**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, document review, and facility policy review, it was determined the facility failed to ensure the care planned intervention to provide continuous line-of-sight monitoring was consistently implemented for one (1) of twelve (12) sampled residents (Resident #66). The facility developed a care plan that included an intervention for Resident #66 to always be within staff's line of sight when he/she was up in a wheelchair. However, on 12/14/2022, the facility failed to supervise Resident #66. Resident #66 exited the facility through the emergency/fire exit doors located on the Ocean Avenue Unit without staff's knowledge. Immediate Jeopardy (IJ) was identified on 02/10/2023 and determined to exist on 12/14/2022. The facility was notified of the IJ on 02/10/2023 at 6:05 PM. The State Survey Agency (SSA) received an acceptable IJ removal plan on 02/12/2023. The SSA validated the removal plan and determined the Immediate Jeopardy had been removed, before exit on 02/12/2023. Noncompliance was lowered to a scope and severity of D The findings include: Review of the facility's policy, titled Resident Care Plan and Physician Orders, revised March 2022, revealed, Care Plans shall focus on the treatment of actual and prevention of potential problems for each resident considering the resident's strengths and unique characteristics. The policy also stated, Care Plans shall be developed and implemented to meet the resident and/or guardian's preferences and goals and provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Review of the facility's job description for Certified Nursing Assistants (CNAs), dated as reviewed 2022, revealed, The general purpose of your job is to keep children who are clients of [the facility] safe at all times and to be respectful of the children and their families as valued customers. Review of the facility's job description for Staff Nurses (Registered Nurses and Licensed Practical Nurses), dated 2022 revealed, The general purpose of your job is to keep children who are clients of [the facility] safe at all times and to be respectful of the children and their families as valued customers. Review of an admission Record revealed the facility admitted Resident #66 on 06/30/2021 with diagnoses that included spastic quadriplegic cerebral palsy (the most severe type of cerebral palsy, a group of disorders that affect movement, muscle tone, balance, and posture, marked by the inability to control and use the legs, arms, and body), epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), restlessness, and agitation. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the Brief Interview for Mental Status (BIMS) should not be completed. Further review revealed Resident #66 had severely impaired cognitive skills for daily decision-making per a staff's assessment for mental status. The MDS indicated the resident used a wheelchair for mobility and required extensive assistance with locomotion on and off the unit. According to the MDS, the resident had not exhibited wandering behavior during the seven-day assessment period. Review of the care plan, dated as initiated 06/30/2021, revealed the resident was at risk for injury related to an inability to protect self from injury; self-mobility in bed, on mat and in wheelchair; and behavioral symptoms including resisting care, screaming out, crying out, entering other residents' rooms or unauthorized spaces, elopement, impulsivity; and had limited self-preservation skills. Review of an intervention dated 06/30/2021, indicated the resident was at risk for Wandering/Elopement and an intervention, dated 07/01/2021, revealed the resident must be in line of sight of staff while up in the wheelchair for safety. Review of the Long Term Care Facility-Self-Reported Incident Form revealed that on 12/14/2022 at approximately 2000 [8:00 PM], {Resident #66} exited the building through a fire door onto the patio in a wheelchair. Review of the facility's Continued 5 [Five] Day Follow Up report for the 12/14/2022 incident revealed the facility identified that Resident #66 was able to exit a faulty fire exit door due to damaged wiring in the ceiling that disabled the alarm, allowing the door to be opened without a proximity card. According to the report, the team members were all providing care in residents' rooms during the time the resident was able to exit through the fire doors during the beginning of a new shift. The facility identified that clear communication regarding monitoring and supervision of the common area had not occurred during shift change. Additionally, the report indicated while team members moved in and out of the area, no one had been directly assigned to monitor the common area as expected. On 02/09/2023 at 11:25 AM, review of the facility's video surveillance footage revealed at 7:46:21 PM, Resident #66 was at the fire exit door and exited the facility at 7:48:25 PM. At 7:56:08 PM, a staff member came to the door to get help with bringing Resident #66 into the facility. The resident was outside from 7:48:45 PM to 7:56:08 PM. Telephone interview, on 02/08/2023 at 7:10 PM with CNA #15, revealed she was assigned to take care of Resident #66 on 12/14/2022 from 3:00 PM to 7:00 PM. She stated prior to leaving the facility at 7:00 PM, Resident #66 was by the nursing station. CNA #15 stated she gave report to CNA #14 and believed she was taking the resident to his/her room or for a snack or a shower. According to CNA #15, she read the residents' [NAME] and care plans before taking care of the residents. She stated staff also gave report about resident care. CNA #15 stated she did not think Resident #66 required one-on-one supervision prior to the incident, but the facility normally had a sitter (Cottage Safety Monitor [CSM]) to supervise the residents. CNA #15 stated if they did not have a sitter, a staff member would have to sit with the residents. CNA #15 stated Resident #66 had not tried to get out of the door before the incident, and she did not think Resident #66 was at risk for elopement, but that he/she was just monitored like other residents in the