**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 87 residents, with three residents reviewed for accidents and hazards. Based on record review, observation, and interview, the facility staff failed to ensure two staff safely transferred Resident (R)1 with a full mechanical lift as care planned. On [DATE] at 01:20 PM, CNA M was transferring R1 into her wheelchair with the full mechanical lift (Hoyer), without the assistance of the required second staff member. During the transfer, the bottom left sling loop came off the Hoyer lift, causing R1 to fall to the ground. Due to CNA M not following R1's care plan, R1 fell, broke her right distal femur, had extreme pain untreated by pain medication, and subsequently died. The facility further failed to ensure a safe environment free from preventable accidents for visually impaired Resident (R) 2, when facility staff did not ensure the ratchet harness was tightened to R2's wheelchair in the facility van before transport. On [DATE], Certified Nurse Aide (CNA) N attached the harness to R2 in the facility van for an out-of-town appointment, but due to a lack of training, did not ensure the ratchet straps were locked in order to prevent the ratchet harness from slipping/loosening. Approximately two miles from the facility, CNA N came to a stop, then accelerated for a right turn, heard the sound of the ratchet harness, and looked back to see R2 fall backwards in her wheelchair. R2 was bleeding from the back of her head and went to the hospital Emergency Room, where R2 received staples to close the scalp laceration to the back of her head. This deficient practice placed R1, and all residents driven to appointments at risk for injury, pain, and potential death.Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right dominant side, major depressive disorder (major mood disorder which causes persistent feelings pf sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and falls.The Annual Minimum Data Set (MDS), dated [DATE], documented R1 had functional impairment on one side of her upper and lower extremities. The MDS documented R1 was dependent on staff for transfer.The Fall Care Area Assessment (CAA), dated [DATE], documented R1 utilized a Hoyer lift.R1's Care Plan directed staff R1 required two staff assistance with a Hoyer lift for transfers using a medium-sized sling. The care plan directed staff R1 was completely dependent on staff for all of her activities of daily living (ADL) ([DATE]). The Nurses Note, dated [DATE], documented upon entering R1's room, LN G saw CNA M and CNA N on the floor with the resident and the Hoyer lift nearby. CNA M sat with R1 with a towel against R1's head to decrease bleeding from a hematoma on the left side of R1's head. R1 was on the floor with an excessively bleeding hematoma on the left side (of her head). R1 was cold and clammy to the touch, alert and oriented, and able to respond to questions. LN G called 911. CNA M stated R1 fell from the Hoyer lift sling when one of the straps snapped off the hook. While doing a head-to-toe assessment, R1 could not bend or stretch her right leg without significant pain. Emergency Medical Services arrived and transferred R1 to the local hospital. Administrative Staff A's Notarized Witness Statement documented, on [DATE] at approximately 01:30 PM, Administrative Staff A passed R1's room, heard a scream and a thud sound, and saw R1 lying on the floor, with the sling still connected to the lift. Administrative Staff A documented, as he walked into the room, he saw blood on the floor and on CNA M's hand as she was holding R1's left side of her head/face. Administrative Staff A could not tell if R1 was speaking or groaning. CNA M's Notarized Witness Statement, dated [DATE], documented she got R1 in the lift sling and when CNA M pulled the lift and pushed R1 toward her chair, one strap fell out, and R1 slipped, falling on her left side to the floor. The emergency room (ER) Report, dated [DATE], documented R1 presented to the ER due to a three-foot fall from a Hoyer lift and hit her head and complained of right knee pain radiating to left hip pain. X-rays showed R1 sustained an acute, mildly impacted fracture (occurs when the broken ends of the bone are driven into each other) of her right femur (thigh bone) and an acute fracture of the distal femoral metadiaphysis (the area of the thigh bone located near the knee joint between the wider part just below the growth plate and the main shaft of the bone) with mild angulation (angular displacement of bone fragments). The report recommended to apply an immobilizer to leave on until seen by a bone specialist and an order for as needed narcotic pain medication (every 4-6 hours). The Nurses Note, dated [DATE], documented R1's body shook after she was transferred to bed. R1 rated her knee pain as a 10 out of 10. The Nurses Note, dated [DATE], documented R1 had severe pain with any type of movement, with transfers, and staff performing cares. R1 made statements of pain with range of motion. R1 was unable to rate her pain but presented with facial grimacing, tearfulness, and yelling out in pain. The staff administered as needed Morphine (narcotic medication used to treat severe pain) and Norco administered to R1 prior to cares and transfers for her severe pain. The Nurses Note, dated [DATE], documented R1 continued to have a bandage to the laceration site on top of the left side of her head. R1 declined her meals but would take sips of water. The staff managed R1's pain through her prescribed narcotic pain medications. The Nurses Note, dated [DATE], documented R1's time of death verified at 10:55 AM.On [DATE] at 10:00 AM, Administrative Nurse D stated she expected all staff to follow the resident's care plan and follow the facility policy requiring two staff assistance for all mechanical lift transfers of residents.On [DATE] at 11:45 AM, CNA M stated she operated the full lift by herself. CNA M stated she had operated the full lift by herself many times because sometimes there was no other CNA on the unit and the nurse or the Certified Medication Aide (CMA) were busy. CNA M stated she knew the policy for two staff for all mechanical lifts and verified she did not follow R1's care plan.The facility's Using a Portable Lifting Machine, dated [DATE], documented a review of the resident's care plan to assess for any special needs of the resident. Two nursing associates were required to perform total lift transfers. Explain the procedure to the resident to ensure their comfort and understanding of the situation. Always have two people provide the transfer. Place the sling under the resident's shoulders to the back of the knees, ensuring the resident is centered in the sling. Raise the resident up to a sitting position with the lift. While you operate the lift, your helper should help you guide the resident. Once the resident is sitting, raise the lift until they are 6 to 12 inches off the bed. Unlock the wheels. Use the steering handle to move the resident directly over the chair. Tell the resident you are going to lower them slowly into the chair. Your helper guides the resident into the chair by moving the sling and pulling it backwards to facilitate proper posture in the chair.On [DATE] at 03:30 PM, Administrative Staff A was provided the IJ template and notified of the facility's failure to ensure staff safely transferred residents with the required two staff assistance with mechanical lifts, as care planned, causing R1 to fall out of the full lift and sustain serious injury, placed R1 in immediate jeopardy.The facility identified and implemented immediate corrective actions, which were completed on [DATE], and included: The clinical staff were educated on following the plan of care with two staff assistance with transfers using a mechanical lift and the proper way of securing slings to the lift hooks, beginning [DATE] and completed on [DATE]. The facility evaluated the mechanical lift in question for malfunctioning with no concerns identified on [DATE]. The facility evaluated the sling on [DATE] and found to be in good condition. The facility began weekly audits on three residents to ensure staff follow the plan of care for transfers and proper sling hook-up with a mechanical lift. The facility would review the fall at the next Quality Meeting.Due to the corrective actions completed before the onsite survey, the citation was deemed past noncompliance at a J scope and severity.