**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 65 with three of residents selected for reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to ensure a safe and secure environment to prevent the elopement of cognitively impaired R1, identified at risk for elopement. On 05/07/24 at 09:40 AM a CNA M let R1 out the front doors of the building. CNA M thought R1 had an appointment and was leaving to get on the facility transport vehicle. When R1 went out the doors his WanderGuard caused an alarm to activate, and CNA M did not check which resident caused the alarm. The facility did not know R1 was not in the building until almost 15 minutes later when a staff member driving by the facility saw the resident outside, unsupervised, and notified the facility. Staff found the resident approximately 90 feet from the facility, heading toward a highly trafficked, 4 lane road. These failures placed R1 in immediate jeopardy. Findings included: - Review of the resident's Electronic Health Record (EHR) revealed Resident (R)1 had diagnoses which included paraplegia, (paralysis characterized by motor or sensory loss in the lower extremities), cognitive communication deficit (an impairment in organization, sequencing, attention, memory planning, problem-solving, and safety awareness), reduced mobility (difficulty with movement), and chronic pain syndrome (pain that last over three months). Review of R1's Quarterly Minimum Data Set (MDS) dated [DATE], revealed R1 had a Brief Interview for Mental Status score of 10, which indicated moderately impaired cognition. The resident did not wander and had no falls during the look back period. R1 required assistance with bathing, transfers, and dressing. Review of R1's Care Plan dated 05/28/23, with a revision date of 09/13/23, revealed R 1 had an elopement risk, wandered, had attempted to leave the facility, and voiced desire to leave. R1 required frequent monitoring by staff. The care plan stated R1 had impaired cognitive function/dementia or impaired thought process. The care plan further revealed the resident had limited physical mobility and used a wheelchair for locomotion and the resident could go outside with staff supervision only. On 09/23/2023 the care plan informed staff that R1 had attempted to get out of the door in his wheelchair when he sat in front of the door and waited for it to open and occasionally voiced a desire to leave the facility. R1's WanderGuard was replaced on his wheelchair on 02/19/24. Review of the Elopement Assessment dated 02/28/24, identified the resident as cognitively impaired, but not independently mobile. Review of the Nurse's Note dated 05/07/24, revealed at 09:40 AM, Certified Nurse Aide (CNA) M let R1 out the front door (of the facility). At 09:45 AM, Administrative Staff C and Dietary Aide BB reported they saw the resident sitting outside of the front door at a table. At 09:55 AM, an unidentified facility staff member no longer saw the resident sitting at the table. CNA N called the facility and talked to CNA O to let her know the resident was wheeling down the street in front of the facility toward the 4-lane street that runs along the side of the facility. CNA O brought the resident back into the facility. Review of the undated facility Incident and Investigation revealed R1 exited the community and wheeled himself down the sidewalk. A staff member saw him and called another staff member at the facility to go get him. The resident was located at the corner of the facility. The investigation further revealed CNA M let R1 out of the front door of the facility as she thought he was going on the transportation vehicle parked in the front of the building. The investigation verified the resident's WanderGuard sounded when triggered at the door of the facility. Review of the 05/07/24 at 10:00 AM Nurse's Note revealed the facility completed an assessment of the resident with no injuries noted. Observation of the resident on 05/15/24 at 09:00 AM, revealed the resident sat in bed with the head of the bed up and watching TV. No wandering behaviors were observed at that time. Observation of the resident on 05/15/24 at 02:10 PM, revealed the resident continued to lay in bed in his room with no behaviors noted. Observation of the area around the facility where the resident left the facility, unsupervised, revealed the resident mobilized toward a busy 4-lane road with speed limits posted at 30 miles per hour. During an interview with R1 on 05/15/24 at 11:21 AM, the resident stated that when he would get to close to the front door, an alarm would go off. The resident stated he had family that lived in another town and that he planned to move to be closer to family. The resident reported he did not remember the day he left the facility and stated his days run together. During an interview on 05/15/24 at 12:08 PM with CNA O, she reported when the resident was outside of the facility, she was in the shower room with another resident. CNA N called CNA O and reported R1 was on the sidewalk heading toward the 4-lane road on the side of the building. CNA N stated she was on break and was driving so she could not stop to get the resident. CNA O went outside and found R1 about 10 feet away from the crosswalk beside the facility. During an interview on 05/15/24 at 12:17 PM with Administrative Nurse D, revealed her expectation was for the staff to know who the residents were that had a risk for elopement. Administrative Nurse D further expected staff to know which residents had a WanderGuard, the location of the elopement book/policy, and if the alarm went off to look for the resident that caused the alarm to sound. Review of the Wunderground.com/accuweather.com report for 05/07/24 at 09:55 AM revealed an outside temperature at the time the resident left the facility and returned to the facility measured 68 degrees Fahrenheit. Review of the 05/23 Elopement Policy revealed it is the policy of the facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. The facility failed to ensure a safe and secure environment to prevent the elopement of cognitively impaired R1, identified at risk for elopement, when on 05/07/24 at 09:40 AM, CNA M let R1 out the front doors of the building, unsupervised. The resident remained out of the building without staff knowledge or supervision for approximately 15 minutes and was found headed toward a busy 4-lane road. On 05/15/24 at 03:31 PM, a copy of the immediate jeopardy (IJ) template was provided to Administrative Staff A and Administrative Nurse D and E for the failure to ensure the safety of R1 when he left the facility, unsupervised, and without staff knowledge. The deficient practice was cited as past non-compliance as the facility implemented the following corrective actions beginning on 05/07/24: 1. The facility located R1 and brought him back to the building. A skin assessment was performed by the Director of Nursing, with no issues found. A WanderGuard was found in place and functioning at the time of the event. R1's Physician and Durable Power of Attorney were notified of the event. Elopement evaluation completed and care plan reviewed. 2. A headcount of all residents was performed. 