common area. During a telephone interview, on 02/08/2023 at 6:22 PM, CNA #14 stated on 12/14/2022, she worked the night shift and was assigned to take care of Resident #66. She stated she saw Resident #66 in the common area at 7:00 PM before she began doing rounds on other residents. She stated she and the nurse were in the same room providing resident care when staff found the resident outside. CNA #14 stated at that time, she was unaware there was not a CSM in the common area to monitor the residents. The CNA stated she reviewed residents' [NAME]/care plans for information on how to take care of the residents and staff also did walking rounds and discussed resident care prior to each shift. Continued interview revealed the nurses updated the care plans if there were any changes; however, CNA #15 stated she was unaware, prior to the 12/14/2022 incident, that Resident #66 was required to always be within staff's line of sight when up in a wheelchair. Attempts were made to interview Registered Nurse (RN) #22, via telephone on 02/08/2022 at 7:41 PM, on 02/09/2022 at 6:35 PM, and on 02/10/2023 at 7:49 AM. Unsuccessful attempts were made via telephone on 02/09/2023 at 4:03 PM and 02/09/2023 at 6:35 PM to reach CSM #20, who was scheduled on 12/14/2022. During an interview, on 02/09/2023 at 12:40 PM, the Infection Preventionist/Quality Assurance Performance Improvement (IP/QAPI) Specialist stated on 12/14/2022, the facility was supposed to have a CSM on duty until 8:00 PM. However, CSM #20 clocked out at approximately 2:40 PM without notifying anyone. She stated staff should have recognized there was no CSM and made sure all residents were supervised in the common area, as required. She stated the incident happened at shift change while the staff were doing their rounds. During an interview, on 02/09/2023 at 3:48 PM, the Manager of Resident Care stated she updated the care plan after the incident, she thought by distracting the resident, the resident would be more occupied by the distraction instead of trying to leave. The Manager of Resident Care stated she was aware this might not prevent the resident from eloping but might distract the resident from being interested in going toward the exit doors. During an interview, on 02/10/2023 at 4:14 PM, the [NAME] President of Nursing (VPN) stated she expected staff to follow resident care plans and to constantly monitor the residents. She stated that the incident related to Resident #66 occurred because staff failed to supervise Resident #66 as care planned. During an interview on 02/10/2023 at 8:49 AM, the Administrator stated the 12/14/2022 incident occurred because supervision was not provided to prevent Resident #66 from exiting the building. She stated Resident #66 was in the common area and staff left the resident unsupervised while they did rounds. Further review revealed staff were present on the unit but did not keep Resident #66 in their line of sight. According to the Administrator, staff knew Resident #66's care plan required the resident to always be within staff's line of sight. She stated staff may have thought the CSM was present to monitor the residents, but either way, Resident #66 was not supervised as required. The Administrator stated she expected staff to follow the care plans and that staff should have recognized and supervised Resident #66. The facility provided an acceptable Immediate Jeopardy Removal Plan alleging removal of the IJ on 02/12/2023. Review of the IJ Removal Plan revealed the facility implemented the following: 1. The following action steps were taken to remove immediate jeopardy from Resident #66. The direct threat in which Resident #66 experienced an elopement was removed on 12/14/2022 when Resident #66 was brought back into the facility by a nurse. Actions taken to further remove the immediacy and severity of the threat included: a review and revision of the Care Plan for Resident #66 on 12/14/2022 by the Manager of Resident Care to add a risk of wandering and elopement along with resident-centered interventions. The interventions included: distraction and redirection and offering engaging activities to mitigate risk of exit seeking and elopement. Review of all residents' Care Plans was conducted to determine if any resident was affected by the same deficient practice of failure to provide line-of-sight supervision on 12/15/2022 by the Manager of Resident Care. No other residents were found to be affected as no other residents required line-of-sight supervision. The Care Plan assessment conducted by the Manager of Resident Care identified 16 residents at risk for elopement and wandering. On 12/15/2022, the Manager of Resident Care revised the Care Plans of the 16 residents identified at risk to include goals and resident-centered interventions to mitigate the risk of elopement including but not limited to distraction and redirection and offering engaging activities to mitigate risk of wandering and elopement. 2. Further action taken on 02/10/2023 included Mandatory Retraining and Notification of Immediate Jeopardy created by the Manager of Resident Care and implemented for all team members. This training included an attestation statement of requirement, responsibility, and expectation in reading, understanding, and following information found in the resident Care Plan and [NAME], before providing care to residents and implementing the plan of care for each resident including providing continuous supervision of residents in the community areas. The Standard of Care Audit Form was revised on 02/10/2023 by the Senior [NAME] President/Administrator to include monitoring elopement risk interventions to the Safety category of Care Plan Auditing Care Task. The Standard of Care Audit Form will be used by the Leadership Team including Manager of Resident Care, Manager of Training and Development, Neighborhood Nurse Managers, Manager of Respiratory Therapy, [NAME] President of Therapy, Manager of Support Services, Director of Medical Social Services, Director of Nursing, and [NAME] President of Nursing to document findings of audits of care delivery to ensure care delivery will be implemented according to the residents' Care Plan. Standards of Care Audits will be conducted weekly on at least ten (10) residents to ensure their person-centered Care Plan will be implemented as written. 