- R2's Electronic Medical Record (EMR) documented R1 had diagnoses of end-stage renal disease (ESRD- a terminal disease of the kidneys), dependence on dialysis (procedure where impurities or wastes were removed from the blood), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), acquired absence of the right lower leg below the knee, and legal blindness.R2's Comprehensive Minimum Data Set (MDS), dated [DATE], documented had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented R2 as independent for all of her activities of daily living (ADLs). The MDS documented R2 used a wheelchair for all locomotion and documented R2 had one non-injury fall during the lookback period.The Fall Care Area Assessment (CAA), dated [DATE], documented R2 as at risk for falls, and staff were to monitor R2 for safety. R2's Care Plan documented R2 was legally blind and directed staff to provide R2 with an environment that accommodated impaired vision ([DATE]). The care plan documented R2 required supervision/touching assistance for transfers, but would often transfer herself, and staff were to encourage R2 to call and ask for assistance ([DATE]). The care plan documented R2 as at risk for falls and R2 wanted to remain free from injury related to falls. The care plan directed staff to keep pathways clear, provide adequate lighting, keep bed at appropriate height, keep personal items in reach, and attach R2's call light to her clothing.The [NAME] Fall Risk Scale, dated [DATE], documented R2 was at risk for falls with a score of 50.The Nurse's Note, dated [DATE], documented R2 as semi-lying on the facility van floor/wheelchair chair accompanied by CNA N at 08:51 AM on [DATE]. R2 was on her back with her feet in air toward the driver and passenger seats, and her head toward rear door in facility van. R2 was injured at the time of the fall and had frank bleeding from the back of her occiput (back of head). Staff called 911 for assistance. R2 denied statements of pain to the head, back, and C-Spine (cervical spine) at time of the fall. R2's level of consciousness was alert with no change from baseline. R2 was pleasant, cooperative with cares, and had no change from baseline. R2's range of motion was full to the upper extremities, full to the lower extremities, no difference noted between sides of the body, with no change from baseline. R2 denied pain with range of motion and fire department and EMS personnel assisted R2 on to the stretcher. R2 went to the local hospital for evaluation and treatment. R2's Care Plan was reviewed with interventions updated as indicated. R2's primary care physician was notified and aware of the event, with no new orders given. Staff attempted to reach R2's daughter twice. CNA N's Notarized Witness Statement, dated [DATE], documented CNA N got R2 in the van. CNA N stated she made sure R2 was secured in the van and checked before she left. As CNA N pushed up on the gas to proceed through the intersection after stopping, she then heard a click, click noise, so she slowed down to look back and saw R2 on the ground. R2 went backwards. CNA N stopped the van, pulled over, and got up to check on R2. CNA N asked R2 if she was okay, and R2 said she was good. CNA N called transportation and the nurse on F court. Two Licensed Nurses (LN) came to help, and CNA N called 911. R2 didn't complain about pain besides just her elbow hurting a little bit, but she was bleeding from the head. CNA N apologized to R2.LN H's Notarized Witness Statement, dated [DATE], documented that at approximately 08:51 AM, she was asked to go to the scene where R2 had fallen in the facility van. Upon arrival, the rear back door was opened. [NAME] blood was immediately noted on the floor of the van. R2 denied having pain. R2 laid in a semi-lying position, still sitting with her head and back on the floor. R2's legs were in the air. Since R2 denied pain, R2's lower body was lifted so the wheelchair could be moved. After moving the wheelchair, R2 was repositioned to her right side. Assessment to the back of R2's head revealed bleeding and lacerations. The bleeding was controlled with pressure, 911 was initiated, and both fire and EMS arrived at the scene. EMS took over the scene and R2 was transferred from the vehicle onto a stretcher. R2 was taken to the local hospital for evaluation and treatment.The emergency room Note, dated [DATE], documented R2 presented with a head laceration to the back of her head, which measured 1.5 centimeters (cm). The laceration was cleansed, and staples were placed to approximate the laceration. R2 may use Tylenol (pain medication) and ice for pain, and have the staples removed in seven days.The Nurses Note, dated [DATE], documented report received from a nurse at the local hospital. R2 has a hematoma on the back of her head where she had two areas of lacerations. She currently has staples in those areas that would need to be removed in 1 week. She will need to return to the ER to have the staples taken out. The area needs to remain clean and dry, and not to be scrubbed too hard. No pain medications were given to R2 during her visit to the ER. R2 received a tetanus shot (vaccine that prevents tetanus-a painful bacterial infection) to the right arm. R2 received as needed Tylenol (pain reliever and fever reducer) 650 milligrams (mg) for pain in the back of the head. R2's discharge paperwork from ER noted a laceration of occipital scalp. R2 fell involving a wheelchair, which caused accidental injury. R2 needed to return for staple removal in one week, for any worsening symptoms or concerns, and to keep the wound clean and dry.The Facility Incident Report, dated [DATE], documented R2 was going to an out-of-town appointment on [DATE], with CNA N in the gray van. R2 is blind and cannot see what happened, but R2 said she could hear that she had retention hooks applied to the front and back of her wheelchair by CNA N. CNA N had applied retention hooks and a seatbelt to R1. CNA N drove approximately 2 miles from the facility when she came to a stoplight, stopped, then turned right. Upon turning right, R2 fell backwards and hit her head, causing lacerations x2. CNA N pulled over immediately, checked on R2, called the on-call nurse, who then called 911, and R2 was taken to the hospital. R2 returned to the facility