**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide a safe environment for residents. The facility's deficient practice had the potential to affect 24 of 24 residents who resided on the English Oak Terrace Unit. On 05/01/2024 a staff member was arrested under suspicion of arson after a fire occurred in Resident (R14) and R466's room. The facility failed to protect residents when a staff member, the Social Services Assistant (SSA), voiced frustration and threatened Resident (R) 14. On 05/01/2024 at approximately 4:45 PM, the Social Services Assistant (SSA) exited an elevator and stated to Certified Nursing Assistant (CNA) 2 he was going to get rid of R14. Subsequently, on 05/01/2024 the SSA was arrested for suspicion of arson after a fire occurred in the room of R14 and R466. Additionally, the fire was set while R14's roommate was in the room, R466. It was determined the facility's non-compliance with one or more requirements of participation caused or was likely to cause serious harm, serious impairment and/or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care were identified at 483.25 Free of Accidents, Hazards, or Supervision, F689. The IJ was identified on 05/10/2024 and was determined to exist on 05/01/2024 at approximately 4:45 PM when the SSA threatened to harm R14. The facility was notified of the IJ and provided a copy of the IJ template on 05/10/2024 at 5:34 PM. An amended IJ template was delivered to the facility on [DATE] at 4:03 PM. An acceptable IJ Removal Plan was received on 05/16/2024. The State Agency validated removal of the IJ on 05/17/2024 at 5:00 PM following the facility's plan for removal of the IJ. The findings include: Review of facility policy Safety and Supervision of Residents, revised July 2017, revealed the facility made resident safety, supervision, and assistance priorities. Review of facility policy Accidents and Incidents, dated July 2017, revealed it was the facility's responsibility to monitor its employees to ensure the safety of its residents. Review of the facility's Kentucky Handbook, revised July 2020, revealed in Section 1.4 General Safety and Security Policy, all company employees are responsible to maintain a healthy and safe work environment. Additionally, employees were to advise their supervisor of any known or potential security risks and/or suspicious conduct of employees, customers, or guests. Review of the Long Term Care Facility - Self-Reported Incident Form initial report to the State Survey Agency, received on 05/01/2024, revealed a fire occurred on 05/01/2024 at 4:57 PM, in the room of Residents (R) 14 and R466. Resident 14 was not in the facility when the fire occurred and R466 was in the room. Resident 466 required total assistance for mobility and ambulation. Continued review of the report revealed the facility's fire alarm was activated, the fire extinguished, and R466 was removed from the room and was evaluated by an emergency medical technician with no injury identified. Review of the facility's Long Term Care Facility - Self-Reported Incident Form final report/5-day follow-up revealed the fire department personnel initially stated the fire began from a power-wheel chair cord; but, upon further inspection discovered suspicious items in the room and contacted a fire investigator who cleared all facility personnel from the room and secured the room. After the investigation, the local police were notified. The local police then arrested the SSA on 05/01/2024, and charged him with arson. Further review of the facility's final report/5-day follow-up revealed immediately prior to the fire, Certified Nursing Assistant 2 noted suspicious behavior from the SSA, including SSA entering and exiting the room where the fire occurred. Review of the facility's video footage of the incident revealed on 05/01/2024, the SSA entered R14 and R466's room at 4:59:20 PM and exited the room at 5:00:18 PM. The SSA was in the resident room for approximately 58 seconds, and after exiting the room, the SSA walked away from the room, turned around and walked past the closed door and glanced at the residents' door at 5:00:52 PM. The fire alarm then sounded at 5:01:33, approximately 41 seconds later. Review of the facility's admission Record revealed the facility admitted Resident (R) 14 on 06/28/2023 with diagnoses including generalized anxiety disorder, schizophrenia, adjustment disorder with mixed anxiety and depressed mood, and post-traumatic stress disorder, unspecified. The facility assessed R14 on the quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) 03/19/2024, as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15. Additionally, the facility's functional assessment from the facility's MDS revealed R14 was independent regarding mobility with use of a motorized scooter. Review of the facility's admission Record revealed the facility admitted R466 on 06/20/2023 with a diagnosis of stroke, hemiparesis and hemiplegia on left side, and unspecified dementia. Review of R466's quarterly MDS, with an ARD of 03/29/2024, revealed the facility assessed him with a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment. Review of the facility's functional assessment from the facility's MDS of R466 revealed he was dependent on care regarding turning, repositioning, toileting, hygiene, and mobility. Review of the facility investigation form Investigation Interview Question and Responses (Employee), (IIQR) undated, revealed Certified Nursing Assistant (CNA) 2, noted on 05/01/2024 at approximately 4:45 PM, she observed the SSA getting out of the elevator and per CNA2, the SSA stated I'm going to get rid of this old fucker. When CNA2 asked the SSA to clarify who, the SSA stated [R14]. Review of the IIQR for Licensed Practical Nurse (LPN) #4, dated 05/02/2024, revealed R14 approached her earlier in the day upset as the SSA had not yet taken R14 to an area store. Additionally, LPN #4 stated when she informed the SSA about R14 waiting for the SSA to take him to the store, the SSA responded by displaying his middle finger and saying fuck [R14] and cussed profusely. Observation of the room of R14 and R466, on 05/09/2024 at approximately 8:20 AM, revealed no discernable effects of a fire other than fire extinguisher residue. Interview with R14, on 05/09/2024 at 9:01 AM, revealed on the morning of 05/01/2024, R14 asked the SSA to escort him to the store and the SSA agreed; however, the SSA did not show. R14 then stated he asked the SSA again and the SSA responded he had an emergency and was not able. Further interview revealed R14 stated maybe he [the SSA] got tired of me asking to do this, the [store] thing. Interview with CNA1, on 05/09/2024 at 10:31 AM, revealed approximately two to three weeks prior to the fire the SSA asked her which residents had cameras in their rooms. CNA1 stated she then escorted the SSA to the room of R14/R466 and pointed out the four cameras installed in the room. CNA1 stated she thought this was an odd question to ask but gave it no further thought. Interview with CNA2, on 05/08/2024 at 10:40 AM, revealed she observed the SSA enter and exit R14's room and shut the door a few minutes prior to the fire alarm sounding. Interview with Certified Medication Technician (CMT) 3 on 05/09/2024 at 11:17 AM, revealed that during the immediate aftermath of the fire, the SSA told her not to worry about R14 as the SSA had a feeling [R14] won't be around here much longer. CMT3 further stated she thought the comment odd but did not question it further. Interview with the Administrator in Training (AIT), on 05/09/2024 at 3:00 PM, revealed he could not recall when the SSA informed him that R14 was getting on him a lot about going to the store. Additionally, he stated the SSA told him that R14 was driving him crazy and the SSA could not get his work done because of assisting R14. Interview with the Administrator, on 05/08/2024 at 2:34 PM, revealed the facility was responsible for keeping residents safe, but it was difficult to predict when an employee may start a fire. Further, the Administrator stated he did not have a formal type of staff monitoring in place, prior to this incident (the fire on 05/01/2024). Since this incident, however, he stated he has provided education to all staff, including agency staff, regarding being aware of their surroundings and suspicious behaviors, from a resident or fellow staff member. Further, staff were provided education related to reporting any suspicious behaviors. In an additional interview with the Administrator on 05/09/2024 at 12:47 PM, he stated he was not present at the time of the fire on 05/01/2024. Further, he stated local law enforcement had already taken the SSA into custody by the time he returned to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility alleged removal of the immediacy of the IJ on 01/01/2022 as follows: 1. On 05/10/2021, Resident #112 was assessed using the Elopement Risk Assessment by Licensed Practical Nurse (LPN) #9. The resident was placed on 15-minute checks until he/she went to the hospital on [DATE]. The resident ' s care plan was updated. The resident has not had further elopements since 05/09/2021. 2. On 05/09/2021, the facility reviewed the State Operations Manual (SOM) and again on 02/03/2023, to go over the definition of elopement. The Interdisciplinary team (IDT), Administrator, Assistant Director of Nursing, Nurse Mangers, and Social Services reviewed the Wander Risk Assessment. Residents that were assessed to require a Wander-guard bracelet were placed in the binder located at each nursing station and front desk. Further, the residents assessed to be an elopement risk, care plans were updated. 3. On 05/10/2021, education began with all the facility staff. The Director of Nursing (DON) provided the education, and it was ongoing. Further, education was provided during all staff meetings on 09/2021 through 11/2021 after the Assistant Regional Director of Services identified potential issues and/or concerns during onsite visits through resident medical record audits and observations. Education that was included was on the Elopement Policy, Wandering, resident/resident representative expectations of signing out prior to resident leaving the facility, and missing resident protocol by the Administrator, DON, Nurse Managers, Social Workers, Admissions Staff, and Supervisors. 4. On 07/02/2021 through 07/27/2021, the Assistant Regional Director of Clinical Services assigned the Director of Clinical Services assigned the DON, Nurse Managers, Charge Nurses, and nurse supervisors, after completion of an onsite audit, to conduct an audit on wandering risk assessments. All residents were verified to have an updated risk assessment in their medical record. 