3. Community review of all residents at risk for elopement was completed on 05/07/24 by the Director of Nursing and Assistant Director of Nursing. Residents identified as having the potential to be affected were evaluated for elopement risk by the Assistant Director of Nursing. 4. Care plan review of residents identified as having the potential to be affected was completed on 05/07/24 by the Assistant Director of Nursing to verify prevention interventions were in place as indicated. 5. Current associates were re-educated by the Assistant Director of Nursing and/or designee on the community Elopement Policy and the community Elopement Evaluation process on 05/07/24. Associates who had not completed the required education on 05/07/24 were required to complete education prior to working their next scheduled shift. 6. An ADHOC QAPI meeting was completed with the community interdisciplinary team on 05/07/24. 7. The facility Medical Director was notified of elopement on 05/07/24 and further notified of the facility compliance plan. 8. Exit doors were evaluated and noted to be functioning without discrepancy. Front door code changed and communicated to the staff. 9. Residents identified with a new risk for elopement or change in elopement risk will be reviewed by clinical/interdisciplinary team during routine clinical huddle to verify elopement risk assessment accuracy, provider notification, and preventative measures. Due to the corrective measures implemented by the facility prior to the onsite complaint investigation on 05/15/24 and 05/16/24, the deficient practice was deemed past non-compliance. The deficient practice remained at a J scope and severity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 64 residents with three residents identified and reviewed for elopement. Based on interview, observation, and record review the facility failed to provide adequate supervision to prevent cognitively impaired Resident (R)1, with a known history of elopement, from leaving the facility unsupervised and without staff knowledge on 12/31/23 at approximately 06:30 AM. The facility staff did not know R1 was not in the facility until the oncoming nurse, Licensed Nurse (LN) D, asked a Certified Nurse Aide (CNA) G to locate R1. The facility staff could not locate R1 on 12/31/23 at 06:30 AM and LN D started the elopement process. At 07:30 AM, CNA G found R1 outside, at the back of the facility, at the bottom of the concrete stairs. R1 exited the facility through a known malfunctioning exit door in the dark, followed the sidewalk around the building, and attempted to walk down 12 unlit concrete steps, at which time R1 fell and hit his head. When R1 left the facility, the temperature measured approximately 30 degrees Fahrenheit (F) with a wind chill of 20 degrees F. R1 was outside, with his location unknown to staff for approximately 60 minutes in the cold weather. This deficient practice placed R1 in immediate jeopardy. Findings included: - Resident (R) 1's Physician Orders dated 01/03/22 revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Modification of Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of two, indicating severely impaired cognition, and identified behavior of wandering that occurred daily. R1 was independent with Activities of Daily Living (ADLs). The Quarterly MDS dated 10/18/23 revealed a BIMS score of three, indicating severely impaired cognition. R1's behavior of wandering was not exhibited on the assessment. The Care Plan indicated R1 was at risk for elopement/wandering, wore a WanderGuard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort), and staff were to check placement and monitor its functioning every shift. Interventions updated on 12/31/23 instructed staff to include R1's picture and information in the elopement book. The Elopement Assessment dated 12/31/23 indicated R1 was cognitively impaired, independently mobile, and had a history of elopement. R1 desired to leave the facility, was exit seeking with a purpose, had a diagnosis of Alzheimer's disease or dementia, and wore a WanderGuard. The Nurses Notes dated 12/31/23 revealed at 06:30 AM Licensed Nurse (LN) D asked Certified Nurse Aide (CNA) G to locate R1. The staff member could not locate R1 and notified LN D. LN D then started the elopement process with a resident head count and LN D instructed the other staff members to walk around the outside of the building to look for R1. LN D then notified Law Enforcement, the director of nursing, and family. At 07:30 AM, CNA G found R1 who fell down 12 concrete stairs at the back of the building. LN D assessed R1, applied a C-collar, and assisted R1 up the stairs to a gurney, where Emergency Medical Service (EMS) transported R1 to the hospital for evaluation and further treatment. The Nurses Note dated 12/31/23 at 11:30 AM, documented R1 returned to the facility from the hospital visit. LN D observed 11 staples at the top of R1's scalp, and abrasions to R1's third, fourth, and fifth knuckles on the right hand. An outside observation on 01/08/24 at 09:25 AM, of the 12 concrete steps in the back of the building where R1 fell on [DATE], revealed the second step from the bottom had gray colored hair attached to the step, which was left from R1's head wound (8 days prior). Observation on 01/08/24 at 11:34 AM, revealed R1 sat in the dining room visiting with family, and R1 had 11 staples on the top of his head. R1's abrasions on his right hand were in the healing process. R1's family member stated R1 had been a wanderer for a long time, and further stated R1 was always an exit seeker. Interview with Administrative Nurse B on 01/08/24 at 10:55 AM revealed the staff checked the WanderGuard system daily to make sure it was functioning properly. Interview with Administrative Staff A on 01/08/24 at 11:00 AM revealed the door at the end of the 200 Hall had been malfunctioning for the last month. Administrative Staff A explained the door did latch properly, but at times the door would bounce off of the door frame and the mag lock would not secure the door closed completely. Interview with CNA G on 01/08/24 at 11:50 AM revealed when she came into work on 12/31/23 at 06:00 AM the charge nurse asked her to locate R1. When she could not locate R1, the charge nurse started the elopement procedure with a head count completed, then CNA G and other staff members started looking for R1. She decided to look around back of the facility and about 07:30 AM she found R1 outside at the bottom of the concrete stairs to the basement. Interview with LN D on 01/08/24 at 12:30 PM revealed during the morning report R1 usually wandered around the facility and was not wandering around at that time, so LN D asked CNA G to locate R1. When staff could not locate R1, the elopement procedure was started and staff completed a head count, notified law enforcement, director of nursing, and R1's family. The other staff members in the facility attempted to help locate R1. CNA G found R1 at the bottom of the basement steps behind the facility. R1 received an injury to the top of his head, which required 11 staples. The facilities Elopement Policy dated 2002 revealed all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified with have these issues addressed in their individual care plans. The Purpose of this policy