9/26 Administrative, 48/90 Nursing, 43/70 CNAs, 2/11 Resident Enrichment Specialists, 13/28 Respiratory Therapists, 1/24 Ancillary Therapists, and 2/4 contractors have completed training as of 2/12/2023 at 9 AM [9:00 AM]. All team members will be required to complete the retraining prior to the start of their next shift. 3. The Medical Director was notified of the Office of Inspector General's finding of immediate jeopardy, including mitigation efforts that included, but were not limited to the review of all residents' care plans, implementation of dedicated team members to provide supervision of residents in the community areas, training of all team members, contractors, and students prior to providing care or service, and standard of care auditing to ensure care plan and physician's orders were implemented as written, on Friday, 02/10/2023, at 8:47 PM by the Senior [NAME] President/Administrator. 4. Outcome measures for completion of Standards of Care Audit Tools will be monitored weekly and tabulated monthly by the [NAME] President of Nursing and reported monthly to the IP/QAPI Specialist. The IP/QAPI Specialist shall report outcomes measures quarterly to the Quality Improvement Committee. The [NAME] President of Nursing shall monitor for trends in non-compliance and address concerns with team members when identified. The [NAME] President of Nursing shall report all findings to the IP/QAPI Specialist monthly for 12 months. IP/QAPI Specialist shall report outcomes measures quarterly Quality Improvement Committee for 12 months. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: The survey team conducted observations, record/document reviews, and interviews on 02/12/2023 to ensure the facility's removal plan was fully implemented and the immediacy was removed, as follows: 1. Review of Resident #66's care plan revealed the facility revised the care plan on 12/14/2022 with interventions that included distracting the resident from wandering by offering pleasant diversions (preferred toys), conversation, television, or a book. Observations of Resident #66 during the survey from 02/07/2023 through 02/12/2023 revealed the resident was within a staff member's line of sight during all observations. Staff provided supervision of the resident as required by the resident's care plan. An interview with the Manager of Resident Care on 02/12/2023 at 12:49 PM revealed the care plans for 16 residents (Residents #5, #10, #45, #39, #19, #46, #69, #64, #72, #52, #66, #56, #8, #58, #22, and #70), who were assessed at risk for elopement/wandering, were updated. Review of the care plans for Residents #5, #10, #45, #39, #19, #46, #69, #64, #72, #52, #66, #56, #8, #58, #22, and #70, revealed the facility revised the care plans with resident-centered interventions to address elopement prevention. Observations of these residents on 02/12/2023 revealed the facility had implemented their care plans. 2. A review of re-training documentation, dated 02/10/2023 through 02/12/2023, revealed the Manager of Resident Care provided retraining regarding understanding and following residents' care plan/[NAME] before providing care and implementing the care plan for each resident. Interview with the IP/QAPI Specialist, on 02/12/2023 at 9:40 AM revealed the agency staff that had returned to the facility had been re-trained, and the additional agency staff had been notified they were not to return to work at the facility until the training was completed. She stated she ensured all staff were trained prior to working their next shift. A phone interview with Nursing Supervisor #39 on 02/12/2023 at 11:45 AM revealed staff were responsible to review the care plan/[NAME] to be informed of residents' care needs. A phone interview with CNA #40 on 02/12/2023 at 11:50 AM revealed she received training related to reviewing the care plan/[NAME] and to read and understand the care plan/[NAME]. A phone interview with RN #41 on 02/12/2023 at 11:55 AM revealed she received training regarding reviewing care plans to make sure staff knew how to take care of the residents. During a phone interview with CNA #42 on 02/12/2023 at 12:10 PM, she stated she received training to always review the [NAME]/care plan and if there were any questions to ask the supervisor. A phone interview with CNA #43 on 02/12/2023 at 12:17 PM revealed she also she received training related to always reviewing the care plan/[NAME] prior to providing any resident care. During an interview with CNA #44 on 02/12/2023 at 12:25 PM, she stated staff were to review the [NAME] before the beginning of each shift and notify staff of any alerts on the [NAME]/care plan. An interview with Nursing Supervisor #45, on 02/12/2023 at 12:40 PM, revealed that, based on the training, staff were supposed to check the [NAME]/care plan before taking care of the residents. An interview with CNA #46, on 02/12/2023 at 12:50 PM revealed she recently received training that staff were to review care plans/[NAME] prior to taking care of the residents. Interview with CNA #47, on 02/12/2023 at 1:10 PM, revealed she received training that the care plans/[NAME] were to be reviewed before the shift and during the shift if needed. She stated the care plan had information about the care of the residents, their behaviors, and the care they required. 3. A review of an email to the Medical Director, dated 02/11/2023, revealed the facility notified him of the Immediate Jeopardy findings. 