5. On 07/02/2021, the Assistant Director of Clinical Services re-educated the DON and Administrator regarding their roles and responsibilities for following the facility's policies which included but was not limited to discharging against medical advice, elopement, and wandering oversight and supervision, QA process and QAPI Program. 6. On 07/29/2021 and 09/24/2021, the Quality Assurance and Performance Improvement meeting was held to review the facility's protocol and policy for elopement. The attendees included the Administrator, Medical Director, Director of Nursing, Assistant Regional Director of Clinical Services, Medical Records, Assistant Director of Nursing, Therapy, Housekeeping, and Activity Director. 7. On 07/29/2021 and 09/24/2021, the facility assessment was reviewed in the Quality Assurance Performance Improvement Committee to review the results of the audits and no changes were needed. Further, the QAPI committee reviewed any discharges or unplanned dischargers from 06/2021 through 12/2021, no concerns were identified. 8. On 08/01/2021, the DON, Nurse Manager, Supervisor or Charge Nurse evaluated all new admissions/re-admissions residents on admission to determine if a resident was triggered to be an elopement risk. The residents who triggered to be at risk for elopement would have a comprehensive person-centered care plan developed and implemented by the Minimum Data Set (MDS) nurse and IDT team, that included the resident's risk for elopement. If concerns were identified, it was discussed in the daily Interdisciplinary Plan of Care Meeting and the DON would report the concerns to the QAPI committee. 9. During the month of August of 2021, the Assistant Regional Director of Clinical Services assigned the Director of Nursing and Administrator to conduct elopement drills. A total of 2 element drills were completed. All elopement drills were reviewed with the Assistant Director of Clinical Services, the Director of Nursing and Administrator. The Emergency Plan for locating a missing resident was reviewed by the Assistant Regional Director of Nursing and the Administrator on 09/24/2021, with no changes indicated. 10. On 11/17/2021, the Governing Body (Regional [NAME] President) received verbal education per the Regional Director of Clinical Services regarding expectations of self-reportable incidents including but not limited to elopements and elopement versus against medical advice. The Assistant Regional Director of Clinical Services and Assistant Regional Director of Clinical Services increased onsite facility visits to 2-3 days per week to ensure that facility Administration and staff were following the Elopement Policy and Procedures. 11. On 12/01/2021 through 12/31/2021, annual competencies were completed, which included but was not limited to elopements. All the new staff received Elopement training upon hire, during new hire orientation, by the staff development coordinator. Staff who had not received the training, to include the agency staff, prior to 12/31/2021 received training prior to the start of their shift by the nursing scheduler, staff development coordinator, nurse management team, or supervisor prior to the start of their shift. Further, self-reportable incidents was reviewed by the Regional Director of Clinical Services and/or Assistant Regional Director of Clinical services on site no later than 72 hours following the incident. The Assistant Regional Director of Clinical Services kept a log of all the self-reportable incidents and was reviewed monthly by the Administrator and the Regional [NAME] President. The State Agency validated the IJ Removal Plan as follows: 1. Review of Resident #112 Admission/Readmission Assessment revealed the resident was accompanied by the paramedics, by ambulance on 05/10/2021. Further review revealed the resident refused to be checked by staff for a skin assessment. Review of the resident's Baseline care plan revealed the resident's care plan was revised to include 15-minute checks and the care plan included the resident was at risk for elopement. 2. Review of the SOM documentation, dated 2021, revealed the facility reviewed the definition of elopement. Review of the elopement binder revealed the facility had placed all residents to be an elopement risk in the binder. 3. Review of the facilities education, provided by the facility revealed education was provided to all staff from 05/2021 to 11/2021. Education provided included Abuse, Wandering Residents, Behaviors, Customer Service, and Infection Control. Review of the facility's Wandering and Elopement policy, revised on 05/17/2020, revealed the facility defined elopement as an unsafe wandering and the facility strived to prevent harm while maintaining at the least restrictive environment for the residents. 4. Review of the QA Audit-Wander guard Tool, dated 07/02/2021, revealed the residents were audited to ensure the residents that were assessed as an elopement risk had an MD order, Wander guard Bracelet, updated care plan, TAR, and were in the elopement book/binder. No concerns were identified. Review of the Care Planning Audit Tool, dated 07/27/2021, revealed the residents who were assessed as an elopement risk care plan was assessed to include the following: Had the comprehensive care plan been developed; Did the residents care plan identify and include areas that pertain to the residents diagnosis; Did the care plan match the resident ' s needs; Were assistive devices in place per the residents plan of care; Was there evidence that the care plan reflected an interdisciplinary approach to the development of the care plan; Did the care plan identify the residents individualized goals, preferences and choices; Did the care plan clearly show a description of the action to be taken and by whom; Did the care plan contain some evidence of supporting or encouraging the individual to self-care/manage their well-being; Was there evidence that the care plan had been reviewed; Did the care and services provided reflect the residents current functioning status; Did the Kardex reflect the resident specific assistance needed to ensure care and services were provided? Continued review of the Audit tool revealed it was signed off and reviewed on 07/29/2021. 5. Review of facility's document, dated 07/02/2021, revealed the ARDCS went over the roles and responsibilities with the Administrator and DON. Further, the ARDCS went over the facility's goals, leadership, and management expectations. The QA Process and QAPI Program and audits were discussed. Continued review revealed the Administrator, DON, and ARDCS, signed the document on 07/02/2021. 6. Review of the Quality Assurance Committee Meeting Minutes, dated 07/29/2021 and 09/24/2021, revealed the committee reviewed elopement drills with no concerns identified. Review of the sign-in sheet revealed the Administrator, DON, Medical Director, ADON, Social Service, Dietary manager, Dietitian, Therapy, Maintenance, Environmental Services, Activities, Admissions, and MDS attended the meeting. 7. Review of the Facility Assessment revealed the QA Committee revealed the results of the audits. There were no changes on concerns identified. 8. Review of the New admission worksheet revealed the residents were assessed to be an elopement risk and was care planned based on assessment. No concerns were identified. 9. Review of the Emergency Plan and Elopement Drills, dated 07/29/2021 and 09/24/2021, revealed no concerns identified. 10. Review of the document, dated 11/17/2021, revealed the Regional Director of Clinical Services met with the Regional [NAME] President to review the self-reportable incidents from the region. The Regional Director of Clinical Services advised that the DON and Administrator was expected to report any allegations to the Regional Director of Clinical and the Regional [NAME] President to meet regulations related to reporting. Further review of the document revealed the Regional [NAME] President and Regional Director of Clinical Services signed off on the document on 11/17/2021. 11 Review of the annual competencies form revealed the facility checked the competency of each staff in areas which included: resident rights, abuse, skin/wound care, medication management, and disaster planning. Continued review revealed staff were checked prior to the start of their shift. During an interview with the ARDCS, on 02/05/2024 at approximately 6:30 PM, she stated she reviewed the incident related to Resident #112's elopement and determined the facility needed additional training on the definition of elopement. She stated she retrained the Administrator, who left in November of 2021, and the DON. Further, she stated she put a Plan of Correction in place to address the concerns, with auditing the residents for changes in behaviors, assessing the residents to be an elopement risk, and updated the resident's care plans. Per the interview, she stated she audited the concern until the end of December. She further stated she had not had concerns with Resident #112 leaving the facility without staff supervision since 2021. Based on interviews, record reviews, and facility document and policy review, it was determined that the facility failed to provide supervision to prevent accidents related to elopement for one (1) of three (3) sampled residents, (Resident #112). Specifically, Resident #112, whom the facility assessed to have moderately impaired cognition and developed a care plan that directed staff to supervise as needed, left the facility without notifying staff on 05/09/2021. The facility failed to notify the police that the Resident was missing until approximately 18 hours after Resident #112 left the facility. On 05/10/2021 at approximately 10:00 AM, Resident #112 was found on the side of a highway, and the resident, who reported walking around all night, was transported by local Emergency Medical Services (EMS) to a local hospital for cold exposure. It was determined the provider's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified at 483.25, Free of Accidents Hazards and Supervision,F689. Additional IJ deficiencies were identified at 483.70 Administration, F835 and F837. The IJ began on 05/09/2021 at approximately 6:00 PM when Resident #112 exited the facility without the staff's knowledge. The facility was notified of the IJ and provided a copy of the IJ template on 02/02/2024 at 5:12 PM. An acceptable IJ Removal Plan was received on 02/05/2024. The IJ was determined to be to past, effective 01/01/2022. 