missing residents shall be defined to mean a resident who has left the facility grounds without signing him/herself out of the facility. Resident who are at risk for elopement shall be provided at least one of the following safety precautions by the facility. Door alarm on facility exit and or a personal safety device that will alert facility staff when the resident has left the building without supervision and or staff supervision. Maintenance will check all door alarms for proper function on a weekly basis. The facility failed to provide adequate supervision to prevent cognitively impaired R1 with a history of elopement from leaving the facility unsupervised and without staff knowledge. R1 exited the facility unsupervised, in the dark, and fell down 12 concrete steps causing a laceration to the head, which required 11 staples to close. This failure placed R1 in immediate jeopardy. On 01/08/24 at 05:01 PM Administrative Staff A and Administrative Nurse B were provided the Immediate Jeopardy Template. The facility identified and implemented the following corrective action on 12/31/23 which included: 1. On 12/31/23 at 07:40 AM, all staff received re-education regarding the facility elopement policy and elopement evaluation. The facility completed training on 01/01/24 at 02:30 PM. 2. The facility identified residents at risk for elopement and an assessment was completed on those residents. 3. A QAPI meeting was completed with the community interdisciplinary team on 12/31/23 at 10:30 AM. 4. Medical director notified of the event on 12/31/23 at 10:00 A 5. Exit doors were evaluated on 12/31/23 and safeguards were placed for staff supervision at the 200 Hall exit door to verify function of door and resident safety on 12/31/23. On 01/01/24 at 10:00 AM the facility had the Mag locking system to secure the 200 hall exit door evaluated. 6. The WanderGuard system and alarms were checked and validated for proper function on 12/31/23 at 09:30 AM with no discrepancies identified. 7. Routine elopement drill's will be scheduled per community policy on varying shifts to confirm staff competency, 8. Quality Assurance plan to monitor facility compliance Director of Nursing will report trends identified with routine reviews to the community QAPI committee for 3 months. Then the QAPI committee will re-evaluate the need for continued monitoring. The surveyor verified the facility implemented the above corrective actions prior to the onsite survey. Therefore, the deficient practice was deemed past noncompliance at a scope and severity of J.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 57 residents with three sampled for elopement. Based on observation, interview, and record review, the facility failed to ensure staff provided a safe and secure environment for cognitively impaired Resident (R)1. On [DATE] at approximately 07:05 AM, Licensed Nurse (LN) I walked in the front doors of the facility to report for her shift while R1 walked out of the front doors. LN I assumed R1 was a visitor or employee. The facility staff did not realize R1 was missing until 07:45 AM (40 minutes later), at which time the facility staff began searching for R1. Around 10:00 AM the family notified the facility R1 was found deceased by the train tracks at approximately 08:30 AM, after being struck by a train. R1 had walked approximately eight city blocks away, crossed a busy four lane street/highway with speed limits of 30 miles per hour, and onto heavily trafficked train tracks. This deficient practice placed R1 in immediate jeopardy. Findings included: - Review of R1's Electronic Medical Record (EMR) revealed a diagnosis of small cell lung carcinoma (cancer) with metastases (when cancer had spread to other parts of the body from the original location) to the brain. The Entry Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility on [DATE] from an acute care hospital. The Care Plan for cognition, dated [DATE], documented the resident had impaired cognition due to metastatic brain cancer. The Care Plan for behaviors, dated [DATE], instructed staff the resident would occasionally pace in the halls and had difficulty sleeping at times. The Care Plan dated [DATE], lacked staff instruction for monitoring the resident for an elopement risk. Review of the resident's EMR revealed an Elopement assessment, completed [DATE], which indicated the resident was not at risk for elopement. Review of the resident's EMR revealed an incomplete Brief Interview for Mental Status (BIMS-a screening tool used to assess cognition) assessment, dated [DATE]. Review of the resident's EMR and information provided by the facility revealed the following: On [DATE] at 07:05 AM, Licensed Nurse (LN) I reported to work at the facility. As LN I approached the front door of the facility, she witnessed the resident walking out of the building, unaccompanied. During shift report on [DATE] at 07:45 AM, LN I and LN R were in the nurse's station when it was determined the resident had possibly eloped (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness, leaves the facility without the knowledge of staff). LN I and LN R immediately notified all staff, who then conducted a head count of all the residents and searched the premises inside and out for R1. LN I and LN R got into their cars and searched a one-mile radius in opposite directions searching for the resident with no success. On [DATE] at 07:47 AM, LN I notified Administrative Nurse D of the possible elopement. Administrative Nurse D requested the facility call the police department to notify them of the possible elopement. On [DATE] at 07:50 AM, the facility notified the resident's family and durable power of attorney (DPOA) the resident could not be located, and the facility had contacted/notified the authorities. On [DATE] at 08:00 AM, the local police department arrived at the facility and were provided with a printed picture and a detailed description of the resident. The facility staff continued their search for missing resident, R1. On [DATE] at 10:00 AM, the resident's family notified the facility the resident R1 was found deceased . The resident walked down paved, populated streets in a residential area and across a busy four lane highway in which the speed limited was posted at 30 miles per hour, to gain access to the highly trafficked train tracks, about eight blocks away. On [DATE] at 12:18 PM, Activity staff Z stated the resident had confusion. She could walk on her own and was independent. Activity staff Z stated she had never seen the resident attempt to exit the facility on her own, but stated she would not have been able to leave the facility unassisted, due to her confusion. On [DATE] at 12:37 PM, Social Service staff X stated she was responsible for completing the BIMS assessments with residents. When she attempted to complete the assessment with the resident on [DATE], the resident was unable to focus her attention to answer the questions of the assessment. On [DATE] at 01:00 PM, Certified Nurse Aide (CNA) M stated the resident had confusion due to having brain cancer. There had been a few times when the resident stood by the door and looked outside, but no one thought the resident would try to elope. The resident was not considered to