**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to develop and implement care plans with individualized person-centered interventions, to include adequate supervision and monitoring for residents at risk for elopement; and for residents with a history of falls, for seven (7) of thirty-three (33) sampled residents (Residents #1, #3, #18, #22, #24, #25, and #26). 1. Resident #1 eloped from the facility on 07/27/2023 without staffs' knowledge. The resident disabled a window alarm in his/her room and climbed out the window. Resident #1 was found at a nearby convenience store approximately forty-five (45) minutes later. Resident #1 had to cross two (2) busy roads with heavy traffic to get to the convenience store. 2. In addition, the facility failed to have an effective system to develop and implement comprehensive care plans with individualized person-centered interventions to evaluate falls and perform root cause analysis of the falls in order to implement individualized interventions, and to monitor the effectiveness of the interventions to prevent additional falls for six (6) of thirty-two (32) sampled residents (Residents #3, #18, #22, #24, #25, and #26). a). Resident #3 sustained a fall on 06/20/2023, from a wheelchair while unattended. The resident was transferred to a local hospital for evaluation, where he/she was evaluated to have a nasal fracture and a subdural hematoma. However, there were no intervetions in place to address the resident's impaired cognition and need to increase supervision and monitoring. b). Resident #24 was found by staff sitting in a chair on 06/25/2023, with pain and swelling to his/her right knee. The resident reported he/she had fallen from the bed during a self-transfer. Resident #24 was transferred to a local hospital where he/she was diagnosed with a right femur fracture. Resident #24 had to have surgery to repair the right femur fracture. c). Resident #26 sustained falls on 06/14/2023, 06/17/2023, 07/02/2023, 07/25/2023, 07/28/2023, two (2) falls on 08/02/2023; and, on 08/15/2023, a total of eight (8) falls. The fall on 07/02/2023 was due to a self-transfer attempt which resulted in fractures to Resident #26's right radius and ulna (bones of the forearm), as well as a fracture to radius ulna and nasal bone. However, Resident #26's care plan revealed no docuemted evidence of person-centered interventions to prevent falls related to the root cause of each fall. d). Resident #22 had falls on 07/07/2023, 07/15/2023, and 07/22/2023, which resulted in a right orbital blowout fracture. Review of the care plan revealed no documeted evidence of person-centered care plan interventions to address Resident #22's implaired cognition and need for increased supervison and monitoring. e). Resident #18 sustained falls from his/her bed twice while attempting to self-transfer from the bed to the wheelchair. On 07/09/2023, Resident #18 was found lying face down on the floor next to his/her bed, with swelling and blood to his/her lip and pain under the left arm. Resident #18 was transferred to the local hospital for evaluation, with no significant injuries evaluated. On 07/29/2023, Resident #18 was again found lying on the floor between the head of the bed and the wheelchair, soiled with feces, injuries noted. f). Resident #25 reported on 07/30/2023, that he/she had fallen the night before, rolling out of bed during care. The resident sustained a knot to the right hip and skin tear to the right elbow as a result of the fall; however, he/she was not sent to the hospital for evaluation. Immediate Jeopardy (IJ) was identified on 08/11/2023 and again on 09/05/2023 and was determined to exist on 07/27/2023 at 42 CFR 483.25 Quality of Care (F689) Free from Accidents/Hazards/Supervision/Devices and 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656). The IJ is ongoing. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689) Free from Accidents/Hazards/Supervision/Devices. The facility was notified of the Immediate Jeopardy on 09/05/2023. The findings include: Review of the facility's policy titled, Baseline and Comprehensive Care Plan Development, Implementation, and Revisions, dated 08/01/2019, revealed care plans were used to direct effective and person-centered care that focused on personal preferences, goals, medications, active diagnoses, and services to be received by the resident. Further review revealed if there was a conflict between the resident's rights and safety, the facility would explore care alternatives through a thorough care planning process in which the resident might participate. 1. Review of Resident #1's admission Record revealed the facility admitted the resident on 03/31/2023, with diagnoses of Unspecified Dementia, Type II Diabetes, and Polyneuropathy. Review of Resident #1's admission MDS dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight (8) which indicated moderate cognitive impairment. Review of Resident #1's Quarterly MDS dated [DATE], revealed the facility failed to complete the Cognitive Patterns Section of the MDS and failed to conduct a BIMS' assessment of the resident. Review of Resident #1's Care Plan dated 08/07/2023, revealed the facility care planned the resident for elopement risk on 04/21/2023, with interventions that included: placement of a Wander Guard bracelet; staff to be aware of the resident's location; and family to provide energy drinks for the resident to discourage wandering. Further review revealed the facility resolved the elopement area of the care plan on 08/04/2023, following the Nurse Practitationer''s determination that Resident #1 was competent to make his/her own decisions. Continued review revealed the care plan was updated on 08/07/2023 to include the resident signing himself/herself out to go to businesses in the surrounding area. However, there was no documented evidence the facility included interventions outlining assessment of Resident #1's current mental status; measures to be taken for the resident's safety while out of the facility; time frames he/she was permitted to be out of the facility; or interventions for diabetes management, such as blood sugar checks and insulin administration scheduling around times the resident was absent from the facility. Observation on 08/09/2023 at 2:14 PM, revealed no visual evidence of energy drinks in Resident #1's room. In an interview at the time of the observation revealed Resident #1 stated he/she did not know what interventions were in his/her care plan. Resident #1 stated he/she made multiple requests for the facility to buy energy drinks for him/her out of the money in his/her account. However, the facility failed to honor the requests. In an interview on 08/12/2023 at 6:46 PM, Certified Nursing Nurse (CNA) #9 stated she did not know what interventions were in Resident #1's care plan as far as elopement preventions, other than placement of a Wander Guard bracelet. Per CNA #9, she did not know if providing Resident #1 with an energy drink was an intervention in his/her care plan to prevent elopement. However, she did know the Physician had approved the resident to have one (1) sugar free energy drink per day upon request. CNA #9 further stated the importance of developing and following a care plan was to make sure the resident was safe, and for facility staff to know the resident's needs. In an interview on 08/08/2023 at 4:31 PM, Licensed Practical Nurse (LPN) #1 stated prior to Resident #1's elopement on 07/27/2023, his/her care plan included interventions such as having a sugar-free energy drink available for the resident and keeping a Wander Guard bracelet in place. She stated Resident #1 had not been care planned for specific monitoring such as fifteen (15) minute checks or 1:1 observation prior to his/her elopement. LPN #1 further stated the importance of care planning was to provide resident-centered care to meet the resident's needs. In an interview on 08/15/2023 at 4:49 PM, LPN #11, who was the Unit Manager of the South Hall, stated on the evening of 08/14/2023, staff reported to her that Resident #1 was attempting to go to the courtyard and they did not know if he/she was allowed to do that. LPN #11 stated she did not know if Resident #1's care plan had been updated to include that the resident was allowed to go to the courtyard without a staff member present. She stated she believed staff were confused with all the changes to Resident #1's care plan because he/she had worn a Wander Guard bracelet for months, then climbed out the window and was under 1:1 observation, and then was allowed to sign himself/herself out of the building. LPN #11 further stated the importance of care planning was to promote resident safety and communicate the residents' needs to staff. In an interview on 08/10/2023 at 10:46 AM, the Activities Director (AD) stated one (1) of her job duties was to go to the store for residents who had specific requests for items to be purchased with money from their resident account. The AD stated she rotated which residents she went to the store for each week because there were too many to go for all of them at once. She stated Resident #1 was not on her list of residents for whom she was to shop. The AD further stated she did not know Resident #1's preferences, as he/she was a newer (Resident was admitted in March, 2023) resident in the facility. However, she stated she planned to add the resident to the list of residents she would shop for in the future. In an interview on 08/21/2023 at 3:49 PM, the MDSC (Minimum Data Set Coordinator) stated Resident #1's care plan for exit seeking, prior to his/her elopement on 07/27/2023, was vague and failed to communicate resident specific interventions that would prevent elopement and ensure the safety of the resident. In interview on 08/24/2023 at 4:24 PM, the MDS Nurse stated all residents were identified as fall risks when admitted to the facility and basic interventions were implemented such as non-skid foot wear, and call light within reach at that time. The MDS Nurse further stated more interventions were put in place once a resident sustained falls. In an interview on 08/14/2023 at 8:23 AM, the Medical Director stated he did not know if providing energy drinks was included in Resident #1's care plan as an intervention to prevent elopement. He stated he believed Resident #1 was also motivated to go to the gas station for socialization, as well as for the energy drinks and cigarettes. The Medical Director further stated he should have been more proactive in contributing to care plan interventions for Resident #1, such as setting a time limit on the resident's absences to ensure the resident received his/her prescribed insulin doses and blood sugar monitoring for Diabetes. In an interview on 08/11/2023 at 9:46 AM, the Director of Nursing (DON) stated the facility told Resident #1's daughter she could bring in energy drinks for her parent; however, the facility did not provide those beverages. She stated the IDT (Interdiscplinary Team) discussed safety interventions for Resident #1 when he/she signed out of the facility independently to include signing out at the nurse's station and/or front desk, telling staff where he/she was going, and ensuring the resident had his/her cell phone in his/her pocket. However, the DON stated the IDT team had failed to include those interventions in Resident #1's care plan as a means to communicate the interventions to staff. She stated therefore, not everyone would have been aware of the safety measures which should have been in place for Resident #1. In an additional interview on 08/24/2023 at 12:19 PM, the DON stated her expectation was for residents' care plans to contain any focus assessments or conditions pertaining to the resident so the facility could have a plan and interventions to communicate the plan of care. In an interview on 08/24/2023 at 3:03 PM, the Administrator stated her expectation was for care plans to be comprehensive and resident centered. She stated the purpose of residents' care plans was to communicate the resident's care needs to staff. The Administrator stated care plan interventions for exit-seeking residents should be developed to address the root cause of the exit-seeking behavior for that particular resident. 2. Review of Resident #3's face sheet revealed the facility admitted the resident on 09/08/2022, with diagnoses that included Hemiplegia to the right side, Diabetes, and Cerebral Infarction. Review of the admission Minimum Data Set (MDS) Assessment, dated 09/08/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15) which indicated moderately impaired cognition. Continued review revealed the facility assessed Resident #3's Activities of Daily Living (ADL's) as one (1) person assist with his/her unsteady balance. Further review revealed the facility assessed Resident #3's mobility assist device as a manual wheelchair with substantial assistance needed. Review of the admission MDS assessment dated [DATE], revealed the facility assessed Resident #3 to have a BIMS' score of seven (7) out of fifteen (15) which indicted severely impaired cognition. Continued review revealed the facility assessed Resident #3's ADL status as requiring one (1) to (2) person extensive assistance. Further review revealed the facility assessed Resident #3's mobility as totally dependent per a manual wheelchair. Review of Resident #3's comprehensive care plan (CCP) dated 09/09/2022, revealed the facility identified the resident as a fall's risk with interventions which included: anticipate and meet the resident's needs; call light within reach and encourage use of assistance as needed; and wear proper footwear. Per review of the CCP, Resident #3 was identified on 06/12/2023 as a fall's risk due to right sided weakness and impulsiveness related to Cardiovascular Accident (CVA/stroke) with a revision date of 06/22/2023. Continued review revealed interventions which included: educating the family to alert staff when leaving if the resident was in the chair, and not to close the room door. Further review of the CCP revealed the facility identified Resident #3's safety insight as poor, with interventions implemented on 06/21/2023 for staff to conduct routine visual rounding per routine care task; however, there was no documented evidence of interventions for closer monitoring prior to the resident's fall on 06/20/2023. Additional review of the CCP revealed the facility identified Resident #3 as being cognitively impaired with poor decision-making skills on 06/13/2023. Further review revealed the interventions included observing Resident #3 for mental status changes; however, there was no documented evidence of interventions noted to guide direct care staff on what actions to take if observations of mental status changes were made; how often to make observations; or who to report their observations to. In interview, on 08/10/2023 at 1:30 PM, the Director of Nursing (DON) stated care plans were maps of care for residents and everyone should be looking at them. She stated the Kardexes (direct care staff plans of care) were updated, and all staff were taught to check those each day. The DON further stated there was no process for auditing to determine if staff were checking the care plans and Kardexes as instructed; however, there was ongoing training and in-services provided. Review of the Nursing admission Data Collection form, dated 09/08/2022, revealed the facility assessed Resident #3 as a fall risk due to falls within three (3) months of admission, elimination with assistance, ambulated with problems/devices, and could not achieve balance without physical help. Review of the Fall Risk