1. A review of an undated facility policy titled, Emergency Procedure - Missing Resident, revealed, Resident elopement resulting in a missing resident is considered a facility emergency. The policy revealed, 2. Staff will implement the protocol for a missing resident upon discovering that a resident cannot be located. Further review of the policy revealed when a resident was missing 1. Announce a Code Pink with the resident's room/unit number. 2. Note the time that the resident was discovered missing. 3. Report to the nursing station to see if the resident was signed out. 4. Notify the Administrator, Director of Maintenance, and Director of Nursing if not on the premises. 5. Report to the resident's unit for briefing and instruction. 6. Initiate a thorough search by staff members to locate the resident. 7. If the search is unsuccessful after a period of ten (10) minutes, call the police to report the resident missing. The policy revealed, 11. Complete an incident report and follow the facility's incident reporting process. 12. Document the incident and events objectively in the resident record, including: a. Circumstances and precipitating factors. A review of an undated facility policy titled Discharging a Resident without a Physician's Approval revealed, A physician's order is obtained for discharges, unless a resident or representative is discharging himself or herself against medical advice. The policy revealed, 3. If the resident or representative (sponsor) requests discharge or leaves the facility on their own accord without the approval of the attending physician, the resident and/or representative (sponsor) will be asked to sign a release of responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members. 4. If a resident wishes to be discharged to a setting that does not appear to meet his/her post-discharge needs, or appears unsafe, the facility will treat this situation similarly to refusal of care, and will: a. discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; b. document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed; c. document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings; and d. determine if a referral to Adult Protective Services or other State entity charged with investigating abuse and neglect is necessary. The referral should be made at the time of discharge. A review of Resident #112's admission Record indicated the facility admitted the resident on 04/01/2021 with diagnoses that included acute kidney failure, stage 3 chronic kidney failure, cerebral infarction (stroke), muscle weakness, type 2 diabetes mellitus, cognitive communication deficit, major depressive disorder, varicose veins of the left lower extremity with an ulcer to the lower leg, essential hypertension, and heart failure. The admission Record revealed the facility discharged Resident #112 on 05/09/2021 at 6:00 PM. The discharged to, Signature, and Personal Effects Sent With, sections of the form were not completed. A review of Resident #112's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/06/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident required extensive assistance of one (1)staff member with dressing, toilet use, and personal hygiene; and required extensive assistance of two (2) or more staff members with transfers. The MDS revealed that Resident #112 required limited assistance (staff provide guided maneuvering of limbs or other non-weight bearing assistance) with locomotion off the unit. Further review revealed Resident #112's balance was not steady. The MDS revealed the resident was not steady and only able to stabilize with staff assistance when transferring from surface to surface. The MDS revealed the resident utilized a walker or wheelchair for mobility. Continued review of the MDS revealed the resident's overall expectation was to remain at the facility. A review of Resident #112's Care Plan revealed a Focus area initiated on 04/12/2021 that indicated the resident had cognitive impairment related to cognitive communication deficit. The facility developed interventions that directed staff to cue, re-orient, and supervise the resident as needed. Further review of Resident #112's Care Plan revealed a Focus area initiated on 04/02/2021 that indicated the resident needed assistance with activities of daily living (ADL) related to weakness. The facility developed interventions that directed staff to assist the resident with ambulation, locomotion, toileting, and transfers. The Care Plan revealed Focus areas initiated on 04/02/2021 related to pain; a wound to the left lower extremity that was at risk for developing infection and/or deterioration; risk for falls related to weakness; diagnosis of diabetes and risk of complications; risk for bleeding and bruising related to Plavix (a blood thinner) medication use; and risk for cardiac issues related to heart failure, hyperlipidemia, and hypertension. A review of Resident #112's Care Plan revealed no documented evidence the facility planned for the resident to leave the facility nor go to a local store without staff supervision. A review of Resident #112's Progress Notes dated 05/09/2021 at 6:36 PM, electronically signed by Licensed Practical Nurse (LPN) #2 (a charge nurse), revealed Resident #112 walked past LPN #2 in the hallway heading back to their room, LPN #2 called out the resident's name, and LPN #2 witnessed the resident leave through double doors. The note revealed LPN #2 called the receptionist at the front desk and asked if Resident #112 left the building. The note revealed the receptionist reported she saw a resident leave the building. The note revealed LPN #2 notified the weekend supervisor, Registered Nurse (RN) #3 and checked the parking lot for the resident. The note revealed LPN #2 then walked to the grocery store next door to the facility to check for the resident. The note revealed LPN #2 witnessed Resident #112 checking out with the cashier at the grocery store and encouraged the resident to return to the facility. Continued review revealed the resident looked at LPN #2 but did not respond. LPN #2 walked out to the front of the store while on the phone with Resident #112's Responsible Party (RP) and another family member, and the resident was following behind. The note revealed LPN #2 turned around to check on the resident, and the resident was missing. According to the note, LPN #2 re-checked the grocery store and parking lot and could not locate Resident #112. The note revealed the nurse returned to the facility to look for the resident and met RN #3 at the front door. RN #3 asked about the resident, and LPN #2 explained what she had witnessed. The note revealed RN #3 went to check the grocery store. Further review of the note revealed LPN #2 was on the phone with the resident's family during the entire search. The note revealed the resident's family had also attempted to reach the resident on a cellular phone, but they were unable to reach the resident. The note also revealed RN #3, the Director of Nursing (DON), and the Administrator were notified. A review of Resident #112's Progress Notes dated 05/09/2021 at 7:47 PM revealed DON #27, a previous DON, documented that the family notified the facility that Resident #112 had discharged AMA (against medical advice), which the family expected. The note revealed the family was in the process of locating the resident by calling the resident's friends. DON #27's documentation revealed a discharge form would be given to a family member. According to the note, the resident's physician was notified of the discharge. A review of Resident #112's Progress Notes dated 05/10/2021 at 10:31 AM, titled Interdisciplinary Note, revealed Administrator #54, a previous Administrator, documented that Nurse Practitioner (NP) #38 was present during a discussion of Resident #112's AMA discharge the day before. According to the note, NP #38 stated she was not surprised by the resident's discharge because the resident told her the resident had been homeless in the past and was used to going out on their own. A review of an undated facility document titled Initial revealed Adult Protective Services (APS) was at the facility on 05/11/2021 (two days after the resident left the facility without staff knowledge) related to Resident #112's AMA discharge over the past weekend. The report revealed the facility notified APS that, per the resident's family, this was normal behavior for the resident and that the resident used to live on the streets. According to the document, the resident was alert and oriented and was their own responsible party with BIMS of 10. The document revealed the resident was readmitted to the facility on [DATE], and a family member was working to get power of attorney. Continued review revealed the facility placed the resident on 15-minute checks to make sure the resident settled back into the facility. The document revealed a care plan conference would be set up with the resident and their family member to discuss not leaving AMA in the future. A review of an undated facility document titled 5-Day revealed the resident's elopement risk assessment indicated the resident was at low risk for elopement (score of 2 of 23) and a Wanderguard bracelet (a bracelet placed on a resident that alerts staff when a resident exits a door equipped with a Wanderguard system) was not placed because the resident's cognition was intact. The document revealed on 05/09/2021, Resident #112 went to a store and bought snacks at approximately 5:45 PM; when the resident did not immediately return, the weekend supervisor (RN #3) went to check on the resident. The report revealed that when RN #3 did not find the resident at the store, she notified the DON, who called the Administrator at approximately 6:04 PM. The document revealed that the Administrator drove along the road looking for the resident but did not find the resident. The facility document revealed the facility contacted the resident's family and notified them the resident had left. The document revealed the Administrator verified with the store's video footage that Resident #112 entered the store at approximately 5:45 PM and left at approximately 5:56 PM with a bag of groceries. The document revealed the resident was wearing a baseball cap and a jacket. According to the document, the resident's family member did not want to file a police report as they considered this normal resident behavior. The document revealed that on 05/10/2021 at 11:24 AM, approximately 18 hours after Resident #112 left the facility, the police were called, and a missing person report was filed. The document revealed that at 12:02 PM on 05/10/2021, the resident's family arrived at the facility and notified them that the resident had been found and was in the