be an elopement risk and did not have a wander guard (a device often worn as a bracelet resident's wear which alerts staff when a resident wanders too far or breaches a perimeter). On [DATE] at 01:12 PM, CNA N stated she had not seen the resident the morning of the elopement. CNA N stated the resident was confused but did not have a wander guard. On [DATE] at 10:23 AM, Administrative Nurse E stated the resident was intermittingly confused. Administrative Nurse E stated the door code would need to be entered for someone to open the door to go outside. On [DATE] at 12:28 PM, LN G stated the resident was confused. Her family visited her often and would take her outside to sit. LN G confirmed that staff should be the only ones who know the code to the front door. On [DATE] at 01:34 PM, LN H stated the resident had lung cancer which had metastasized to her brain. The resident was very confused and forgot things quickly. She was able to ambulate around the facility on her own. LN H stated she considered the resident to be at risk for elopement due to her confusion and being able to ambulate independently. LN H stated she had not done an elopement risk assessment with the resident and confirmed the resident did not wear a wander guard at the time of her elopement. On [DATE] at 02:14 PM, LN I stated she reported to work at the facility on [DATE] at 07:05 AM and as she approached the front door, a woman walked out of the door wearing a decorative surgical cap and they exchanged pleasantries. LN I stated she believed the woman was a staff member going outside for a break. LN I did not recognize the woman as a resident as she had not worked at the facility since the resident admitted on [DATE]. While receiving report at 07:45 AM, LN R described the newly admitted resident to LN I. LN I stated it was at that time, she realized the woman who had walked out of the door when she entered, was a resident. LN I stated they immediately did a head count of the residents in the building and then began the search for the resident. LN I stated there was no one in the lobby by the front door who could have opened the door for the resident, and LN I was unsure of how the resident knew the code. LN I stated the facility changed the door code frequently. On [DATE] at 03:02 PM, Administrative Nurse D confirmed the resident had confusion but the elopement risk assessment, completed on [DATE], found her to not be at risk for elopement. Administrative Nurse D stated at approximately 08:30 AM, someone informed them a body had been discovered by the train tracks, but they did not receive confirmation until 10:00 AM from the resident's family. Administrative Nurse D stated the facility began their corrective measures immediately on [DATE] and would complete the education on [DATE]. No staff members were allowed to work until the elopement education was completed. The facility reviewed all of the residents elopement assessments, to ensure accuracy. The facility policy for Elopements, reviewed 05/2023, included: It is the policy of the facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. The facility failed to ensure staff provided a safe and secure environment for cognitively impaired Resident (R)1. On [DATE] at approximately 07:05 AM, R1 walked out the front door of the facility as LN I arrived for work. The facility staff did not realize R1 was missing for 45 minutes. R1 walked approximately eight city blocks, crossed a busy four lane street/highway with speed limits of 30 miles per hour, and onto heavily trafficked train tracks. Around 10:00 AM R1's family notified the facility she had been found deceased by the train tracks at approximately 8:30 AM. This deficient practice placed R1 in immediate jeopardy. On [DATE] at 04:30 PM Administrative Staff A was provided a copy of the immediate jeopardy (IJ) template and informed of the IJ for failure to ensure the safety of R1 when she left the facility, unsupervised, and without staff knowledge. The deficient practice was cited as past non-compliance as the facility implemented the following corrective actions beginning on [DATE]: 1. The facility reviewed all residents in the facility at risk for elopement to verify preventative interventions were in place, as indicated. 2. Current facility staff were re-educated by Administrative Nurse D/or designee regarding the facility's Elopement policy and Elopement Evaluation process. Staff were required to complete the education prior to working their next scheduled shift. 3. A Quality Assurance Improvement Plan (QAPI) meeting was completed with the interdisciplinary team where the corrective plan was developed on [DATE]. 4. The facility's medical director was notified of the incident on [DATE] at 07:56 AM. 5. The exit doors were evaluated and noted to be functioning without discrepancy. The numerical code to the front door was changed and communicated to the community staff. 6. Any resident identified with a new risk for elopement or change in elopement risk will be reviewed by the clinical interdisciplinary team to verify elopement risk assessment accuracy. The resident's physician will be notified, and preventative interventions will be put into place, as indicated. If discrepancies are identified immediate correction will be completed and one on one education will be completed as indicated. 7. Any resident identified with a change in elopement risk or who have had an elopement attempt will be reviewed during the routine risk meeting by clinical interdisciplinary team. 8. Routine elopement drills will be scheduled periodically on varying shifts to confirm staff competency. Findings of elopement drills will be reported to the facility administrator and reviewed at the following morning meeting. If discrepancies are identified, immediate correction will be completed and one on one education will be provided, as indicated. Due to the correction measures implemented by the facility prior to the onsite complaint investigation on [DATE], the deficient practice was deemed past non-compliance. The deficient practice remained at a J scope and severity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 55 residents with 11 selected for review including three reviewed for risk of elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, record review, and interview, the facility failed to ensure a safe environment for cognitively impaired and independently mobile Resident (R)2, who was identified as at risk of elopement, had a history of elopement, and the facility discontinued her elopement risk interventions. On 09/23/22, R2 exited the facility without staff awareness or supervision and crossed a heavily traveled four lane street. The staff who were outside of the facility on break, observed her and assisted her back to the building. This deficient practice placed the resident in immediate jeopardy. Additionally, the facility identified R8 as an elopement risk and failed to complete 15 minute checks, and identified R9 as an elopement risk and failed to check the wander alarm bracelet (bracelet that sets off an alarm when resident wearing one nears or attempts to exit facility without an escort) for placement and function. Furthermore, upon review of three residents for accident