the same day. The retention hooks on the front do not auto-retract, creating no tension on the strap, on the front 2 retention hooks only, unless a button is pressed in the back of the vehicle. CNA N was not aware of this button. Education provided to CNA N and all staff who assist in transportation. Abuse, neglect, or exploitation was not substantiated. The Nurses Note, dated [DATE], documented R2 had a fall on [DATE]. The fall caused a laceration to the back of her head. R2 has not complained of any pain today. Staff attempted to clean some of the blood out of her hair because it bothered R2. On [DATE] at 11:00 AM, observation revealed R2 sat in her wheelchair in her room. R2's head laceration had healed. R2 stated she heard and felt CNA N hook up all of the harnesses to her wheelchair, and she buckled her in with the seat belt. R2 stated she felt safe being transported by facility staff.On [DATE] at 10:00 AM, Administrative Staff A verified all safety checks had been performed on the facility vehicle. Administrative Staff A verified CNA N did not know about the button in the gray van that put tension on the front harnesses. Administrative Staff A stated that all of the staff who drove a facility vehicle for appointments were re-educated on all safety mechanisms in the vehicles. Administrative Staff A stated he expected all staff driving a facility vehicle for resident appointments to be completely trained.On [DATE] at 01:00 PM, CNA N stated she was trained on all of the vans last year, but staff only get trained yearly at the skills fair, and she normally only drove independent people who just had to sit up front and put their seat belt on. She stated she did not know about the button in the grey van that put tension on the front harnesses, so the wheelchair would not move. CNA N verified that no one had shown her the button.The facility's Driver and Fleet Safety Policy, dated [DATE], documented before allowing new associates to drive the manager is responsible for conducting the following requirements: verify required driving record information has been completed and approved, ensure competency training has been assigned and completed following Driver and Fleet Safety Training document, review vehicle safety checklist process, review instructions on save driving practices, review proper use of the vehicle and safe operating features, and the accident reporting process. Instruction for drivers will be provided on an annual basis. On [DATE] at 03:30 PM, Administrative Staff A was provided the IJ template and notified of the facility failure to ensure a safe environment free from accidents for R2 when CNA M was not properly trained in all of the safety features of the gray van and R2 subsequently fell in her wheelchair in the van due to not being properly harnessed.The facility identified and implemented immediate corrective actions, which were completed on [DATE] included: R2 was taken to the emergency room for evaluation. The resident was evaluated and treated for lacerations to the scalp, and the resident returned to the community. Provider notified on [DATE]. The staff attempted to notify R2's legal representative. R2's Care Plan was reviewed and deemed appropriate. The van has been inspected, and no mechanical defects have been noted. The last van inspection prior to the incident occurred on the week of [DATE], and no abnormal findings were present. Any other resident transported in the van has the potential to be affected. Review of the incident reports for the last 30 days indicates no other incidents have been reported. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. AdHoc QAPI meeting was held by the interdisciplinary team on [DATE] for root cause analysis discussion, and this plan of correction was developed and implemented. Facility Director, and any other staff who are responsible for oversight of resident transportation, will be re-educated by the Executive Director or designee on or before [DATE] to ensure they understand all components of the requirements for drivers under the community's policy and the expectation for signing off of the monthly vehicle checklist appropriately. A competency validation tool has been developed to ensure documented competency of skills for each type of bus available to be utilized. The approved drivers would be re-educated on transportation policy, the vehicle's wallet with the appropriate vehicle information, and would be re-educated prior to their next scheduled time to drive the vehicle with the new competency validation tool. The interdisciplinary team has reviewed the policy and procedure Ascension Living Driver and Fleet Safety Policy. Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at a J scope and severity.

The facility identified a census of 80 residents with three residents reviewed for medication errors. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from significant medication errors. On 12/07/23 R1 admitted to the facility with a physician's order for glimepiride (medication used to lower blood glucose [sugar] levels) 2 milligrams (mg) twice daily. Staff incorrectly transcribed the order as glimepiride 4 mg twice daily. R1 received a total of seven doses of glimepiride, at twice the prescribed dosage, before staff caught the error on 12/11/23 at 09:30 PM. Staff did not check R1's blood sugar but notified R1's representative and primary care physician (PCP) and stated there were no adverse effects from the error. A short while later, at 10:15 PM, staff found R1 face down on the floor of his room with his call light still hooked to his shirt. R1 was drowsy, with non-reactive pupils and then became non-verbal. Staff called Emergency Medical Services (EMS). EMS arrived and initiated transport to the Emergency Department (ED). EMS assessed R1's blood sugar in the ambulance as 36 milligrams (mg)/ per deciliter (dL) (normal range is 70-130 mm/dL). The facility failure to ensure R1 remained free from significant medication errors placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dysphagia (swallowing difficulty), aspiration (inhaling liquid or food into the lungs), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The admission Minimum Data Set was not yet completed. Social services performed a Brief Interview for Mental Status (BIMS) and R1's BIMS was 10, which indicated moderate cognitive impairment. The EMR lacked Care Area Assessment documentation. R1's Care Plan, date 12/07/23, documented R1's safety and psychosocial needs would be met. The care plan lacked any documentation regarding R1's diabetes mellitus needs. The Hospital Discharge Instructions, dated 12/07/23, directed nursing staff to administer glimepiride 2 mg by mouth twice daily. R1's December 2023 Electronic Medication Administration Record (EMAR) documented an order entered by Licensed Nurse (LN) G for glimepiride 4 mg by mouth twice daily starting on 12/07/23. The EMAR documented R1 received 4 mg of glimepiride on seven occasions. The Progress Note, dated 12/07/23, documented R1 was admitted to the facility for skilled nursing, physical therapy, occupation therapy, and speech therapy with diagnoses of diabetes mellitus and dementia (progressive mental disorder characterized by failing memory, confusion). R1 was alert and oriented to who he was and where he was but was slow to process with communication. R1 was