Assessment for Resident #3 dated 06/20/2023 at 3:57 PM, revealed the facility scored the resident as a six (6), which indicated he/she was a high risk for falls. Review of the Progress Notes for Resident #3 dated 06/14/2023 through 06/19/2023 revealed the resident was documented to have confusion. Continued review revealed no documented evidence the Physician was notified of Resident #3's confusion. Review of the Occupational Therapy (OT) note dated 06/14/2023, revealed during Activities of Daily Living (ADL) retraining Resident #3 required maximum assist with verbal cues. Review of the facility's Fall Scene Investigation Report dated 06/20/2023 at 4:02 PM, revealed Resident #3 was found lying on the floor in his/her room after ambulating alone and unattended. Continued review revealed Resident #3's mental status prior to the fall was confused and having decreased awareness. Further review revealed the Fall Prevention Book was to be updated. In an interview on 08/29/2023 at 2:25 PM, with the Assistant Director of Nursing (ADON) at 2:25 PM, and Licensed Practical Nurse (LPN) #2 at 2:40 PM, revealed the facility had no Fall Intervention Books which were noted on the 06/20/2023, Fall Scene Investigation Report. Review of Resident #3's Progress Note dated 06/20/2023 at 3:12 PM, revealed the Unit Manager was called to the resident's room after a CNA found him/her lying on the floor at the foot of the bed. Review of the Progress Note, dated 06/20/2023 at 4:03 PM, revealed the Primary Care Provider (PCP) was notified with a recommendation to send Resident #3 to the Emergency Department (ED). The facility transferred the resident to the ED. Review of the Progress Note, dated 06/21/2023 at 11:03 AM, revealed Resident #3 had been admitted to the hospital with a broken nose and subdural hematoma. Review of the Pain Evaluation dated 06/20/2023 at 4:02 PM, for Resident #3 revealed the Wong-Baker face scale for pain was utilized for assessing the resident's pain. Continued review of the Pain Evaluation revealed hurts even more with moaning and facial grimacing were marked on the form as well as, pain increasing with movement with the likely cause of the pain being the fall. Review of the local hospital records for Resident #3 dated 06/20/2023, revealed a Computerized Tomography (CT) scan was performed on the resident at 4:56 PM, of his/her head and facial bones. Review of the findings revealed an acute thin subdural hematoma and acute minimally displaced fracture of the nasal bone indicated from a frontal head injury. Observation of Resident #3 on 08/08/2023 at 9:25 AM and at 1:50 PM; and on 08/29/2023 at 2:30 PM revealed the resident alone in his/her room without supervision of staff nearby. Continued observation on 08/31/2023 at 11:55 AM, revealed Resident #3 sitting in the common area alone and unattended and no device observed to call for assistance if needed. In interview on 08/09/2023 at 12:55 PM, Certified Nurse Aide (CNA) #38 stated she went by what she was told in shift report and did not always look at residents' Kardex for their care needs. In interview on 08/08/2023 at 9:30 AM with CNA #2 and at 4:30 PM with LPN #1 they stated Resident #3 could only respond to yes and no questions. In interview on 08/28/2023 at 4:06 PM, LPN #7 stated she had been told in report by night shift staff that during the night on 06/19/2023, Resident #3 had attempted to get out of bed two (2) times by placing his/her feet on the floor. She stated staff were constantly needing to remind Resident #3 to not get up and to call for help. The LPN stated on 06/20/2023, she thought Resident #3 had simply just stood up and tried to walk when he/she sustained the fall. She further stated that day staff had brought Resident #3 had brought him/her out into the common area to keep an eye on him/her until his/her daughter arrived. In interview with CNA #20 on 08/29/2023 at 1:15 PM, she stated she attempted to round more often on residents who had low BIMS scores; however, got busy and could not always do that. In an interview with CNA #16 on 08/28/2023 at 4:46 PM, she stated due to staffing shortages she no longer worked at the facility. She stated there were other residents besides Resident #3 who needed closer supervision residing at the facility. In an interview on 08/30/2023 at 9:55 AM, the Activities Director (AD) stated Resident #3 would not be safe to self-transfer and was seated in the common area due to concerns of his/her getting up without staff. She stated Resident #3 probably needed closer supervision due to his/her inability to remember instructions. In an interview with the ADON on 08/31/2023 at 2:11 PM, she stated the facility's documentation did not reveal a root cause analysis for Resident #3's fall sustained on 06/20/2023. She stated she was not that familiar with the incident since it had happened on the Rehabilitation Unit. 3. Review of Resident #24's medical record revealed the facility admitted the resident on 02/02/2022, with diagnoses that included Dementia, Repeated Falls, Atrial Fibrillation, and urinary and bowel incontinence. Review of the admission MDS assessment dated [DATE], revealed the facility assessed Resident #24 to have a BIMS score of five (5) out of fifteen (15) which indicated he/she was severely cognitively impaired. Continued review revealed the facility assessed Resident #24's ADLs status as requiring the assistance of one (1) staff for transfers, walking, and toilet use. Further review revealed the facility assessed Resident #24's balance as unsteady and the resident was only able to stabilize with human assistance. In addition, record review revealed the facility assessed the resident to utilize a wheelchair for mobility. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of three (3) out of fifteen (15), also indicating severely impaired cognition. Further review revealed the facility assessed the resident's balance as being only able to stabilize with human assistance. Review of Resident #24's Comprehensive Care Plan (CCP) dated 02/04/2022, revealed the facility identified the resident as a fall risk with interventions implemented on 02/07/2023, anti-roll back devices to his/her wheelchair for safety. Per review, additional interventions included toileting the resident every two (2) to three (3) hours with CNA rounds; however, with no revision date noted. Continued review revealed on 08/15/2023, Resident #24's care plan was revised with anti-roll-back devices, encourage, and remind the resident to use the call light. Further review of Resident #24's CCP revealed the facility also identified the resident as having impaired cognition related to Dementia on 06/30/2023, with interventions which included observations for any changes in the resident's cognitive function. However, there was no documented interventions informing staff what action to take if observations were made of changes resident's cognition. Further review of Resident #24's CCP revealed the facility identified the resident as having bowel and bladder incontinence which had been initiated on 02/17/2022 and revised on 01/18/2023. Review of the bowel and bladder incontinence care plan further revealed interventions implemented on 02/22/2022, and revised on 04/20/2023, which included to check and change the resident every two (2) hours. Review of the Progress Note, dated 03/21/2023, revealed Resident #24's Dementia was a contributing factor for his/her recurrent falls as he/she was uneducable and unable to remember to lock his/her brakes on the wheelchair, use the call light, or ask for assistance. Review of Resident #24's Fall Risk Assessments dated 03/19/2023 and 04/21/2023, revealed the facility assessed the resident to have a score of twelve (12) indicating he/she was a high fall risk. Review of the facility's Incident Report dated 06/25/2023 at 3:00 PM, revealed Resident #24 had been found to be sitting on his/her bottom on the floor by the bed with injury to his/her right knee. Continued review of the Report revealed the facility identified predisposing factors included for Resident #24 which included confusion, incontinence, gait imbalance, impaired memory, and ambulating without assistance. Review of the Fall Risk Assessment for Resident #24, dated 06/25/2023, revealed the facility assessed the resident to have a score of ten (10) indicating he/she was a high fall risk. Review of the facility's Fall Risk Evaluation dated 06/25/2023 at 3:31 PM, revealed Resident #24's cognition was baseline. Continued review revealed the resident had sustained falls since admission; required staff assistance with elimination; and was only able to stabilize for toilet use with staff's assistance. Review of the Progress Note dated 06/25/2023 at 3:30 PM, revealed upon assessment of Resident #24's right knee the resident complained of pain, and the knee was observed to be very swollen, with the resident unable to bear weight on that leg. Continued review revealed Resident #24 was transported to a local hospital for evaluation. Review of Resident #24's Progress Note, dated 06/27/2023 at 9:19 AM, provided by the DON, revealed right before the resident sustained the fall, he/she had been lying on his/her bed asleep. Continued review revealed the resident self-reported falling from his/her bed. Review of the hospital records, dated 06/25/2023, revealed Resident #24 received right knee/femur imaging performed at 7:35 PM, with the findings of the imaging noted as a fracture to the right femur. Continued review of the hospital records revealed Resident #24 underwent surgery for right femur nailing (procedure to stabilize the femoral bone) on 06/26/2023. Further review revealed Resident #24 was discharged and returned to the facility on [DATE]. Observation on 08/31/2023 at 2:15 PM, revealed Resident #24 sitting up unattended in a wheelchair with anti-roll back devices which he/she was moving about throughout facility. In interview on 08/31/2023 at 10:15 AM, CNA # 29 stated Resident #24 did not have a device to his/her wheelchair to prevent it from tilting, such as anti-roll backs. She stated the resident was confused and she tried to check on him/her frequently due to confusion. In interview on 08/30/2023 at 9:55 AM, the AD stated Resident #24 would just get up when he/she wanted to, and she felt the resident would never be safe enough to self-transfer. She further stated she would instruct staff regarding that information. In interview on 08/31/2023 at 2:11 PM, the ADON stated the RCA (Root Cause Analysis) for Resident #24's fall on 06/25/2023 was determined to have been his/her attempting to self-transfer and rolled out of bed while doing so. She further stated the RCA for Resident #24's other falls had been his/her attempting to self-transfer and his/her impulsiveness. In interview on 09/05/2023 at 11:35 AM, the DON stated a Fall Scene Investigation Report had not been performed on 06/25/2023, for Resident #24 fall. However, the entries documented in the Progress Notes was how the event occurred. 4. Review of Resident #26's admission Record revealed the facility admitted the resident on 05/12/2023, with diagnoses that included Alzheimer's Disease, Parkinson's Disease, and Repeated Falls. Review of Resident #26's admission MDS Assessment, dated 05/22/2023, revealed no documented evidence the facility assessed the resident with a BIMS' score. Continued review revealed the facility assessed Resident #26 to require one (1) person physical assist when transferring between surfaces and when toileting. Review of Resident #26's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of seven (7) out of a possible fifteen (15), which indicated severe cognitive impairment. Further review revealed the facility again assessed Resident #26 to require one (1) person physical assist when transferring between surfaces and when toileting. Review of Resident #26's Care Plan dated 08/15/2023, revealed the facility identified the resident at risk for falls on 05/12/2023. Interventions included: Physical and Occupational Therapy (PT/OT) evaluations and treatment; conduct rounds per routine care task to determine additional safety cueing; ensure the resident used a walker for ambulation; and ensure the resident wore nonskid footwear during transfers. Continued review revealed the interventions included: placing a nightlight in his/her room; offering toileting before meals; and applying red tape to call light to remind resident to ask for assistance. Review of Resident #26's medical record revealed the resident sustained falls on 06/14/2023; 06/17/2023; 07/02/2023; 07/25/2023; 07/28/2023; on 08/02/2023 at 5:33 PM and 9:15 PM; and on 08/15/2023. Review of the facility's Fall Scene Investigation Report dated 06/14/2023 at 1:36 PM, revealed Resident #26 attempted to self-transfer back into the bed from too far away, causing the resident to fall to the floor. Continued review revealed the facility's initial interventions were to re-educate Resident #26 on asking for assistance when needed, and educating the resident on checking to make sure he/she was close enough to the object before sitting down. Review of Resident #26's Care Plan revealed no documented evidence of the interventions the facility identified for the resident after the 06/14/2023 fall. The interventions were to re-educate the resident to ask for assistance when needed; and, to check to ensure he/she was close enough to the object he/she was transferring to. Review of the facility's Fall Scene Investigation Report dated 06/17/2023 at 2:05 PM, revealed Licensed Practical Nurse (LPN) #4 witnessed Resident #26 walking in the hallway with a cane, lose his/her balance and fall to the floor. Continued review revealed Resident #26 sustained no injury. Review of Resident #26's Care Plan revealed on 06/19/2023, the facility implemented an intervention for staff to ensure the resident had a walker when ambulating. Review of the facility's Fall Scene Investigation Report dated 07/02/2023 at 11:45 PM, revealed CNA #36 and LPN #8 found Resident #26 lying on the floor at the foot of his/her roommate's bed, near the bathroom, covered in blood. Review of Resident #26's hospital records dated 07/09/2023, revealed the resident was admitted to the hospital on [DATE], for fractures to his/her left radius and ulna, as well as nasal fractures due to a fall. Review of Resident #26's Care Plan revealed on 07/03/2023, the facility implemented an intervention of a night light to the resident's room for safety. Review further revealed however, no documented evidence the facility developed Resident #26's care plan to include interventions to address the resident's attempt to self-toilet. Review of Resident #26's Fall Scene Investigation Report dated 07/25/2023 at 2:06 AM, revealed LPN #14 found the resident sitting on the floor, leaning against the bathroom door. Review of Resident #26's Care Plan revealed on 07/25/2023, the facility implemented an intervention for having Resident #26 wear nonskid footwear when transferring. However, continued review revealed no documented evidence the facility developed interventions to address the resident's attempt to self-toilet as the cause of the fall. Review of the facility's Fall Scene Investigation Report dated 07/28/2023 at 2:30 PM, revealed LPN #3 found Resident #26 lying on the floor beside his/her bed after the resident attempted to self-transfer. Review of Resident #26's Progress Note documented dated 07/28/2023 at 2:41 PM, documented by LPN #3 revealed the resident told her he/she slid out of the lift chair while attempting to transfer to his/her bed. Continued review revealed LPN #3 re-educated Resident #26 to ask for assistance with transferring. Review of Resident #26's Care Plan revealed on 07/28/2023, the facility implemented an intervention of

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure adequate supervision and monitoring to prevent elopements for one (1), Resident #1; and falls for six (6), Residents #3, #18, #22, #24, #25 and #26, of thirty-three (33) sampled residents. The facility failed to have an effective system to ensure adequate supervision and monitoring; and failed to develop and follow care plan interventions to prevent elopement for Resident #1. The facility was notified of the IJ at 42 CFR 483.25, Quality of Care, F689, Supervision to Prevent Accidents and 42 CFR 483.21, Comprehensive Care Plans, F656, Develop and Implement on 08/11/2023, which was determined to exist on 07/27/2023. 