**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to ensure a residents' right to formulate an advance directive were honored for one of four residents reviewed for advance directives out of 35 sampled residents (Resident (R) 85). R85 who was his own decision maker, requested and signed to be a full code status (life saving measures) upon admission to the facility; however, the facility inadvertently entered a Do Not Resuscitate (DNR) order which contradicted the resident's decision. Additionally, the facility allowed the resident's Power of Attorney (POA) to sign DNR documents instead of the resident signing his own code status forms. This failure placed the resident at risk for death in the event of a cardiac and/or respiratory failure. An Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], in §483.10 F578: Request/Refuse/Discontinue; Formulate Advance Directives. The Administrator was notified on [DATE] at 3:57 PM of the Immediate Jeopardy. An acceptable Immediate Jeopardy Plan of Removal was provided on [DATE] at 12:55 PM and was validated on [DATE] at 10:55 PM. The Administrator was notified the Immediate Jeopardy was removed. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of a D. The findings include: Review of the facility's policy titled, Advance Directives, revised 10/2023, revealed Advance directives will be respected in accordance with state law and facility policy .3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative or resident representative in accordance with state and federal laws .7. In accordance with the State and Federal requirements, the legal representative may also have the right to refuse or forego treatment .a. Advance Directive-a written instruction, such as a living will or durable power of attorney for heath care, recognized by State law, relating to the provisions of health care when the individual is incapacitated .c. Durable Power of Attorney for Health Care (i.e., Medical Power of Attorney)-a document delegating authority to a legal representative to make health care decisions in case the individual delegating that authority subsequently becomes incapacitated .14. Nursing Services or designee will notify the Attending Physician as necessary of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. Review of the facility's Physician orders Process, revised 11/2022 revealed .5. Code status for residents will [be] based upon the completed code status form signed by the resident or the resident representative or legal representative. Physician order will be obtained. 6. The physician or extender that gives a verbal order will be required to electronically sign the order in accordance with the most update [sic] federal and state regulation . Review of R85's undated Face Sheet, located in the resident's electronic medical record (EMR) under the Face Sheet, tab revealed the resident was admitted to the facility [DATE] with diagnoses which included chest pain, asthma, hypercholesterolemia, hypertension, and coronary atherosclerosis of unspecified type of vessel, native or graft. Further review of R85's Face Sheet revealed the resident had a POA. Review of R85's Minimum Data Set (MDS), with an assessment reference date (ARD) of [DATE] and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of R85's MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. Review of R85's Directives for Code Status, dated [DATE] and provided by the facility revealed R85 chose to be a Full Code. R85 signed the document himself. Review of R85's Physician Verbal Order, dated [DATE] revealed an order of Do Not Resuscitate [DNR]. The order was entered by Licensed Practical Nurse Unit Manager (LPNUM) 1. During an interview on [DATE] at 3:39 PM, R85 stated if he was found unresponsive, he would want staff to start cardiopulmonary resuscitation (CPR) on him. During a subsequent interview on [DATE] at 4:20 PM, R85 told a Registered Nurse Surveyor he had signed a paper saying he wanted to be a full code. When asked what a full code meant, R85 stated if his heart stopped, or he stopped breathing, he wanted chest compressions to be done. During an interview on [DATE] at 4:29 PM, LPNUM1 reviewed R85's code status in the EMR and stated R85 was a DNR, so no CPR would be done. During an interview on [DATE] at 4:30 PM, LPN1 was asked what he would do if he found R85 unresponsive. LPN1 checked his assignment sheet which documented R85 as a DNR. The LPN then checked R85's physician order in the EMR which also reflected the code status of DNR. LPN1 stated CPR would not be done on R85. Review of the facility's untitled and undated assignment sheet provided by LPN1 revealed the document had R85 listed as a DNR. During an interview on [DATE] at 4:56 PM, Social Worker (SW) 1 stated R85 was his own decision maker. When asked what R85's code status was, SW1 stated she thought he was a DNR. When asked who should have signed the DNR paperwork, SW1 stated R85 or the POA should have. During an interview on [DATE] at 6:42 PM, POA 85 stated he signed DNR papers back in [DATE] because he did not want his brother to just lay there, so