emergency room (ER). The document revealed that the facility concluded that Resident #112 went to a store and decided to go visit a friend who lived nearby. The document revealed the resident stated they had always come and gone as they pleased and didn't have to tell anyone what they were doing or where they were going. The document revealed the resident stated they did not tell anyone where they were going because they did not want to, and they had originally planned to come back to the facility after buying snacks. There was no documented evidence the facility followed their Emergency Procedure - Missing Resident protocol that required staff to Initiate a thorough search for the resident and contact the police if the resident was not found within ten minutes. A review of Google Maps revealed the store was a four-minute walk, or 0.2 miles from the facility. A review of an untitled and undated facility document revealed DON (Director of Nursing) #27, the previous DON, signed a statement that LPN (Licensed Practical Nurse) #2 reported Resident #112 told them that they were going to the store. However, according to the statement, LPN #2 also called the receptionist about the resident, and the receptionist stated the resident went out the door as a visitor was entering the facility. The statement indicated the nurse followed the resident who was at a store across the street; the resident was getting items at the store and agreed to return to the facility when they were finished. The statement revealed that DON #27 verified with the nurse that the resident was alert, oriented, and able to make their own decisions. Further review revealed the resident was also their own responsible party. DON #27's statement revealed that when the resident did not return, LPN #2 went back to the store, and the resident had left. The nurse notified Resident #112's RP, who stated they were expecting this. A review of an untitled facility document dated 05/12/2021 revealed Administrator #54, a previous Administrator, signed a statement that revealed LPN #2 reported that on 05/09/2021, Resident #112 left the facility to go to the store. However, the statement also revealed LPN #2 observed the resident walk past the front part of the unit, which prompted her to call the receptionist. Further review revealed LPN #2 stated the receptionist informed her that while she was talking with a family member at the desk, Resident #112 had went through the front doors. The statement revealed that LPN #2 walked to the store, made contact with the resident, and waited by the side door for the resident to exit. The resident did not exit the store, so LPN #2 entered the store and observed that the resident had left. The statement indicated LPN #2 contacted the resident's family. A review of another untitled facility document dated 05/12/2021 revealed Administrator #54, a previous Administrator, signed a statement that revealed RN #3, the weekend supervisor, went to the store after LPN #2 returned without the resident. After several minutes at the store, RN #3 was unsuccessful at determining where the resident went and notified the DON. A review of Resident #112's AMA Release Form revealed two (2 ) forms dated 05/09/2021 that were electronically signed by DON #27, the former DON. One of the AMA forms was dated 05/09/2021 at 8:13 PM and revealed Resident #112's RP's name was typed in the section of the form for the Resident/Responsible Party Signature and dated 05/09/2021. The second AMA form for Resident #112 was dated 05/09/2021 at 8:42 PM and revealed an N was documented for the Resident/Responsible Party Signature and for witness one's and two's signatures sections of the form. A statement on the AMA Release Forms revealed 1. This document serves to certify that the above named resident at the above named facility, am leaving against the advice of the attending physician. I acknowledge that I have been informed of the risks involved and hereby release the attending physician and the facility from all responsibility from all ill effects which may result from such discharge. A review of Resident #112's Emergency Department Encounter note dated 05/10/2021 at 11:18 AM, revealed the resident presented to the Emergency Department (ED) via EMS with cold exposure. The note revealed the resident left the facility the night before at approximately 7:30 PM to go to the store without informing staff. The resident got lost when trying to get back and ended up on the expressway. The note revealed EMS found the resident that morning and stated the resident was out in the cold all night. Continued review revealed the first documented body temperature for Resident #112 was taken on 05/10/2021 at 2:45 PM, and the resident's body temperature was 99.2 degrees Fahrenheit (F). The ED record revealed the resident's diagnoses were chronic confusion, medically noncompliant, and non-intractable vomiting with nausea. A review of Resident #112's ED Laboratory Results report dated 05/10/2021 revealed the resident's blood glucose level was 250 milligrams per deciliter (mg/dL) and was documented as high. The report reference range for blood glucose was 74-99 mg/dL. A review of Resident #112's hospital Discharge Plan Update dated 05/10/2021 at 12:50 PM revealed the hospital Social Worker documented Resident #112 had confusion, and the Social Worker spoke with the resident's family about discharge from the hospital. A review of The Weather Channel's weather history for the area where the facility was located revealed the lowest temperature from 5:56 PM on 05/09/2021 through 11:56 AM on 05/10/2021 was 43 degrees F with no precipitation. During a telephone interview on 01/31/2024 at 12:04 PM, LPN #2, the Charge Nurse stated Resident #112 was due for blood glucose testing at 6:00 PM on 05/09/2021; however, the resident was not in their room. She stated the resident was ambulatory and went throughout the facility, visiting with residents and staff. LPN #2 stated when she could not find the resident, she went to the receptionist at the front desk. LPN #2 stated the regular/routine receptionist was not at the front desk; there was a new person at the desk. She stated she described the resident to the new receptionist, and the receptionist remembered pushing the button to open the front doors for the resident to exit the facility. LPN #2 stated the receptionist told her she thought the resident was a visitor. LPN #2 stated she walked out the front door to see if Resident #112 was in the parking lot. She stated she did not see the resident, so she notified her supervisor, RN #3 because she was not sure what she should do. LPN #2 stated RN #3 told her to return to her duties on the floor. LPN #2 stated that RN #3 stated she would walk to the store to see if the resident was there. LPN #2 stated RN #3 returned to the facility and stated the resident was not in the store, and she had notified Administrator #54, who stated they were to create a report that indicated the resident had notified the staff the resident was going to the store. LPN #2 stated the resident had not told her they were going to the store; she did not know where the resident had gone. She stated the facility did not ask her to write a statement. She stated she had spoken to the family when she noticed the resident was missing. She stated the family attempted to call the resident on their cell phone, and the resident did not answer. The LPN stated she wrote a lengthy progress note describing the elopement and told the family the res[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility document and policy review, it was determined the facility failed to ensure that the Administrator of the facility took proper measures to ensure the safety of a resident for 1 (Resident #112) of three (3) sampled residents reviewed for elopement. Specifically, Resident #112, whom the facility assessed to have moderately impaired cognition and developed a care plan that directed staff to supervise the resident as needed, left the facility without notifying staff on 05/09/2021. The facility failed to notify the police that the resident was missing until approximately 18 hours after the resident left the facility. On 05/10/2021 at approximately 10:00 AM, Resident #112 was found on the side of a highway. It was reported that Resident #112, who had been walking around all night, was transported by local Emergency Medical Services (EMS) to a local hospital for cold exposure. It was determined the provider's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25(d) Accidents, at a scope and severity of J. The IJ began on 05/09/2021 at approximately 6:00 PM when Resident #112 exited the facility without the staff's knowledge. The facility was notified of the IJ and provided a copy of the IJ template on 02/02/2024 at 5:12 PM. An acceptable IJ Removal Plan was received on 02/05/2024. The IJ was determined to be to past, effective 01/01/2022. The findings included: A review of the facility's policy titled Administrator, dated March 2021, revealed, A licensed Administrator is responsible for the day-to-day functions of the facility. The policy revealed, The Administrator is responsible for, but not limited to: d. implementing established resident care policies, personnel policies, safety and security policies and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long term care facilities; and e. serving as liaison to the governing to the governing board, medical staff, and other professional and supervisory staff. A review of an undated facility policy titled, Emergency Procedure - Missing Resident revealed, Resident elopement resulting in a missing resident is considered a facility emergency. The policy revealed, 2. Staff will implement the protocol for missing resident upon discovering that a resident cannot be located. The policy revealed, 6. Initiate a thorough search by staff members to locate the resident. 