1. On 04/20/2023, Resident #1 attempted to exit the building by walking out of the front door of the facility. At that time, the facility failed to assess the resident's cognition. However, as a measure to prevent elopement, the facility placed a Wander Guard bracelet on the resident. Further, the facility failed to have a system in place to ensure the resident's window alarm, which alerted staff when opened, was checked routinely. Subsequently, the resident exited the facility, without staff knowledge, by disabling a window alarm in his/her room and climbed out of the window, on 07/27/2023. The resident was missing from the facility for approximately forty-five (45) minutes and was found at a nearby convenience store. The resident had to cross two (2) roads with heavy traffic to get to the store. In addition, the facility failed to have an effective system to determine the root cause: evaluate falls: implement individualized interventions, and to monitor their effectiveness to prevent additional falls for six (6) of thirty-three (33) sampled residents (Residents #3, #18, #22, #24, #25, and #26). 2. Resident #3 had a fall from a wheelchair on 06/20/2023, while unattended. The facility transferred the resident to a local hospital for evaluation. The hospital assessed Resident #1 to have a nasal fracture and a subdural hematoma. 3. The facility found Resident #24 sitting in a chair on 06/25/2023. The resident was noted to have pain/swelling to his/her right knee. Resident #24 reported he/she had fallen from the bed during a self-transfer. The resident was transferred to a local hospital; the radiology findings revealed a right femur fracture. The resident had surgery to repair the right femur fracture. 4. Resident #26 had falls on 06/14/2023, 06/17/2023, 07/02/2023, 07/25/2023, 07/28/2023, twice on 08/02/2023 and 08/15/2023. The fall on 07/02/2023 was due to a self-transfer attempt which resulted in fractures to the resident's right radius and ulna, as well as, a fracture to the nasal bone. 5. Resident #22 had falls on 07/07/2023, 07/15/2023, and 07/22/2023, which resulted in a right orbital blowout fracture. The fall on 07/22/2023 occurred while the resident was unattended and attempted to self-transfer. 6. Resident #18 had a fall from his/her bed twice while attempting to self-transfer from the bed to the wheelchair. On 07/09/2023, the facility found the resident face down on the floor next to the bed. The fall resulted in swelling and blood to the resident's lip and pain under his/her left arm. The facility transferred Resident #18 to the local hospital for evaluation, with no significant injuries found. Subsequently, on 07/29/2023, Resident #18 was found on the floor between the head of the bed and the wheelchair, soiled with feces. 7. Resident #25 reported, on 07/30/2023, that he/she had fallen the night before, on 07/29/2023, rolling out of the bed while staff assisted with the resident's care. The resident sustained a knot to the right hip and a skin tear to the right elbow. The incident; however, was not reported until 07/30/2023. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care; (F689) Free from Accidents/Hazards/Supervision/Devices. The facility was notified of the Immediate Jeopardy on 08/11/2023. The findings include: Review of the facility's policy titled, Elopement/Unsafe Wandering Risk Evaluations, not dated, revealed the facility ensured each resident received adequate supervision to prevent accidents, including elopement. Further review revealed elopement was defined as when a resident left the facility without authorization or supervision, usually without staff knowledge. 1. Record review revealed the facility admitted Resident #1, on 03/31/2023, with diagnoses of Unspecified Dementia, Type II Diabetes, and Polyneuropathy. Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 04/10/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight (8) of fifteen (15) which indicated moderate cognitive impairment. Review of Resident #1's Quarterly MDS Assessment, dated 07/05/2023, revealed the facility failed to assess the resident with a BIMS score, a cognitive assessment. Review of Resident #1's Comprehensive Care Plan (CCP), dated 08/07/2023, revealed the facility care planned Resident #1 for an elopement risk, on 04/21/2023. Interventions included: placement of a Wander Guard bracelet, staff to be aware of resident's location, and family to provide energy drinks to resident to discourage wandering. Review of Resident #1's Progress Note, dated 04/20/2023, revealed the facility identified Resident #1 as an elopement risk when he/she attempted to exit the front door. Further review revealed the resident stated he/she wanted to go to the store to purchase cigarettes and an energy drink. Review of the Note revealed the facility failed to perform a cognitive assessment at that time. However, the facility placed a Wander Guard bracelet (a device placed on the resident that would trigger an alarm to sound if the resident exited a door equipped with an alarm) on Resident #1 as an elopement prevention measure. Review of Resident #1's Incident Report, dated 07/27/2023, revealed on 07/27/2023 at approximately 9:30 PM, Certified Nursing Assistant (CNA) #10 noted Resident #1 was not in his/her bed and initiated a Code Green. This code was used for a missing resident. Further review revealed CNA #9 located Resident #1 at a local gas station and brought him/her back to the facility at 10:15 PM, approximately forty-five (45) minutes after Resident #1 was noted to be missing. Further review revealed Resident #1 disabled the window alarm so staff would not hear him/her leave. Continued review revealed the facility assessed the resident to be free from injury upon return to the facility. Review of the weather data, according to www.weatherunderground.com, revealed on 07/27/2023 at 9:54 PM, the temperature in the area was eighty-six (86) degrees Fahrenheit with clear skies. Observation of the route to the gas station revealed it was seven-tenths (0.7) of a mile from the facility, crossing two (2) roads with heavy traffic. In an interview on 08/09/2023 at 2:14 PM, Resident #1 stated, on 07/27/2023, he/she turned off the alarm on the window of his/her room and climbed out the window to get an energy drink and some cigarettes from the local gas station. He/she stated that prior to the night he/she climbed out the window, he/she had asked facility staff to take his/her money and buy him/her an energy drink, but they never provided the energy drink as requested. Resident #1 stated the first time he/she tried to exit the facility through the front door, facility staff told him/her that he/she was not allowed to leave the facility but did not explain why he/she was not allowed to leave. Per the interview, the nurses talked to the resident a few days after he/she came back to the facility and told the resident that he/she was allowed to leave the facility if he/she signed out and told staff where he/she was going. In an interview on 08/14/2023 at 4:42 PM, CNA #10 stated she was working the night Resident #1 eloped and had seen him/her in the courtyard at approximately 8:30 PM on 07/27/2023. She further stated she went to Resident #1's room while conducting routine resident care rounds at approximately 9:30 PM and noted the resident was not in his/her bed, so CNA #10 checked the courtyard. Per the interview, when she did not see Resident #1 in the courtyard, she informed the nurse, and they called the Code Green, the code for a missing resident. In further interview, CNA #10 stated Resident #1 often asked for an energy drink and cigarettes, and she believed if the resident had those items available in the facility, he/she would not have eloped. In an interview on 08/12/2023 at 6:46 PM, CNA #9 stated Resident #1 frequently asked for cigarettes and an energy drink, so when CNA #9 heard Resident #1 was not found in the building or on the grounds on 07/27/2023, she told Licensed Practical Nurse (LPN) #1 that she believed the resident might be at the local gas station. She stated she drove her car down to look for him/her. CNA #9 stated she found Resident #1 sitting on the curb at the gas station, smoking a cigarette, and drinking an energy drink. In further interview, CNA #9 stated the physician approved Resident #1 to receive one (1) sugar-free energy drink per day, due to his/her diabetes and heart conditions. However, she stated she was not sure how the energy drinks were made available to the resident or what was in the care plan about the process. CNA #9 stated Resident #1 had worn a Wander Guard bracelet as long as she had worked at the facility. However, she stated she was not sure why Resident #1 wore the Wander Guard bracelet. In an interview on 08/10/2023, LPN #3 stated she was working on 04/20/2023 and recalled Resident #1 attempting to exit through the front doors. She stated she redirected Resident #1 back to his/her room and after consulting with management, placed a Wander Guard bracelet on Resident #1 to alert staff if he/she attempted to exit through the doors. In an interview on 08/08/2023 at 4:31 PM, LPN #1 stated she was working on the South Hall on 07/27/2023 when Resident #1 eloped. She further stated when CNA #10 told her Resident #1 was not in his/her bed and the window was open, staff called a Code Green. She stated CNA #9 drove to the gas station where she found Resident #1 and brought him/her back to the facility. In an interview on 08/21/2023 at 3:23 PM, the Maintenance Director stated he did not perform routine inspections of window alarms, because that duty was assigned to housekeeping. In an interview, on 08/21/2023 at 3:31 PM, the Housekeeping Supervisor stated it was the responsibility of the housekeeping staff to check the window alarms. In further interview, she stated, prior to 07/27/2023, the housekeeping staff checked the batteries and the function of the window alarms twice per year by raising the window to check if the alarm sounded. The Housekeeping Supervisor stated the current owners of the facility did not have a policy on how often the batteries should be checked. In an interview on 08/14/2023 at 8:23 AM, the Medical Director (MD) stated the facility contacted him when Resident #1 eloped on 07/27/2023. He further stated his recommendations at that time were to ensure the resident remained in the building until the IDT met to discuss the resident. In further interview, the MD stated the facility was ultimately responsible for Resident #1 while he/she was a resident within the facility. In an interview on 08/11/2023 at 9:46 AM, the Director of Nursing (DON) stated Resident #1 first tried to exit the front door of the facility on 04/20/2023 to go to the gas station the resident was familiar with from the neighborhood near the facility where his/her daughter lived. The DON stated she told Resident #1 and his/her daughter, at that time, that the resident would not be allowed to walk out of the facility on his/her own due to his/her admission BIMS assessment that indicated cognitive impairment. The DON further stated the facility's process for determining if a resident was capable of making his/her own decisions was to look at the BIMS' score. The DON stated if the BIMS score was an eight (8) or below, the facility would not consider the resident to be mentally competent. In further interview, the DON stated when staff members noted Resident #1 was not in his/her bed on 07/27/2023, they knew where to look for the resident because the resident had previously stated he/she had frequented that gas station prior to admission to the facility. The DON further stated she worried about Resident #1 when he/she was out of the facility. In an interview, on 08/24/2023 at 3:03 PM, the Administrator stated the facility determined Resident #1 eloped from the facility on 07/27/2023 through the window in his/her room to go get energy drinks and cigarettes. She further stated, that prior to the resident's admission to the facility, the facility was not aware that Resident #1's daughter allowed the resident to go to the gas station independently, a habit which she stated could have been a contributing factor in his/her elopement. Review of the facility's policy titled, Falls Protocol, revised 03/18/2019, revealed the facility would assess residents for fall risks upon admission, readmission, and with a significant change in medical condition. Per the policy, in the event of an actual fall, an attempt would be made to eliminate the causal factors and prevent further falls. Residents experiencing an actual fall would have the following interventions: neurological checks performed and documented for falls that involved a possible head injury or were unwitnessed, incident investigation completed to determine the root cause of the fall and/or if the event was isolated in nature. Further review revealed implementation of preventative measures prior to the end of the shift based on the incident investigation findings, request of primary care physician (PCP) for x-ray order for any resident alert to self, only with any external signs of an injury after a fall to rule out a possible fracture, and review of the fall at the next Interdisciplinary Team (IDT) meeting to assure that the interventions were appropriate, to evaluate the need for any additional preventative measures, and to verify appropriate interventions had been implemented. Further review of the facility's policy titled, Falls Protocol, revised 03/18/2019, revealed the care plan would be revised for any new fall prevention interventions, and the Fall Intervention Book would be updated immediately for staff reference. The policy stated a resident with two (2) falls within a ninety (90) day period would have a review conducted by the IDT regarding all documentation and findings related to previous falls and would discuss this with the resident/family and physician. Per the policy, additional educational interventions utilized for prevention and any refusals related to recommended safety interventions would be documented. 