Based on interview, record review, and review of the facility's policies, the facility failed to have an effective system in place to ensure residents were free from exploitation. As the representative payee for Resident (R) 17, the facility failed to properly manage and account for the R17's personal funds for one of four sampled residents (Resident (R)17). Review of R17's financial record titled Resident Statement Landscape which provided documentation of Resident Fund Management Service (RFMS), revealed large amounts of withdrawals, without a check and balancing system, beginning 12/22/2021 through 12/19/2023. Immediate Jeopardy (IJ) was identified on 11/15/2024 at 5:16 PM and was determined to exist on 12/22/2021 and Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, Freedom from Abuse and Neglect, F602, related to KY00044055. The facility was notified of IJ and SQC on 11/15/2024 at 5:16 PM. On 11/15/2024 at 5:16 PM, the facility Administrator, Director of Nursing (DON), and Care Consultant were provided a copy of the IJ Template and notified that the facility failed to ensure it safeguarded, handled, and tracked monetary funds as the representative payee for Resident (R)17. This failure allowed resident(s) to potentially be exploited by family, staff, and friends. The facility provided an acceptable plan for removal of the IJ on 11/20/2024 alleging the deficient practice constituted Past IJ. The survey team validated the IJ was removed on 08/23/2024, following the facility's implementation of the plan for removal of the IJ. The deficient practice remained at a D scope and severity (S/S) following the removal of the IJ. The findings include: Review of the facility's policy titled, Resident Trust Fund (RTF), effective date 11/10/2014 and last reviewed and revised 12/01/2018, revealed the facility was entrusted with safeguarding, holding, handling, and tracking certain monetary funds belonging to its residents per their written request. Continued review revealed no more than the monthly state allowable amount would be issued in the form of cash to any one resident. Further review of the policy revealed larger amounts of the residents money would be issued as a check and required a minimum of a 24 hour notice. The policy revealed the authorized signer must evaluate the check for reasonableness and support. Continued review of the policy revealed the BOM should report immediately any unusual activity, to include the resident requesting large sums of cash, to the Administrator and the Business Services Consultant. In December of 2023, the facility reported to the State Survey Agency (SSA) that the Social Security Administration investigated concerns related to possible exploitation of a resident's money, in which the facility was the Representative Payee (Resident (R)17). According to the report, during an annual routine audit, the Social Security Administration discovered the resident's money was not spent according to the Social Security guidelines. Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, dated 05/27/2016 with revision date of 09/15/2023, revealed the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property. The policy defined exploitation as taking advantage of a resident for personal gain through use of manipulations, initiation, threats, or coercion. Review of R17's Face Sheet revealed the facility admitted the resident on 12/17/2019 with diagnoses to include anxiety disorder, altered mental status, and transient cerebral ischemic attack (TIA). Review of R17's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Review of the Social Security Administration Correspondence to R17, dated 06/04/2020, revealed the Social Security Administration had chosen the facility to become her representative payee, and the facility would use the resident's money for her needs. Review of the Social Security Administration Correspondence to the facility, dated 10/11/2023, revealed the Protection and Advocacy conducted a review of the facility's residents. Further review revealed the Protection and Advocacy evaluated the facility's service provided as the residents representative payee, on behalf of the Social Security Administration. Review of the former Social Service Progress Note, dated 11/16/2023 at 2:45 PM, revealed the resident had verbal outbursts regarding her money. Per the progress note, R17's child had recently gotten out of jail and was calling her and asking for funds. Continued review revealed R17 was educated to spend money on self, but she still became angry. Review of R17's Progress Note, dated 11/22/2023 at 2:57 PM, revealed R17 had requested $2000 for her child and grandchildren for Christmas, monies (cash), and gift cards. The note stated the request was denied, and R17 became irate and demanded money. Additional review revealed R17's BIMS score was 12 on this date, indicating a moderate cognitive deficit. Review of the Protection and Advocacy Correspondence to the facility, dated 03/19/2024, revealed the Protection and Advocacy met with the facility on 11/02/2023 and reported its findings to the facility. Further review of the correspondence revealed the facility had inadequate controls for safeguarding beneficiary funds, receipts for large and unusual purchases, missing records not retained for two (2) years, and accounting reports were not returned on time. Review of the Social Security Administration Correspondence to the facility, dated 05/20/2024, revealed the facility had met with the Protection and Advocacy representative on 11/02/2023 to conduct a review of the facility's Corrective Action Plan. Further review revealed the Protection and Advocacy Analyst determined the facility had implemented its Corrective Action Plan and it was determined the facility had fulfilled its duties as the representative payee. Review of R17's document titled Resident Statement Landscape [Facility's Name] Resident Trust Acct, revealed debits titled as personal needs deductions, with no distinction between cash or gift cards, of $100 or greater per day as follows: 12/22/2021 - $2000; 02/23/2022 (1) - $100 (2) $22.00; 02/28/2022 - $100; 04/06/2022 - $200; 04/12/2022 - $2000; 05/09/2022 - (1) $60 and (2) $60; 06/17/2022 - (1) $150 and (2) $45; 06/22/2022 - (1) $2000, (2) $25, and (3) $45; 06/28/2022 - $180; 07/05/2022 - (1) $130 and (2) $500; 07/11/2022 - $200; 07/13/2022 - (1) $120 and (2) $30; 07/27/2022 - (1) $55 