pleasant and cooperative. The facility's Physician's Order Sheet, dated 12/08/23, documented R1's PCP signed R1's admission orders with a signature stamp. The order's included the glimepiride 4 mg by mouth twice a day. The Progress Note, dated 12/11/23 at 09:30 PM, documented R1 had inadvertently received Amaryl (glimepiride) 4 mg by mouth twice daily. R1's order actually stated Amaryl 2 mg by mouth twice daily. No adverse reaction was noted. R1's order was updated, R1's representative notified of the event, and R1's PCP was notified of the event. The Fall Documentation Note, dated 12/11/23 at 11:08 PM, documented Certified Nurse's Aide (CNA) M found R1 lying on the floor at 10:15 PM. R1 was face down with his feet toward the middle of the room and his head toward the wall of the room. R1's forehead rested on the metal bar of the rolling bedside table with his body horizontal to the bed and six to eight inches away from the bed. R1's call light was still clamped on his shirt. R1 was unable to state what happened but was able to answer pain questions and responded to requests to move his extremities. R1 was log rolled to his back with three staff assist. R1's forehead had a large, reddened area across his forehead and his left eye was starting to discolor. Neurological checks revealed R1's pupils were unequal and not reactive to light. Staff called EMS at 10:23 PM due to the results of the neurological exam. R1's level of consciousness was drowsy. Before EMS arrived R1 became non-verbal. R1 left the facility at 10:41 PM. The Progress Note, dated 12/12/23 at 03:09 AM documented LN G received a phone call from the emergency room with an update. The emergency room nurse stated the computed tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) scan showed no signs of a brain bleed. R1's blood sugars were under control and ordered the facility to check R1's blood sugars every two hours. Facility staff picked R1 up from the emergency room. The Physician Communication Note, dated 12/12/23, documented R1's PCP called the facility with new orders to discontinue R1's order for glimepiride and to check R1's blood sugars twice a day and as needed. The undated Facility Incident Report documented on 12/12/23 at 09:25 PM staff identified R1's glimepiride was inadvertently transcribed incorrectly and R1 received seven doses of glimepiride 4 mg by mouth twice a day. The order was entered by LN H on 12/07/23. R1's order per discharge instructions was for Amaryl 2 mg by mouth twice daily. The glimepiride order was corrected upon discovery on 12/11/23. R1's PCP was notified by fax on 12/12/23. At that time R1 had not had an adverse event. On 12/11/23 at 10:15 PM, LN G found R1 lying on the floor face down with his feet toward the middle of the room and his head toward the wall in his room. R1's call light was not initiated. R1 was not able to state what happened but was able to move his extremities when asked and report he had pain. R1 was drowsy at the time of assessment with a change from baseline noted. R1 was non-verbal when EMS arrived. When EMS checked R1's blood sugar his blood sugar was low at 36 mg/dL. EMS administered R1 Dextrose (sugar) 10% (D10). Upon R1's arrival to the emergency room, his blood sugar was in the 60's. A comprehensive metabolic panel (CMP-lab test) was obtained in the emergency room and R1's blood sugar was 76 mg/dL. The emergency room treated R1 with 25 milliliters (ml) of dextrose 50% (D50) and fed R1. R1 was monitored and returned to the facility at 03:45 AM. A CT of R1's head was negative. R1's PCP was notified of the event and orders were received to discontinue the glimepiride and to complete blood sugars checks twice a day. LN I's Witness Statement, dated 11/12/23, documented LN I was called to the unit by LN H for assistance for a resident fall. Upon arriving to R1's room, LN I observed R1 lying supine (face up) on his room floor parallel to his bed. R1 was accompanied by two CNA's and LN H. R1 had a full body lift under him at that time. LN I observed LN H assessing R1, and advised LN I R1 was found with his head down and his forehead on the bottom bar of the bedside table. R1's fall was unwitnessed and due to R1's decline, LN H and LN I decided to contact EMS for patient transport to the hospital. R1 was minimally responsive and unable to answer staff appropriately. According to the CNAs, no vitals were obtained yet. LN I obtained R1's vital signs and noted his blood pressure was elevated. LN I checked R1's pupils and noted them to non-reactive to light. EMS arrived and R1 was transported to the hospital. CNA N's Witness Statement, dated 12/12/23, documented CNA N went to R1's room and R1 was laying on his stomach on the ground with his head on the metal part of his side table. R1 was saying his left arm hurt and he could barely move it. CNA N stated staff pulled R1 away from the table and then moved him on his side. CNA M's Witness Statement, dated 12/12/23, documented CNA M went to check on R1 and found R1 face first on the floor. CNA M told CNA N to get LN H while CNA M stayed with R1. CNA M, CNA N, and LN H turned R1 onto his back. LN I was called to assist, and EMS was called. EMS took R1 to the ER. On 12/13/23 at 12:45 PM, observation revealed R1 sat at the dinner table with food in front of him. He was picking at his food and not eating. R1 was unable to hold a conversation. On 12/13/23 at 02:00 PM, Administrative Nurse D stated the facility did not check blood sugars unless they were ordered by the physician. Administrative Nurse D stated even if a resident was showing signs of hypoglycemic (blood glucose reading less than 60 mg/dL) crisis the facility would have to obtain an order to check any residents blood sugar. Administrative Nurse D stated none of the residents who were just on oral anti-diabetic medication received blood sugar checks. Administrative Nurse D stated it was unfortunate the incident happened, and LN G felt horrible about transcribing the order incorrectly. Administrative Nurse D stated the facility was changing their order verification process so all orders were double checked by a second nurse and both nurses would have to sign that they verified the orders; if blood sugar checks were not ordered by the physician, the staff would query the physician. Administrative Nurse D stated LN G received coaching regarding the medication error. The facility's admission Assessment and Follow Up: Role of the Nurse, revised March 2023, documented the purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments. The nurse will reconcile the list of medications by reviewing the home medication history, the hospital discharge summary, and admitting orders. The nurse will transcribe active orders into the electronic health record or community record to generate a physician's order list, a treatment administration record and a medication administration record. The facility failure to ensure R1 remained free from significant medication errors placed R1 in immediate jeopardy. On 12/13/23 the surveyor verified the following actions to remove the immediacy: An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the interdisciplinary team on 12/13/23 and a plan of correction was developed and implemented. All medication orders were audited on 12/13/23 to verify orders were entered accurately. All residents with diabetic medications were reviewed for blood sugar monitoring. The provider was notified for orders for any resident found without an order for blood sugar monitoring. Current nurse associates were re-educated by the Director of Nursing or designee by 12/13/23 or prior to working the next scheduled shift on order transcription and medication reconciliation. The Interdisciplinary team reviewed the admission Assessment and Follow Up policy and procedure for compliance with the Centers for Medicare and Medicaid Services (CMS) regulation F760. After removal of the immediacy, the deficient practice existed at a scope and severity of a G.