2. Review of Resident #3's admission Record revealed the facility admitted the resident, on 09/08/2022, with diagnoses to include Hemiplegia to the Right Side, Diabetes, and Cerebral Infarction (Stroke). Review of Resident #3's admission MDS Assessment, dated 06/16/2023, revealed the facility assessed the resident to have a BIMS score of seven (7) of fifteen (15), indicating cognition to be severely impaired. A manual wheelchair was assessed on 06/16/2023 for an assistive device with the resident being totally dependent. Review of Resident #3's Comprehensive Care Plan (CCP), dated 09/09/2022, revealed he/she was identified as a fall risk with interventions in place which included anticipating and meeting the resident's needs, call light within reach and encourage usage for needed assistance, wear proper footwear, and the resident needed a prompt response for assistance. Additional review of Resident #3's CCP revealed the resident was identified on 06/12/2023 as a fall risk due to right sided weakness and impulsiveness due to stroke with revision date of 06/22/2023. Interventions were placed for educating family to alert staff when leaving if resident was in his/her chair and not to close the door. Continued review of the CCP revealed the resident's safety insight was poor, with interventions placed on 06/21/2023 for staff to conduct routine visual rounding per routine care task; however, no interventions for closer monitoring were indicated on the CCP prior to the fall on 06/20/2023. Review of Resident #3's Fall Scene Investigation Report (FSIR), dated 06/20/2023 at 4:02 PM, revealed Resident #3 was found on the floor in his/her room after ambulating while alone and unattended. The Fall Scene Investigation Report revealed Resident #3's mental status prior to the fall was confused, and the resident had decreased awareness. Continued review of the FSIR revealed the Fall Prevention Book would be updated. However, per interview on 08/29/2023 at 2:25 PM with the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #2 on 08/29/2023 at 2:40 PM, both stated there were no Fall Intervention Books, to update staff on new fall prevention interventions, as noted in the Fall Scene Investigation Report. Review of Resident #3's Progress Note, dated 06/20/2023 at 3:00 PM, revealed Resident #3 was transported to the Emergency Department (ED). Review of Resident #3's Progress Note, dated 06/21/2023 at 11:03 AM, revealed Resident #3 had been admitted to the hospital with a broken nose and a subdural hematoma. Review of Resident #3's Progress Note, dated 06/24/2023 at 10:00 AM, revealed Resident #3 returned to the facility from the hospital. Review of Resident #3's hospital records, dated 06/20/2023, revealed a Computed Tomography (CT) scan of the head and facial bones was performed on 06/20/2023 at 4:56 PM. The findings were an acute thin subdural hematoma and an acute minimally displaced fracture of the nasal bone indicated from a frontal head injury. Observation of Resident #3 on 08/08/2023 at 9:25 AM and at 1:50 PM; and on 08/29/2023 at 2:30 PM, revealed the resident was alone in his/her room without nearby staff. Continued observation on 08/31/2023 at 11:55 AM, revealed Resident #3 was sitting in the common area alone and unattended. In an interview with CNA #2 on 08/08/2023 at 9:30 AM and LPN #1 at 4:30 PM, they stated Resident #3 could only respond to yes and no questions. In an interview with LPN #7, on 08/28/2023 at 4:06 PM, she stated she had been told in report by night shift staff that Resident #3 had attempted to get out of bed two (2) times through the night by placing his/her feet on the floor on the night of 06/19/2023. Review of Resident #3's Medical Record; however, revealed no documented evidence to support staff assessed the resident to determine if his/her interventions were appropriate, to include providing increased supervision and monitoring of the resident when he/she attempted to get out of bed on 06/19/2023. In continued interview, the LPN stated staff constantly needed to remind Resident #3 to not get up and to call for help. She stated she thought Resident #3 had simply stood up and tried to walk when he/she fell. She stated, that on the day of the fall, staff had brought the resident to the common area to keep an eye on him/her until the resident's daughter arrived. In an interview with CNA #20 on 08/29/2023 at 1:15 PM, she said she attempted to round more often on residents who had a low BIMS score. However, she stated when she became busy, she could not always do that. In an interview with the Activities Director on 08/30/2023 at 9:55 AM, she stated Resident #3 would not be safe to self-transfer and would be seated in the common area due to concerns of getting up. She stated Resident #3 probably needed closer supervision because the resident was not able to remember instructions. In an interview with the Assisted Director of Nursing (ADON), on 08/31/2023 at 2:11 PM, she stated documentation did not reveal a root cause analysis for the fall sustained by Resident #3 on 06/20/2023. She stated she was not that familiar with the incident since it had happened on the Rehabilitation Unit. 3. Review of Resident #24's admission Record revealed the facility admitted the resident, on 02/02/2022, with diagnoses to include Dementia, Repeated Falls, and Urinary and Bowel Incontinence. Review of Resident #24's Quarterly MDS Assessment, dated 04/28/2023, revealed the facility assessed the resident to have a BIMS score of three (3) of fifteen (15), indicating cognition to be severely impaired. Review of the facility's assessment revealed the resident required assistance of one (1) for transfers, walking, and toileting. In addition, the assessment revealed the resident's balance was unsteady, and he/she was only able to stabilize with human assistance. Continued review revealed the facility assessed the resident to require a wheelchair for mobility. Review of Resident #24's CCP, dated 02/04/2022, revealed Resident #24 was identified as a fall risk with interventions placed on 02/07/2023 for antiroll-backs for the wheelchair, with a revision date of 08/15/2023. Additional interventions included toileting every two (2) to three (3) hours with CNA rounds, no revision date noted. The CCP revealed staff were to encourage and remind the resident to use the call light with a revision date of 08/15/2023. Continued review of the CCP revealed Resident #24 was identified as having bowel and bladder incontinence initiated on 02/17/2022 and revised on 01/18/2023. Interventions placed on 02/22/2022 included check and change every two (2) hours with a revision date of 04/20/2023. A review of Resident #24's Falls Risk Assessment, dated 03/19/2023 and 04/21/2023, both revealed a score of twelve (12), indicating a High Fall Risk. A Falls Risk Assessment, dated 06/25/2023 revealed a score of ten (10), indicating a High Fall Risk. Review of Resident #24's Progress Note by the Physician's Assistant, dated 03/21/2023, revealed under assessment and plan, Resident #24's dementia was a contributing factor for recurrent falls as he/she was uneducable and unable to remember to lock the brakes on his/her wheelchair, use the call light and ask for assistance. Review of the resident's care plan; however, revealed staff were to encourage and remind the resident to use his/her care light. There was no documented evidence to support the facility reviewed the resident's care plan, on 03/21/2023, to ensure that the interventions were appropriate, evaluated for the need for additional preventative measures, and verified that appropriate interventions were implemented, as the resident was uneducable and was unable to remember. Review of Resident #24's Incident Report, dated 06/25/2023 at 3:00 PM, revealed Resident #24 was noted to be sitting on his/her bottom on the floor by his/her bed with an injury to the right knee. The report identified predisposing factors included confusion, incontinence, gait imbalance, impaired memory, and ambulating without assistance. Review of Resident #24's Progress Note, dated 06/25/2023 at 3:30 PM, revealed upon assessment of the right knee, the resident complained of pain. The note stated the right knee was noted to be very swollen, and the resident was unable to bear weight to the right leg. The note stated Resident #24 was transported to the local hospital for evaluation. Review of Resident #24's Fall Risk Evaluation, dated 06/25/2023 at 3:31 PM, revealed cognition was baseline, had sustained falls since admission, required staff assistance with elimination, and was only able to stabilize for toilet use with staff assistance. Review of Resident #24's hospital record, dated 06/25/2023, revealed a right knee/femur image series was performed at 7:35 PM with findings of a fracture to the right femur. Continued review revealed Resident #24 underwent surgery of the right femur nailing on 06/26/2023, was discharged , and returned to the facility on [DATE]. Review of a copy of Resident #24's Progress Note, dated 06/27/2023 at 9:19 AM, and provided by the DON, after the SSA Surveyor requested a copy of the FSIR, revealed the resident self-reported he/she had fallen from his/her bed and right before the fall, Resident #24 had been sleeping in bed. Observations of Resident #24 from 08/08/2023 to 09/05/2023 , revealed the resident was unattended in a wheelchair mobilizing throughout the facility with an anti-rollback device on the wheelchair. In an interview with CNA #29, on 08/31/2023 at 10:15 AM, she stated Resident #24 did not have a device to the wheelchair to prevent tilting. She added Resident #24 was confused, and she tried to check on him/her frequently due to confusion. In an interview with the Activities Director on 08/30/2023 at 9:55 AM, she stated Resident #24 would just get up when he/she wanted, and she felt the resident would never be safe enough to self-transfer. She stated she did instruct staff of this. In an interview with the ADON, on 08/31/2023 at 2:11 PM, she stated the Root Cause Analysis (RCA) for Resident #24's fall on 06/25/2023 was attempting to self-transfer and rolled out of bed. In an interview with the Director of Nursing (DON), on 09/05/2023 at 11:35 AM, she stated an Fall Scene Investigation Report (FSIR) had not been performed on 06/25/2023 for Resident #24's fall, but entries in the progress notes presented how the event happened. 4. Review of Resident #26's admission Record revealed the facility admitted the resident, on 05/12/2023, with diagnoses including Alzheimer's Disease, Parkinson's Disease, and Repeated Falls. Review of Resident #26's admission Minimum Data Set (MDS) Assessment, dated 05/22/2023, revealed the facility failed to assess the resident with a BIMS score. Further review revealed the facility assessed the resident to require a one (1) person physical assist when transferring between surfaces and when toileting. Review of Resident #26's Quarterly MDS Assessment, dated 07/21/2023, revealed the facility assessed the resident with a BIMS score of seven (7) of fifteen (15), indicating severe cognitive impairment. Further review revealed the facility assessed the resident to require a one (1) person physical assist when transferring between surfaces and when toileting. Review of Resident #26's Comprehensive Care Plan (CCP), dated 08/15/2023, revealed the facility identified Resident #26 was at risk for falls on 05/12/2023 and included interventions such as physical and occupational therapy evaluation and treatment, conducting routine visual rounding per routine care task to determine additional safety cueing, ensuring the resident used a walker for ambulation, ensuring the resident wore nonskid footwear during transfers, place a nightlight, offer toileting before meals, and applying red tape to the call light to remind the resident to ask for assistance. Review of Resident #26's Fall Scene Investigation Report (FSIR), dated 06/14/2023 at 1:36 PM, revealed Resident #26 attempted to self-transfer back into the bed and sat down while too far away, causing him/her to fall onto the floor. The initial interventions listed were to re-educate the resident on asking for assistance when needed and educating the resident on checking to make sure he/she was close enough to the object before sitting down. Review of Resident #26's FSIR, dated 06/17/2023 at 2:05 PM, revealed LPN #4 witnessed the resident walking in the hallway with a cane, when the resident lost his/her balance and fell to the floor without injury. Observation on 08/30/2023 at 3:22 PM, revealed the facility failed to apply red tape to the call light after moving Resident #26 to a new room, as noted in the resident's care plan. In an interview, on 08/28/2023 at 10:48 AM, Resident #26 stated he/she used a wheelchair because if he/she tried to stand up and walk, he/she would fall. Resident #26 further stated he/she fell at home and that was why he/she moved into the facility so the staff could assist him/her and keep him/her safe. In an interview on 08/16/2023 at 2:36 PM, Licensed Practical Nurse (LPN) #4 stated he recalled Resident #26's fall in June when he/she was ambulating in the hallway with a cane. He further stated that though he did not recall if he was aware of the therapy's recommendations before the fall, he found out afterwards that therapy had recommended Resident #26 was not able to safely use a cane. He stated staff asked Resident #26's son to remove the cane so the resident would use his/her walker for ambulation. Review of Resident #26's Fall Scene Investigation Report (FSIR), dated 07/02/2023 at 11:45 PM, revealed CNA #36 and LPN #8 found Resident #26 at the foot of his/her roommate's bed, near the bathroom, covered in blood. In an interview on 09/03/2023 at 6:46 PM, CNA #36 stated, on 07/02/2023, she offered assistance with toileting to Resident #26 around 11:00 PM, but the resident stated he/she did not require assistance at that time. CNA #36 stated that around 11:30 PM, a new aide whose name she did not recall, told her he heard screaming from Resident #26's room, so she ran to the room and found Resident #26 lying on the floor with an open wound on his/her arm and large amounts of blood around it. She stated Resident #26 reported to her that he/she had been incontinent and was ashamed to ask for help, so he/she attempted to get to the bathroom without asking for assistance to clean himself/herself. In an interview on 08/23/2023 at 7:51 AM, LPN #8 stated she responded to CNA #36's call for help with Resident #26 on the night of 07/02/2023 and found Resident #26 on the floor with a large amount of blood around him/her, so LPN #8 called 911. She further stated she heard Resident #26 broke his/her arm and nose in the fall but did not recall any further details. Review of Resident #26's hospital records, dated 07/09/2023, revealed Resident #26 was admitted to the hospital on [DATE] for a fall with fractures to the left radius and ulna, as well as nasal fractures. Review of Resident #26's FSIR, dated 07/25/2023 at 2:06 AM, revealed LPN #14 found Resident #26 sitting on the floor, leaning against the bathroom door. Further review revealed a section of a written statement from CNA #35, which revealed the CNA reported Resident #26 refused an offer to help with toileting at 1:00 AM, stating he/she did not need to go at that time. In an interview with CNA #35, on 09/04/2023 at 4:22 PM, he stated he did not recall Resident #26 falling on his shift on 07/25/2023. He further stated he checked on residents who had cognitive impairment and a history of falls every fifteen (15) minutes, although he could not recall if he had done that for Resident #26. Review of Resident #26's FSIR, dated 07/28/2023 at 2:30 PM, revealed LPN #3 found Resident #26 on the floor beside his/her bed after the resident attempted to self-transfer. Review of Resident #26's Progress Note, written by LPN #3 and dated 07/28/2023 at 2:41 PM, revealed Resident #26 told her that he/she slid out of the lift chair while attempting to transfer to bed. Per the note, LPN #3 re-educated the resident to ask for assistance with transferring. Review of Resident #26's FSIR, dated 08/02/2023 at 5:33 PM, revealed LPN #3 witnessed Resident #26 slide out of bed while attempting to self-transfer. Further review revealed LPN #3 described Resident #26 as impatient and his/her mental status as drowsier than baseline. Review of Resident #26's