7. If the search is unsuccessful after a period of ten minutes, call the police to report the resident missing. A review of Resident #112's admission Record indicated the facility admitted the resident on 04/01/2021 with diagnoses that included acute kidney failure, stage 3 chronic kidney failure, cerebral infarction (stroke), muscle weakness, type 2 diabetes mellitus, cognitive communication deficit, major depressive disorder, varicose veins of the left lower extremity with an ulcer to the lower leg, essential hypertension, and heart failure. The admission Record revealed the facility discharged Resident #112 on 05/09/2021 at 6:00 PM. The discharged to, Signature, and Personal Effects Sent With, sections of the form were not completed. A review of Resident #112's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/06/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident required extensive assistance of two or more staff members with transfers. Resident #112's balance was not steady, but was able to stabilize when walking or turning around. Resident #112 utilized a walker or wheelchair for mobility. Review of the MDS revealed the resident's overall expectation was to remain at the facility. A review of Resident #112's Care Plan revealed a Focus area initiated on 04/12/2021 that indicated the resident had cognitive impairment related to cognitive communication deficit. The facility developed interventions that directed staff to cue, re-orient, and supervise the resident as needed. Further review of Resident #112's Care Plan revealed a Focus area initiated on 04/02/2021 that indicated the resident needed assistance with activities of daily living (ADL) related to weakness. The facility developed interventions that directed staff to assist the resident with ambulation, locomotion, toileting, and transfers. A review of Resident #112's Care Plan revealed no documented evidence the facility planned for the resident to leave the facility or go to a local store without staff supervision. A review of Resident #112's Progress Notes dated 05/09/2021 at 6:36 PM, electronically signed by Licensed Practical Nurse (LPN) #2 (a charge nurse), revealed Resident #112 walked past LPN #2 in the hallway heading back to their room. The note revealed the receptionist reported she saw a resident leave the building. Continued review revealed LPN #2 notified the weekend supervisor (Registered Nurse (RN) #3) and checked the parking lot for the resident. The note also revealed RN #3, the Director of Nursing (DON), and the Administrator were notified. A review of Resident #112's Progress Notes dated 05/09/2021 at 7:47 PM revealed DON #27, a previous DON, documented that the family notified the facility that Resident #112 had discharged AMA (against medical advice), which the family expected. DON #27's documentation revealed a discharge form would be given to a family member. According to the note, the resident's physician was notified of the discharge. A review of Resident #112's Progress Notes dated 05/10/2021 at 10:31 AM, titled Interdisciplinary Note, revealed Administrator #54, a previous Administrator, documented that Nurse Practitioner (NP) #38 was present during a discussion of Resident #112's AMA discharge the day before. According to the note, NP #38 stated she was not surprised by the resident's discharge because the resident told her the resident had been homeless in the past and was used to going out on their own. However, during an interview on 02/02/2024 at 11:27 AM, NP #38 stated Administrator #54 misquoted her in the Progress Notes dated 05/10/2021, which indicated she was not surprised that the resident had left AMA. She stated she had notified Administrator #54 that she did not make the statement and told him to remove that note from the Progress Notes. She stated she did not see Resident #112 on 05/09/2021, 05/10/2021, or 05/11/2021. She stated she saw the resident on 05/06/2021, prior to the resident leaving the facility, and the resident did not voice anything about leaving the facility. NP #38 stated usually, when a resident left AMA, the resident voiced that they were leaving and not coming back. She stated she thought DON #27, the former DON, notified her that Resident #112 had left AMA, but later, she was told the resident had eloped. She stated she would have called the family and police and would have looked for the resident. She stated the facility should have done more. NP #38 stated the resident could have been seriously injured and was in danger. A review of an undated facility document titled Initial revealed Adult Protective Services (APS) was at the facility on 05/11/2021 (two days after the resident left the facility without staff knowledge) related to Resident #112's AMA discharge over the past weekend. A review of an undated facility document titled 5-Day revealed on 05/09/2021, Resident #112 went to a store and bought snacks at approximately 5:45 PM. However, the resident did not immediately return. The facility document revealed the facility contacted the resident's family and notified them the resident had left. The document revealed the Administrator verified with the store's video footage that Resident #112 entered the store at approximately 5:45 PM and left at approximately 5:56 PM with a bag of groceries. However, further review revealed that not until 05/10/2021 at 11:24 AM, approximately 18 hours after Resident #112 left the facility, was the police called, and a missing person report was filed. The document revealed that at 12:02 PM on 05/10/2021, the resident's family arrived at the facility and notified them that the resident had been found and was in the emergency room (ER). There was no documented evidence the facility followed their Emergency Procedure - Missing Resident protocol that required staff to Initiate a thorough search for the resident and contact the police if the resident was not found within ten minutes. A review of Resident #112's Emergency Department Encounter note dated 05/10/2021 at 11:18 AM revealed the resident presented to the Emergency Department (ED) via EMS with cold exposure. The note revealed the resident got lost when trying to get back and ended up on the expressway. The note revealed EMS found the resident that morning and stated the resident was out in the cold all night.with nausea. A review of The Weather Channel's weather history for the area where the facility was located revealed the lowest temperature from 5:56 PM on 05/09/2021 through 11:56 AM on 05/10/2021 was 43 degrees F with no precipitation. During a telephone interview on 01/31/2024 at 12:04 PM, LPN #2, the Charge Nurse stated Resident #112 was due for blood glucose testing at 6:00 PM on 05/09/2021; however, the resident was not in their room. She did not see the resident, so she notified her supervisor (RN #3) because she was not sure what she should do. LPN #2 stated RN #3 returned from the store and stated the resident was not in the store, and she had notified Administrator #54, who stated they were to create a report that indicated the resident had notified the staff the resident was going to the store. LPN #2 stated the resident had not told her they were going to the store; she did not know where the resident had gone. She stated she wrote a lengthy progress note describing the elopement and told the family the resident had eloped. She stated she considered it an elopement because no one knew where Resident #112 was located. LPN #2 stated she had never known Resident #112 to leave the facility unattended before. During a follow-up interview by phone on 02/01/2024 at 5:43 PM, LPN #2 stated the Progress Notes dated 05/09/2021 at 6:36 PM, with her electronic signature, were inaccurate. She stated the resident did not notify her that they were going to the store, as documented in the note. She stated she would have told the resident not to go. She stated she also did not see the resident leave through the double doors; again, she would have tried to stop the resident. LPN #2 also stated she did not go to the store looking for the resident. She stated she would not have left the residents on her unit without a nurse. LPN #2 stated she did not speak to the resident at the store because she was not there. She stated if she had been at the store and the resident was behind her, the resident could not have disappeared quickly, as stated in the Progress Notes. She explained the resident was ambulatory, but the resident walked very slowly because both of the lower legs were wrapped with dressings. During an interview on 01/29/2024 at 11:56 AM, Resident #112 stated prior to admission to the facility, the resident had a stroke and had mini-strokes. Resident #112 stated they walked to the gas station, and when they exited the store, the resident went the wrong way. Resident #112 stated they thought they knew the area and where their friend lived, but they could not find the friend's house. Resident #112 stated they did not plan on leaving the facility permanently. Resident #112 stated they did not sleep anywhere that night; they just walked around. Resident #112 stated the next morning, someone found them on the side of the highway. Resident #112 stated they had never gone to the store before and would never do that again. During a telephone interview on 02/01/2024 at 3:28 PM, Resident #112's RP stated the former Administrator (Administrator #54) called them and reported the resident had gone to the store and had not returned. Resident #112's RP stated Administrator #54 asked them to call the police. Resident #112's RP stated they told Administrator #54 that the facility should call the police, but the Administrator refused. Resident #112's RP stated they ended up calling the police; however, they lived in another state, and due to jurisdiction issues, the police told them they needed to go to the facility/facility area to make the report. Resident #112's RP stated that before they arrived at the facility on the morning of 05/10/2021, the police found the resident. Resident #112's RP stated Administrator #54 had tried to get them to sign a waiver indicating the resident had left the facility AMA; however, they refused to sign the form and told Administrator #54 the resident was confused and was not capable of making a decision to leave AMA. Resident #112's RP stated the resident's mind was not right, and the resident did not understand what was going on. During a telephone interview on 02/01/2024 at 1:48 PM, Administrator #54, the former Administrator stated the resident was alert, oriented, and their own POA and was allowed to leave. According to Administrator #54, the facility was not a prison. He stated he notified the family, who stated that before entering the facility, the resident would leave without telling anyone. He stated the resident's family notified him the next day that the resident was in the hospital. He stated he visited the resident in the hospital, and the resident stated they had wanted to visit with friends. He stated he also did not know whether the facility had assessed the resident's ability to go to the store because [the resident] left AMA. Administrator #54 further stated he did not remember whether the facility had a policy related to determining whether a resident was capable of going to the store. He stated if the resident was alert and oriented and their own POA, they had the right to go, we cannot stop them. He added he did not remember anything else. During an interview on 02/06/2024 at 9:46 PM, the Administrator stated he was not at the facility when the incident occurred and did not know what happened; however, he stated the incident with Resident #112 should have been investigated if the resident eloped. The Administrator stated the facility's policy should have been followed, and it should have been investigated a long time ago. The facility alleged removal of the immediacy of the IJ on 01/01/2022 as follows: 1. On 05/10/2021, Resident #112 was assessed using the Elopement Risk Assessment by Licensed Practical Nurse (LPN) #9. The resident was placed on 15-minute checks until he/she went to the hospital on [DATE]. The resident ' s care plan was updated. The resident has not had further elopements since 05/09/2021. 