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 85 residents. The sample included three residents. Based on observations, record review, and interviews, the facility failed to provide a safe environment free from preventable accidents for Resident (R) 1 and R2. On 10/14/23 Certified Medication Aide (CMA) R picked R1 up from the emergency room (ER) using the facility transportation van. CMA R assisted R1, who used a wheelchair, into the van. CMA R failed to secure the two front straps as well as the lap strap. As CMA R made the first left hand turn after leaving the hospital, R1's wheelchair tipped backward, and R1 fell from the chair and hit his head. R1 returned to the ER where he was diagnosed with a fracture of the cervical vertebrae (neck spine). The facility further failed to ensure R2 remained free from preventable accident hazards when staff allowed cognitively impaired R2 outside without staff supervision. Staff failed to recognize R2, who was at risk for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) and wore a Wander Guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort), as a resident and failed to respond appropriately to Wander Guard alarms. This allowed R2 to exit the facility through the Assisted Living (AL) wing and remain outside without staff supervision for eight minutes, until the resident went back to the door to be allowed in. These failures placed both R1 and R2 in Immediate Jeopardy. Findings included: - R1 admitted to the facility on [DATE]. He transferred to the ER on [DATE] related to hyperglycemia (high blood sugar). R1's Electronic Medical Record (EMR) documented a diagnosis of diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). R1's Care Plan dated 10/13/23, directed R1 needed assistance with daily activity of daily living (ADL) care and directed R1 needed limited assistance with two staff support for mobility and used a wheelchair. The facility's investigative report dated 10/20/23 documented, on 10/14/23 at approximately 04:00 PM, R1 was returning to the facility from the ER in a facility van, accompanied by CMA R. R1 sat in the wheelchair with the bilateral brakes applied as well as the wheelchair securement straps in the facility van. CMA R reported R1's wheelchair fell backward when she made the first left turn after leaving the hospital and R1 hit the back of his head and reported having pain in his neck and chest. CMA R immediately pulled over to the nearest parking place and called for assistance. Licensed Nurse (LN) G and Social Services X arrived and assisted R1 off of the van floor and back to his wheelchair using the gait belt. LN G assessed R1 and felt he should return to the ER for evaluation and treatment and escorted R1 back to the ER with CMA R. The report documented Social Services X reported when LN G and she arrived to where CMA R was parked, R1 was sitting in front of his wheelchair. Social Services X climbed through the side of the van, opposite side of CMA R, and LN G went through the back of the van to assess R1. After LN G assessed R1, he was assisted with three staff to his wheelchair. Once R1 was back in his wheelchair, Social Services X asked CMA R if R1 was strapped in properly and CMA R stated yes. The report documented R1 then spoke up and told Social Services X he did not have a seatbelt on, and he flew backward then hit his head on the back door. In the ER, R1 was diagnosed with a C5 (cervical vertebra level five) fracture with no further intervention needed per neurology. R1 returned to the facility at approximately 07:10 PM by facility van in his wheelchair and was escorted back with two staff present. In a Witness Statement, dated 10/16/23, CMA R documented on 10/14/23, after R1 discharged from the ER, she loaded R1 into the van and applied the wheelchair locks and the locks secured to the van. CMA R documented that as she left the hospital parking lot and turned left, R1 fell back; CMA R rushed to the nearest parking lot. CMA R stated she tried to get R1 off the floor but could not get him up, so she called LN G for help. Upon Social Services X and LN G's arrival, they got R1 into his wheelchair and his head was bleeding. In a Witness Statement, dated 10/16/23, LN G documented on 10/14/23 she received a call from CMA R saying R1's wheelchair tipped back on the way back from the hospital in the van and R1 was bleeding. She and Social Services X left the facility to assess R1. LN G stated when they arrived, R1 was sitting on the floor of the van. In a Witness Statement, dated 10/16/23, Social Services X documented on 10/14/23, LN G was in the office when her phone rang; it was CMA R who was picking a resident up from the hospital. Social Services X told LN G she could run over to where CMA R was but needed a nurse to assess the resident. Upon arriving to the area where CMA R was parked, R1 was not in his wheelchair but sat in front of it on the floor. Social Services X stated she climbed through the side of the van, the opposite side of CMA R, and LN G climbed through the back. It took two tries to get R1 back in his wheelchair and once he was back in his wheelchair, Social Services X asked CMA R if the resident was strapped in properly and CMA R stated yes. Social Services X stated R1 spoke up and told her No, he did not have a seat belt on, and he flew backward then hit his head on the backdoor. An emergency room Note on 10/14/23 documented R1 was just dismissed from the ER and was in the van going back to the nursing home when he became loose and fell backwards hitting his head. R1 did not lose consciousness and complained of some head pain and neck pain. A computed tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) scan revealed a fracture of the C5 (5th cervical vertebrae). On 10/26/23 at 04:14 PM, R1 sat in his wheelchair in his room. He had a neck pillow wrapped around his neck from the front and he was unable to look up. He stated he had constant pain in his neck and was unable to lift it up when sitting in the wheelchair to watch television. R1 stated on 10/14/23, the wheelchair was not fastened down and he tipped backward but he did not remember if he wore a seatbelt. On 10/26/23 at 12:09 PM, CMA R stated on 10/14/23 when she picked R1 up for transportation, she failed to strap him in properly and he fell. She stated she failed to utilize the two front straps from the van and the lap belt. CMA R stated she was really busy that day and just did not think about fastening the straps at the time. On 10/16/23 at 01:21 PM, Administrative Nurse D stated R1 was admitted on [DATE] and on the morning shift on 10/14/23, he was transferred to the ER for high blood sugar. R1 was stabilized and the facility picked him back up. She stated staff had been trained on the