Progress Note, written by LPN #3 and dated 08/02/2023 at 5:25 PM, revealed LPN #3 observed Resident #26 slide out of bed onto the floor. Further review revealed LPN #3 assessed the resident and found the resident was wearing nonskid footwear, had adequate lighting, and had personal items within reach. Continued review revealed LPN #3 notified Resident #26's son, who requested a bedside commode to be placed in Resident #2[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #23's EMR revealed the facility admitted the resident on 05/11/2021, with diagnoses including Alzheimer's Disease, Adult Failure to Thrive, and Age-Related Debility. Review of Resident #23's Quarterly Minimum Data Set (MDS) Assessment, dated 11/06/2022, revealed the facility assessed the resident to have a BIMS' score of two (2) out of fifteen (15), which indicated severe cognitive impairment. Further review revealed the facility also assessed Resident #23 as requiring limited assistance for transferring between surfaces, walking in his/her room, and toileting; and needed substantial assistance to put on footwear. Review of Resident #23's Comprehensive Care Plan, dated 11/13/2022, revealed the facility identified the resident was at risk for falls and care planned him/her for the fall risk. Per review of the Care Plan, the interventions included: for staff to be sure the call light was within Resident #23's reach; place a bedside commode at his/her bedside; place nonskid strips in the bathroom; continue to re-educate the resident to ask for assistance with toileting; encourage the resident to wear appropriate footwear when up; and place a raised toilet seat in the resident's bathroom. Observation, on 01/17/2023 at 10:21 AM, revealed Resident #23 sitting on his/her bed with his/her walker out of reach of the bed, and a bedside commode placed directly outside the bathroom door, out of the resident's reach and with no receptacle in it for the resident to be able to use it. Further observation in Resident #23's bathroom revealed there was a raised toilet seat with grab bars; however, no nonskid strips were present in the bathroom as per the resident's care plan. Interview with Resident #23's Resident Representative (RR) on 01/18/2023 at 5:32 PM, revealed the resident had fallen on multiple occasions since admission to the facility. The RR stated Resident #23 had Dementia and forgot that he/she needed to use a walker when going to the bathroom. Per interview with the RR, the facility had been asked to keep a bedside commode at Resident #23's bedside so the resident would be able to urinate without needing to walk to the bathroom. Further interview revealed the RR stated the bedside commode was usually in the bathroom when the RR came to visit Resident #23, and not beside the bed as requested. Interview with CNA #40 on 01/23/2023 at 11:01 AM, revealed she was aware of Resident #23's history of falls, including a fall with an injury. CNA #40 stated when she cared for Resident #23, she knew if the resident tried to get up independently, he/she was at high risk for a fall with injury. Per CNA #40, she assisted Resident #23 with getting up to go to the bathroom in the morning and after meals, and assisted the resident to his/her recliner after toileting. Further interview revealed CNA #40 did not recall a bedside commode being located in the resident's room as per his/her care plan. She further stated Resident #23 did not like to use a walker or wheelchair, so she made sure she assisted the resident with ambulation to protect him/her from falling. Interview with LPN #11, South Unit Manager on 01/26/2023 at 2:07 PM, revealed she was aware of Resident #23's history of falls and his/her care plan interventions. LPN #11 stated there were nonskid strips in place in the resident's bathroom that the facility had reapplied when the strips showed signs of wear and tear. Per LPN #11, Resident #23 could not be educated due to the resident's Dementia diagnosis. Continued interview revealed staff had repeatedly educated Resident #23 about using his/her call bell and waiting for assistance to go to the bathroom; however, the resident continued to get up without assistance. LPN #11 stated Resident #23 did not like to use the bedside commode, and the facility attempted offering frequent toileting to the resident. According to the LPN, Resident #23 would tell staff he/she did not need help and a short time later would get up to go to the bathroom without staffs' assistance. Further interview revealed after that happened multiple times, the facility determined offering a toileting schedule was not an effective intervention for Resident #23 and therefore, discontinued the intervention. 3. Review of Resident #57's EMR revealed the facility admitted the resident on 10/04/2019, with diagnoses which included Type II Diabetes, Peripheral Vascular Disease, Cellulitis of Bilateral Lower Limbs, and Stage III Chronic Kidney Disease. Review of Resident #57's Quarterly Minimum Data Set (MDS) Assessment, dated 11/07/2022, revealed the facility assessed the resident to have a BIMS score of a fourteen (14) out of fifteen (15), indicating the resident was cognitively intact and interviewable. Further review of the MDS Assessment revealed the facility assessed Resident #57 as having five (5) venous and/or arterial ulcers. Review of Resident #57's Care Plan, dated 01/06/2023, revealed the facility care planned the resident for impaired skin integrity with interventions including: to provide treatments to the bilateral lower extremities as per the Physician's Orders, and to encourage the resident to elevate his/her legs during the day. Observation of Resident #57 on 01/03/2023 at 2:08 PM, revealed gauze dressings on the resident's legs with a foul odor noted in the resident's vicinity. Continued observation revealed the gauze dressings were loose with yellow areas in multiple places on the dressings on each leg. Further observation of Resident #57 on 01/03/2023 at 3:50 PM, revealed the dressings remained with an odor and the appearance of the dressings was unchanged from the previous observation. Review of Resident #57's Physician's Orders, dated 01/17/2023, revealed staff were to daily clean the resident's bilateral lower extremities with wound cleanser, apply calcium alginate with silver to open lymph wounds, and secure with gentle tubi-grip (a pressure bandage). Review of Resident #57's wound note, dated 01/17/2023 at 7:08 AM, revealed the wound doctor's recommendation were to cover the topical medication on the resident's leg wounds with an absorbent pad, held in place by a stretchy gauze roll, covered by an ACE bandage, which was to be changed every day for thirty (30) days. Review of Resident #57's Treatment Administration Record (TAR) dated 01/2023, revealed the dressings on the resident's legs were not documented as having been changed as required on 01/22/2023 or 01/23/2023. Observation of Resident #57 on 01/23/2023 at 10:56 AM, revealed yellow areas observed on the gauze dressings bilaterally with no ACE bandage or tubi-grip in place as ordered. Observation further revealed Resident #57 was sitting up in his/her wheelchair with his/her eyes closed and his/her feet on the floor with no footrests for elevating his/her feet as per the care plan. Interview with Resident #57 on 01/23/2023 at 10:57 AM, revealed the dressings on his/her bilateral legs were only changed twice per week after his/her showers. Interview with CNA #40 on 01/23/2023 at 11:01 AM, revealed in her experience when caring for Resident #57, the dressings on his/her legs were only changed twice per week with showers, even if the resident had urinated on the dressings while trying to use a urinal, which she had witnessed multiple times. CNA #40 stated on those occasions, she had removed the urine-soaked dressings and informed the nurse. Further interview revealed there had been one (1) occasion when the dressings had not been reapplied the next day, though CNA #40 did not recall who the nurse was or when this had occurred. Interview with the MDS Coordinator on 01/27/2023 at 3:03 PM, revealed her practice was to update residents' care plans based on new orders put in their EMR by the wound care nurse. Further interview revealed the importance of following the care plan was so the residents received the care they needed through the interventions care planned. 4. Review of Resident #71's EMR revealed the facility admitted the resident on 11/25/2019, with diagnoses including Hemiparesis of Right Dominant Side, Aphasia (inability to speak), Dysphagia (difficulty swallowing), and Gastrostomy (a feeding tube directly in the stomach). Review of Resident #71's Quarterly MDS Assessment, dated 01/13/2023, revealed the resident was not assigned a score under the BIMS assessment due to communication barriers and not being interviewable. Further review revealed the facility assessed the resident to have a gastrostomy feeding tube in place and to receive twenty-five percent (25%) or less of his/her total calories from tube feedings. Review of Resident #71's Care Plan dated 11/19/2022, revealed the facility care planned the resident for his/her tube feedings with interventions for gastrostomy care including site care and dressing changes to be performed each shift as per the Physician's Order. Observation, on 01/23/2023 at 9:26 AM, of Resident #71 revealed there was no dressing in place to the resident's gastrostomy site when LPN #5 pulled the resident's clothing back to begin gastrostomy site care. Continued observation revealed LPN #5 cleansed a moderate amount of dried brown drainage from around the gastrostomy tube insertion site. Further observation revealed LPN #5 removed the tube feeding and flush tubing from the previous shift that had not been dated. Interview with LPN #5 on 01/23/2023 at 9:32 AM, revealed the night shift nurse should have performed the gastrostomy site care, to include cleansing the drainage from around the gastrostomy site and re-applying a dressing to the site according to the Physician's Order. LPN #5 stated following the care plan and orders for gastrostomy site care was important to protect the resident from complications including skin breakdown. 5. Review of Resident #255's EMR revealed the facility admitted the resident on 08/26/2022, with diagnoses including Sepsis, Pneumonitis due to Inhalation of Food and Vomit, Dysphagia, Seizures, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #255's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of five (5) out of fifteen (15), indicating severe cognitive impairment. Review of the Discharge MDS assessment dated [DATE], for Resident #255 revealed the facility discharged the resident assessed needs of: requiring extensive assistance to transfer between surfaces; utilizing a wheelchair; and requiring a mechanically altered diet. Review of Resident #255's Care Plan revealed the facility failed to develop care plans for the resident's need for aspiration prevention and fall prevention. Interview with Resident #255's RR on 01/04/2023 at 3:00 PM, revealed staff did not keep the resident's bed in the lowest position, and the height of the bed at times was concerning. The RR stated there had been nothing in place for Resident #255 regarding fall prevention such as, a fall mat, bed rails, or anything else. Further interview revealed there had been multiple occasions when the RR observed staff members, including CNA #13 and LPN #20 giving Resident #255 thin liquids, even after the RR told them the resident had aspirated on thin liquids in the past. Interview with CNA #13 on 01/06/2022 at 2:25 PM, revealed he recalled Resident #255 and remembered the resident had been a high fall risk and was unable to transfer from the bed to the chair without assistance. CNA #13 stated when he worked he ensured Resident #255 wore non-skid footwear and had his/her bed kept in the lowest position. He stated he offered the resident toileting every two (2) hours to reduce his/her risk of falling. In addition, CNA #13 stated he relied on shift report to know what Resident #255's needs were due to inconsistent documentation including the resident's care plan interventions. CNA #13 further stated the inconsistent documentation was due to the frequent management changes at the facility. 6. Review of Resident #348's EMR revealed the facility admitted the resident on 01/05/2023, with diagnoses including Hemiplegia of the Left Side, Dysphagia, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #348's admission MDS assessment dated [DATE], revealed the facility's assessed the resident with a BIMS score of three (3) out of fifteen (15), indicating severe cognitive impairment. Further review revealed the facility assessed Resident #348 as requiring a mechanically altered diet and extensive assistance with eating. Review of Resident #348's Care Plan dated 01/24/2023, revealed the facility failed to develop a care plan for the resident's need for aspiration prevention and extensive assistance with meals. Observation on 01/05/2023 at 3:13 PM, revealed LPN #5 was at Resident #348's bedside, encouraging him/her to take deep breaths and instructing the resident not to drink soda out of the can because he/she would get choked. Interview with LPN #5 at 3:16 PM, revealed Resident #348 became choked easily when his/her family provided soda that had not been thickened. LPN #5 stated she educated the resident's family, and they had taken the remaining cans of soda home with them. Further interview revealed LPN #5 stated Resident #348 required assistance with eating to prevent aspiration. Interview with the niece of Resident #348 on 01/18/2023 at 1:54 PM, revealed she did not understand why Resident #348 could not have soda to drink. She stated the facility would only provide thickened water for the resident to drink. Interview, with the MDS Coordinator on 01/27/2023 at 3:03 PM, revealed she was responsible for developing care plans based on residents' assessed conditions which were discussed in clinical meetings with the interdisciplinary care team (IDT). Per the MDS Coordinator, she also developed care plans according to new orders entered by the Physician. Further interview revealed she believed a resident's need for thickened liquids was adequately conveyed in the care plan under the weight loss section with the intervention of Diet per MD orders. Interview, with the Director of Nursing (DON) on 01/27/2023 at 3:34 PM, revealed her expectations were for care plans to be developed and followed according to policy. Interview with the Administrator on 01/28/2023 at 1:27 PM, revealed her expectations were for care plans to be individualized in development and interventions followed so residents could achieve their highest quality of life. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 01/18/2023, alleging removal of the IJ on 12/20/2022. Review of the IJ Removal Plan revealed the facility implemented the following: 1. On 11/22/2022, Resident #1 was placed on one-on-one (1:1) supervision immediately upon being brought back into the facility. 1:1 was provided by CNAs. Resident #1 received a head-to-toe assessment by LPN #3, with no new concerns noted. Wander Guard was initiated, and Physician and family were notified. 2. On 11/22/2022 Therapy Director (TD) and LPN #3 were re-educated on the elopement policy, the Wander Guard system, and the red box alarms by the DON. 3. On 11/22/2022 the Administrator and DON completed Ad Hoc Quality Assurance (QA) with the Chief Nursing Officer (CNO) and the Clinical Consultant (CC) to discuss the interviews collected at the time of the event and the investigation preliminary to determine root cause of elopement to be LPN #3, did not notify the DON of an attempted exit seeking behavior of Resident #1, further LPN #3 requested assistance from Rehab staff to deactivate the alarm and did not validate the alarm had been reactivated completely. 