2. On 05/09/2021, the facility reviewed the State Operations Manual (SOM) and again on 02/03/2023, to go over the definition of elopement. The Interdisciplinary team (IDT), Administrator, Assistant Director of Nursing, Nurse Mangers, and Social Services reviewed the Wander Risk Assessment. Residents that were assessed to require a Wander-guard bracelet were placed in the binder located at each nursing station and front desk. Further, the residents assessed to be an elopement risk, care plans were updated. 3. On 05/10/2021, education began with all the facility staff. The Director of Nursing (DON) provided the education, and it was ongoing. Further, education was provided during all staff meetings on 09/2021 through 11/2021 after the Assistant Regional Director of Services identified potential issues and/or concerns during onsite visits through resident medical record audits and observations. Education that was included was on the Elopement Policy, Wandering, resident/resident representative expectations of signing out prior to resident leaving the facility, and missing resident protocol by the Administrator, DON, Nurse Managers, Social Workers, Admissions Staff, and Supervisors. 4. On 07/02/2021 through 07/27/2021, the Assistant Regional Director of Clinical Services assigned the Director of Clinical Services assigned the DON, Nurse Managers, Charge Nurses, and nurse supervisors, after completion of an onsite audit, to conduct an audit on wandering risk assessments. All residents were verified to have an updated risk assessment in their medical record. 5. On 07/02/2021, the Assistant Director of Clinical Services re-educated the DON and Administrator regarding their roles and responsibilities for following the facility's policies which included but was not limited to discharging against medical advice, elopement, and wandering oversight and supervision, QA process and QAPI Program. 6. On 07/29/2021 and 09/24/2021, the Quality Assurance and Performance Improvement meeting was held to review the facility's protocol and policy for elopement. The attendees included the Administrator, Medical Director, Director of Nursing, Assistant Regional Director of Clinical Services, Medical Records, Assistant Director of Nursing, Therapy, Housekeeping, and Activity Director. 7. On 07/29/2021 and 09/24/2021, the facility assessment was reviewed in the Quality Assurance Performance Improvement Committee to review the results of the audits and no changes were needed. Further, the QAPI committee reviewed any discharges or unplanned dischargers from 06/2021 through 12/2021, no concerns were identified. 8. On 08/01/2021, the DON, Nurse Manager, Supervisor or Charge Nurse evaluated all new admissions/re-admissions residents on admission to determine if a resident was triggered to be an elopement risk. The residents who triggered to be at risk for elopement would have a comprehensive person-centered care plan developed and implemented by the Minimum Data Set (MDS) nurse and IDT team, that included the resident's risk for elopement. If concerns were identified, it was discussed in the daily Interdisciplinary Plan of Care Meeting and the DON would report the concerns to the QAPI committee. 9. During the month of August of 2021, the Assistant Regional Director of Clinical Services assigned the Director of Nursing and Administrator to conduct elopement drills. A total of 2 element drills were completed. All elopement drills were reviewed with the Assistant Director of Clinical Services, the Director of Nursing and Administrator. The Emergency Plan for locating a missing resident was reviewed by the Assistant Regional Director of Nursing and the Administrator on 09/24/2021, with no changes indicated. 10. On 11/17/2021, the Governing Body (Regional [NAME] President) received verbal education per the Regional Director of Clinical Services regarding expectations of self-reportable incidents including but not limited to elopements and elopement versus against medical advice. The Assistant Regional Director of Clinical Services and Assistant Regional Director of Clinical Services increased onsite facility visits to 2-3 days per week to ensure that facility Administration and staff were following the Elopement Policy and Procedures. 11. On 12/01/2021 through 12/31/2021, annual competencies were completed, which included but was not limited to elopements. All the new staff received Elopement training upon hire, during new hire orientation, by the staff development coordinator. Staff who had not received the training, to include the agency staff, prior to 12/31/2021 received training prior to the start of their shift by the nursing scheduler, staff development coordinator, nurse management team, or supervisor prior to the start of their shift. Further, self-reportable incidents was reviewed by the Regional Director of Clinical Services and/or Assistant Regional Director of Clinical services on site no later than 72 hours following the incident. The Assistant Regional Director of Clinical Services kept a log of all the self-reportable incidents and was reviewed monthly by the Administrator and the Regional [NAME] President. The State Agency validated the IJ Removal Plan as follows: 1. Review of Resident #112 Admission/Readmission Assessment revealed the resident was accompanied by the paramedics, by ambulance on 05/10/2021. Further review revealed the resident refused to be checked by staff for a skin assessment. Review of the resident's Baseline care plan revealed the resident's care plan was revised to include 15-minute checks and the care plan included the resident was at risk for elopement. 2. Review of the SOM documentation, dated 2021, revealed the facility reviewed the definition of elopement. Review of the elopement binder revealed the facility had placed all residents to be an elopement risk in the binder. 3. Review of the facilities education, provided by the facility revealed education was provided to all staff from 05/2021 to 11/2021. Education provided included Abuse, Wandering Residents, Behaviors, Customer Service, and Infection Control. Review of the facility's Wandering and Elopement policy, revised on 05/17/2020, revealed the facility defined elopement as an unsafe wandering and the facility strived to prevent harm while maintaining at the least restrictive environment for the residents. 4. Review of the QA Audit-Wander guard Tool, dated 07/02/2021, revealed the residents were audited to ensure the residents that were assessed as an elopement risk had an MD order, Wander guard Bracelet, updated care plan, TAR, and were in the elopement book/binder. No concerns were identified. Review of the Care Planning Audit Tool, dated 07/27/2021, revealed the residents who were assessed as an elopement risk care plan was assessed to include the following: Had the comprehensive care plan been developed; Did the residents care plan identify and include areas that pertain to the residents diagnosis; Did the care plan match the resident ' s needs; Were assistive devices in place per the residents plan of care; Was there evidence that the care plan reflected an interdisciplinary approach to the development of the care plan; Did the care plan identify the residents individualized goals, preferences and choices; Did the care plan clearly show a description of the action to be taken and by whom; Did the care plan contain some evidence of supporting or encouraging the individual to self-care/manage their well-being; Was there evidence that the care plan had been reviewed; Did the care and services provided reflect the residents current functioning status; Did the [NAME] reflect the resident specific assistance needed to ensure care and services were provided? Continued review of the Audit tool revealed it was signed off and reviewed on 07/29/2021. 5. Review of facility's document, dated 07/02/2021, revealed the ARDCS went over the roles and responsibilities with the Administrator and DON. Further, the ARDCS went over the facility's goals, leadership, and management expectations. The QA Process and QAPI Program and audits were discussed. Continued review revealed the Administrator, DON, and ARDCS, signed the document on 07/02/2021. 6. Review of the Quality Assurance Committee Meeting Minutes, dated 07/29/2021 and 09/24/2021, revealed the committee reviewed elopement drills with no concerns identified. Review of the sign-in sheet revealed the Administrator, DON, Medical Director, ADON, Social Service, Dietary manager, Dietitian, Therapy, Maintenance, Environmental Services, Activities, Admissions, and MDS attended the meeting. 7. Review of the Facility Assessment revealed the QA Committee revealed the results of the audits. There were no changes on concerns identified. 8. Review of the New admission worksheet revealed the residents were assessed to be an elopement risk and was care planned based on assessment. No concerns were identified. 9. Review of the Emergency Plan and Elopement Drills, dated 07/29/2021 and 09/24/2021, revealed no concerns identified. 10. Review of the document, dated 11/17/2021, revealed the Regional Director of Clinical Services met with the Regional [NAME] President to review the self-reportable incidents from the region. The Regional Director of Clinical Services advised that the DON and Administrator was expected to report any allegations to the Regional Director of Clinical and the Regional [NAME] President to meet regulations related to reporting. Further review of the document revealed the Regional [NAME] President and Regional Director of Clinical Services signed off on the document on 11/17/2021. 