he thought it would be best to sign the DNR paperwork. Continued interview revealed the POA did not recall having a telephone conversation with a nurse regarding a decision to make the resident a DNR or full code. The POA stated approximately two years ago R85 became severely ill and R85 was a DNR; however, he had not had a conversation since then with his brother regarding code status and he did not know R85 wanted to be a full code. The POA also stated R85 could make his own decisions, and the facility should follow his brothers wishes. During an interview on [DATE] at 5:01 PM, the Social Service Director (SSD) stated she was not really familiar with R85 as he was not on her case load. The SSD stated R85 had a BIMS of 14 so she would assume he could make his own decisions. The SSD confirmed R85 signed a Directives for Code Status, document on [DATE] choosing to have a full code status. The SSD also confirmed a DNR was signed by POA1 on [DATE]. Review of R85's Directives for Code Status, dated [DATE] and provided by the facility revealed POA85 chose for R85 to be a DNR. POA85 signed the document and not R85 who was his own decision maker. During an interview on [DATE] at 5:28 PM, the Director of Nursing (DON) stated residents who had decision making capacity would make their own code status decision. The DON confirmed R85 signed to be a full code on [DATE]. The DON also confirmed a physician's order dated [DATE] which ordered R85 to be a DNR. When asked why the resident's decision to be a full code status and the physician's order contradicted each other, the DON stated it appeared the physician's order entered on [DATE] which ordered the resident to be a DNR was entered in error. During an interview on [DATE] at 10:24 AM, LPNUM1 confirmed she was the nurse who entered the physician's order for R85 to be a DNR. LPNUM1 stated she reviewed R85's Directives for Code Status, document dated [DATE] and seen the resident selected to be a full code. The LPNUM also stated when she put the electronic order in the EMR, it was a drop-down box and she erroneously selected DNR instead of Full Code. Continued interview revealed on [DATE] she called R85's POA in the presence of R85 to go over the resident's baseline care plan. During this conversation, she discussed R85's code status of DNR with the POA and the R85 per the physician's order on [DATE]. LPNUM1 stated neither R85 nor POA85 questioned the code status. The LPNUM further stated she let the resident and the POA know that paperwork (DNR form and EMS form) needed to be signed and the POA stated he would sign the paperwork the next time he was at the facility. During an interview on [DATE] at 4:48 PM, the Executive Director stated it was his expectation residents' wishes regarding code status would have been honored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement person centered comprehensive care plans for four of 35 sampled residents (Resident (R) 85, R90, R59, and R117). Upon admission to the facility, R85 chose his code status to be a full code; however, the resident's Care Plan contradicted his code status by having conflicting information when his care plan indicated he was a full code and had a do not resuscitate (DNR) code status. This placed the resident at risk for death in the event of cardiac and/or respiratory failure episode. An Immediate Jeopardy was identified at on [DATE] and was determined to exist on [DATE] at §483.21(b)(1) F656-Develop/Implement Comprehensive Care Plan. The Administrator was notified on [DATE] at 3:57 PM of the Immediate Jeopardy. An acceptable Immediate Jeopardy Plan of Removal was provided on [DATE] at 12:55 PM and was validated on [DATE] at 10:55 PM. The Administrator was notified the Immediate Jeopardy was removed. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of a D. Findings include: Review of the facility's policy dated 04/17 revised on 03/24, titled Care-Plans Comprehensive revealed The facility must develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of the Policy interpretation and implementation revealed The interdisciplinary Team, in coordination with the resident, his/her resident representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS [Minimum Data Set] . Each resident's comprehensive care plan will include services that are to be furnished to maintain the resident's highest practical physical, mental, psychosocial wellbeing, including advance directive code status . Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plans . Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change . the interdisciplinary Team is responsible for the review and revision of care plans after each assessment, including comprehensive and quarterly assessments. 