and (2) $65; 08/01/2022 - $290; 08/09/2022 - $3000; 08/22/2022 - (1) $50 and (2) $80; 08/25/2022 - (1) $1200 and (2) $20; 09/01/2022 - (1) $60 and (2) $40; 09/30/2022 - (1) $60, (2) $2760.96, and (3) $100; 11/22/2022 - (1) $1700 and (2) $60; 12/28/2022 - $1900; 01/12/2023 - $1773.19; 01/25/2023 - $150; 02/24/2023 - $1900; 03/23/2023 - $150; 03/30/2023 - (1) $75, (2) $18, and (3) $150; 04/12/2023 - $250; 05/08/2023 - $1000; 05/30/2023 - $850; 07/05/2023 - $2150; 08/08/2023 - $400; and 12/19/2023 - $300. Review of R 17's document titled Resident Statement Landscape [Facility's Name] Resident Trust Acct, dated 12/28/2023, revealed the facility reimbursed the resident 18,594. During interviews with R 55 on 11/11/2024 at 9:15 AM, R 44 on 11/11/2024 at 10:00 AM, and R 15 on 11/11/2024 at 9:00 AM, they stated they had no concerns with their funds at the facility, and the facility took good care of them. R 15's daughter was present during the resident's interview and reported no concerns. During an interview on 11/12/2024 with R 17, she stated she had no concerns with money other than she did not get enough of it. Further, she stated she just wanted to go home and did not want to discuss her funds. In an interview with Family Member (FM)17, on 11/15/2024 at 11:38 AM, he stated he, his wife, and children no longer received gift cards or cash from his mother, R17. FM 17 stated in the past his cousin or his father would pick up gift cards and large amounts of cash from the facility that the former Social Services Director (SSD) would leave in an envelope at the front desk to be picked up. FM 17 stated, if his cousin or his father were not able to stop by the facility to pick up the gift cards and cash, the former SSD would mail them to him, his wife, and kids, which was out-of-state where they resided. He stated he would call and text the former SSD on her personal cellular phone to make the request for gift cards and cash from R17. The FM 17 stated he was not sure if the former SSD informed R17 of the amounts requested for gift cards and cash. During an interview with the former BOM on 11/13/2024 at 1:15 PM, she stated she was now employed as the Social Services Assistant but had been the BOM during the time R17s funds were distributed to her family. The former BOM stated she could not recall the policy or process for the distribution of the resident's funds during that time. During an interview with the current BOM on 11/13/2024 at 10:25 AM, he stated he was not employed at the facility during 2023 and could not speak to R17's distribution of funds. He stated his tasks as BOM included keying in all deposits and keeping track of most all of the transactions. He stated the Administrator was in charge as the representative payee, but he did not know who was responsible in 2023 since he did not work at the facility then. He stated the process now was that residents made a request to the Assistant BOM. He stated then the BOM would check to see if the funds were available to cover the request. Further, he stated the facility would make out the check, and each check must have two signatures and proof of what the funds were for, with the Administrator signing the check last. He stated if the funds were not being spent for the resident's needs, the transaction would not go through. He stated if the request was for a large amount of money, usually above the resident's $60 monthly allowance, then that would be broken up in increments over a few days. During an interview with the Protection Agency Analyst Representative on 11/14/2024 at 8:57 AM, she stated her job title was representative payee analyst. She stated her department looked at the representative payee for social security payees. Per the interview, she stated she was familiar with R17's financial statements for November and December of 2023. However, she stated she was prohibited by the Social Security Administration to report her findings to anyone. She advised the State Survey Agency (SSA) Surveyor to ask the facility for reports of the Corrective Action Plan and the Verification of Correction, which were given to the facility. In an interview with the former Social Service Director (SSD), on 11/15/2024 at 11:46 AM, she stated she was unaware the facility was R17's representative payee. The former SSD stated R17 came to her office and made requests to send FM 17, his wife, and her grandchildren gift cards and cash. The former SSD stated once R17 made the request, the former Administrator would write her a check. The former SSD stated once she received the check, she would cash the check to make the requested purchases for R17. The former SSD stated if she was busy and was not able to attend to R17's request right away, R17 would come to her office angry, irate, yelling, and harassing her to get her request filled immediately. She further stated she gave R17's son, wife, and grandchildren gift cards and cash. Per the interview, she stated she did not feel as though she was doing anything wrong at the time, as she thought she was meeting the needs of the resident. Further interview with the former SSD, on 11/15/2024 at 11:46 AM, she stated she was never paid for goods and services. The former SSD stated in November 2023 the former BOM handed her a reconciliation form and told the former SSD she needed to complete the form. The former SSD stated the former BOM explained to her that a form should have been completed as the facility was the resident's representative payee. Further, the former SSD stated she was informed at that time that the previous BOM had applied on the facility's behalf to become the resident's representative payee so that the resident's monthly expenses could be covered. In continued interview, on 11/15/2024 at 11:46 AM, the former SSD stated an investigation was initiated by the Regional Business Office Consultant and Adult Protective Services. The former SSD stated in 12/2023 the investigation was completed, and she came to the facility and handed the former Administrator her resignation letter, which was effective immediately. The former SSD stated she was devastated to learn the facility was the resident's representative payee and would have never given the resident large sums of money to give away to her family and friends. In an interview with the former Social Worker (SW), on 11/14/2024 at 10:40 AM, she stated she remembered R17. She stated she remembered