hazards, the facility failed to implement appropriate interventions following falls and failed to investigate all falls for R4. The facility failed to implement new interventions following falls for R3 and failed to investigate all falls, failed to implement fall interventions, and failed to transfer R3 in a safe manner. Findings included: - The Medical Diagnosis tab for R2 included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), muscle weakness, anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), restlessness, and agitation. The Quarterly Minimum Data Set (MDS) dated [DATE], assessed R2 with a Brief Interview of Mental Status Score (BIMS) of two, indicating severe cognitive impairment, and noted R2 did not wander. R2 required supervision and setup help for walking and used a wander/elopement alarm daily. The Annual MDS dated 12/23/22, assessed R2 with a BIMS score of six, indicating severe cognitive impairment. The MDS noted R2 continued not to wander, was independent with walking, and used a wander/elopement alarm daily. The Activities of Daily Living [ADL] Care Area Assessment (CAA) dated 12/31/22 revealed R2 ambulated throughout the facility independently. The Elopement Assessment -V3 dated 06/21/22 revealed R2 was cognitively impaired and independently mobile and had a history of elopement. Since those items were answered on the assessment, the assessment indicated the resident was at risk for elopement and to proceed with interventions and elopement risk care plan. The assessment revealed discontinued off elopement risk because she acclimated to facility and is no longer exit seeking. The Care Plan dated 12/03/22 revealed R2 ambulated through the facility with no assistive device, was a risk for elopement or to wander, a wander alert device was added on 09/23/22, and the staff added her picture to the elopement book due to her elopement/wandering risk. The care plan history revealed the facility discontinued her elopement risk problem on 08/10/22. The Progress Note dated 09/23/22 at 11:29 AM revealed the staff informed R2's DPOA (Durable Power of Attorney) she left the building this morning after following a visitor out. The staff observed R2 walking down the sidewalk. The staff placed a wander alarm bracelet on her for her safety. The facility Incident Information dated 09/26/22 revealed on 09/23/22 at approximately 09:45 AM the housekeeping staff who were outside on break, discovered R2 walking across the street from the facility, headed towards a park (located across the heavily traveled four lane street). When the staff approached her, R2 stated she was going for a walk and when asked how she got out, R2 stated the lady let me out. The staff brought her back to the facility at 09:50 AM. R2 had been last seen at 09:30 AM holding some clothes and hangers sitting in the common area, which were later discovered on her bed. The facility concluded R2 was let out by a visitor while she was sitting close to the main entrance. The Witness Statement dated 09/23/22 by Administrative Nurse F revealed staff saw R2 walking about in the dining room and the common area about 09:30 AM with clothes hanging over her arm, with the hangers still attached, and R2 spoke to other residents and staff. The Witness Statement dated 09/23/22 by Housekeeping/Maintenance Staff U revealed while outside on break in the back parking lot talking to two other housekeepers, one of the housekeepers asked if that was R2. When the staff looked up, Housekeeping/Maintenance Staff U saw R2 stumble and they ran to R2, who was on the other side of street, south of the facility. R2 told Housekeeping/Maintenance Staff U she was going on a walk and a lady let her out. When brought back inside, the staff applied a wander alarm bracelet to R2. On 01/04/23 at 03:02 PM, observed R2 sitting in the dining room for a facility activity, a she wore a wander alarm bracelet on her left ankle. On 01/04/23 at 03:47 PM observed, with Administrative Staff A, the area the facility staff saw R2 on 09/23/22, when she exited. The street was a four-lane road with a speed limit of 30 miles per hour and heavily traveled. The location R2 crossed lacked a stop sign or traffic light for the four-lane traffic traveling alongside the north of the facility grounds. The park was located across the busy street. On 01/04/23 at 03:50 PM, Administrative Staff A stated a visitor let R2 out but the facility did not know who it was and the facility has a sign posted about not letting anyone out without checking with the staff. On 01/04/23 at 05:03 PM, Administrative Nurse D stated when the staff completed the elopement risk assessment in June 2022, R2 was at risk and to discontinue the elopement interventions was probably not the correct intervention. On 01/05/23 at 09:44 AM, Administrative Staff A stated R2 sat by the front doors before the morning meeting and R2 said she followed a visitor out, so that was how the facility knew R2 went out one the front doors (on 09/23/22). On 01/05/23 at 09:58 AM Housekeeping/Maintenance Staff U stated she was outside on break when she noticed R2 walking across the street, so she ran to get R2. R2 was walking on one street then crossed to the other street and was stumbling trying to step up on the curb. R2 was on the sidewalk when Housekeeping/Maintenance Staff U got to her. R2 went back to the facility with Housekeeping/Maintenance Staff U. R2 had said a lady let her out however, she could not describe her and did not know who she was. Housekeeping/Maintenance Staff U stated as R2 crossed the street there was not any traffic traveling on one road, but there was on their way back to the facility and she had to stop the traffic for her and R2 to cross the street. The facility Elopement Policy undated, revealed using the MDS assessment schedule, all residents are reviewed for safety concerns and precautions. Any residents that are at risk for elopement should be identified and interventions placed in their individual plan of care. Residents at risk for elopement shall be placed in an elopement book located at the reception desk and nurse's stations. This will be updated whenever new resident safety issues are identified. The facility failed to continue with elopement risk interventions for R2, who had severe cognitive impairment and was independently ambulatory, when assessed at risk on the elopement assessment on 06/21/22 and eloped on 09/23/22. This placed R2 at risk for immediate jeopardy. On 01/05/23 at 01:43 PM, Administrative Staff A was informed that they were in immediate jeopardy status and provided the Immediate Jeopardy Template for failure to continue with elopement risk interventions when R2 was at risk per the elopement assessment completed on 06/21/22. R2 eloped from the facility on 09/23/22. The facility completed implementation of the following corrective measures on 09/23/22 at 09:00 PM: 1. Wander alarm initiated to her left ankle. 2. Picture and resident information added to the elopement book. 3. Staff re-educated on elopement policy immediately following the resident's return back to the building, further education provided to staff before the beginning of their shifts. The majority, of staff, received education on 09/23/22. 