1. Review of R85's undated Face Sheet, located in the resident's electronic medical record (EMR) under the Face Sheet, tab revealed the resident was admitted to the facility [DATE] with diagnoses which included chest pain, asthma, hypercholesterolemia, hypertension, and coronary atherosclerosis of unspecified type of vessel, native or graft. Further review of R85's Face Sheet revealed the resident had a Power of Attorney (POA). Review of R85's Minimum Data Set (MDS), with an assessment reference date (ARD) of [DATE] and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. During an interview on [DATE] at 3:39 PM, R85 stated if he was found unresponsive, he would want staff to start cardiopulmonary resuscitation (CPR) on him. During a subsequent interview on [DATE] at 4:20 PM, R85 told a Registered Nurse Surveyor he had signed a paper saying he wanted to be a full code. Review of R85's Directives for Code Status, dated [DATE] and provided by the facility revealed R85 chose to be a Full Code. R85 signed the document himself. Review of R85's Physician Verbal Order, dated [DATE] revealed an order of Do Not Resuscitate [DNR]. The order was entered by Licensed Practical Nurse Unit Manager (LPNUM) 1. Review of R85's Comprehensive Care Plan, created and effective on [DATE] and last evaluated (updated) on [DATE], located in the resident's EMR under the Care Plan tab revealed a problem of . [R85's Name] advance directive: Full Code. The Care Plan had a goal of [R85's Name] wishes will be respected and honored. Interventions included .EMS DNR IN PLACE . which contradicted the residents wishes to be a full code and indicated EMS would not perform CPR in the event of a cardiac and/or respiratory event. During an interview on [DATE] at 10:24 AM, LPNUM1 confirmed she was the one who completed the code status section of R85's initial comprehensive care plan which reflected full code. The LPNUM stated she forgot that the resident had wanted to be a full code and when she went over the baseline care plan, she was looking at the ribbon of the EMR which indicated DNR based on the physician's order she entered on [DATE]. The LPNUM also confirmed the care plan indicated the resident was a full code; however, the care plan included DNR . as an intervention which contradicted each other. During an interview on [DATE] at 2:49 PM, the [NAME] President of Risk Management (VP) 1 confirmed the resident's care plan had a problem which indicated the resident was a full code but had an intervention which indicated the resident was a DNR. VP1 stated it was her expectation residents' care plans would have been reflective of person centered care which included residents' code status wishes. During an interview on [DATE] at 4:48 PM, the Executive Director stated it was his expectation resident's code status wishes be honored and followed. The Executive Director also stated it was his expectation care plans would be accurate and reflected the resident's preferences and care needs. (Cross Reference F578) 2. Review of the Face Sheet located in the EMR under the Profile tab revealed R117 was admitted to the facility on [DATE] with diagnoses of neoplasm (cancer) of the prostrate, injury of ureter, obstructive uropathy, and acute kidney failure. Review of R117's admission MDS located in the EMR under the MDS tab with an ARD of [DATE] revealed R117 had a BIMS of 15 out of 15 which indicated the resident was cognitively intact. Review of the MDS revealed R117 had an indwelling foley catheter. Review of R117's admission comprehensive Care Plan dated [DATE] located in the EMR under the Care Plan tab revealed a problem was not addressed for the use of the foley catheter. Review of R117's physician orders located in the EMR under the Orders tab with a date of 08/2024 revealed an order for an 18 French (FR) with a 10 cubic centimeter (cc) balloon. The physician order further revealed R117 was to have catheter care done twice daily and urine output was to be documented. During an observation of R117 on [DATE] at 11:16 AM revealed the resident was lying in bed and had a foley catheter bag attached to the bedside. During an interview with R117 on [DATE] at 11:16 AM revealed he had prostate cancer and used the foley. During an interview on [DATE] at 1:12 PM with the MDS Coordinator (MDSC) confirmed she did not see a care plan in place for the foley catheter use and there should be. The MDSC further revealed the foley catheter should have an individual problem with individual interventions. The MDSC revealed the physician orders should have been on the Care Plan. The MDSC further revealed the Care Plan was utilized to provide staff with the knowledge of what needs to be done for the residents. The MDSC revealed she updated the care plans; however, the nurses should update the care plans too. The MDSC revealed the care plan was also carried over to the resident summary which went into the kiosk so that the Certified Nursing Assistants (CNAs) could see what care needed to be done. During an interview on [DATE] at 4:39 PM with the Director of Nursing (DON) revealed a foley catheter use should be care planned. The DON further revealed the staff would use the care plan as a guide for care of R117. During an interview on [DATE] at 5:18 PM with the Executive Director revealed the care plan should be updated according to the resident's needs. 