4. Ad Hoc QA initiated corrective action validating the alarms and facility doors were in working condition on 11/22/2022. 5. Education for nursing, dietary, laundry, housekeeping, therapy, activities, and administrative staff was initiated by the Administrator and DON on 11/22/2022 and continued using the train the trainer method. Education consisted of: elopement policy and procedure; notification of elopement and exit seeking behavior; alarms and functioning; elopement assessment accuracy; care planning revisions and interventions; elopement binders and resident information; and maintaining equipment and access to keys to override sounding alerts. On 11/22/2022, The DON began conducting education with agency staff before assignment related to the elopement policy and procedure, notification of elopement and exit seeking behavior, alarms and functioning, elopement assessment accuracy, care planning revisions and interventions, elopement binders and resident information, maintaining equipment and access to keys to override sounding alerts. This training was amended on 11/24/2022 by the DON, with management staff then training their employees. Training consisted of the following: Red Box Alarm Key being placed on the North and Rehab Narcotic Key Ring; responding to the Red Box alarms; identifying the source for the alarm sounding; implementing an Elopement Drill if the source was not identified; Nurse printing off census and verifying each resident was accounted for; if not able to account for each resident to contact the Abuse Coordinator (the Administrator); the process of searching the facility and grounds; ensuring the alarm had been re-activated; and drill was complete once residents were all accounted for. 6. Education reconciliation completed by the Human Resources Director to ensure staff received education prior to working. Training initiated on 11/22/2022 immediately upon return of Resident #1 and continued through 11/27/2022. Staff not educated by this date were educated prior to working their next scheduled shift. 7. A door check function was completed by a contracted service with no concerns noted. 8. On 11/23/2022, the DON completed 1:1 education with the Social Services Director (SSD) related to care planning and elopement assessment. 9. On 11/23/2022, the DON and SSD reassessed all sixteen (16) residents on the rehab unit for elopement utilizing care plans, progress notes, and admission assessment tool to determine potential elopement risk. The DON and SSD completed reviews of care plans for residents identified at risk for wandering to ensure care plans reflected accurate interventions. Included sixteen (16) residents on rehab unit. 10. On 11/24/2022, Red Box Alarm access was modified by the Administrator to the nurses' stations and Maintenance Director. Modified access implemented nurses' response to door alarms and Maintenance Director as a backup for key retrieval. 11. On 11/24/2022 the QA Committee reviewed the door audits, elopement education, door alarm education, assessments of residents deemed at risk for elopement/wandering. The QA Committee reviewed the data and determined it appropriate according to the events of Resident #1 elopement from the facility on 11/22/22. 12. A medication review was completed on 11/25/2022 by the Consulting Pharmacist for Resident #1 with no new orders given. 13. Resident was readmitted to the facility on [DATE], after discharge to a psychiatric hospital on [DATE], with documentation of medication review completed by the psychiatric hospital. Medication changes implemented consisted of Depakote 125 milligram (mg) change from two times a day (bid) to three times a day (tid), and Seroquel 75 mg by mouth (PO) bedtime changed to Seroquel 50 mg PO at bedtime, Seroquel 25 mg PO at AM. 14. Nursing readmission assessment completed on 12/13/2022 by LPN #5, with Resident #1 deemed a potential risk for elopement. Wander Guard remained in effect, although the 1:1 intervention was discontinued. 15. Following a second elopement from the facility by Resident #1 on 12/14/2022, Resident #1 was placed on 1:1 observation by Administrator and DON to remain in effect until secure unit placement was established. 1:1 observation completed by CNAs. Additionally, the dining room doors were locked when not in use to prevent access to the dining room emergency exit. 16. On 12/14/2022, a skin assessment was attempted, and a pain evaluation was completed for Resident #1 by LPN #13. 17. On 12/14/2022, the facility Administrator along with the DON completed an ad hoc QA meeting with the CNO and CC to discuss the interviews collected at the time of the event and the investigation preliminary to determine the root cause of the elopement to be dining room emergency exit door did not annunciate at a volume that staff could respond to, which allowed the resident to exit the facility. The Ad Hoc Committee implemented immediate corrective training with staff on shift on supervising residents, additional training was initiated at the time to include the Wander Guard system, care planning, and elopement assessments by the DON and the Administrator and continue with each staff prior to being assigned or reporting to duty and continue until 100% staff training was completed. 18. The Medical Director and Resident #1's daughter (Daughter #1) were notified of the elopement by the Administrator on 12/14/2022. 19. A change of condition assessment was completed by the DON on 12/14/2022. 20. As of 12/14/2022, current staff have been re-educated on the Elopement Policy with an emphasis on notifying the DON when a resident attempts to leave the facility, responding to alarms, not turning off alarms without ensuring residents were accounted for. This education was completed by the DON and/or a nurse manager and continued using train the trainer method. Current facility staff educated: Administrative Staff: 20 of 20; Licensed Nurses: 5 of 5; Certified Medication Aides: 6 of 6; Certified Nursing Assistants: 34 of 34; Dietary Department: 13 of 13; Housekeeping/Laundry Department: 17 of 17; Maintenance Department: 1 of 1; and Therapy: 16 of 16. Staff not educated were to be educated prior to their next scheduled shift. Agency staff were to be educated prior to working by a nurse manager. Newly hired employees were to be educated during orientation. 21. On 12/14/2022, current facility licensed nurses were re-educated on completing Elopement Risk Assessments and accuracy and to complete a new Elopement Risk Assessment if the resident was wandering or exit seeking and to notify the DON if/when a resident was exhibiting exit seeking behavior or wandering. Current staff educated: Licensed Nurses: 5 of 5; Administrative Nurses: 6 of 6; agency staff were to be educated prior to working by a nurse manager; newly hired employees were to be educated during orientation; elopement drills were completed on rotating shifts by the interdisciplinary team. 22. On 12/15/2022, current facility residents had an Elopement Risk Assessment completed by the nurse management team, consisting of the DON, LPN #11, LPN #12, and the Wound Care Manager. This assessment included ninety-seven (97) residents. 23. Wander Guard placement was initiated on 12/15/2022 for residents deemed at risk for elopement/wandering. Risk assessment was completed by Social Services Director (SSD) and LPN #13. Three (3) of ninety-seven (97) residents evaluated for elopement/wander risk were found to be at risk, in addition to Resident #1, and Wander Guard placement was initiated. Wander Guard placement and function checks were completed for current residents with Wander Guards in place and identified at risk for elopement/wandering by SSD. 24. Care plan reviews and updates were completed for residents identified at risk for elopement/ wandering by SSD. Four (4) care plans were reviewed and updated. 25. Facility wide elopement books were reviewed and updated to reflect residents at risk for elopement/wandering by SSD. 26. A care plan review and update were completed by the Wound Care Manager. Revision made to care plan to reflect Resident #1 as a high risk for elopement. 27. On 12/19/2022, The IDT conducted an Ad Hoc QA meeting to discuss the root cause analysis of Resident #1's elopement from the facility on 12/14/2022. The root cause analysis of the event reviewed was the door alarms of the facility's main dining room and keypad did not annunciate to be audible at the nearest nurses' station. Thus, Resident #1 exited the facility through the main dining room emergency exit door on 12/14/2022. The Ad Hoc QA committee initiated corrective action validating that alarms, resident Wander Guard, and facility doors were in working condition. 28. On 12/19/2022, the QA Committee reviewed the door audits, education on elopements, care plans, elopement assessments, elopement drills, door alarms, and assessments of residents deemed at risk for elopement/wandering. The QA Committee reviewed the data and determined it to be appropriate according to the events of Resident #1's elopement from the facility on 12/14/2022. 29. On 12/19/2022, procedure implemented for the DON or assigned designee to conduct education with agency staff before assignment related to elopement policy and procedure, notifications of elopement and exit seeking behaviors, alarms and functioning, elopement assessment accuracy, care planning revisions and interventions, elopement binders/resident information, maintaining equipment, and access to keys to override sounding alarms. 30. On 12/19/2022 the Ad Hoc Committee implemented system changes, audits, and continued to evaluate the remaining investigation through chart reviews, staff interviews, facility environment, and education to adjust the ongoing changes as needed. 31. The main dining room door was rewired by a contracted agency on 12/22/2022 to annunciate at the north nurses station. 32. Daily door checks were being completed to verify maglock function, alarm annunciation, and red box proper alarm validation, Wander Guard and keypad function by the interdisciplinary team (IDT). 33. Elopement drills were completed on rotating shifts by the IDT. The elopement drills were completed on the following dates/times: 12/14/2022 at 7:26 PM; 12/14/2022 at 11:59 PM; 12/16/2022 at 4:40 PM; 12/17/2022 at 11:45 PM; 12/18/2022 at 1:00 PM; 12/19/2022 at 4:47 PM; 12/21/2022 at 2:00 PM; 12/29/2022 at 5:40 PM; 12/31/2022 at 3:45 PM; 01/06/2023 at 1:00 AM; 01/07/2023 at 4:00 AM; 01/09/2023 at 9:00 AM; and 01/13/2023 at 1:33 PM. 34. The Administrator would perform Quality Assurance Review to ensure the door checks were being completed accurately via review of the records and/or observation of the IDT while performing the door checks. The review was to occur five (5) to seven (7) times weekly for four (4) weeks, then three (3) to five (5) times weekly for four (4) weeks then one (1) to three (3) times weekly for four (4) weeks then monthly for six (6) months. Areas of concern were to be addressed immediately. Findings were to be reported to the Quality Assurance Performance Improvement (QAPI) Committee monthly. 35. The clinical IDT were to review current facility residents Elopement Risk Assessments and care plan quarterly and with a significant change to ensure the Elopement Risk Assessment had been completed accurately and the care plan had been updated with appropriate interventions to prevent an elopement. 36. The DON was to perform Quality Assurance Review to ensure the clinical IDT had reviewed the Elopement Risk Assessment and care plans for new residents during the daily clinical meeting and current facility residents quarterly and with a significant change. The review was to occur one (1) to three (3) times weekly for four (4) weeks then weekly for four (4) weeks then monthly for six (6) months. Areas of concern were to be addressed immediately. Findings were to be reported to the Administrator with each review and the QAPI Committee monthly. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of 1:1 Monitoring documentation revealed Resident #1 remained on one-on-one (1:1) observation by staff from 1:30 PM on 11/22/2022 through 11/29/2022 when transferred to a psychiatric facility, with a break from 11:45 AM on 11/26/2022 through 1:30 AM on 11/27/2022 at which time Resident #1 was out of the facility. Review of Resident #1's EMR revealed a skin assessment was completed by, LPN #3 on 11/22/2022 at 1:40 PM alleged, with no concerns identified. Review of Resident #1's Physician's orders revealed an order dated 11/22/2022 at 3:15 PM, to apply a Wander Guard for elopement risk. Continued review of Resident #1's EMR revealed a progress note dated 11/22/2022 at 3:39 PM, completed by the DON documenting the Physician was notified. Interview on 01/24/2023 at 10:39 AM with CNA #3 revealed she was one (1) of the first staff assigned to Resident #1's 1:1 supervision after the 11/22/2022 elopement. Per CNA #3, when providing the 1:1 supervision of Resident #1 she was to always keep the resident in sight. Interview on 01/24/2023 at 8:08 AM, with the Medical Director confirmed he was contacted on 11/22/2022, of Resident #1's elopement, by the DON. The Medical Director stated he was reassured by DON that the facility was proactively ensuring this type of event would not happen again. Further interview revealed the DON also informed him that Resident #1 had been moved and relocated to a more secure unit and staff were providing 1:1 supervision of the resident pending a psychiatric hospitalization. Interview on 01/23/2023 at 9:08 AM, with Resident #1's daughter (Daughter #1) confirmed the facility had contacted her following the resident's elopement. She stated she had visited the evening of 11/22/2022, and knew they had changed Resident #1's room to a more secure unit and placed an alarm bracelet on him/her. Further interview revealed Resident #1 had been doing well when she saw him/her the evening of 11/22/2022. 