4. All resident elopement assessments reviewed and updated. 5. R2's care plan reviewed and updated. 6. Maintenance director conducted wander alarm door inspection to all exit doors. The deficient practice with elopement was deemed past non-compliance due to the implemented corrective actions and existed at a J scope and severity. - The Medical Diagnosis tab for R9 included diagnoses of anxiety (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), encephalopathy (the functioning of the brain is affected by some agent or condition such as a viral infection or toxins in the blood), muscle weakness, and abnormalities of gait and mobility. The admission Minimum Data Set (MDS) dated [DATE] assessed R9 with a Brief Interview of Mental Status (BIMS) score of eight, indicating moderate cognitive impairment, rejected care one to three days, and wandered one to three days. R9 walked in/out of room with supervision and did not require setup assistance from staff, used a walker for mobility and she required a wander/elopement alarm to be used daily. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 10/18/22 revealed R9 ambulated with a walker and the staff supervised as needed. The Care Plan dated 12/03/22 revealed R9 had been seen several times within the area lost and not knowing where she lived or where she was going and had come to the facility for long term care and was finding adjusting difficult. R9 was at risk for elopement and lacked a wander alarm was in place. Staff were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and a book. The Elopement Assessment V-3 dated 09/29/22 revealed R9 was cognitively impaired and independently mobile, had a desire to leave the facility, was exit seeking with a purpose, and had wandering activity. This indicated R9 was at risk for elopement. The Orders tab for R9 lacked instructions for the staff to check for placement and functioning of a wander/alarm bracelet. The Task tab lacked instructions for the Certified Nurse Aides (CNA's) to check for wander alarm placement and functioning. On 01/04/23 at 03:15 PM observed R9 in her room with a wander alarm bracelet in place to her right ankle. On 01/05/23 at 08:46 AM observed R9 ambulating down the hallway on her own using a walker, wander alarm bracelet was in place to her right ankle. On 01/10/23 at 01:57 PM CNA N stated R9 was at risk for elopement and that she had a wander alarm bracelet in place, she has helped put her hose on so knows she has one. CNA N stated the CNA's do not document anything about wander alarms and believed management checks them. CNA N stated R9 wanted to get out of the facility when she first came I but had not witnessed her exit seeking or talking about leaving. On 01/11/23 at 08:53 AM Administrative Nurse D stated each nurse's cart had a device to check the wander alarm bracelet each 12-hour shift and would document the check on the Treatment Administration Record (TAR). Administrative Nurse D stated if a resident had a wander alarm in place it would be on the TAR to check for placement and function, and the wander alarm would be on the care plan. On 01/11/23 at 09:15 AM, Administrative Nurse D stated R9 did not have the wander alarm in place on the TAR to instruct the staff to check for placement and functioning. On 01/11/23 at 09:35 AM, CNA P stated R9 was at risk for elopement and had a wander alarm bracelet in place to her ankle. On 01/11/23 at 02:12 PM, Licensed Nurse (LN) G stated if a resident was an elopement risk, she would let Administrative Nurse A know, get an order from the doctor for a wander alarm bracelet, and would do checks to see if wander alarm was in place and working. When the order comes from the doctor it would be placed on the TAR for the nurses to check every shift or placement and if it is working with the device the facility has to check the wander alarm with. The facility Elopement Policy undated, lacked instructions for checking for placement and function of the wander alarm bracelet. The facility failed to perform checks of the wander alarm bracelet for placement and functioning, which increased the risk of R9, who had moderate cognitive impairment, to exit the facility without staff awareness. - The Medical Diagnosis tab for R8 included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) with psychotic disturbance (serious illness affecting how one thinks and perceives reality). The Annual Minimum Data Set (MDS) dated [DATE] for R8 assessed him with a Brief Interview of Mental Status (BIMS) score of six, indicating moderate cognitive impairment and did not exhibit wandering. R8 required supervision and setup for walking in/out of the room and used a wheelchair and walker for mobility. R8 did not require a wander/elopement alarm. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 09/26/22 revealed R8 had cognitive loss due to head trauma. The Activities of Daily Living [ADL] CAA dated 09/26/22 revealed R8 was independent with most ADL's but may need assistance of one person with some. The Quarterly MDS dated 12/16/22, assessed R8 with a BIMS score of seven, indicating severe cognitive impairment, rejected care one to three days, and did not require a wander/elopement alarm. The Care Plan dated 12/03/22 revealed the facility identified R8 as a risk for elopement on 08/31/22. He attempted elopement on 10/27/22 when upset that the staff had not taken him to Walmart. R8 observed the staff leave the facility and thought they were not going to take him, so he decided to go himself. The care plan revealed the staff were to communicate the time they would take him and talk to him if the time needed to be changed. The staff placed R8's picture and resident information in the elopement book. The care plan included on 11/08/22 R8 removed two wander alarm bracelets and would not keep them on and would not allow a third to be placed on his person. The staff were to monitor and document his location in the facility, the nurses every two hours and the aides were to document hourly. The care plan revealed R8 ambulated independently, with or without a device, and would use a wheelchair for mobility or he would walk. The Elopement Assessment V-3 dated 09/23/22 revealed R8 was cognitively impaired and independently mobile and had a desire to leave the facility. This placed the resident at risk for elopement and the staff were to proceed with interventions and an elopement risk care plan. The Task tab instructed staff to Monitor - every one-hour check and revealed from 12/27/22 through 01/16/23 the staff failed to perform hourly checks on 01/04/23, 01/08/23, 01/10/23, and 01/15/23. Each day from 12/27/22 through 01/16/23 revealed hours of the day the staff failed to complete the instructed hourly checks. The Progress Note dated 10/31/22 at 06:36 PM, revealed R8 refused a wander alarm and stated, I decided to stay. Another staff attempted to place a wander alarm and he refused and became agitated. The Progress Note dated 11/08/22 at 04:35 AM, revealed the staff placed a wander alarm on R8 and he removed it stating he would stay there and not try to leave again. On 01/04/23 at 01:50 PM, observed R8 without a wander alarm in place. R8 was in his room resting on his bed. On 01/04/23 at 05:08 PM, Administrative Nurse A stated