3. Review of R90's quarterly MDS with an ARD of [DATE], located in the MDS tab of the EMR, revealed an admission date of [DATE]. R90 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R90's cognition was intact. R90's vision was severely impaired, received dialysis and chronic renal failure. Review of R90's Care Plan with an effective date of [DATE] to present, located in the EMR under the Care Plan tab, revealed R90 has the potential for complications related to hemodialysis for diagnosis of chronic renal failure and a goal Resident will remain free from complications related to renal dialysis, goal date [DATE]. An intervention included Monitor access area for redness or pain or signs of infection and report to MD [physician]. Review of R90's [DATE] Treatment Administration Record (TAR) located in the EMR under the Order tab revealed: Dialysis: Dialysis: Assess Access Site () Two Times Daily starting [DATE], order date: [DATE], Discontinued ([DATE]), Notes: Monitor Tunnel Catheter twice daily right chest, Dialysis: Check for Thrill, Bruit, and Assess Site () Two Times Daily starting [DATE], order date: [DATE], Deleted-entry error, Notes: right chest tunnel cath. Order ID: 977651 has not been assigned administration times in the Date Range Specified, and Scheduled 3 times weekly Three Times Weekly starting [DATE], order date: [DATE], Notes: days of dialysis Monday, Wednesday, Friday at 6:30 AM . Review of R90's Dialysis Communication forms, dated [DATE], [DATE], and [DATE] located in the EMR under the Provider tab revealed no monitoring of R90's right chest tunnel catheter. Review of R90's notes, dated [DATE] to [DATE], located in the EMR under the Note tab revealed no documentation of R90's right chest tunnel catheter. During an interview on [DATE] at 9:46 AM, the Director of Nursing (DON) was asked where the implementation of R90's Care Plan related to the documentation for the monitoring of R90's right chest tunnel catheter was located. The DON reviewed the TAR in the EMR and stated she could not find a treatment order specifically for monitoring the catheter, just a general order for infection. The DON then pointed to a treatment order that had been discontinued for monitoring the Tunnel Catheter. The DON stated the treatment order had inadvertently been discontinued. The DON stated R90's access site had changed several times from her arm to her chest and confirmed the order must not have been reinstated. During an interview on [DATE] at 11:09 AM, Registered Nurse (RN)2 was asked if he checked R90's chest catheter after dialysis. RN2 stated, No, he only checked to ensure the port was covered because the dialysis center would check for bruit/thrill before they covered it. At 11:25 AM, the RN stated the old order was discontinued because R90's port sites changed from the arm to the chest. During an interview on [DATE] at 2:06 PM, the Executive Director was asked if he was aware of R90's access catheter for dialysis was not being implemented per the Care Plan. The Executive Director stated he was not aware. The Executive Director stated his expectation would be for staff to follow protocols, physician orders, and the Care Plan. During an observation and interview on [DATE] at 6:53 PM, R90 was asked if the nurse checked her access site on her right chest after dialysis. R90 stated, No, the nurse just checked her blood sugar. R90 then pointed to the bandaged area over her access site. 4. Review of R59's significant change MDS with an ARD date of [DATE], located in the MDS tab of the EMR, revealed an admission date of [DATE]. R59 had a BIMS score of 15 out of 15 indicating R59's cognition was intact. The MDS indicated the resident received an anticoagulant (blood thinner), and had diagnoses of coronary artery disease, atrial fibrillation, and deep venous thrombosis. Review of R59's physician Orders located in the EMR under the Order tab, revealed warfarin 4 mg [milligram] tablet Every Day, dated [DATE] and warfarin 1 mg tablet Every Evening, dated [DATE]. The medication notes on the orders included side effects that should be monitored any signs of serious bleeding, including nosebleeds that happen often or don't stop, unusual pain/swelling/discomfort, unusual/easy bruising, prolonged bleeding from cuts or gums unusually heavy/prolonged menstrual flow, pink/dark urine, coughing up blood, vomit that is bloody or looks like coffee grounds, severe headache, dizziness/fainting, unusual tiredness/weakness, bloody/black/tarry stools, chest pain, shortness of breath, difficulty swallowing. Review of R59's Care Plan with an effective date of [DATE] to present, located in the EMR under the Care Plan tab, revealed no evidence of a Care Plan for the ordered warfarin Review of R59's [DATE] TAR located in the EMR under the Order tab revealed no evidence of monitoring for bleeding and other side effects. Review of R59's Notes dated [DATE] to [DATE], located in the EMR under the Note tab revealed no documentation of monitoring for warfarin potential side effects. During an interview on [DATE] at 7:31 AM, Licensed Practical Nurse (LPN)2 confirmed there was no care plan developed for R59's ordered warfarin or monitoring being