van and on the weekends, floor staff provided transportation usually. Administrative Nurse D stated she expected staff providing transportation to wheel the resident up to the square area behind the front seat, secure the two buckles to the back of the wheelchair, secure the two buckles to the front of the wheelchair, and put the seatbelt on. She stated from her understanding, the seatbelt and two front straps were not secured and that was why R1 tipped backward. On 10/26/23 at 04:26 PM, Administrative Staff A stated he expected transportation staff to go over safety checks to make sure the resident was strapped in properly which included a traditional seatbelt and retention hooks attached to four non-moveable parts of the wheelchair. The facility's Fleet Safety Guidelines policy, not dated, directed all drivers had a responsibility to themselves, their ministry, and to their community to adhere to safe driving practices. Drivers were required to wear safety belts and require other occupants to do so. The facility failed to ensure CMA R properly secured R1 in the transportation van. During transportation, CMA R turned left and R1 fell backward in his wheelchair, hitting his head on the backdoor. This deficient practice resulted in a C5 fracture for R1 and placed him in immediate jeopardy. The facility put the following corrections in place by 10/20/23: A Quality Assurance and Performance Improvement (QAPI) meeting was held on 10/18/23. All associates were retrained on vehicle competency during the skills fair on 10/19/23. CMA R was fired from the facility on 10/20/23. All corrections were completed prior to the onsite survey therefore the deficient practice was cited at past noncompliance and remained at a scope and severity of J. - R2 was admitted on [DATE] for respite care (short term health services to the dependent adult) and discharged home on [DATE]. R2's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and abnormalities of gait and mobility. R2's Care Plan dated 10/19/23, documented R2 was at risk for increased behavioral expressions, altered mood, elopement, and impaired adjustment ability to new environment. The care plan documented interventions for staff to follow community elopement evaluation and monitoring process, identify current mood and behavioral expressions and monitor for changes; and orient R2 to the community layout, routines, and schedules. An Elopement Risk Screening and Evaluation on 10/19/23, documented R2 had a score of 16 which indicated staff were to assume R2 was at risk for elopement. A Faber Fall Risk Assessment on 10/19/23, documented R2 had a score of 17 which indicated R2 was a moderate risk for falls. The facility's investigative report, dated 10/27/23, documented on 10/20/23 at approximately 07:20 PM, R2 went downstairs and asked CMA S and Certified Nurse Aide (CNA) M how to get out. CMA S asked CNA M to show R2 due to inadvertently thinking R2 was a visitor. At 07:28 PM, CNA M assisted R2 to the front door where they both exited the building. At this time, the door alarm was sounding through the double doors and CNA M was unable to turn the alarm off from the side of the door he was on, due to the Wander Guard system. R2 was with CNA M between the double doors in the foyer. The report documented CNA M left R2 at the front entrance to go around the building to let R2 back in the building at the same time another resident's family member came from inside the building after seeing R2 and let him inside the building using the 15 second delayed egress. R2 followed the family member to AL, setting off the door alarm there. CNA M returned to the front doors to let R2 back in the building but R2 was not there, he then reset the front door alarm and the AL door alarm then returned to long term care (LTC) at 07:32 PM. The report documented while R2 was in the AL, AL staff A let another resident's family member out of the building at 07:33 PM and R2 followed the family member out of the AL dining room door. AL staff A thought R2 was a family member's husband. At 07:41 PM, AL staff B head the alarm of the AL dining room door and went to investigate it when she noted a man trying to get in the building. When AL staff B tried to let R2 back in the building, she first entered the door code which did not release the door, she then entered the Wander Guard code and realized that R2 was wearing a Wander Guard bracelet. The report documented AL staff B asked R2 his name and where he lived. AL staff B assisted R2 back to LTC. Upon returning to his unit, LN H assessed R2, and no injuries were noted. R2's Wander Guard was checked and verified to be working appropriately and the Wander Guard system and door system were functioning correctly. In a Witness Statement, dated 10/23/23, CMA S documented on 10/20/23, R2 asked her where the door was to get out and she was passing medications. She asked she asked the CNA to help R2 out. In a Witness Statement, dated 10/23/23, CNA M documented on 10/20/23, R2 seemed to be lost and he did not know R2 was a resident because he did not have his walker and was asking how he could leave. CNA M stated he walked R2 through the doors and the Wanderguard did not work as the door alarm did not go off. He and R2 were stuck in the front doors so CNA M went back around the facility to open the doors for R2 but he was not there when CNA M returned. In a Witness Statement, dated 10/21/23, AL staff A documented at approximately 08:00 PM on 10/20/23, she exited a resident's room and saw a lady standing by the AL door. The lady stated she was an AL resident's family member and was told she could move the resident's stuff into her AL apartment. AL staff A stated she opened the door for the lady and a gentleman who she thought was the lady's husband was with her. As they began moving furniture through the door, the alarm sounded, and AL staff A assumed the door had timed out and alarmed so she reset the door. In a Witness Statement, dated 10/23/23, AL staff B documented on 10/20/23 the alarm on the South AL door went off, she went to investigate, and saw a man trying to get in. She directed him to the doors in the dining room and finally assisted him into the building. She stated that was when she noticed the Wanderguard on his left wrist, but she did not recognize him, so she asked him his name and where he lived. AL staff B stated she walked R2 back to LTC. According to the Kansas State University Historical Weather website, the temperature on 10/20/23 at 07:00 PM was 65.5 degrees Fahrenheit (F) and at 08:00 PM it was 61.8 degrees F. On 10/26/23 at 01:28 PM, observation of the door and area R2 eloped from revealed the AL dining room door exited onto a well-maintained sidewalk that wrapped around the building. There was parking available in front of the sidewalk and there were streets in front and to the side of the building. The streets in front and to the side of the building had a speed limit of 30 miles per hour (mph). On 10/26/23 at 01:28 PM, Maintenance U stated on 10/20/23 R2 exited LTC with staff that let him through the double doors and was left between the double doors while staff went around the building. He stated a family member let R2 back in and he followed the family member into AL where he sat in a chair. Maintenance U stated the AL resident's family member was with an AL staff member and when they