4. Interview with the IP/QAPI Specialist, on 02/12/2023 at 9:40 AM, revealed the agency staff that had returned to the facility had been re-trained, and the additional agency staff had been notified they were not to return to work at the facility until the training was completed. She stated she ensured all staff were trained prior to working their next shift. An interview with the IP/QAPI Specialist on 02/12/2023 at 1:03 PM revealed all staff were trained to review residents' care plan/[NAME] at the start of every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, document review, and facility policy review, it was determined the facility failed to provide effective monitoring and supervision to prevent elopement for one (1) of three (3) sampled residents reviewed for accidents (Resident #66). The facility assessed Resident #66 to be at risk for elopement and was care planned for him/her to always be within staff's line of sight when up in a wheelchair. However, the resident exited the facility undetected by staff on 12/14/2022 at 7:48 PM and was outside unsupervised for approximately eight (8) minutes. Immediate Jeopardy (IJ) was identified on 02/10/2023. The IJ was determined to exist on 12/14/2022, when Resident #66 exited the facility through the emergency/fire exit doors located on the Ocean Avenue unit and accessed the outside patio unsupervised for eight (8) minutes. The State Survey Agency (SSA) received an acceptable IJ removal plan on 02/12/2023. The SSA validated the Immediate Jeopardy had been removed, before exit on 02/12/2023. Noncompliance was lowered to a scope and severity of D The findings include: Review of a facility policy titled, Resident Monitoring and Supervision, revised March 2022, revealed the Facility shall provide resident monitoring and supervision as an intervention and a means of mitigating risks. Monitoring and supervision shall be determined based on the residents' assessed needs, including behavioral health needs, and identified hazards in the care environment. Levels of supervision may vary from resident to resident and from time to time for the same resident. Review of job descriptions for the facility's staff nurses (Registered Nurses and Licensed Practical Nurses) and for Certified Nursing Assistants (CNAs) revealed, The general purpose of your job is to keep children who are clients of [the facility] safe at all times and to be respectful of the children and their families as valued customers. Review of an undated facility training document titled, Cottage Safety Monitor: [Contract Agency Name] Training, revealed, Cottage Safety Monitoring shall be utilized during working hours on cottages where additional supervision is required to monitor residents and mitigate the risk of injury, abuse or neglect. The document also indicated the primary roles of Cottage Safety Monitors (CSMs) included, Provide continuous oversight and supervision of residents. Monitor mobile residents at all times in the community area. Maintain awareness of where residents are on the cottage, paying particular attention when residents leave the community area activities. Ensure continuous coverage of the cottage by delegating the CSM role to another available team member. The document indicated additional expectations of the CSMs included, When the CSM needs to leave the community area for breaks and meal times, team members on the cottages shall provide coverage and supervision until the CSM has returned. Review of the admission Record revealed the facility admitted Resident #66 on 06/30/2021 with diagnoses that included spastic quadriplegic cerebral palsy (the most severe type of cerebral palsy, a group of disorders that affect movement, muscle tone, balance, and posture, marked by the inability to control and use the legs, arms, and body), epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), restlessness, and agitation. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the Brief Interview for Mental Status (BIMS) should not be completed. Further review revealed Resident #66 had severely impaired cognitive skills for daily decision-making per an assessment for mental status. The MDS assessment indicated the resident used a wheelchair for mobility and required extensive assistance with locomotion on and off the unit. According to the MDS, the resident had not exhibited wandering behavior during the seven-day assessment period. Per the MDS, the cognitive assessment was the staff's assessment for mental status - they did not complete a BIMS. Review of a care plan, dated as initiated 06/30/2021, revealed the resident was at risk for injury related to an inability to protect himself/herself from injury; self-mobility in bed, on mat, and in wheelchair; behavioral symptoms including resisting care, screaming out, crying out, entering other residents' rooms or unauthorized spaces, elopement, impulsivity, and had limited self-preservation skills. Interventions included for staff to monitor for and respond to behavioral symptoms which placed the resident at risk for injury, as the resident was self-mobile in a wheelchair and had a RED Safety Circle Designation. An intervention dated as initiated 06/30/2021 indicated, Wandering/Elopement, and an intervention dated as initiated 07/01/2021 indicated the resident must be in line of sight of staff while up in wheelchair for safety. A review of an incident report, dated 12/14/2022 at 8:02 PM, revealed Resident #66 went out the back door of the facility after last having been seen by Registered Nurse (RN) #22 at approximately 7:00 PM in the common area. The report indicated the emergency exit door alarm did not sound to alert staff that the door had been opened. The report indicated Licensed Practical Nurse (LPN) #16 went outside for a break and saw the resident outside in his/her wheelchair, unattended. The report revealed LPN #16 attempted to take the resident back inside, but the resident held the wheels of the wheelchair and repeatedly said no. LPN then locked the brakes on the resident's wheelchair, went to the door, and called for assistance, after which LPN #23 came and assisted LPN #16 to get the resident inside the building. The report indicated upon entering the unit, all team members were in other residents' rooms. Further review of the facility's investigation revealed the resident was assessed to have no injuries and all facility doors were assessed to ensure proper functioning. Further review revealed the investigation indicated the door through which the resident exited the building was found to have a malfunctioning fire exit bar that did not alarm and allowed the door to open