there had been a huge investigation about R17's funds, and when it was discovered no one at the facility knew the facility was the resident's representative payee (RP). She stated when R17 was first admitted , there were issues with her son taking funds. She stated that in order for the facility to receive payment, the BOM had to request to become the resident's RP, on behalf of the facility. The SW stated the previous BOM should have informed staff of the facility's responsibility as R17's RP, prior to leaving the facility. However, she did not tell anyone. During an interview with the Regional Business Office Consultant (RBOC) on 11/14/2024 at 3:00 PM, she stated she had been doing this for about 20 years. She stated her job duties included making sure facilities were following guidelines set forth by the Social Security Administration and assuring facility documents were filled out correctly. She stated she was still performing monthly random audits as guided by the Corrective Action Plan. She stated she discovered R17's discrepancies when she looked at the RP audits. She stated she found all the receipts for gifts and monies. She stated she felt the facility did not follow the RP procedures at that time, but the old policy was very vague. She stated the policy was revised after R17's incident to reflect segregation of duty and to include more specifics. In continued interview with the Regional Business Office Consultant (RBOC), on 11/14/2024 at 3:00 PM, she stated currently R17 was the only resident the facility had listed as its Representative Payee (RP), adding this facility had very few people that used the RP services. She stated the purchase of the gift cards was very excessive and staff was allowing R17 to have more money than she should have received. During an interview with the former Administrator on 11/14/2024 at 9:19 AM, she stated she was the Administrator from April 2023 to August 2024. She stated she reported the allegation of exploitation to the SSA back in December of 2023. She stated the report was based on an audit the Social Security Administration performed. She stated she really could not remember the findings, but until that time the facility was unaware they were R17's RP and that was why the distribution of monies happened. She stated the prior BOM had left employment at the facility, and no one knew the facility was R17's RP. She stated the former SW would purchase items for the resident, but was unsure of what really happened with R17's funds. In an interview with the former [NAME] President of the facility on 11/15/2024 at 4:33 PM, she stated the complaint reported was self-reported by the facility. The former [NAME] President stated she found out the Social Security Administration had visited the facility to complete the RP audits. The former [NAME] President stated the SSD bought everything R17 had asked for and that included purchasing gift cards and large amounts of cash available for family to pick up at the facility. The [NAME] President stated the facility reimbursed R17 in a check due to the facility taking responsibility and recognizing the facility failed to protect the resident from exploitation. She stated the former SSD was suspended while this incident was investigated. During an interview with the facility's current Interim Administrator on 11/14/2024 at 9:43 AM, he stated the facility acted as a gatekeeper for all transactions when assigned as the RP for a resident. He stated if the facility saw a resident was giving away monies to family, there would be a concern since those monies were there for resident needs and supplies. Further, he stated if there was any suspicious activity in a resident's account, the facility would look into it as soon as possible. The facility provided an acceptable IJ Removal Plan on 11/20/2024 that read verbatim: 1. Resident #17 account was audited by the Signature Compliance Department on 11/22/23 and credited by the facility for $18,594.15 on 12/13/23. The facility is the representative payee for Resident 17. The ResidentTrust Fund policy was reviewed and revised on 3/26/24 by the Signature Compliance Department and Signature Business Services Department to include requirements for disbursement logs for petty cash box, remaining funds deposited back into a resident trust account after shopping, direct debit, and representative payee. Resident 17 was interviewed on 8/19/24 by the Administrator. Resident stated she had no issues, complaints, or concerns on how her money was being handled at that time. Resident 17 was concerned about the personal needs allowance being $40 and was reminded by the Facility Administrator that the amount was increased to $60 in July 2024, and she expressed understanding. Business Services Consultant audited Resident 17's trust account on 8/19/24 to ensure there are no concerns related to the withdrawals, deposits, closed accounts, representative payee accounts, authorization agreements, trust fund petty cash box, and recordkeeping practices. No concerns were noted. Resident followed by psychiatric services and social services and remains at her baseline. Resident also continues to participate actively in group and individual activities with no concerns noted. Required updates are being provided to the Social Security Administration regarding representative payee account for Resident #17 by the Business Office Manager as indicated. Business Office Manager reviews Resident#17'strust account monthly to ensure all monies dispersed are for resident care needs and receipts/invoices are present to account for the monies dispersed. 2. The facility is the representative payee for no other residents. Out of an abundance of caution, starting on 8/19/24 and completed on 8/21/24, the Business Services Consultant audited all resident trust accounts to ensure there are no concerns related to the withdrawals, deposits, closed accounts, representative payee accounts, authorization agreements, trust fund petty cash box, and recordkeeping practices. Starting 8/19/24 and completed on 8/21/24, all current residents with a Brief Interview for Mental Status (BIMS) score of 8 or above were interviewed by the Social Services Director to inquire if they had any concerns about their trust account. Starting 8/19/24 and completed on 8/21/24, resident representativesfor residents with BIMSbelow8 were interviewed by Social Service Director to inquire if they had any concerns about the resident trust account. No concerns were noted. 