2. Review of facility's documentation revealed on 11/22/2022 at 3:20 PM, the DON spoke with LPN #3 regarding Resident #1's behavior prior to elopement, and discussed timely notification to the unit manager, DON, and Administrator of any behaviors indicative of elopement risk, and documenting and care planning those behaviors. Continued review of the facility's documentation revealed a note erroneously documented as an 11/12/2022 note, for the 11/22/2022 incident involving Resident #1, signed by the Administrator. Review of the note revealed the Administrator met with the Therapy Director (TD) in response to door alarms, by calling a code green, and notifying the DON and Administrator. Interview on 01/23/2023 at 3:26 PM, with the DON confirmed she re-educated the TD and LPN #3 on the facility's elopement policy. She stated she spoke to them and told them if a resident had been exhibiting exit seeking behaviors, they should have contacted the Administrator and [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies and investigations, it was determined the facility failed to have an effective system in place to ensure residents who exhibited wandering behaviors or were assessed at risk for elopement received adequate supervision and monitoring for one (1) of sixty-four (64) sampled residents (Resident #1). The facility admitted Resident #1 on 11/12/2022 with diagnoses of Dementia with Agitation and assessed not to be an elopement risk on admission. The facility assessed the resident to have wandering behaviors on one (1) to three (3) days during the seven (7) day look back period. Resident #1 was documented to have been wandering the hallways and attempting to go into other residents' rooms on 11/18/2022; however, there was no documented evidence the facility reassessed the resident for elopement risk. Interview revealed Licensed Practical Nurse (LPN) #3 was administering medication on 11/22/2022 at approximately 10:00 AM, when an alarm sounded, and the LPN observed Resident #1 at the emergency exit. LPN #3 stated even though Resident #1 often talked about having things to do outside of the facility, she did not feel the resident was at risk for elopement, and did not inform the Charge Nurse or Director of Nursing (DON) of that information. On 11/22/2022 at approximately 1:15 PM, Resident #1 eloped from the facility without staff's knowledge and without the alarm on the door sounding. The facility was notified by a passerby at 1:18 PM of a resident walking down the sidewalk next to a major road with no shoes on. Staff responded and located and returned Resident #1 to the facility at 1:26 PM. Staff determined the Resident #1 had exited the unsecured Southwest door on the rehab unit, which was the same door the resident had triggered the alarm on at 10:00 AM that same day. The facility was unable to determine if the red box alarm on the door had been turned off by a staff person, and why the magnetic (mag) lock keypad alarm had not been sounding. Resident #1 was placed on one to one (1:1) supervision until sent out to a psychiatric hospital on [DATE]; and readmitted to the facility from the hospital on [DATE], with no report of exit seeking behaviors. Resident #1's comprehensive care plan had been revised on 11/22/2022, to include interventions of a Wander Guard (a device placed on a resident's ankle that caused a door also equipped with the Wander Guard to alarm when the resident exited the door), room change, and increased supervision by staff; however, the resident's one-to-one (1:1) supervision was not resumed. On 12/14/2022 at approximately 6:35 PM, the facility again allowed Resident #1 to elope from the facility without staff's knowledge, through an emergency exit door not equipped with a Wander Guard alarming system. Staff coming to work observed Resident #1 at the edge of the parking lot at 6:40 PM, and returned him/her to the facility. Per interview, alarms had sounded in the dining room which was in use at the time and with the doors closed the alarms could not be heard by staff at the nearest nursing station. The facility's failure to have an effective system in place to ensure each resident received adequate supervision and monitoring to prevent elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 01/07/2023, and determined to exist on 11/22/2022 in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F656, at a Scope and Severity (S/S) of a J; and 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F689 at a S/S of a J, along with Substandard Quality of Care. The facility was notified of the Immediate Jeopardy (IJ) on 01/07/2023. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 01/18/2023, alleging removal of the IJ on 12/20/2022. The State Survey Agency (SSA) validated removal of the IJ on 01/25/2023, prior to exit on 01/28/2023, and determined the facility had removed the immediacy of the Jeopardy on 12/20/2022, as alleged, before the initiation of the survey. However, additional deficient practice was identified at F689 at the scope and severity of G. The facility failed to protect residents from accidents for two (2) of the sixty-four (64) sampled residents, Resident #23 and Resident #255. On 12/26/2021, Resident #23 fell in his/her room, sustaining a fracture to his/her right arm, which required hospitalization. Resident #23 fell in the room again on four (4) additional occasions: on 04/08/2022, 07/10/2022, 09/14/2022, and 10/23/2022. On 08/28/2022, a staff member found Resident #255 lying on the floor, bleeding from a laceration on his/her forehead. The findings include: 1. Review of the facility's policy titled, Elopement/Exit Seeking, revised 09/02/2019, revealed cognitively impaired residents with the physical ability to leave the facility without assistance, and who had demonstrated or vocalized a desire to leave the facility were to be placed on a unit with an electronic monitoring system or similarly secured unit. Continued review revealed the resident's elopement risk would be care planned to reduce the potential for elopement and/or redirect the resident if an elopement attempt was made. Further review revealed staff were to promptly report any resident who tried to leave the premises to the Charge Nurse or Director of Nursing (DON). Review of Resident #1's Electronic Medical Record (EMR) revealed the facility admitted the resident on 11/12/2022, with diagnoses that included Dementia with Agitation, Anxiety Disorder Unspecified, and Insomnia Unspecified. Per review, of the admission Minimum Data Set (MDS) Assessment, dated 11/16/2022, for Resident #1 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) of four (4) out of fifteen (15), indicating severe cognitive impairment. Continued MDS review revealed the facility assessed Resident #1 with wandering behaviors exhibited one (1) to three (3) days during the seven (7) day look-back period. Continued review of Resident #'1 EMR revealed a Progress Note, dated 11/18/2022 at 1:00 PM, signed by Registered Nurse (RN) #1, the Rehabilitation (Rehab) Unit Manager which documented the resident had been wandering in hallways and attempting to go into other residents' rooms, demonstrating agitation or aggressiveness with redirection or assistance. Review of the Progress Note, dated 11/18/2022, revealed RN #1 contacted the Nurse Practitioner (NP) and received an order for Ativan (a narcotic medication used to treat anxiety and insomnia) prn (as necessary). Review of Resident #1's Comprehensive Care Plan revealed no documented evidence of a care plan addressing elopement or wandering behaviors for the resident prior to his/her elopement from the facility on 11/22/2022. 1. A. Review of the facility's incident report, dated 11/25/2022, revealed Receptionist #1 received a call on 11/22/2022 at 1:18 PM, of a potential missing resident walking on the sidewalk by a busy road next to the facility and was not wearing shoes. Per review of the report, Receptionist #1 notified the Director of Nursing (DON) and the Administrator, and the facility initiated an elopement drill at 1:20 PM. Continued review revealed Resident #1 was located by staff ambulating on the sidewalk next to a busy road at 1:23 PM, and was returned to the facility by staff at 1:26 PM. Review of the incident report further revealed Resident #1 had last been seen in his/her room by staff at approximately 1:15 PM, and had exited the facility's southwest door on the rehab unit without alarms sounding and without staff's knowledge. Review of the report revealed Resident #1 was assessed, placed on 1:1 observation, and moved to a different room. Per the report, the Physician and family were notified, Resident #1's medications (meds) were reviewed, and his/her care plan was reviewed and updated. Further review of the facility's incident report revealed staff education and elopement drills were initiated, doors were checked by an outside contractor and deemed to be functioning properly, and door checks for security were ongoing. Observation, on 01/04/2023 at 3:00 PM, of the path taken by Resident #1 on 11/22/2022, from the facility's emergency exit to the sidewalk by the road, revealed it was approximately one hundred and sixty (160) feet from where Resident #1 was located. Review of Resident #1's care plan revealed on 11/22/2022, the care plan was updated to include a care area noted for elopement/wandering with interventions which included: distracting the resident by offering pleasant diversions, structured activities, food , conversation, television, and books. Continued review revealed the area on the care plan related to Resident #1's preferences was left blank. Further review revealed additional interventions included: monitoring Resident #1 throughout each shift, documenting his/her wandering behaviors and attempted diversions; providing structured activities to include walking inside and outside, reorientation strategies including signs, pictures and memory boxes and toileting; placement of a wander guard to him/her related to elopement; and 1:1 supervision related to elopement. Review of the facility's 1:1 Monitoring documentation revealed the facility kept Resident #1 on 1:1 staff observation from 11/22/2022 at 1:30 PM through 11/29/2022 when the resident was transferred to the psychiatric facility. Continued review of the 1:1 Monitoring documentation revealed a break in the 1:1 documentation from 11/26/2022 at 11:45 AM through 11/27/2022 at 1:30 AM. Review of Resident #1's EMR revealed a skin assessment was completed by LPN #3 on 11/22/2022 at 1:40 PM with no concerns identified. Per EMR review, an elopement risk assessment was completed on 11/22/2022 by LPN #11 with Resident #1 noted as at high risk for elopement with a score of fourteen (14), with anything over a ten (10) indicating a risk for elopement. Further review of the elopement risk assessment revealed Resident #1's room had been changed and a wander guard placed, with orders for the wander guard at that time. Review of pharmacy documentation revealed the Consultant Pharmacist reviewed Resident #1's medications on 11/25/2022 and determined the resident was not on any medication that would cause or increase agitation. Resident #1 was started on Seroquel 25 mg at hour of sleep (hs) following the 11/22/2022 elopement. Review of a Time and Materials Ticket from an outside contractor revealed all facility doors had been checked on 11/22/2022, with all doors determined to be functioning properly. Interview, with Receptionist #1 on 01/20/2023 at 2:11 PM, revealed she received a call after lunchtime on 11/22/2022 from a lady who said she saw an older person on a nearby busy highway with no shoes on. Receptionist #1 stated as soon as she got off phone she went to the DON's (Director of Nursing) office, where the DON, Administrator, and all unit coordinators were at that time. She stated she announced a code green, and everybody went to search. Interview ,on 01/04/2022 at 2:26 PM, with Certified Nursing Assistant (CNA) #2, who worked the rehab unit where Resident #1 was initially admitted , revealed she described Resident #1 as very confused when he/she first arrived, constantly talking about wanting to go home, needing to go to the bank, or wanting to pick up vehicles from the mechanic. She stated Resident #1 had been unsteady upon arrival and staff had to walk with him/her. CNA #2 stated Resident #1 would wander around the unit, and although the resident would go to the doors, he/she would stop at the doors. Continued interview revealed CNA #2 had been working on 11/22/2022, assisting CNA #3 with a resident who required a Hoyer (brand of mechanical lift) lift to go to bed, at the far hallway with the resident's door closed. She stated when she and CNA #3 came out of that room, they heard the code green paged overhead. Per CNA #2, she and CNA #3 started checking resident rooms and noted Resident #1 was not in his/her room. According to CNA #2, she had observed Resident #1 in his/her room maybe five (5) minutes prior to assisting CNA #3 with the Hoyer lift. She stated she stayed on the unit while RN #1 and LPN #3 went other places to search. Further interview revealed when staff returned with Resident #1, they stated he/she was just outside the fence standing next to the road. CNA #2 further stated she sat with Resident #1 until the end of her shift at 3:00 PM, and it was her understanding other staff sat with Resident #1 until he/she was moved that evening to another unit. Interview on 01/04/2022 at 2:45 PM, with CNA #3 revealed Resident #1 was pleasant with wild moments, which she described as the resident would start yelling and nothing you could do would calm him/her down, you would just have to walk away. She stated Resident #1 would sometimes pack all his/her stuff, come to the door, and state he/she was going to catch the bus. Per CNA #3, just about everyday Resident #1 would yell about catching the bus and would talk about leaving the facility often. The CNA stated Resident #1 made comments in front of nursing staff about leaving. She stated she was working on 11/22/2022 with CNA #2 putting a resident to bed in that resident's room with the door closed. Continued interview revealed they heard the code green called overhead when they came out of the room. She stated they did a head count of all residents on the unit and could not locate Resident #1. According to CNA #3, she and a nurse ran down the road to catch Resident #1, who had been standing on the sidewalk right next to the road heading towards an intersection, with a jacket on and non-skid socks on his/her feet. Further interview revealed Resident #1 asked if we were taking him/her back to jail, and when staff told the resident they were taking him/her back to the building, he/she was okay with that. CNA #3 further stated when brought back in, Resident #1 laid down on the bed in his/her room. Interview with LPN #3 on 01/05/2022 at 9:01 AM, and again on 01/06/2022 at 1:20 PM, revealed Resident #1's baseline had been confusion. She stated Resident #1 would often talk about being in the market for a car, having a job interview later, or a meeting scheduled with an attorney, or would be waiting for a train. Continued interview revealed she described Resident #1's behavior as confused, rambling and stated if she had believed the resident to be an elopement risk, she would have stayed glued to him/her. LPN #3 stated she was working the morning of 11/22/2022, and Resident #1 had been up at the nurse's station that morning, looking for a train. Per LPN #3, around 10:00 AM, Resident #1 had set the alarm off on the Southwest emergency exit door of the unit, and when she observed the resident, he/she was holding his/her arms up as though startled and being arrested. Interview revealed LPN #3 had not observed Resident #1 attempting to exit, and it appeared he/she had accidentally set the alarms off by leaning on the door. LPN #3 stated as she did not have a key to the red box alarm on the door that was sounding, she asked the Therapy Director (TD) to turn off the alarm. The LPN stated she observed the TD turn the alarm off, then turned it back to the on position once it stopped alarming. Additionally, LPN #3 stated her intent had been to alert the Unit Manager, RN #1, about the incident of Resident #1 setting off the alarm when she returned to the unit from staff meetings; however, she had not considered it a priority as she did not believe Resident #1 to be exit seeking. Continued interview with Licensed Practical Nurse (LPN) #3 on 01/05/2022 at 9:01 AM, and again on 01/06/2022 at 1:20 PM, revealed when she left for her lunch break, Resident #1 had been standing at the nurse's station talking to CNA #12 (also a medication aide). She stated when she returned from her lunch break, Resident #1 was in his/her room, after having eloped from the facility. She stated she did a head-to-toe assessment of him/her and took vitals. Per LPN #3, Resident #1 had no injuries and was at his/her baseline confusion. Further interview revealed she had been told the alarms had not sounded. Interview further revealed it was believed