by just pushing the door. Continued review revealed that Resident #66 was able to exit the facility through the malfunctioning fire door while the team members who were assigned to the resident's unit were all providing care in other residents' rooms. The investigation revealed clear communication regarding monitoring and supervision of the common area had not occurred during shift changes. While team members moved in and out of the area, no one had been directly assigned to monitor the common area as expected. A review of an online Weather History report at (https://www.wunderground.com/history/daily/us/ky/louisville) revealed on 12/14/2022 at 7:56 PM, the temperature in the city where the facility was located was 56 degrees Fahrenheit (F) with no precipitation noted. Review of Progress Notes revealed a Social Services Note, dated 12/15/2022 at 5:15 PM, which indicated Resident #66 had a temporary elopement from the facility last night. Further review of the Progress Notes revealed a Parent/Guardian Contact Note, dated 12/15/2022 at 3:30 PM which indicated staff had a conference call with Resident #66's guardian and provided a recap of the resident's elopement. Observation on 02/07/2023 at 11:10 AM revealed Resident #66 in bed. Observation of Resident #66 on 02/07/2023 at 1:15 PM revealed the resident was sitting in a wheelchair participating in an activity with a staff member. During a telephone interview, on 02/08/2023 at 6:22 PM, Certified Nursing Assistant (CNA) #14 stated that on 12/14/2022, she worked the night shift (7:00 PM - 7:00 AM) and was assigned to Resident #66's hall that night. She stated that when she started her rounds, Resident #66 was in the common area, and CNA #14 was unaware supervision was not being provided by a CSM at that time. She stated she and RN #22 went into a room to assist other residents and did not see Resident #66 go outside. CNA #14 stated she was unaware that the exit door was malfunctioning prior to the incident with Resident #66. During a telephone interview, on 02/08/2023 at 7:10 PM, CNA #15 stated that on 12/14/2022, she was assigned to take care of Resident #66 from 3:00 PM to 7:00 PM. She stated the last time she saw Resident #66 was at 7:00 PM in the common area of the cottage when she gave report to CNA #14. She stated CNA #14 was assigned to take care of Resident #66 for the 7:00 PM to 7:00 AM shift on 12/14/2022. During a telephone interview on 02/08/2023 at 7:23 PM, LPN #16 stated on 12/14/2022 at 8:00 PM, she stepped outside from another unit to get some fresh air and noticed a resident sitting in a wheelchair in the grass near the patio area. She stated it was not cold or raining and that the resident was fully dressed. LPN #16 indicated she looked to see if any staff were with the resident but found no one. She stated she attempted to take Resident #66 back inside the facility, but the resident grabbed the wheels of the wheelchair and yelled no. The LPN stated she locked the wheelchair brakes and went to the door to yell for assistance. She stated no one came to help the first time she called out, but then LPN #23 came and helped her get Resident #66 back into the facility. Further interview revealed she was told RN #22 was assigned to Resident #66, but she was in another resident's room at the time of the incident. LPN #16 stated the supervisors asked about the monitors (CSMs), and she informed them that she did not see a monitor and that the monitors often left the area without telling anyone they were leaving. On 02/09/2023 at 11:25 AM, the SSA team reviewed the video footage for the date/time of the incident. The video footage timestamp at 7:46:21 PM revealed Resident #66 was at the exit door. At 7:48:25 PM, the resident exited the facility. At 7:56:08 PM, a staff member came to the door to get help with bringing Resident #66 back into the facility. The resident was outside from 7:46 PM to 7:56 PM. During an interview on 02/09/2023 at 10:09 AM, the Maintenance Director stated he was not aware of any doors not working properly prior to the incident on 12/14/2022 with Resident #66. He stated he was not notified about the door not working properly until the next day. He asserted that he checked the doors on a weekly basis but did not keep a log. He stated he expected staff to notify maintenance if they had any issues with the doors. During an interview, on 02/09/2023 at 12:40 PM, the Infection Preventionist/Quality Assurance Performance Improvement (IP/QAPI) Specialist stated that on 12/14/2022, the facility was supposed to have a CSM to monitor the residents in the common area until 8:00 PM, but the CSM (CSM #20) left at 3:00 PM without notifying anyone. She stated the staff did not realize there was no one monitoring the residents in the common area. During an interview, on 02/09/2023 at 5:14 PM, the [NAME] President of Nursing (VPN) stated after the elopement of Resident #66 on 12/14/2022, the facility immediately checked all the exit doors to ensure they were locking and alarming appropriately. He stated the exit door through which Resident #66 exited the building was fixed the following day and monitored until it was fixed. The VPN indicated she expected all facility staff to be responsible for the residents. During an interview, on 02/10/2023 at 8:49 AM, the Administrator stated that immediately after the incident on 12/14/2022, the door company was contacted and came that night to assess the door, which was fixed the next day. She stated all residents were accounted for to ensure resident safety. The Administrator indicated she expected staff to keep all the residents safe and prevent any type of injury. She stated the failure occurred because supervision was not provided to prevent Resident #66 from exiting the building. She stated the CSM was scheduled to work until 8:00 PM but left around 3:00 PM without notifying anyone. The Administrator stated the staff should have recognized this and supervised the resident. She stated Resident #66 was in the common area, and staff left the resident unsupervised while they did their rounds. She stated they were unaware the door did not work properly until