3. The Resident Trust Fund policy was reviewed and revised on 3/26/24 by the Signature Compliance Department and Signature Business Services Department to include requirements for disbursement logs for petty cash box, remainingfunds deposited back into a resident trust account after shopping, direct debit, and representative payee. The Regional Business Services Consultant educated the Signature Care Consultant (SCC) on the ResidentTrust Fund Policy on 8/19/24. A posttestwasgiven and 100% was obtained.The sec educated the Interim Administrator on the Resident Trust Policy on 8/19/24. A posttest was given and 100% was obtained.The Interim Administrator educated the Director of Nursing, Social Service Director, Business Office Manager, and Assistant Business Office Manager on the Resident Trust Policy on 8/19/2024 and completed by 8/21/24. A posttest was given to these staff members after the education was provided. A score of 100% was required and anyone not receiving a 100% score was re-educated and provided another posttest. This process continued until a 100% score was obtained by all staff. All new Administrators, Business Office Managers, Social Service Directors, and Assistant Business Office Managers will be required to have all education and posttest during orientation by the Administrator or Regional Business Services Consultant prior to their working. A score of 100% is required and anyone not receiving a 100% score will be re educated and provided another posttest. This process will continue until a 100% score is obtained by all staff. The Signature Care Consultant educated the Interim Administrator, Social Service Director, Unit Managers, Staff Development Coordinator, Activities Director, Minimum Data Set Coordinator, Business Office Manager and Interim Director of Nursing on the Abuse, Neglect and Misappropriation of property policy starting on 8/16/2024 and completed by 8/20/24. A Post test was given to these staff members starting on 8/16/24 and completed by 8/20/24 after the education was provided. A score of 100% was required and anyone not receiving a 100% score was re-educated and provided another posttest. This process continued until a 100% score was obtained by all staff. The Interim Administrator, Social Service Director, Unit Managers, Staff Development Coordinator, Activities Director, Minimum Data Set Coordinator, Business Office Manager and Interim Director of Nursing educated all facility staff which included certified nurse aides, Kentucky Medication Aides, Licensed Nurses, Therapy staff, Environmental Staff, activities staff, maintenance staff and business office staff on the Abuse, Neglect and Misappropriation of property policy starting on 8/17/24 and completed by 8/22/24. Post test given to these staff members starting on 8/17/24 and completed by 8/22/24 after the education was provided. A score of 100% was required and anyone not receiving a 100% score was re-educated and provided another posttest. This process continued until a 100% score was obtained by all staff. Any Staff not receiving this education and posttest by 8/22/24 will receive this education and post test prior to being able to work their next shift. A score of 100% will be required and anyone not receiving a 100% score will be re-educated and provided another posttest. This process continued until a 100% score was obtained by all staff. The facility does not utilize agency staff. All new hires to the facility will receive education on Abuse, Neglect and Misappropriation of funds and posttest during orientation by the Administrator, Director of Nursing, or Staff Development Coordinator prior to their working. A score of 100% is required and anyone not receiving a100% score will be re-educated and provided another posttest. This process will continue until a 100% score is obtained by all staff. Starting 8/24/24 ongoing, the Business Office Manager conducts a monthly audit of all residents for whom the facility is the representative payee to ensure that all monies dispersed are for resident care needs and receipts/invoices are present to account for the monies dispersed. The Social Services Director, Business Office Manager, or Assistant Business Office Manager will conduct interviews of 5 random residents or resident representatives to determine if they have any concerns related to the resident trust account. This will occur weekly x 4 weeks, then reduce to monthly x 2 months. Results of the audits will be presented to the QAPI Committee for review and recommendation, once the committee determines the problem no longer exists the audits will be conducted on a random basis. The Regional Business Services Consultant will audit 2 resident trust accounts weekly x 4 weeks and then reduce to 2 resident trust accounts monthly x 2 months to ensure there are no concerns related to the withdrawals, deposits, closed accounts, representative payee accounts, authorization agreements, trust fund petty cash box, and recordkeeping practices. 4. An Ad Hoc Quality Assurance meeting was held on 8/19/24 with the Medical Director, the Facility Administrator, the Director of Nursing, and the Signature Care Consultant (SCC) regarding plan of correction that was formulated and implemented at that time on 8/19/24. The facility administrator presented the plan and information at the QAPI meeting on 8/19/24. The Medical director attended on 8/19/24 and was notified of implementation of plan of correction. The Medical Director reviewed the entirety of the plan and made no further suggestions. The Medical Director stated the plan was appropriate. Starting on 8/19/24 the Facility Administrator held a Quality Assurance meeting weekly for 4 weeks to review audits and discuss any concerns related to those audits regarding resident #17 exploitation. No concerns for exploitation or misappropri ati on were noted in the audits dating back to 8/19/24. QAPI meetings were then decreased to monthly for recommendations and further follow up regarding the above stated plan. No concerns for misappropriation or exploitation have been identified and 100% compliance has been maintained. Moving forward the facility administrator will continue to be the person who presents the information and audits at the QAPI Meetings, and the following members are expected to be present unless unable