11 Review of the annual competencies form revealed the facility checked the competency of each staff in areas which included: resident rights, abuse, skin/wound care, medication management, and disaster planning. Continued review revealed staff were checked prior to the start of their shift. During an interview with the ARDCS, on 02/05/2024 at approximately 6:30 PM, she stated she reviewed the incident related to Resident #112's elopement and determined the facility needed additional training on the definition of elopement. She stated she retrained the Administrator, who left in November of 2021, and the DON. Further, she stated she put a Plan of Correction in place to address the concerns, with auditing the residents for changes in behaviors, assessing the residents to be an elopement risk, and updated the resident's care plans. Per the interview, she stated she audited the concern until the end of December. She further stated she had not had concerns with Resident #112 leaving the facility without staff supervision since 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility document and policy review, it was determined the facility's governing body failed to ensure policies regarding the management and operation of the facility were implemented. The governing body was aware that on 05/09/2021, at approximately 6:00 PM, a resident whom the facility assessed to have moderate cognitive impairment left the facility and was missing. The facility failed to implement its missing resident protocol and notify the police of the missing resident. The governing body was aware that the facility concluded Resident #112 left against medical advice (AMA) and took no further action to find the resident. The police found Resident #112 along a highway (unknown location) on 05/10/2021 at approximately 10:00 AM, approximately eighteen (18) hours after the resident left the facility. Emergency Medical Services (EMS) transported Resident #112 to a local hospital for cold exposure. It was determined the provider's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care were identified at 483.25, Free of Accidents Hazards and Supervision/F689. Additional IJ deficiencies were identified at 483.70 Administration; F835 and F837. The IJ began on 05/09/2021 at approximately 6:00 PM when Resident #112 exited the facility without the staff's knowledge. The facility was notified of the IJ and provided a copy of the IJ template on 02/02/2024 at 5:12 PM. A Removal Plan was requested. The findings include: A review of the facility's policy titled, Administrative Management (Governing Board), dated October 2017, revealed The governing board shall be responsible for the management and operation of the facility. 1. The facility's governing board is the supreme authority and has full legal authority and responsibility for the management and operation of our facility. The policy revealed, 3. The governing board is responsible for, but not limited to: a. Oversight of facility care and services in accordance with professional standards of practice and principles; and d. Establishment and ongoing review of all administrative programs governing facility management and operations, including: (3) Quality Assurance and Performance Improvement; and j. Establishment of a system whereby the Administrator reports to the governing body, including: (5) How the Administrator will be held accountable for facility management and operations. A review of an undated facility policy titled Emergency Procedure - Missing Resident, revealed, Resident elopement resulting in a missing resident is considered a facility emergency. The policy revealed, 2. Staff will implement the protocol for missing resident upon discovering that a resident cannot be located. Further review of the policy revealed when a resident was missing 6. Initiate a thorough search by staff members to locate the resident. 7. If the search is unsuccessful after a period of ten (10) minutes, call the police to report the resident missing. The policy revealed, 11. Complete an incident report and follow the facility's incident reporting process. 12. Document the incident and events objectively in the resident record, including: a. Circumstances and precipitating factors. A review of Resident #112's admission Record indicated the facility admitted the resident on 04/01/2021 with diagnoses that included acute kidney failure, stage 3 chronic kidney failure, cerebral infarction (stroke), muscle weakness, type 2 diabetes mellitus, cognitive communication deficit, major depressive disorder, varicose veins of the left lower extremity with an ulcer to the lower leg, essential hypertension, and heart failure. The admission Record revealed the facility discharged Resident #112 on 05/09/2021 at 6:00 PM. The discharged to, Signature, and Personal Effects Sent With, sections of the form were not completed. A review of Resident #112's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/06/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident had moderate cognitive impairment. The MDS revealed the resident required extensive assistance of one (1) staff member with dressing, toilet use, and personal hygiene; and required extensive assistance of two (2) or more staff members with transfers. The MDS revealed the resident was not steady and only able to stabilize with staff assistance when transferring from surface to surface and moving on and off the toilet. The MDS revealed the resident utilized a walker or wheelchair for mobility. A continued review of the MDS revealed the resident's overall expectation was to remain at the facility. A review of Resident #112's Care Plan revealed a Focus area initiated on 04/12/2021 that indicated the resident had cognitive impairment related to cognitive communication deficit. The facility developed interventions that directed staff to cue, re-orient, and supervise the resident as needed. Further review of Resident #112's Care Plan revealed a Focus area initiated on 04/02/2021 that indicated the resident needed assistance with activities of daily living (ADL) related to weakness. The facility developed interventions that directed staff to assist the resident with ambulation, locomotion, toileting, and transfers. A review of Resident #112's Care Plan revealed no documented evidence the facility planned for the resident to leave the facility or go to a local store without staff supervision. A review of an undated facility document titled 5-Day revealed on 05/09/2021, Resident #112 went to a store and bought snacks at approximately 5:45 PM; when the resident did not immediately return, the weekend supervisor Registered Nurse (RN) #3 went to check on the resident. The report revealed that when RN #3 did not find the resident at the store, she notified the DON, who called the Administrator at approximately 6:04 PM. The facility document revealed the facility contacted the resident's family and notified them the resident had left. The document revealed the Administrator verified with the store's video footage that Resident #112 entered the store at approximately 5:45 PM and left at approximately 5:56 PM with a bag of groceries. According to the document, the resident's family member did not want to file a police report as they considered this normal resident behavior. The document revealed that on 05/10/2021 at 11:24 AM, approximately 18 hours after Resident #112 left the facility, the police were called, and a missing person report was filed. The document revealed that on 05/10/2021 at 12:02 PM, the resident's family arrived at the facility and notified them that the resident had been found and was in the emergency room (ER). There was no documented evidence the facility followed their Emergency Procedure - Missing Resident protocol that required staff to Initiate a thorough search for the resident and contact the police if the resident was not found within 10 minutes. A review of Resident #112's Emergency Department Encounter note dated 05/10/2021 at 11:18 AM revealed the resident presented to the Emergency Department (ED) via EMS with cold exposure. The note revealed the resident left the facility the night before at approximately 7:30 PM to go to the store without informing staff. The note revealed the resident got lost when trying to get back and ended up on the expressway. Continued review of the note revealed EMS found the resident that morning and stated the resident was out in the cold all night. The note revealed the first documented body temperature for Resident #112 was taken on 05/10/2021 at 2:45 PM, and the resident's body temperature was 99.2 degrees Fahrenheit (F). The ED record revealed the resident's diagnoses were chronic confusion, medically noncompliant, and non-intractable vomiting with nausea. A review of Resident #112's ED Laboratory Results report dated 05/10/2021 revealed the resident's blood glucose level was 250 milligrams per deciliter (mg/dL) and was documented as high. The report reference range for blood glucose was 74-99 mg/dL. During an interview with the Regional [NAME] President of Operations (RVPO) on 01/30/2024 at 11:56 AM, the RVPO stated they did not consider the 05/09/2021 incident as an elopement because Resident #112 was their own POA and was alert and oriented. He stated Resident #112 walked to a store located near the facility. The RVPO stated if a resident was alert, oriented, and responsible for themselves they were allowed to go to the store unsupervised. The RVPO stated when it was observed the resident was not in the facility, a staff member walked to the store to escort Resident #112 back to the facility; however, the resident refused to return to the facility. The RVPO stated the staff member waited at the door of the store for the resident, but the resident exited the store through a different door and left the grounds. The RVPO stated that since the resident had refused to return to the facility, they considered the resident to have left AMA. The RVPO stated they immediately notified the family and reported to the state agency on 05/11/2021 or 05/12/2021 that the resident left AMA, after an Adult Protective Services (APS) visit on 05/11/2021. During a follow-up interview on 02/02/2024 at 5:18 PM, the RVPO stated Resident #112 had a right to leave and stated the facility even went to the store to check on the resident. The RVPO stated they did not check on every resident who went to the store. The RVPO shook his head and stated he did not know why they checked on Resident #112. The facility alleged removal of the immediacy of the IJ on 01/01/2022 as follows: 1. On 05/10/2021, Resident #112 was assessed using the Elopement Risk Assessment by Licensed Practical Nurse (LPN) #9. The resident was placed on 15-minute checks until he/she went to the hospital on [DATE]. The resident ' s care plan was updated. The resident has not had further elopements since 05/09/2021. 