after this incident. The State Survey Agency validated the facility had taken the following actions: 1. The following action steps were taken to remove immediate jeopardy from Resident #66. Further action was taken to remove the immediate jeopardy from Resident #66 including conducting 30-minute checks on Resident #66 immediately following the elopement throughout the night while Resident #66 slept from 12/14/2022 - 12/15/2022. The RN Clinical Supervisor circulated each Neighborhood on 12/14/2022 and confirmed the whereabouts and safety of all residents on all Neighborhoods. All residents were accounted for and safe. 2. Actions taken to further remove the immediacy and severity of the threat included a review and revision of the Care Plan for Resident #66 on 12/14/2022 by the Manager of Resident Care to add a risk of wandering and elopement along with personalized interventions which included but were not limited to distraction and redirection, offering engaging activities to mitigate the risk of exit seeking. A review of all resident Care Plans was conducted on 12/15/2022 by the Manager of Resident Care which identified 16 residents at risk for elopement and wandering. On 12/15/2022, the Manager of Resident Care revised the Care Plans of the 16 residents identified at risk to include goals and interventions to mitigate the risk of elopement. 3. The RN Clinical Supervisor confirmed that all exit doors were secured, locked, prox [proximity] card readers were properly functioning, alarms were sounding, with the exception of the Ocean Avenue Patio door. The Ocean Avenue Patio door through which the resident eloped was unlocked and no alarm was functional. The Ocean Avenue Patio door was then continuously monitored by a [Company Name] team member until the vendor arrived on-site on 12/15/2022 and repaired the door securing it and ensuring the door was working properly with the exception of 7:00 AM to 8:00 AM, during which time Resident #66 was off campus and other residents at risk for elopement were supervised by team members. 4. Actions taken to further remove the immediacy and severity of the threat also included checks of all exit doors every two (2) hours by the RN Clinical Supervisor on shift beginning 12/14/2022 documenting findings on the Neighborhood Emergency Door Rounding Log. The checks will be documented on the Neighborhood Emergency Door Rounding Log and will include the expectation to ensure the door was locked, could not be opened without using the prox card, alarm sounded when the fire egress bar was compressed, door opened after the fire egress bar was compressed for 15-30 seconds, door closed completely, and was locked following the check. The RN Clinical Supervisor on shift shall notify the Maintenance on-call team member if any issues were identified and assign a team member to continuously monitor the door until a Maintenance team member arrived. The RN Clinical Supervisors will continue checks until the door hardware has been replaced by a certified vendor and the vendor certified the door functioned as expected. RN Clinical Supervisors were trained on the expectation of door checks. 5. Further action included implementing routine door checks by Maintenance or Information Management Technology team members beginning on 02/10/2023 twice daily between 7:00 AM and 4:00 PM, and again between 4:00 PM and 10:00 PM. This will continue until the immediacy has been abated; the door hardware has been replaced; and, the vendor has verified the doors were fully functioning as expected. Team members or contractor will be assigned to supervise residents when in community areas to ensure residents remain in the building and will complete training prior to providing care. Routine door checks by Maintenance or Information Management Technology team members shall continue daily for 30 days, then weekly for 12 months. Door checks shall ensure: the door was locked; cannot be opened without using the prox card; alarm sounded when the fire egress bar was compressed; door opened after the fire egress bar was compressed for 15-30 seconds; door closed completely and was secure following the check. Maintenance and Information Technology team members completing door checks shall take immediate action to correct the identified issue and/or request the vendor to report to the facility and repair the door. Maintenance and Information Technology team members were provided retraining by the Chief Operations Officer on their role to check doors or will be trained prior to completing door checks. Maintenance and Information Technology team members signed an attestation of training and commitment. 6. Further action taken included the purchase of replacement delayed egress crash bar hardware and access control through the vendor on 2/10/2023 by the Director of Information Technology and the purchase of Alarm Mats on 02/08/2023 by the Director of Procurement to serve as a secondary alarm notification of a resident approaching an exit door. The alarm mats were expected to be delivered on 02/14/2023. Mitigation interventions included the above-noted door checks and Maintenance door checks shall continue until doors are certified by the vendor to function as expected. 7. Further action taken to remove the Immediate Jeopardy includes the implementation of unannounced rounding observations on each Neighborhood by leadership team members, including the Manager of Resident Care, Manager of Training and Development, Neighborhood Nurse Managers, Manager of Respiratory Therapy, [NAME] President of Therapy, Manager of Support Services, RN Clinical Supervisors, Director of Medical Social Services, and [NAME] President of Nursing, twice daily beginning on 12/20/2022 to ensure compliance of supervision expectations. Leadership team members document findings on the Neighborhood Supervision Compliance Auditing Tool. Observations were completed twice daily and will continue until replacement of the door hardware, then completed daily for 30 days and at least twice weekly for 12 months to ensure continued compliance. 