to attend: Facility Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Staff development Coordinator, Plant Ops Director, Social Services Director, Activity Director, Therapy Director, and MDS Coordinator. The QAPI Committee willdetermine at what frequency any ongoing audits will need to continue. The Administrator is responsible for implementing this plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's policies, and review of the facility's investigation, the facility failed to have an effective system to ensure residents' baseline care plans were developed and implemented to include instructions needed to provide person-centered care related to residents assessed to be at possible risk of elopement for 1 of 39 sampled residents, Resident (R) 6, who exited the facility on 07/10/2023 without staff knowledge. On 07/18/2024 at 7:27 PM, the Chief Executive Office (CEO) and Regional Nurse Consultant (RNC) were provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure elopement risk interventions were added to R6's baseline care plan to prevent elopement is likely to cause serious injury, impairment, or death and constituted IJ at 42 CFR 483.21 (F655). The IJ was determined to exist on 07/10/2023 when the facility discovered R6 had eloped from the building. The facility provided an acceptable plan for the removal of the IJ on 07/24/2024 at 11:27 AM. This plan alleged the IJ was removed, and the deficient practice was corrected on 07/14/2023, prior to the initiation of this investigation. The plan provided by the facility alleged the following: 1. On 07/10/2023 R6 was dressed in pants, pull over shirt, and tennis shoes. The temperature was 84 degrees Fahrenheit (F). R6 was placed on one-on-one supervision upon coming back into the facility on [DATE]. R6 was helped to her room and a head-to-toe assessment by the Director of Nursing (DON) was completed on 07/10/2023 with no injuries or concerns noted. R6 had a pain assessment completed by a licensed nurse on 07/10/2023 with no concerns identified. R6 had a new elopement risk assessment and a care plan update completed on 07/10/2023 by the RNC. R6 had a Brief Interview for Mental Status (BIMS) completed on 07/10/2023 with a score of 12 (moderate cognitive impairment). R6's physician and family were notified of the elopement on 07/10/2023. Certified Nurse Aide (CNA) 3 who was on her 15-minute break sitting in her car in front of the facility, saw R6 come outside. This CNA notified staff inside the facility by calling them on the phone while continually watching the resident until staff came out, and the resident went back inside the facility with staff. 2. A head count of all residents was completed by the Social Services Director (SSD) and the DON on 07/10/2023, and all residents were accounted for. The Director of Maintenance (DOM) rechecked all door locks and alarms, and all were in working order on 07/10/2023. The Regional [NAME] President (RVP) and Chief Executive Officer (CEO) also checked all door locks and alarms on 07/10/2023, and all were in working order. A review of all door checks for the previous 30 days before the elopement, 06/10/2023 to 07/10/2023, was performed by the RVP on 07/10/2023, and all checks had been completed. On 07/10/2023 the RVP reviewed elopement drills for the last 90 days, 04/10/2023 to 07/10/2023, and all had been completed. On 07/10/2023 the DON reviewed the last 30 days, 06/10/2023 to 07/10/2023, of events for current residents for any noted attempts of elopements. No concerns were identified. The RNC and the [NAME] President of Clinical Operations (VPCO) reviewed the last 30 days, 06/10/2023 to 07/10/2023, of progress notes looking for signs of elopement or exit seeking, and none were noted on 07/10/2023. All residents received a new elopement risk assessment on 07/10/2023 by the DON, Assistant Director of Nursing (ADON), Unit Manager (UM), or RNC. Any resident who was at risk based on the assessment had their care plan reviewed and revised as needed, and the elopement binders were reviewed to ensure residents were in the binder. 3. Initiated and completed on 07/10/2023, the RNC educated the CEO and the DON on the Comprehensive and Baseline care plan policies. Education was started on 07/10/2023 and was completed for all staff including clinical staff, housekeeping, dietary, administrative, business office, therapy, and activities by 07/11/2023 on the Comprehensive and Baseline care plan policies by the CEO, DON, UM, ADON, Minimum Data Set (MDS) Nurse Coordinator, or the RNC. A post-test was administered to all staff until a test score of 100% was achieved. Test questions were as follows: 1. What is a code green? 2. How do you know who is an elopement risk? 3. If you see a resident walking up to doors, pushing on doors, or talking of leaving, what should you do? 4. If a regular visiting family member asks for the door code, is it ok to give it to them? 5. If you hear a door alarm ringing, you go to the door, and you see no resident around, what should you do? 6. What is the difference in exit seeking and wandering? 7. How or where are interventions updated for exit seeking residents? 8. Where are the elopement books located? 9. What is tailgating? 10. What do you do when a code green is paged? 11. Do you let anyone out of exit doors if you are unsure if they are a resident? 12. How does anyone alert a nurse to a change in condition or behaviors of a resident? Any staff not educated by 07/11/2023, new staff, or new agency staff would be educated by the CEO, DON, ADON, UM, SSD, MDS Nurse Coordinator, or RNC prior to them working. Starting on 07/10/2023, the post-test on the education of policies would be given to 15 random staff weekly for 30 days, then 10 random staff for the next 30 days, and then five random staff for the next 30 days to make sure staff members were retaining knowledge. A grade of 100% was required or re-education was to be completed. The post-test was to be administrated by the CEO, DON, ADON, UMs, or SSD. Starting on 07/11/2023, elopement drills would be conducted daily for 10 days by the Director of Maintenance (DOM) or Weekend Manager and then monthly thereafter. Starting on 07/13/2023, all residents' progress notes would be read seven days a week for any exit seeking behavior or elopement concerns by the CEO, DON, UM, SSD, ADON, or RNC for 30 days and then Monday through Friday in the daily clinical morning meeting