one (1) of the housekeepers had disabled the alarms, as they had been in and out earlier in the day to go to a storage room; however, she was not there and did not know for certain. Interview with CNA #12, on 01/06/2022 at 10:20 AM, and again on 01/10/2022 at 5:00 PM, revealed she had worked with Resident #1 once or twice prior to his/her elopement. CNA #12 stated Resident #1 had been on one-on-one (1:1) at those times due to his/her behaviors, as the resident had aggressive behaviors and tried to strike a staff member. Per CNA #12, Resident #1 walked around the unit, and often talked about going home. Continued interview revealed CNA #12 had been working on 11/22/2022, when Resident #1 set off the door alarm that morning, and later on was at the nurse's station talking about going home. According to CNA #12, that afternoon she was on the medication (med) cart (as she was a medication aide) and noted Resident #1 was really confused and was again talking about going home. CNA #12 stated she encouraged Resident #1 to sit down, at which point the resident went back towards his/her room. Further interview revealed CNA #12 went back to passing medications (meds) and did not hear any alarms going off. She further stated if the alarm had gone off, it was quite loud and she would have heard it sounding. In addition, she stated she did not see Resident #1 again until staff brought him/her back inside after the resident eloped, at which point he/she had been placed on 1:1 supervision. Interview with RN #1, the Rehab Unit Manager on 01/05/2022 at 1:09 PM; on 01/06/2022 at 2:18 PM; and again on 01/23/2023 at 2:48 PM, revealed Resident #1 was kind of everywhere, and when asked to clarify that statement, she stated the resident had not appeared as focused on one (1) specific thing and walked around a lot. She stated Resident #1 would talk about wanting to play poker, and did other things not available at the facility, but never said anything specific about leaving the facility. According to RN #1, when asked about the progress note she made on 11/18/2022, Resident #1 had been wandering and attempting to enter other residents' rooms. She stated she did not consider Resident #1 as an elopement risk. RN #1 stated she was working on 11/22/2022; however, she had not heard about Resident #1 setting the alarm off earlier that morning, because she was probably in a meeting when that occurred. Continued interview revealed had she been aware of Resident #1 setting off the alarm that morning, it would have prompted her to put interventions in place to address that behavior. She stated interventions would probably have included moving Resident #1 to a more secure unit and 1:1 supervision, which were the common interventions for exit seeking residents. Per RN #1, when Resident #1 eloped, she was in her office on the far hallway of the unit and might not have been able to hear the alarm, even if it had been functioning correctly. Further interview revealed alarms had not been sounding when she received the phone call alerting her to a potential elopement. RN #1 further stated she had never known the red box or keypad alarms to not function unless the red box was turned off with a key and someone had punched in the code for the keypad alarm. In addition, RN #1 stated Resident #1 was moved to the South Unit on 11/22/2022, for increased supervision, as they had a Wander Guard system over there. Interview on 01/05/2023 at 9:45 AM, with the Housekeeping Supervisor (HS) and Housekeeping #2, revealed carpet cleaning machines used to be stored in a storage area on the rehab unit which was through the Southwest emergency exit. However, the machines had been moved to the nursing side as it was more convenient. The HS stated she used to have a key to the red box alarms on the doors, but after the incident of Resident #1 eloping, she now had to get nursing staff to turn off the alarms. Continued interview revealed the Housekeeping staff members had no idea who might have turned the red box alarm off on 11/22/2022, the day Resident #1 eloped. Interview on 01/05/2023 at 10:08 AM, with the Director of Therapy (DT), whose department was just outside the rehab unit, revealed she was working on 11/22/2022, and had Resident #1 on her caseload. She stated she had already been to the rehab unit that day, and last observed Resident #1 lying on his/her bed. Per the DT, she had been at her 9:00 AM morning meeting, when she heard a loud alarm on the rehab unit. Continued interview revealed LPN #3 asked her if she could come reset the door alarm, as Resident #1 had leaned up against the door causing it to go off. The DT stated she turned the red box alarm off, then back to the on position. According to the DT, she then went and provided Resident #1's thirty (30) minute occupational therapy session. Interview revealed later that day when the code green was called overhead, the alarms were not sounding on the rehab unit. She stated they had received several in-services since that day, on what to do when the alarm was sounding. Further interview revealed she had not been aware staff should have done a head count and ensured all residents were present when the alarm went off that morning. Interview with the Administrator on 01/05/2023 at 10:24 AM, revealed the red box alarm was not sounding when Resident #1 eloped from the rehab unit on 11/22/2022. She stated the alarms were working, but the red box alarm had been turned off, and she had not been able to determine who had turned it off. Per the Administrator, at the time Resident #1 eloped, various department heads had a key to the door alarms, which included therapy and housekeeping, as well as maintenance. She stated the keypad alarm was found to be working as well, although someone had punched in the code so it was not alarming. Continued interview revealed she had not been able to determine who had done that. She stated Resident #1 got out the exit door, traveled just outside facility property, and was located by staff. The Administrator stated the red box alarm keys were now kept on the two (2) nurse's stations with the narcotic room keys, and with maintenance to ensure proper oversight of alarms. Further interview revealed staff had been educated on the facility's alarm system and how to respond to alarms. The Administrator further stated Resident #1 was moved to a different unit which was considered more secure and was placed on 1:1 supervision until transfer to a psychiatric facility on 11/29/2022. Interview, on 01/05/2023 at 9:28 AM, with Maintenance revealed he had not been present for either of Resident #1's elopements on 11/22/2022. He stated prior to Resident #1's elopement on 11/22/2022 he had been checking all exits doors weekly for functioning, and since the elopement he had been checking the doors daily. He stated he checked to ensure the red boxes were on and functioning, and that the mag locks were locked. Interview, on 01/24/2023 at 8:08 AM, with the Medical Director revealed he had been contacted on 11/22/2022 by the DON of Resident #1's elopement. Per interview, he was reassured by the DON that the facility was proactively ensuring elopements would not happen again. Further interview revealed the DON further assured him Resident #1 had been relocated to a more secure unit and staff were sitting with him/her 1:1 supervision pending psychiatric hospitalization. Interview, on 01/23/2023 at 9:08 AM, with Resident #1's daughter (Daughter #1) revealed the facility had contacted her following Resident #1's elopement. She stated she had visited the evening of 11/22/2022 and knew they had changed Resident #1's room to a more secure unit and placed an alarm bracelet on him/her. Further interview revealed Resident #1 was doing well when she saw him/her the evening of 11/22/2022. Interview on 01/25/2023 at 3:15 PM, with the Consulting Pharmacist revealed she completed a pharmacy review on Resident #1 medications on 11/25/2022. She stated a review was requested as Resident #1 had been found outside of the facility. Continued interview revealed she reviewed Resident #1's medications looking for anything that would cause or contribute to Resident #1's agitation and the resident was not on any medication which would make him/her agitated. She stated Resident #1 was on Trazadone for anxiety, and prn Lorazepam for severe agitation, and was started on Quetiapine (med used to treat some mood/mental conditions) following the elopement. Interview on 01/23/2023 at 2:13 PM with the MDS Coordinator (RN #3), revealed she updated Resident #1's care plan to include the 1:1 observation and Wander Guard placement the evening of 11/22/2022. Review of Resident #1's EMR revealed a Progress Note from 11/29/2022 noting Resident #1 had been transferred to an inpatient psychiatric facility at 6:30 PM by ambulance. Continued review revealed a nursing readmission assessment completed by LPN #5 upon Resident #1's return on 12/13/2022 revealed the resident to be at risk for elopement. Review of the documentation from the psychiatric facility noted Resident #1 had been treated for a urinary tract infection (UTI) with Macrobid 100 mg bid (an antibiotic) while there. Per review, Seroquel 75 mg hours of sleep (hs) changed to Seroquel 50 mg hs and Seroquel 25 mg at 9:00 AM. In addition, Divalproex 125 mg twice a day (bid) for anxiety was increased to Divalproex 125 mg tid. 1. B. Review of Resident #1's EMR revealed the the resident was readmitted from the psychiatric facility on 12/13/2022, and reassessed as at risk for elopement. Resident #1 again eloped from the facility 12/14/2022 (the day after being readmitted ) as per review of the facility's incident report dated 12/19/2022. Review of the incident report revealed RN #4 arrived at the facility at 6:42 PM on 12/14/2022, and saw Resident #1 standing at the entrance to the parking lot as she pulled in. Per review, RN #4 observed Resident #1 with his/her thumb out (as if hitchhiking), and rolled her window down to ask the resident if he/she needed a ride. Continued review revealed Resident #1 told RN #4, he/she did need a ride to get to the bus stop. Review revealed RN #4 invited Resident #1 into her vehicle to get warm, and Resident #1 agreed and got into the car. The incident report review revealed RN #4 turned on her seat warmers and parked the vehicle, observing Resident #1's clothing to be barely wet (it was raining outside). Per the incident report, RN #4 called the Administrator and chatted with Resident #1 until the Administrator arrived at approximately 6:57 PM, and the resident was escorted back into the facility at 7:02 PM, with the wander guard intact on his/her right ankle. Review revealed during the investigation, Resident #1's wheelchair was observed in the doorway of the dining room, and it was determined the resident had exited the facility through the dining room emergency exit, with the alarms sounding. According to review of the incident report, the alarms were not able to be heard at the nearby nurses station with the dining room doors closed. Further review revealed Resident #1 was assessed, the Physician and family were notified, the care plan was reviewed and updated, and the resident was placed on 1:1 observation ongoing. Review of Resident #1's Comprehensive Care Plan revealed an elopement/wandering care plan with an intervention for 1:1 supervision was added on 12/14/2022, the day he/she eloped from the facility (the resident's care plan had also been revised with 1:1 supervision on 11/22/2022). Review revealed the elopement/wandering care plan interventions also included checking the resident's wander guard daily to ensure proper functioning which was added on 12/15/2022. Review of the facility's 1:1 Monitoring documentation revealed Resident #1 was placed on the monitoring upon return to the facility following the 12/14/2022 elopement. Review of an Invoice from a contract company, dated 12/29/2022 revealed on 12/22/2022 the company wired the dining room door to sound at the nurse's station when the emergency exit was opened. Interview with RN #4 on 01/24/2023 at 8:03 AM, revealed she had cared for Resident #1 when the resident was placed on the rehab unit. She stated she came in to work a little early on the evening of 12/14/2022, and saw Resident #1 standing in the parking lot in the rain, with his/her thumb out like he/she was hitchhiking. Per RN #4, she rolled down her window and asked Resident #1 if he/she needed a ride somewhere, and the resident replied yes, he/she needed a ride to the bus stop. RN #4 stated she encouraged the resident to get in and turned on the seat warmer and heat. Further interview revealed Resident #1 did not appear very wet, and she believed the resident hadn't been outside for very long. RN #4 stated she called the Administrator, who arrived quickly and the resident was returned to the facility with the Administrator. Interview with RN #3, the MDS Coordinator, on 01/23/2023 at 2:13 PM, revealed she updated Resident #1's care plan to include 1:1 supervision on 12/14/2022, after his/her elopement. In addition, she stated she also updated the resident's care plan for checking the functioning of his/her wander guard daily on 12/15/2022. Interview with CNA #6 (also a medication aide) on 01/05/2023 at 3:01 PM, revealed Resident #1 was very confused, hard to redirect, and combative at times. She stated on 12/14/2022 staff were up front waiting on meal trays, and she was passing meds. Per CNA #6, she remembered Resident #1 coming out into the hallway, flailing his/her arms and yelling something she could not understand. CNS #6 stated she continued passing meds, and within thirty (30) minutes she heard Resident #1 had gotten out. She stated Resident #1 had a wander guard on when brought back into facility; however, she had not heard any alarms going off. CNA #6 stated after Resident #1 came back in, staff were assigned to 1:1 supervision of the resident to keep an eye on him/her, twenty-four hours (24) a day seven (7) days a week. Continued interview revealed she had not observed Resident #1 around any of the doors, although he/she would walk up and down the hallway, and was always talking about leaving. CNA #6 further stated since Resident #1's elopement, the alarm now sounded at the nurse's station. Interview on 01/05/2023 at 3:27 PM, with CNA #8 who had been assigned as Resident #1's aide at times after his/her elopement to sit with him/her to provide 1:1 supervision. CNA #8 revealed she had been working on 12/14/2022, when Resident #1 eloped; however, she had been giving showers and had not heard the alarm or the code green announced. She stated when Resident #1 was returned to the facility, he/she had been a little wet, tired, and stated he/she was going to lay down. She stated she sat near Resident #1's bedside when he/she did so. Interview on 01/18/2023 at 8:47 AM, with CNA #29 revealed when they called the code green on 12/14/2022, she ran outside the facility looking for the resident. Interview with the Administrator on 01/05/2023 at 10:24 AM, revealed Resident #1 exited through the dining room emergency exit and had still been in the parking lot when a staff member pulled in for work and noticed the resident. She stated the doors worked and the alarms were supposed to and were sounding; however, during the investigation it was determined the alarm had not been audible at the nurse's station. Further interview revealed following the elopement, Resident #1 was placed on 1:1 supervision, and the doors to the dining room had been locked until the alarm was rewired by the contract company in order for it to be audible at the nurse's stat[TRUNCATED]