8. Further action taken on 12/16/2022 included immediate mandatory retraining of all team members on their role and expectations for providing resident supervision while residents were in the community areas to prevent resident elopement. Supervision and Safety Training with Attestation of Commitment was created by the Manager of Training and Development and expectation for completion was communicated via email by the Senior [NAME] President/ Administrator on 12/16/2022 to all team members. All team members, contractors, and students were required to complete the mandatory training prior to the start of their next shift. 23/23 Administrative, 92/93 Nurses, 67/69 CNAs, 27/27 Respiratory Therapists, 30/30 Ancillary Therapists/Resident Enrichment have completed training as of 02/11/2023. Agency team members, if used, will complete retraining on providing supervision. They cannot be sitting at the door and providing supervision simultaneously. Supervision of residents while residents are in the community area prevents any resident elopement. 9. Further action taken on 02/10/2023 to mitigate risk included assigning team members, or select contractors, to provide dedicated supervision and monitoring of residents on all Neighborhoods from 8:00 AM to 10:00 PM while residents were present in common areas to prevent resident elopement, accidents, and hazards. 10. Further action was taken to remove Immediate Jeopardy on 02/10/2023 including Mandatory Retraining and Notification of Immediate Jeopardy created by the Manager of Resident Care and implemented for all team members. This training included Expectations for Resident Supervision and an Acknowledgement Attestation of Training and Expectations of Supervision. 09/26 Administrative, 48/90 Nursing, 43/70 CNAs, 02/11 Resident Enrichment Specialists, 13/28 Respiratory Therapists, 01/24 Ancillary Therapists, and 2/4 contractors have completed training as of 02/12/2023 at 9:00 AM. All team members, contractors, and students were required to complete the retraining prior to the start of their next shift. 11. Further action taken on 02/11/2023 included notification of contracted agency by the [NAME] President of Nursing that the individual contractor, who was assigned to Ocean Avenue on 12/14/2022, and left the Neighborhood prior to the end of her shift without notifying members of her departure was no longer permitted to return to the facility. Contractors will complete retraining prior to the start of their shift should they be permitted to provide services. RN Clinical Supervisor on shift shall ensure training was completed prior to the team member, contractor, or student providing care or service. To ensure coverage, the facility continued to ensure each individual had the required training prior to providing care or service. 12. Outcome measures for completion of [Company Initials] Incident Response Attestation and Immediate Jeopardy Notification and Retraining with Acknowledgment Attestation of Training and Expectations for Supervision, will be tabulated weekly by the Manager of Training and Development and reported weekly to the IP/QAPI Specialist for quarterly reporting to the Quality Improvement Committee for review and compliance. Outcome measures from the completion of Neighborhood Supervision Compliance Observation Tools will be tabulated and reported by the [NAME] President of Nursing weekly for 12 months. The [NAME] President of Nursing shall monitor for trends in non-compliance and address concerns with team members when identified. The [NAME] President of Nursing shall report all findings to the IP/QAPI Specialist monthly for 12 months. IP/QAPI Specialist shall report outcomes measures quarterly Quality Improvement Committee for 12 months. The State Survey Agency validated the facility took the following actions: 1. Review of Resident #66's medical record revealed the facility staff brought the resident back into the facility on [DATE]. The resident was assessed to have no injuries. Multiple observations were made of Resident #66 throughout the survey, and the resident was always in line of sight of staff. Resident #66 was observed from 10:00 AM to 3:00 PM on 02/11/2023 and from 10:00 AM to 11:20 AM on 02/12/2023, with no concerns identified. Staff provided ongoing supervision, as per the care plan. 2. Review of Resident #66's Progress Notes revealed RN #22 documented 30-minute checks on 12/14/2022 through 12/15/2022. A phone interview with CNA #14 on 02/08/2023 at 6:22 PM revealed the staff did 30-minute checks on Resident #66 from 12/14/2022 through 12/15/2022. An interview with the Administrator on 02/10/2023 at 8:49 AM revealed the resident was placed on 30-minute checks from 12/14/2022 to 12/15/2022. Interview with RN #17 on 02/09/2023 at 5:04 PM revealed she confirmed the safety and whereabouts of all residents on 12/14/2022. She stated all residents were accounted for and were safe. Review of Resident #66's care plan revealed the facility revised the care plan on 12/14/2022 with interventions that included distracting the resident from wandering by offering pleasant diversions (preferred toys), conversation, television, or a book. An interview with the Manager of Resident Care, on 02/12/2023 at 12:49 PM revealed on 02/10/2023, the care plans for 16 residents, who were assessed for elopement/wandering, were updated with interventions. Review of the care plans for Residents #5, #10, #45, #39, #19, #46, #69, #64, #72, #52, #66, #56, #8, #58, #22, and #70, identified by the facility as at risk for elopement/wandering, revealed the facility had revised the care plans with resident-centered interventions to prevent elopement. Observations of Residents #5, #10, #45, #39, #19, #46, #69, #64, #72, #52, #66, #56, #8, #58, #22, and #70 on 02/12/2023 revealed the facility was implementing their care plans. 