for 60 days. Any resident identified would have an elopement assessment completed, and if determined to be at risk, would have interventions put in place, such as the care plans reviewed/revised as needed and the elopement binder reviewed/revised as needed. Starting on 07/13/2023 the CEO, DON, ADON, UM, SSD, MDS Nurse Coordinator, or RNC would review all new admissions Monday through Friday with Saturday and Sundays being reviewed on Mondays. This would occur for 90 days to ensure any resident who was assessed on admission as being an elopement risk would have this on the baseline care plan or a comprehensive care plan and would be implemented addressing the elopement risk. 4. A Quality Assurance Performance Improvement (QAPI) meeting was held on 07/11/2023 to review this plan of correction. The QAPI committee members, the Medical Director, CEO, DON, Activities Director, UM, ADON, SSD, DOM, Therapy Director, and MDS Nurse Coordinator attended and would attend as able to do so. The Medical Director had no other recommendations. Starting on 07/11/2023 QAPI would be held weekly for four weeks. On 07/11/2023 the DOM, Rehabilitation Services Manager, MDS Nurse Coordinator, Activities Director, SSD, Medical Director, ADON, and the DON were present for the QAPI meeting. An Extended Survey was initiated on 07/15/2024, and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on 07/30/2024. Based on the findings of this survey, it was determined the IJ was removed and the deficient practice was corrected as alleged on 07/14/2023, prior to initiation of the investigation. Therefore, the IJ was determined to constitute Past Jeopardy. The findings include: Review of the facility's policy titled, Baseline Care Plan, revised 09/15/2023, revealed it was developed and implemented to increase resident safety and safeguard against adverse events that were most likely to occur right after admission. Per the policy, baseline care plans would be developed and implemented within 48 hours of a resident's admission. Review of the facility's policy titled, Elopement, revised 09/15/2023, revealed a care plan would be developed and implemented with interventions in place for each resident identified as an elopement risk. Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating she was moderately cognitively impaired. Review of R6's electronic medical record (EMR) Face Sheet, revealed the facility admitted the resident on 06/30/2023 with diagnoses to include urinary tract infection, adult failure to thrive, and anxiety disorder. Review of R6's admission Observation Detail List Report, dated 06/30/2023, revealed R6 was assessed to be at risk for elopement. Review of R6's Baseline Care Plan, dated 06/30/2023 revealed no documented evidence the facility developed a care plan to address R6's risk for elopement. Review of the Facility Reported Incident, dated 07/10/2023, revealed R6 was observed by Certified Nurse Aide (CNA) 3 walking in the front parking lot at 10:37 AM unsupervised. In an interview with Registered Nurse (RN) 3 on 07/18/2024 at 4:20 PM, she stated the initial or baseline 48-hour care plans were completed by the nurses on the floor. She stated care plans could be created or revised by the Licensed Practical Nurse (LPN) or RN. She stated observation assessment documentation did not trigger for anything to be added to care plans. She stated nurses on the floor were expected to revise the care plan for any change in the resident's condition. She stated the facility had 21 days to complete the comprehensive care plan (after the comprehensive admission assessment was completed). She stated she assumes care plan changes get discussed at morning meetings with the clinical team after progress notes were reviewed. In an interview with the Director of Nursing (DON) on 07/18/2024 at 2:15 PM, she stated according to the baseline care plan policy, when the resident was assessed as being at risk for elopement, the nurse should have developed and implemented a care plan with interventions in place for the resident identified as an elopement risk. In an interview with the CEO on 07/30/2024 at 4:30 PM, she stated care plans were essential to providing resident-centered care for the resident, and it was her expectation that staff followed the care plan and revised them as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's policies, review of the facility's investigation, and review of the website Weatherchannel.com, the facility failed to have an effective system in place to ensure residents' safety for 1 of 39 sampled residents (Resident (R) 6). On [DATE], R6 eloped from the facility unescorted, unsupervised, and without staff knowledge. On [DATE] at 7:27 PM, the Chief Executive Officer (CEO) and Regional Nurse Consultant (RNC) were provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure residents were provided supervision and protected from further elopement is likely to cause serious injury, impairment, or death and constituted IJ at 42 CFR 483.25 F689. The IJ at F689 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.25. The IJ was determined to exist on [DATE] when the facility discovered R6 had eloped from the building. The facility provided an acceptable plan for the removal of the IJ on [DATE] at 11:27 AM. This plan alleged the IJ was removed, and the deficient practice was corrected on [DATE], prior to the initiation of the investigation. The plan provided by the facility alleged the following: 1. On [DATE] R6 was dressed in pants, pull over shirt, and tennis shoes. The temperature was 84 degrees Fahrenheit (F). R6 was placed on one-on-one supervision upon coming back into the facility on [DATE]. R6 was helped to her room and a head-to-toe assessment by the Director of Nursing (DON) was completed on [DATE] with no injuries or concerns noted. R6 had a pain assessment completed by a licensed nurse on [DATE] with no concerns identified. R6 had a new elopement risk assessment and a care plan update completed on [DATE] by the RNC. R6 had a Brief Interview for Mental Status (BIMS) completed on [DATE] with a score of 12 (moderate cognitive impairment). R6's physician and family were notified of the elopement on [DATE]. Certified Nurse Aide (CNA) 3 who was on her 15-minute break sitting in her car in front of the facility, saw R6 come outside. This CNA notified staff inside the facility by calling them on the phone while continually watching the resident until staff came out, and the resident went back inside the facility with staff. 