walked by R2, he followed the family member out of the door. He stated the AL staff member was able to put the code in at that point and R2 exited the building. R2 walked around the sidewalk to the other door then came back around to the AL dining room door. He stated R2 tried to get in and that was when AL staff realized they had to put the Wanderguard code in to let R2 back inside and that he was a resident. On 10/26/23 at 02:57 PM, Administrative Nurse D stated she expected if a resident was exit seeking, staff attempted to redirect the resident. She stated if a door alarm sounded, she expected staff to respond timely, search the surroundings before shutting off the alarm, and call each court to do a headcount. Administrative Nurse D stated R2's elopement was different because staff had let him outside and she had talked to CNA M on 10/20/23 but he was unaware that R2 was a resident there. On 10/26/23 at 03:57 PM, CMA S stated she knew what residents were at risk of elopement by looking in the CNA/CMA book for the elopement risk photos. She stated if a resident was wandering or exit seeking, she looked to see if they had a Wanderguard, and called the court the resident lived on to ask for assistance. CMA S stated if a door alarmed, she ran to the door to make sure a resident did not go out and called all of the courts to alarm them to check rooms to make sure all residents were there. She stated staff went outside to look for the resident as well. On 10/26/23 at 04:04 PM, LN H stated elopement was prevented by responding to door alarms and calling all courts to make sure the Wanderguard residents were where they needed to be. She stated there was an elopement risk list in the CNA binders, at the nurse's stations, and at the front desk. She stated staff verified if someone was a resident before they put the door code in. On 10/26/23 at 04:26 PM, Administrative Staff A stated he expected staff to know which residents were at high risk for elopement based on the elopement precautions, where those residents were located in the building, and where residents were regardless of cognition if they were outside the building with staff present if they were not cognitively intact. The facility's Elopement Response policy, last revised July 2022, directed if an associate observed a resident leaving the premises, he/she attempted to prevent departure in a courteous manner, got help from other associate members in the immediate vicinity if necessary, and instructed another associate member to inform the charge nurse that a resident left the premises. The facility failed to ensure staff recognized R2 as a resident and responded to door alarms when R2 exited the building after staff let him out. He was outside the facility for eight minutes. This deficient practice placed R2 in immediate jeopardy. The facility put the following corrections in place by 10/24/23: R2 was placed on 15-minute checks immediately on 10/20/23 and continued until his discharge to home. Administrative Nurse E reviewed other residents at risk for elopement on 10/20/23. Mass text alerts were sent out to staff regarding elopement risk residents on 10/20/23 at 10:45 PM A Quality Assurance and Performance Improvement meeting was held on 10/24/23. All corrections were completed prior to the onsite survey therefore the deficient practice was cited at past noncompliance and remained at a scope and severity of J.

The facility identified a census of 79 residents with three residents reviewed for elopements. Based on record review, observation, and interview, the facility failed to provide adequate supervision to prevent an elopement (when a cognitively impaired residents exits the facility without staff knowledge or supervision) for cognitively impaired Resident (R) 1, who also wore a Wander Guard (bracelet which alarms when close to participating doors). Staff further failed to respond appropriately to two door alarms and failed to respond appropriately to the cognitively impaired R1. On 07/22/23 at 08:53 PM a visitor entered the code to the locked double doors and R1 followed the visitor through the double doors, exiting the unit. R1 wore a Wander Guard bracelet which caused the alarms of the double doors to sound and Licensed Nurse (LN) G came and silenced the alarm to the double doors but did not perform a search. At 08:54 PM, R1 followed the visitor out of the facility front doors, which caused the front doors alarms to sound. Certified Nurse Aide (CNA) N went to the front doors of the building, saw R1 and the visitor talking in the parking lot, but misinterpreted the visitor looking at her as acknowledgement the resident was okay, and CNA N went back to her shift. At 08:54 PM, the visitor realized R1 should not be outside and left R1 in the parking lot as she went back into the facility to get help. At 09:08 PM, CNA O and CNA R found R1 on the sidewalk. At 09:22 PM, the staff brought R1 back into the facility. The facility failed to provide adequate supervision to prevent an elopement, failed to respond to door alarms, and failed to respond appropriately to the cognitively impaired R1, who was outside without staff supervision. This deficient practice placed R1 in Immediate Jeopardy. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses of cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and aphasia (condition with disordered or absent language function). The admission Minimum Data Set (MDS), dated 05/15/23, documented R1 had a Brief Interview for Mental Status score of two, which indicated severe cognitive impairment. The MDS documented R1 required supervision to limited assistance of one staff for all of her activities of daily living. The MDS documented R1 had no behaviors. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/15/23, documented R1 had memory problems, impaired decision-making skills, and impaired ability to comprehend. The CAA directed staff to call R1 by her name, orient R1 daily to facility routines and activity schedules, use environmental cues to stimulate R1's memory and promote appropriate behaviors, provide cues to promote independence and ensure R1's safety, and provide consistent physical environment and daily routines. The Communication CAA, dated 05/15/23, documented after R1's cerebral infarction R1 had difficulty remembering conversations, was English speaking prior to the cerebral infarction, but now spoke mostly Spanish. The Cognitive Loss/Dementia Care Plan, dated 05/22/23, directed staff to call R1 by her name, provide daily orientation to the facility routines and activity schedules, and provide cues to promote independence and ensure R1's safety. The Safety Care Plan, revised 06/09/23, documented R1 was at risk for increased behavioral expressions, altered mood, and impaired adjustment to her new environment. The care plan directed staff to follow the community elopement evaluation and monitoring process, orient R1 to the community layout, routines, and schedules, and ensure R1 had a Wander Guard on her left wrist. The Facility Incident Report, dated 07/27/23, documented on 07/22/23 at approximately 08:45PM, R1 sat in the atrium on the first floor. At 08:53 PM, a visitor entered the code to the double doors and R1 followed her out the double doors of the long-term care (LTC) unit. R1 wore a Wander Guard, and the alarms of the double doors did alarm. Licensed