On 12/3/22 at 2:30 PM increased malaise and nausea prompted Covid test and test was negative. e. On 12/3/22 at 5:30 PM continues to complain of nausea, fluids encouraged. A Nutritional assessment dated [DATE] at 3:00 PM showed that the resident required 2100-2200 milliliters of fluids daily. According to the Activities of Daily Living documentation flow sheet for December included the following milliliters (ml) of fluid per day: a. December 1st 500 ml b. December 2nd 720 ml c. December 3rd 720 ml e. December 4th 720 ml A Nursing Note dated 12/5/22 at 5:54 AM showed that Resident #82 was taken to the emergency room by ambulance at that time. A follow up nursing note on 12/5/22 at 1:32 PM indicated that the facility received a call from the hospital that the resident had passed away at 12:45 PM on that day. According to the hospital report on 12/5/22 at 6:25 AM, Resident #82 arrived in the emergency room with a chief complaint of shortness of breath and a clinical impression of dehydration with dry mouth and cracked lips. Upon arrival to the emergency room his oxygen saturation was 75%, blood pressure was 97/46, heart rate 104 beats per minute, respirations 32 per minute and a temperature of 101 Fahrenheit. The hospital report dated 12/5/22 at 1:00 PM indicated that the time of death was 12:55 with cause of death being acute or chronic respiratory failure and viral sepsis as result of Covid-19. At 4/12/23 at 10:16 AM the Medical Director (MD) said that he did not remember that the resident had a fall on 12/4/22 and said that the fall would not have had any relation to the sepsis on 12/5/22. However, if the resident had experienced a change in condition on 12/4/22 more sets of vitals and lung assessments would have been helpful for the on-call doctor to have known sooner. On 4/11/23 at 5:48 AM Registered Nurse (RN) Staff V said that she mostly worked overnights and she had been working with Resident #82 the night before he went out to the hospital. She said that he had been restless and agitated the night before he went to the hospital. He was yelling at staff and refused his medications and had even refused his pain medication which he rarely did. She said that he did have a cough through the night but she didn't remember if she had assessed his lungs. The Assistant Director of Nursing (ADON) had come in the next morning and tested him for Covid-19 and that was when he tested positive and they send him to the hospital. On 4/11/23 at 8:30 AM a family member for the resident said that the resident presented to the emergency room with a bowel obstruction and Covid-19. He said that he had visited the resident on Sunday 12/4/22 because he had gotten a call about the fall. When he came in to visit, the resident was out of it, very confused and didn't feel well. He said that the resident had spilled a soda on him and Certified Nursing Assistant (CNA) Staff R got the resident cleaned up and back in bed. The resident was struggling to breathe so the CNA elevated that head of the bed that seemed to help him breathe a little better. While he was at the facility he did not see a nurse do a lung assessment or take any vitals. On 4/11/23 at 9:15 AM RN Staff W said she remembered having found the resident on the floor by the bathroom with the wheel chair in front of him on 12/4/22. She did not remember him having a cough or rattily lungs. She said that it was an unwitnessed fall and the facility policy is to do neurological assessment so she would have completed that task. She said she would not use previous vitals for each assessment. On 4/13/23 at 10:15 AM CNA Staff R remembered working with Resident #82 on 12/4/22, it was a Sunday, and she said that she had been working every other weekend. Staff R remembered the family being at the facility while she got the resident cleaned up after he had spilled some soda on himself. Staff R said he looked like death, his legs and abdomen were swollen and she could hear his lungs were rattling as soon as she walked in the room. She put the head of the bed up because he was having trouble breathing and she went and told the nurse that he wasn't doing very well. The nurse told her that he had just tested positive for Covid-19 and the symptoms that he was experiencing were to be expected. Other staff members told her that the resident hadn't eaten for at least two days. Staff R did not see a nurse go in and assess his lungs or take any vitals. She said that the nurses would often dismiss the concerns of the CNA's and not listen to them when they have a concern about residents. 2) According to the MDS dated [DATE], Resident #83 had a BIMS score of 0 (severe cognitive deficit). The resident was totally dependent on two staff for bed mobility, transfers, dressing and toileting needs. A Care Plan revised on 10/31/22 showed that Resident #83 was at risk for unmanaged pain, staff were directed to observe for signs of pain such as facial grimacing, hesitancy with movement, and refusing to move or transfer. The resident was at risk for fractures and injuries related to a history of pathological femur fracture, osteoporosis and osteoarthritis, osteopenia, and had hip and knee joint replacements. Resident #83 required the Hoyer mechanical lift with 2 staff assistance for all transfers staff were to use caution with all transfers related to extremities due to risk for injury and fractures. A Nurse Note dated 9/29/22 at 2:06 PM noted Resident #83 was discovered on her floor mat beside her bed. She was in the seated position with back resting on side of the bed. She was soiled with BM at that time. Bed was in lowest position. Resident was assisted back to bed x3 assist, BM cleaned, care provided, assessed for injury. Director of Nursing notified. Power of Attorney notified. Fall follow up initiated per facility protocol. The Nursing Notes included one set of vitals taken on 9/29/22 at 2:06 PM and the chart lacked documentation of a neurological evaluation. According to the policy titled Neurological Evaluation dated 3/28/23, A neurological evaluation will be performed by a licensed nurse when a residents status warrants; an unwitnessed fall to identify a change in condition related to a possible head injury. According to a facility policy titled: Notification of Change in Resident Condition reviewed on 4/28/21 the attending physician and resident's representative would be notified of change in condition per standards of practice. The guidelines for notification of physician include a signification change on condition.