R8 is not supposed to have a wander alarm bracelet on, he had removed two and refused the third to be placed. The nursing staff was to check him every two hours and instructed them to do so on the Treatment Administration Record. Administrative Nurse A stated R8 walked independently, however, he stayed in his room or close to the nurse's station. On 01/05/23 at 08:20 AM, observed R8 sitting in a wheelchair in the dining room eating breakfast. On 01/10/23 at 01:00 PM, Certified Nurse Aide (CNA) M stated R8 usually eats breakfast in the dining room and has lunch and supper in his room. He will come out of his room if he wants to use the phone and will use the wheelchair to come out of his room but walk on his own in the room. CNA M stated R8 was an elopement risk, and they were to do hourly checks on him and document. CNA M stated she was pretty sure he had a wander alarm bracelet on his ankle. On 01/11/23 at 08:30 AM, observed R8 move himself away from the table in the dining room, move the foot pedals on his wheelchair down, place his feet on the pedals, and propel himself to his room. On 01/11/23 at 08:53 AM, Administrative Nurse A stated she expected the CNA's to complete hourly checks. The facility policy Elopement Policy undated, revealed any residents that are at risk for elopement should be identified and interventions placed in their individual plan of care. The facility failed to follow the care plan by lack of completion of hourly checks for R8, with severe cognitive impairment and assessed at risk for elopement, placing him at increased risk to exit the facility without staff awareness. - The Medical Diagnosis tab for R4 included diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebrovascular disease (reduction of blood flow to your brain or bleeding in part of the brain) affecting right dominant side, tremor, muscle weakness, and abnormalities of gait and mobility. The admission Minimum Data Set (MDS) dated [DATE] for R4 assessed him with a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. He required limited assist of one for transfers and walking in/out of the room. R4's balance was not steady and required staff assistance to stabilize and he had limitations to one side of his upper and lower extremities. He used a walker and a wheelchair for mobility. R4 was always continent of bladder and occasionally incontinent of bowel. R4 had falls in the last six months prior to entry and had no falls since admission, on 02/25/22. The admission MDS dated 05/25/22 for R4 assessed him with a BIMS score of three indicating severe cognitive impairment and required extensive assist of one staff for transfers. R4 did not ambulate and continued to require staff to stabilize his balance. There were not changes to his upper and lower extremity range of motion and continued to use a walker and wheelchair for mobility. R4 was frequently incontinent of urine and always incontinent of bowel. He had falls in the last month and last two to six months prior to reentry, and no falls since reentry on 05/12/22. The Falls Care Area Assessment dated 05/26/22 revealed R4 had right sided weakness and was a fall risk. He walked with a walker and had unsteady gait. The staff were to observe him with ambulation and provide one person assist as needed. The Quarterly MDS dated 11/23/22 assessed R4 with a BIMS score of three, indicating severe cognitive impairment and was totally dependent of two or more staff for transfers. He did not ambulate. His balance during transitions and walking did not occur and there were no changes to his range of motion. R4 used a wheelchair for mobility and was always incontinent of bowel and bladder. Resident had no falls since the prior assessment on 08/26/22. The Care Plan dated 12/03/22 revealed R4 was a high risk for falls, and included these fall interventions: 1. On 02/25/22, the staff were to make sure his call light was within reach and to encourage him to use it for assistance as needed. 2. On 03/18/22, the staff educated R4 to ask for assistance when ready to stand up in the shower. 3. On 03/20/22, the staff placed a Call don't fall sign. 4. On 04/02/22, the Certified Nurse Aides (CNA's) were to offer him to be one of the first residents assisted to meals. 5. On 04/14/22, R4's room changed to one with a more open floor plan to better enable him to get in and out of the bathroom. 6. On 04/23/22, the staff were to assist R4 to the bathroom after meals as needed. 7. On 05/03/22, the staff were to place R4's bed in a low position. 8. On 05/05/22, the staff were to place a floor mat on the floor beside the bed when R4 was in bed. 9. On 06/11/22, the staff were to offer to assist R4 to the recliner or bed after meals. 10. On 06/13/22, the staff were to encourage him to watch something other than ghost/haunted shows at bedtime. 11. On 06/25/22, the staff were to offer reposition, fluids, snack, and/or bathroom during rounds. 12. On 07/17/22, the staff were educated/reminded that R4's bed was to be in the low position and the floor mat next to his bed when napping. 13. On 08/20/22, the staff educated R4 to use the call light and to use safety when trying to reach items. The Fall Risk Data Collection 1019 - V 2 dated 02/25/22 for R4 revealed a score of 29, indicating high risk for falls. intervention was for call light within reach and encourage him to use it for assistance as needed. The Electronic Medical Record (EMR) and facility documentation revealed R4 had 14 falls between 03/18/22 through 08/20/22. The Progress Note dated 03/18/22 at 07:30 PM revealed R4 was lying on the floor on his back in the shower room. He did not respond at first then was slow responding and a small lump was on the back of his head. R4 could not recall falling. The intervention for the fall was education to ask for assistance when ready to stand up in the shower. The facility failed to implement an appropriate intervention as his BIMS score was 10, indicating moderate cognitive impairment. The Progress Note dated 05/03/22 at 06:03 PM revealed R4 was found on his knees in front of the bed, the wheelchair brakes were not locked, had regular socks on his feet, the room was dark, and he was incontinent at the time of the fall. R4 had a scabbed over skin tear to his left forearm from a previous fall that re-opened. R4 stated he was trying to walk to his closet to get pants to change into and lost his balance and fell in front of the closet then scooted on his knees back to his bed. The intervention was to place the bed in the low position. The facility failed to implement an appropriate intervention relating to the cause of the fall. The Progress Note dated 05/05/22 at 06:30 AM revealed R4 was found in his room lying on his back on the floor next to the wheelchair and recliner. The facility lacked a post fall investigation to determine the root cause analysis of the fall. The facility implemented an intervention to place a floor mat on the floor beside the bed when he was in bed. The Progress Note dated 05/27/22 at 10:30 AM revealed R4 had a fall this shift. The facility Risk Watch report dated 05/27/22 revealed R4 was self-transferring from bed to wheelchair and could not find the call light in the bedding. The facility failed to implement a new