2. On 05/09/2021, the facility reviewed the State Operations Manual (SOM) and again on 02/03/2023, to go over the definition of elopement. The Interdisciplinary team (IDT), Administrator, Assistant Director of Nursing, Nurse Mangers, and Social Services reviewed the Wander Risk Assessment. Residents that were assessed to require a Wander-guard bracelet were placed in the binder located at each nursing station and front desk. Further, the residents assessed to be an elopement risk, care plans were updated. 3. On 05/10/2021, education began with all the facility staff. The Director of Nursing (DON) provided the education, and it was ongoing. Further, education was provided during all staff meetings on 09/2021 through 11/2021 after the Assistant Regional Director of Services identified potential issues and/or concerns during onsite visits through resident medical record audits and observations. Education that was included was on the Elopement Policy, Wandering, resident/resident representative expectations of signing out prior to resident leaving the facility, and missing resident protocol by the Administrator, DON, Nurse Managers, Social Workers, Admissions Staff, and Supervisors. 4. On 07/02/2021 through 07/27/2021, the Assistant Regional Director of Clinical Services assigned the Director of Clinical Services assigned the DON, Nurse Managers, Charge Nurses, and nurse supervisors, after completion of an onsite audit, to conduct an audit on wandering risk assessments. All residents were verified to have an updated risk assessment in their medical record. 5. On 07/02/2021, the Assistant Director of Clinical Services re-educated the DON and Administrator regarding their roles and responsibilities for following the facility's policies which included but was not limited to discharging against medical advice, elopement, and wandering oversight and supervision, QA process and QAPI Program. 6. On 07/29/2021 and 09/24/2021, the Quality Assurance and Performance Improvement meeting was held to review the facility's protocol and policy for elopement. The attendees included the Administrator, Medical Director, Director of Nursing, Assistant Regional Director of Clinical Services, Medical Records, Assistant Director of Nursing, Therapy, Housekeeping, and Activity Director. 7. On 07/29/2021 and 09/24/2021, the facility assessment was reviewed in the Quality Assurance Performance Improvement Committee to review the results of the audits and no changes were needed. Further, the QAPI committee reviewed any discharges or unplanned dischargers from 06/2021 through 12/2021, no concerns were identified. 8. On 08/01/2021, the DON, Nurse Manager, Supervisor or Charge Nurse evaluated all new admissions/re-admissions residents on admission to determine if a resident was triggered to be an elopement risk. The residents who triggered to be at risk for elopement would have a comprehensive person-centered care plan developed and implemented by the Minimum Data Set (MDS) nurse and IDT team, that included the resident's risk for elopement. If concerns were identified, it was discussed in the daily Interdisciplinary Plan of Care Meeting and the DON would report the concerns to the QAPI committee. 9. During the month of August of 2021, the Assistant Regional Director of Clinical Services assigned the Director of Nursing and Administrator to conduct elopement drills. A total of 2 element drills were completed. All elopement drills were reviewed with the Assistant Director of Clinical Services, the Director of Nursing and Administrator. The Emergency Plan for locating a missing resident was reviewed by the Assistant Regional Director of Nursing and the Administrator on 09/24/2021, with no changes indicated. 10. On 11/17/2021, the Governing Body (Regional [NAME] President) received verbal education per the Regional Director of Clinical Services regarding expectations of self-reportable incidents including but not limited to elopements and elopement versus against medical advice. The Assistant Regional Director of Clinical Services and Assistant Regional Director of Clinical Services increased onsite facility visits to 2-3 days per week to ensure that facility Administration and staff were following the Elopement Policy and Procedures. 11. On 12/01/2021 through 12/31/2021, annual competencies were completed, which included but was not limited to elopements. All the new staff received Elopement training upon hire, during new hire orientation, by the staff development coordinator. Staff who had not received the training, to include the agency staff, prior to 12/31/2021 received training prior to the start of their shift by the nursing scheduler, staff development coordinator, nurse management team, or supervisor prior to the start of their shift. Further, self-reportable incidents was reviewed by the Regional Director of Clinical Services and/or Assistant Regional Director of Clinical services on site no later than 72 hours following the incident. The Assistant Regional Director of Clinical Services kept a log of all the self-reportable incidents and was reviewed monthly by the Administrator and the Regional [NAME] President. The State Agency validated the IJ Removal Plan as follows: 1. Review of Resident #112 Admission/Readmission Assessment revealed the resident was accompanied by the paramedics, by ambulance on 05/10/2021. Further review revealed the resident refused to be checked by staff for a skin assessment. Review of the resident's Baseline care plan revealed the resident's care plan was revised to include 15-minute checks and the care plan included the resident was at risk for elopement. 2. Review of the SOM documentation, dated 2021, revealed the facility reviewed the definition of elopement. Review of the elopement binder revealed the facility had placed all residents to be an elopement risk in the binder. 3. Review of the facilities education, provided by the facility revealed education was provided to all staff from 05/2021 to 11/2021. Education provided included Abuse, Wandering Residents, Behaviors, Customer Service, and Infection Control. Review of the facility's Wandering and Elopement policy, revised on 05/17/2020, revealed the facility defined elopement as an unsafe wandering and the facility strived to prevent harm while maintaining at the least restrictive environment for the residents. 4. Review of the QA Audit-Wander guard Tool, dated 07/02/2021, revealed the residents were audited to ensure the residents that were assessed as an elopement risk had an MD order, Wander guard Bracelet, updated care plan, TAR, and were in the elopement book/binder. No concerns were identified. Review of the Care Planning Audit Tool, dated 07/27/2021, revealed the residents who were assessed as an elopement risk care plan was assessed to include the following: Had the comprehensive care plan been developed; Did the residents care plan identify and include areas that pertain to the residents diagnosis; Did the care plan match the resident ' s needs; Were assistive devices in place per the residents plan of care; Was there evidence that the care plan reflected an interdisciplinary approach to the development of the care plan; Did the care plan identify the residents individualized goals, preferences and choices; Did the care plan clearly show a description of the action to be taken and by whom; Did the care plan contain some evidence of supporting or encouraging the individual to self-care/manage their well-being; Was there evidence that the care plan had been reviewed; Did the care and services provided reflect the residents current functioning status; Did the [NAME] reflect the resident specific assistance needed to ensure care and services were provided? Continued review of the Audit tool revealed it was signed off and reviewed on 07/29/2021. 5. Review of facility's document, dated 07/02/2021, revealed the ARDCS went over the roles and responsibilities with the Administrator and DON. Further, the ARDCS went over the facility's goals, leadership, and management expectations. The QA Process and QAPI Program and audits were discussed. Continued review revealed the Administrator, DON, and ARDCS, signed the document on 07/02/2021. 6. Review of the Quality Assurance Committee Meeting Minutes, dated 07/29/2021 and 09/24/2021, revealed the committee reviewed elopement drills with no concerns identified. Review of the sign-in sheet revealed the Administrator, DON, Medical Director, ADON, Social Service, Dietary manager, Dietitian, Therapy, Maintenance, Environmental Services, Activities, Admissions, and MDS attended the meeting. 7. Review of the Facility Assessment revealed the QA Committee revealed the results of the audits. There were no changes on concerns identified. 8. Review of the New admission worksheet revealed the residents were assessed to be an elopement risk and was care planned based on assessment. No concerns were identified. 9. Review of the Emergency Plan and Elopement Drills, dated 07/29/2021 and 09/24/2021, revealed no concerns identified. 10. Review of the document, dated 11/17/2021, revealed the Regional Director of Clinical Services met with the Regional [NAME] President to review the self-reportable incidents from the region. The Regional Director of Clinical Services advised that the DON and Administrator was expected to report any allegations to the Regional Director of Clinical and the Regional [NAME] President to meet regulations related to reporting. Further review of the document revealed the Regional [NAME] President and Regional Director of Clinical Services signed off on the document on 11/17/2021. 11 Review of the annual competencies form revealed the facility checked the competency of each staff in areas which included: resident rights, abuse, skin/wound care, medication management, and disaster planning. Continued review revealed staff were checked prior to the start of their shift. During an interview with the ARDCS, on 02/05/2024 at approximately 6:30 PM, she stated she reviewed the incident related to Resident #112's elopement and determined the facility needed additional training on the definition of elopement. She stated she retrained the Administrator, who left in November of 2021, and the DON. Further, she stated she put a Plan of Correction in place to address the concerns, with auditing the residents for changes in behaviors, assessing the residents to be an elopement risk, and updated the resident's care plans. Per the interview, she stated she audited the concern until the end of December. She further stated she had not had concerns with Resident #112 leaving the facility without staff supervision since 2021.