2. A head count of all residents was completed by the Social Services Director (SSD) and the DON on [DATE], and all residents were accounted for. The Director of Maintenance (DOM) rechecked all door locks and alarms, and all were in working order on [DATE]. The Regional [NAME] President (RVP) and Chief Executive Officer (CEO) also checked all door locks and alarms on [DATE], and all were in working order. A review of all door checks for the previous 30 days before the elopement, [DATE] to [DATE], was performed by the RVP on [DATE], and all checks had been completed. On [DATE] the RVP reviewed elopement drills for the last 90 days, [DATE] to [DATE], and all had been completed. On [DATE] the DON reviewed the last 30 days, [DATE] to [DATE], of events for current residents for any noted attempts of elopements. No concerns were identified. The RNC and the [NAME] President of Clinical Operations (VPCO) reviewed the last 30 days, [DATE] to [DATE], of progress notes looking for signs of elopement or exit seeking, and none were noted on [DATE]. All residents received a new elopement risk assessment on [DATE] by the DON, Assistant Director of Nursing (ADON), Unit Manager (UM), or RNC. Any resident who was at risk based on the assessment had their care plan reviewed and revised as needed, and the elopement binders were reviewed to ensure residents were in the binder. 3. Initiated and completed on [DATE], the RNC educated the CEO and the DON on the Comprehensive and Baseline care plan policies. Education was started on [DATE] and was completed for all staff including clinical staff, housekeeping, dietary, administrative, business office, therapy, and activities by [DATE] on the Comprehensive and Baseline care plan policies by the CEO, DON, UM, ADON, Minimum Data Set (MDS) Nurse Coordinator, or the RNC. A post-test was administered to all staff until a test score of 100% was achieved. Test questions were as follows: 1. What is a code green? 2. How do you know who is an elopement risk? 3. If you see a resident walking up to doors, pushing on doors, or talking of leaving, what should you do? 4. If a regular visiting family member asks for the door code, is it ok to give it to them? 5. If you hear a door alarm ringing, you go to the door, and you see no resident around, what should you do? 6. What is the difference in exit seeking and wandering? 7. How or where are interventions updated for exit seeking residents? 8. Where are the elopement books located? 9. What is tailgating? 10. What do you do when a code green is paged? 11. Do you let anyone out of exit doors if you are unsure if they are a resident? 12. How does anyone alert a nurse to a change in condition or behaviors of a resident? Any staff not educated by [DATE], new staff, or new agency staff would be educated by the CEO, DON, ADON, UM, SSD, MDS Nurse Coordinator, or RNC prior to them working. Starting on [DATE], the post-test on the education of policies would be given to 15 random staff weekly for 30 days, then 10 random staff for the next 30 days, and then five random staff for the next 30 days to make sure staff members were retaining knowledge. A grade of 100% was required or re-education was to be completed. The post-test was to be administrated by the CEO, DON, ADON, UMs, or SSD. Starting on [DATE], elopement drills would be conducted daily for 10 days by the Director of Maintenance (DOM) or Weekend Manager and then monthly thereafter. Starting on [DATE], all residents' progress notes would be read seven days a week for any exit seeking behavior or elopement concerns by the CEO, DON, UM, SSD, ADON, or RNC for 30 days and then Monday through Friday in the daily clinical morning meeting for 60 days. Any resident identified would have an elopement assessment completed, and if determined to be at risk, would have interventions put in place, such as the care plans reviewed/revised as needed and the elopement binder reviewed/revised as needed. Starting on [DATE] the CEO, DON, ADON, UM, SSD, MDS Nurse Coordinator, or RNC would review all new admissions Monday through Friday with Saturday and Sundays being reviewed on Mondays. This would occur for 90 days to ensure any resident who was assessed on admission as being an elopement risk would have this on the baseline care plan or a comprehensive care plan and would be implemented addressing the elopement risk. 4. A Quality Assurance Performance Improvement (QAPI) meeting was held on [DATE] to review this plan of correction. The QAPI committee members, the Medical Director, CEO, DON, Activities Director, UM, ADON, SSD, DOM, Therapy Director, and MDS Nurse Coordinator attended and would attend as able to do so. The Medical Director had no other recommendations. Starting on [DATE] QAPI would be held weekly for four weeks. On [DATE] the DOM, Rehabilitation Services Manager, MDS Nurse Coordinator, Activities Director, SSD, Medical Director, ADON, and the DON were present for the QAPI meeting. On [DATE] the Medical Director, CEO, UM, ADON, and the DON were present for the QAPI meeting. On [DATE] the Medical Director, CEO, UM, ADON, and the DON were present for the QAPI meeting. On [DATE] the Medical Director, CEO, UM, ADON, and the DON were present for the QAPI meeting. Weekly QAPI meetings were held to discuss reportables, elopement education, to review audits, to verify this plan was working, and to achieve compliance. QAPI meetings would then go to monthly thereafter. The QAPI committee would make any recommendations or changes to this plan if compliance was not being achieved. There were no concerns with compliance through the QAPI process. An Extended Survey was initiated on [DATE], and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on [DATE]. Based on the findings of the survey, it was determined the IJ was removed and the deficient practice was corrected as alleged on [DATE], prior to initiation of the investigation. Therefore, the IJ was determined to constitute Past Jeopardy. The findings include: Review of the facility's policy titled, Elopement, revised [DATE], revealed each resident should be evaluated for elopement risk upon admission and re-evaluated as needed. Additionally, a care plan would be developed and implemented with interventions in place for each resident identified as an elopement risk. Review of