intervention to prevent further falls. The facility Witness Statement dated 06/02/22 revealed at 10:30 AM while delivering clean linen, R4 was found faced down on the floor by his bed. The facility has no documentation of this event, unknown if it was a new fall or regarding the fall on 05/27/22. The care plan lacked a fall intervention for 05/27/22 and 06/02/22. The Progress Notes dated 07/18/22 at 03:48 AM revealed R4 was on the floor of his room sitting facing his bed with legs folded under him, his left arm was across the bed and right arm hanging at side, and the wheelchair was directly behind him. R4 stated he was leaning across the bed and slipped out of bed landing on knees. The intervention was the staff educated R4 to use the call light and use safety when trying to reach items. The intervention was not appropriate, as R4's BIMS score was three, indicating severe cognitive impairment. On 01/10/23 at 09:58 AM, observed R4 resting in bed in a semi-private room, bed in low position, mat on floor next to bed, and call light across the blanket covering him. On 01/11/23 at 09:19 AM, observed R4 sitting up in his wheelchair in his room, next to and facing the bed, lights off in the room, and the call light activated. On 01/11/23 at 09:24 AM, CNA NN and CNA P responded to the call light and R4 told them he was ready to lay down. CNA NN and CNA P transferred R4 using the lift from his wheelchair to his bed, bed placed in low position, mat placed on floor beside him on the left side of the bed. CNA NN asked if he was dry and R4 responded yes. The CNAs did not offer toileting to R4 at the time. On 01/11/23 at 09:35 AM, CNA P stated she was made aware of falls and the new interventions by a teachable moment board in the nurses' station, which is on a clipboard which informs the staff if there was a care plan change, and the board is looked at before shift starts. CNA P stated R4 was a fall risk, he was to have a fall mat beside the bed and his bed was to be lowered to the floor, make sure his call light was in reach, and explained that he was not on a toileting program. On 01/11/23 at 02:12 PM, Licensed Nurse (LN) G stated when a resident has a fall, she does an assessment, asks questions, has the CNA's write statements, completes the facility fall packet, and can add an intervention to the care plan from the electronic assessment. The family, medical provider and Administrative Staff D would be notified of the fall and documented in the progress note or the Risk Watch report. New interventions would be documented on the fall assessment and the floor staff educated. On 01/24/23 at 01:16 PM, Administrative Staff A stated each fall should have a new intervention implemented, each fall should be investigated to determine the root cause of the fall, the staff should follow the care plan, and education to a resident when their BIMS score was below 13 was not an appropriate intervention. The facility Fall Policy dated 09/17/19 revealed following any falls, the facility staff completes an Occurrence Report. Details of the fall would be recorded, and potential causative factors identified and investigated. Interventions would be implemented, and the care plan updated. The Occurrence Reports would be reviewed at clinical meetings to ensure completeness. The facility failed to implement new and appropriate interventions for the above falls and failed to investigate falls to determine the root cause, placing him at risk for further falls and injury. - The Medical Diagnosis tab for R3 included diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), muscle weakness, and abnormalities of gait and mobility. The Annual Minimum Data Set (MDS) dated [DATE] assessed R3 with a Brief Interview of Mental Status (BIMS) score of three indicating severe cognitive impairment and required two assist or more for transfers and walking in/out of her room. Her balance during transitions and walking was not steady and required staff assistance to stabilize. R3 had no impairments to her range of motion and used a walker and a wheelchair for mobility. She had two or more non-injury falls since the prior assessment on 03/31/22. The Falls Care Area Assessment dated 04/28/22 revealed R3 was a fall risk, had vascular dementia, and impaired standing and walking balance. The resident required assistance with activities of daily living (ADL's). She was incontinent of bowel and bladder and had fall interventions in place. The Quarterly MDS dated 07/12/22 assessed R3 with the same BIMS score and transfer status. She required extensive assist of one person for walking in the room and two or more when walking in the corridor. There were no changes in her balance or range of motion, and she used a wheelchair only for mobility. R3 had one non-injury fall since the last assessment on 04/11/22. The Quarterly MDS dated 10/12/22 assessed R3 with the same BIMS score as the prior assessment. She required extensive assistance of two or more staff for transfers and did not ambulate in or out of her room. Her walking balance assessment did not occur, and she continued to need staff to stabilize her when moving from seated to standing. There were no changes to her range of motion and continued to use the wheelchair for mobility. R3 had two or more non-injury falls since the prior assessment. The Care Plan dated 12/03/22 for R3 revealed she was at risk for falls related to her dementia, impaired mobility, and decreased safety awareness and included these interventions: 1. On 04/02/21, the staff were to make sure her call light was in reach and encourage her to use if for assistance as needed, revised on 06/02/21. 2. On 04/07/21, R3 will get down and crawl on the floor when she sees something she wants to get. The staff were to ensure her personal items were within reach. 3. On 04/07/21, R3's bed was to be in the low position when she was in bed, revised on 12/27/22. 4. On 04/08/21 R3 was to have gripper socks. Intervention revised 08/26/22. 5. On 04/09/21, mat on floor beside bed when resident is in bed. 6. On 04/20/21, Dycem (non-slip material) to be under the wheelchair cushion and on top of the cushion. 7. On 04/21/21, grip strips in font of recliner. 8. On 05/05/21, anti-roll back brakes on wheelchair, revised on 08/26/22. 9. On 05/07/21, Dycem to the armchair seat, revised on 08/26/22. 10. On 06/01/21, the staff were to make sure the recliner was in the right position before the grip strips. 11. On 06/23/21, Dycem to be on top of pad in recliner (replaced 02/01/22 related to a non-injury fall). 12. On 03/07/22, the staff replaced the sign family had placed on the door to say R3 was a fall risk and please peek in on me I may be on the floor thank you and the family wants the sign left up. 13. On 08/09/22, R3 was found on the floor, and she has a history of putting herself on the floor, suspected she did this on this day however not witnessed, monitor her as able when in the wheelchair. 14. On 08/17/22 and 08/20/22 R3 slid out from wheelchair when trying to transfer herself, anti-roll brakes were not put on this new chair and maintenance had applied them now. 15. On 09/02/22, the staff were to offer her snacks, toileting, nap, or activity to discourage behavior of sitting her[TRUNCATED]