Nurse (LN) G came and silenced the alarm to the double doors but did not perform a search. At 08:54 PM R1 followed the visitor out of the front doors. Again, the door alarms sounded. Certified Nurse Aide (CNA) N went to the front doors of the building, saw R1 and the visitor talking in the parking lot, and asked if they were okay. The visitor looked at CNA N and CNA N took that as acknowledgement that the resident was okay and went back to her shift. At 08:54 PM the visitor realized R1 should not be outside but did not think she could get R1 back to the building. The visitor left R1 in the parking lot and went back into the building to get help. At 09:02 PM the visitor went to Court A and informed CNA M R1 was out in the parking lot. At 09:03 CNA M from A Court exited the front doors and searched for R1. At 09:08 PM, CNA N and CMA R from B Court found R1 on the sidewalk over by the independent living houses. At 09:22 PM, R1 was brought back into the facility. CNA N's Witness Statement, dated 07/22/23, documented CNA N was going downstairs to find a laundry basket when she heard the long-term care alarms going off. CNA N stated by the time she got to the double doors, someone else had already cleared the alarm to the double doors. CNA N exited the long-term care doors and then heard the alarms to the front doors sounding. CNA N went to the frond doors and silenced the alarm. CNA N walked outside to check and saw R1 on the sidewalk with what CNA N thought was a friend and CNA N asked if they were okay. CNA N stated the lady with R1 turned and looked at her which CNA N took as acknowledgement they were okay. CNA N then returned to her shift. LN G's Witness Statement, dated 07/22/23, documented on 07/22/23 at approximately 09:10 PM, LN G was at B court when CMA R notified her R1 eloped. After obtaining the details of the resident and elopement, LN G stated she went through the main entrance to the building and scanned over the front of the facility parking lot and then made her may towards the side of the facility towards the independent houses. CNA M, CNA O, and CMA R were already outside in the area searching for R1. Before reaching the independent houses, LN G agreed that one of the CNAs should start a searching in a vehicle. As LN G moved closer to the independent houses, CNA M walked towards LN G and stated they found R1. LN G continued to walk toward the independent houses until R1 was in sight. CNA O and CMA R were walking with R1, who was walking with her walker. R1 appeared calm and was cooperative with CMA R, who was brought R1 back to the facility. R1 was fully clothed with house slippers on both feet. LN G, who understood Spanish, asked R1 what she was doing while heading back into the facility. R1 was placed in a wheelchair for safety. R1 stated she was looking at the houses hoping to find somewhere to stay while she looked for her son. R1 became emotional and said, I did not mean to do anything bad, that is all I was doing. Once inside the facility, LN G asked R1 how she got through the doors. R1 stated when she reached the doors, they were locked and when a lady from upstairs opened the doors, R1 went through the doors and stated the lady kept looking at her while walking towards the front entrance. R1 told her to wait a minute and the lady kept the front doors open for her and R1 went through and was outside. LN G assessed R1 for any pain or signs and symptoms of any injuries and none were noted or reported. Fifteen-minute location checks were initiated for R1. CMA R's Witness Statement, dated 07/22/23, documented CMA R was passing medications when a family member told CNA M that R1 was outside in a wheelchair and could not speak English. CMA R went outside to look for R1 and did not see her. CMA R came back inside and told LN G and looked in R1's room. R1 was not in her room. CMA R called the on-call to inform her of the situation. CMA R went back outside and looked for R1 next door and found R1 in the cul-de-sac with her walker. CNA O's Witness Statement, dated 07/22/23, documented a visitor came to CNA O and told her R1 was outside. CNA O and CMA R went outside with the visitor. The visitor told CNA N R1 went up by the houses. CNA O and CMA R went over by the houses and then found R1 just standing there. CNA O went and got a wheelchair for R1 to help her get back to the facility. On 08/10/23 at 10:45 AM, observation revealed R1 slept in bed. R1 had a Wander Guard on her left wrist. On 08/10/23 at 10:00 AM, Administrative Nurse D stated R1 went through the double doors out of the long-term care unit behind a visitor. The alarms to the double doors alarmed and LN G deactivated the alarm but did not do a search. Administrative Nurse D stated R1 continued to follow the visitor out of the front doors of the facility. The door alarms did sound, and CNA M went to the front doors, and turned off the alarm. She said the CNA saw R1 and the visitor in the parking lot but did not go out and investigate the situation and ensure R1 was safe. Administrative Nurse D stated she expected all staff to respond to door alarms and search the area for the resident who set the alarms off. On 08/10/23 at 11:30 AM, LN H stated R1 wandered the facility frequently. LN H stated R1 had not adjusted well to being in the facility and they moved her several times to different courts to make R1 feel more comfortable. LN H stated R1 spent a lot of time in the atrium sitting and people watching. On 08/10/23 at 01:15 PM, Administrative Staff A stated R1 had a hard time adjusting to living in the facility. R1's son had placed her in the facility after R1 suffered a stroke because the facility had staff that spoke Spanish. Administrative Staff A stated R1 did not want to be at the facility and wanted to go back to her home. Administrative Staff A stated the staff at the facility did not search the unit and surrounding area when the door alarms sounded, which resulted in R1 being alone in the parking lot. The facility's Elopement Response Policy, dated July 2022, documented staff of the facility shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. If a staff member discovers that a resident is missing from the community, he/she shall: determine if the resident is out on an authorized pass; if the resident was not authorized to leave, initiate a search of the building(s) and premises. When the resident returns to the community the Charge Nurse shall examine the residents for injuries, contact the resident's attending physician and report findings; notified the residents legal representative, complete and file an event report, and report per State reporting guidelines. The facility failed to ensure staff responded appropriately and provided adequate supervision to prevent an elopement for cognitively impaired R1, who wore a Wander Guard. This deficient practice placed R1 in Immediate Jeopardy. On 07/29/23 the facility completed corrective actions for the deficient practice which included educations for all staff on policy and procedure for Elopement, Code White, Elopement Search Assignment, Sign Out Logs, Resident attempting to leave Safe Area as well as responding to door alarms, and resident supervision for high-risk residents. All corrective actions were completed prior to the survey therefore the citation was issued as past noncompliance and existed at the scope and severity of J.