R6's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses to include urinary tract infection, adult failure to thrive, and anxiety disorder. Further review revealed R6 was discharged from the facility on [DATE] at 6:03 PM and sent to an acute care facility for an evaluation. Review of R6's admission Observation Detail List Report, dated [DATE], revealed R6 was assessed to be at risk for elopement. Review of R6's Baseline Care Plan, dated [DATE], revealed no documented evidence the facility developed a care plan to address R6's risk for elopement. Review of R6's quarterly MDS, with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident to have a BIMS score of 12 out of 15, indicating she was moderately cognitively impaired. The MDS also revealed R6 required partial/moderate assistance with ambulation. Review of R6's Progress Note, dated [DATE], revealed R6 was seen by Licensed Practical Nurse (LPN) 1, walking up the hall with her belongings packed stating she was going to be picked up by the sheriff. Review of R6's Progress Note, dated [DATE], by Registered Nurse (RN) 1 revealed R6 exhibited more confusion than she did on [DATE]. Review of the Facility Reported Incident, dated [DATE], revealed R6 was observed by CNA3 walking in the front parking lot on [DATE] at 10:37 AM unsupervised, and the facility was unable to determine the cause of the elopement. According to the internal investigation documentation, the Weather Channel revealed the outside temperature for [DATE] was 86 degrees F, sunny skies with a breeze. This was verified by the State Survey Agency (SSA) Surveyor at Weatherchannel.com. In an interview with R6's daughter and emergency contact on [DATE] at 9:22 AM, the daughter stated R6 was confused and recently diagnosed with dementia by two separate hospitals. The daughter stated R6 was admitted to the facility on [DATE] to be with her spouse, who had suffered a heart attack a couple of days after R6's arrival to the facility and was transferred to a local hospital. The daughter stated R6's spouse expired the day she eloped from the facility. The daughter stated the facility's staff reported to her that R6 walked out the front door. She stated the facility's staff told her R6 was dressed in normal clothing, and staff failed to recognize R6 was not a visitor. She stated the facility's staff told her R6 had told staff she was going to visit her spouse. In an interview with CNA3 on [DATE] at 12:00 PM, she stated she was the aide who witnessed R6 in the facility's parking lot. She stated the facility had conducted an elopement drill earlier that morning. She stated after the elopement drill, CNA3 went out of the building at 10:30 AM to take a 15-minute break in her car. She stated she saw R6 walking outside in the parking lot approximately 20 feet from the building's entrance, and she recognized R6. She stated she then called CNA1, who was working inside the building, to ask about R6 being outside. She stated staff immediately came out and helped assist R6 back inside. According to CNA3, R6 stated she was going to the hospital to see her husband. When CNA3 was asked how R6 exited the building, CNA3 stated, I'm guessing she followed someone out. CNA3 stated she was parked in the fourth spot on the north side of the facility, and R6 was seen walking away from the building toward the road and was approximately 20 feet from the front door at the round landscaping circle area. In an interview with LPN1 on [DATE] at 8:02 PM, she stated R6 was mostly confused. LPN1 stated she felt R6 was an elopement risk the day she was assigned to her on [DATE]. LPN1 stated she did not remember if the provider was notified regarding R6's increased confusion and wandering behaviors. A telephone interview with RN5, who was present at the time of the elopement and one of R6's nurses, was attempted on [DATE] at 3:00 PM and again at 7:45 PM. Voice messages were left by the SSA Surveyor for a return call; however, no return call was received. In an interview with the Business Office Manager (BOM) on [DATE] at 9:15 AM, she stated she was working the front desk the day of the incident. She stated her job during the elopement drill was to watch/check the front desk, front door, front porch, and front conference room. She stated she was not familiar with the resident and did not know what R6 looked like. The BOM stated she did not remember if she opened the door or if she was at the front desk at the time of the elopement. In an interview with the former Social Worker (SW) on [DATE] at 9:20 PM, she stated R6 was alert and oriented with intermittent confusion, and sundowning (when residents with dementia experience increased confusion and wandering from late afternoon into the night) was a concern. In an interview with the DOM on [DATE] at 3:45 PM, he stated he was working the day of the elopement; however, he did not know how R6 got out. He stated the surveillance cameras were updated after [DATE], and therefore no surveillance tapes were available for review. In an interview with the ADON on [DATE] at 1:13 PM, she stated R6 arrived at the facility to be with her spouse, who was a resident at the facility. She stated CNA3, who was taking a break and sitting in her car in the front parking lot, called into the building to ask if R6 was allowed to be outside unsupervised, and CNA3 was told no. She stated staff then went out to bring R6 back inside the building. She stated she attempted to call and notify R6's spouse, since he was listed as next of kin and was in the hospital, and then called R6's daughter and made her aware of the elopement. The ADON stated, I assumed the resident got out by tailgating behind someone else leaving. In an interview with the DON on [DATE] at 2:15 PM, she stated it was her expectation that the staff member responsible for managing the front door would ensure that no resident walked out behind any visitor, and they should verify the door was fully closed to prevent an elopement. In an interview with the CEO on [DATE] at 1:40 PM, she stated she was scheduled to be off work the day of the incident. She stated she was not in the building at the time of the elopement and was called into the facility after the elopement occurred. The CEO stated R6 made it to the front of the building and was brought back in by CNAs. She further stated elopement education was provided to all staff. The CEO stated she was unsure how R6 exited the building.