3. During an interview on 02/09/2023 at 5:14 PM, the VPN confirmed that all other exit doors were secured, the card readers were properly functioning, and alarms were sounding. She stated the Ocean Avenue patio door through which the resident eloped was unlocked and the alarm was not functional at the time of the incident on 12/14/2022 so she ensured a staff member continuously monitored the Ocean Avenue patio door until a vendor arrived on-site on 12/15/2022. On 12/15/2022, the vendor repaired the door, securing it and ensuring the door was working properly. An interview with the Maintenance Director on 02/09/2023 at 10:09 AM revealed the door company came to the facility on [DATE] to assess the exit door and then returned at 8:00 AM on 12/15/2022 to repair the door. 4. Review of Neighborhood Emergency Door Rounding Logs revealed the RN Clinical Supervisors monitored all exit doors every two hours beginning 12/14/2022. Interviews with RN #17 on 02/09/2023 at 5:04 PM and Nursing Supervisor #45 on 02/12/2023 at 12:40 PM revealed they were monitoring all exit doors every two hours to ensure the doors were locked, could not be opened without using a proximity card, alarms sounded when fire egress bars were compressed, doors opened after fire egress bars were compressed for 15-30 seconds, closed completely, and were locked following the checks. Nursing Supervisor #45 indicated she was still checking the doors every two hours and if she found any concerns, she would notify maintenance or administration. 5. Review of Maintenance Door Checks revealed routine door checks were completed twice daily by the maintenance staff or information management staff beginning on 02/10/2023 between 7:00 AM and 4:00 PM and again between 4:00 PM and 10:00 PM. An interview with Maintenance on 02/12/2023 at 12:10 PM revealed since 02/10/2023, the maintenance department had monitored the doors twice daily. 6. A review of purchase invoices revealed the facility purchased delayed egress crash bar hardware and alarm mats. An interview with the Administrator on 02/10/2023 at 8:49 AM revealed the door mats and replacement egress crash bar hardware had been ordered for all exit doors. 7. A review of Neighborhood Supervision Compliance Auditing Tools revealed observation rounds were completed twice daily beginning 12/20/2022 by members of the leadership team. An interview with the Administrator on 02/10/2023 at 8:49 AM revealed leadership continued to do unannounced observations twice daily since 12/20/2022. 8. A review of training documentation dated 12/16/2022 revealed staff received Supervision and Safety Training. During a phone interview with CNA #14 on 02/08/2023 at 6:22 PM, she stated after the incident, she completed an online training about resident safety and staff responsibilities. During a phone interview with CNA #50 on 02/08/2023 at 6:59 PM, she stated she received retraining about resident supervision responsibilities after the incident on 12/14/2022. A phone interview with LPN #16 on 02/08/2023 at 7:23 PM revealed she had an online training after the incident on 12/14/2022. 9. Review of staffing schedules revealed staff were assigned to provide dedicated supervision on all Neighborhoods from 8:00 AM-10:00 PM daily, starting 02/10/2023. An interview with the Administrator on 02/12/2023 at 9:50 AM revealed staff knew that supervisors, along with staff, were to continuously monitor the residents at all times. She indicated staff were aware they were responsible to not leave the residents until someone else was monitoring or supervising them. 10. Review of training documentation dated 02/10/2023 through 02/12/2023 revealed staff were trained on the expectations for resident supervision. A phone interview with Nursing Supervisor #39 on 02/12/2023 at 11:45 AM revealed staff were responsible for the residents and, if there were no CSMs, the staff were responsible for the safety of the residents. She stated staff were responsible for monitoring the doors/residents at all times. A phone interview with CNA #40 on 02/12/2023 at 11:50 AM revealed she received training related to supervision responsibilities and monitoring the doors and residents at all times. A phone interview with RN #41 on 02/12/2023 at 11:55 AM revealed she received training on supervision and monitoring the doors and residents at all times. A phone interview with CNA #42 on 02/12/2023 at 12:10 PM revealed all staff were responsible to keep the residents safe at all times and if there was no CSM then they need to supervise/monitor the residents at all times. During a phone interview with CNA #43 on 02/12/2023 at 12:17 PM, she stated she received training that residents should always be in staff' line of sight while in the common area, and they were to always monitor/supervise all of the residents to make sure the residents were safe. During an interview with CNA #44 on 02/12/2023 at 12:25 PM, she stated the trainings were about how the staff were to protect the residents at all times, and if no CSM was present, the staff would rotate to make sure the residents were kept safe. She stated it was everyone's responsibility to keep the residents safe. During an interview with Nursing Supervisor #45 on 02/12/2023 at 12:40 PM, she stated the trainings were about supervision of the residents to include always having someone monitoring the residents. She indicated it was the staff's responsibility to monitor and supervise the residents. 11. A review of training documentation dated 02/10/2023 through 02/12/2023 revealed contract staff had been retrained to ensure each staff member had the required training prior to providing care and services to the facility's residents. Review of an e-mail, dated 02/11/2023, revealed notification to the contract company that the CSM on duty on 12/14/2022 was no longer allowed to work at the facility. An interview with the Administrator on 02/10/2023 at 8:49 AM revealed the issue with the CSM was addressed with the agency company. 12. Interview with IP/QAPI staff on 02/12/2023 at 9:40 AM, revealed they trained the agency staff that had returned to the facility and the additional staff had been notified they were not to return to work until this training was completed. An interview with Agency CSM #48 on 02/12/2023 at 1:14 PM revealed she received training on her roles and responsibilities as a CSM. She stated if a resident was in a common area, they were to monitor the resident and listen for any alarms. She stated she would keep the residents safe at all times.