completed except for laboratory tests. LPN2 stated her expectation would be for the warfarin to be care planned. LPN2 confirmed it was important to have a care plan for the use of an anticoagulant to ensure the resident was monitored for bleeding gums, stools, and when using the electric razor. During an interview on [DATE] at 4:38 PM, the DON stated she was not aware R59 did not have a Care Plan for the ordered warfarin, however; she stated the resident should have had one developed. During an interview on [DATE] at 2:09 PM, the Executive Director stated he was not aware of R59's anticoagulant not being care planned or that the resident was not monitored for bleeding, however, his expectation would be to care plan the medication, follow the care plan, monitor the medication for side effects, and follow the physician order and any protocols.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's camera footage, and review of the facility's policy, it was determined the facility failed to develop a Comprehensive Care Plan (CCP) to ensure one (1) of seventy-six (76) sampled residents (Resident #1) was provided adequate supervision to prevent elopement from the facility on [DATE]. Staff found Resident #1, outside, at the back of the facility on [DATE] at 10:26 PM, approximately five-hundred fifty-eight (558) feet from his/her room. The resident was found on the sidewalk face down and unresponsive behind the facility. Resident #1 was taken to a local Emergency Department (ED) by Emergency Medical Services (EMS). Resident #1 expired, on [DATE] at 11:23 PM. Resident #1's Elopement Risk Assessment, completed on admission, revealed the resident was too weak to have the ability to exit the facility and was not identified as an elopement risk. Resident #1's care plan did not identify any interventions needed to prevent elopement, such as increased supervision because he/she was not identified as an elopement risk. However, per the Director of Nursing's (DON) interview on [DATE] at 12:54 PM, the resident's status changed, and he/she became more mobile and should have been reassessed, and the resident's care plan should have been developed with new interventions added. The facility's failure to ensure each resident had a comprehensive care plan developed to direct staff to provide adequate supervision to prevent accidents and hazards through elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the area of 42 CFR 483.21 Comprehensive Care Plans (F-656) Develop and Implement Comprehensive Care Plan at a Scope and Severity (S/S) of a J. The facility submitted an acceptable Immediate Jeopardy (IJ) Removal Plan on [DATE], alleging the Immediate Jeopardy's removal and substantial compliance, on [DATE]. The State Survey Agency validated the IJ Removal Plan, prior to exit on [DATE], and determined the facility had implemented corrective actions and was in substantial compliance on [DATE], as alleged, before the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Care Plans-Comprehensive, last reviewed 08/2018, revealed the facility must develop and implement a comprehensive person-centered care plan for each resident, to meet the resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Per the policy, assessments were ongoing and care plans were to be revised as changes and conditions of the resident changed. Review of Resident #1's medical record revealed the facility admitted the resident, on [DATE], for Rehabilitation Services related to increased weakness, increased confusion, and a high number of falls. The resident's diagnoses included Wernicke Encephalopathy, Vascular Dementia without Behaviors, Unspecified Convulsions, Insomnia, and Alcohol Dependence with Withdrawal. Review of the Brief Interview for Mental Status (BIMS) assessment, completed on [DATE], revealed the resident scored nine (9) of fifteen (15), which indicated moderate cognitive impairment. Review of Resident #1's CCP, dated [DATE], revealed the resident had an altered mental thought process, was at risk for self-care deficits, and at risk for injury related to his/her Dementia diagnosis. The goal set for the resident revealed he/she would be monitored for safety. Interventions, for this problem, included to facilitate the use of assistive devices for ambulation as appropriate, assess risk of elopement and initiate appropriate interventions, provide assistive devices per therapy evaluation to steady gait for ambulation. The interventions listed were to provide only the amount of assistance/supervision that was needed and to report any changes in Activities of Daily Living (ADL) self performance to the nurse. The facility was to provide the adaptive/safety equipment: walker and/or wheelchair. Record review revealed the facility care planned Resident #1 for psychotropic drug use. Staff was to observe the resident for signs and symptoms related to hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL decline, and decline in appetite. Review of the Elopement Risk Assessment, completed for Resident #1, on [DATE] by Registered Nurse (RN) #13, revealed upon admission the resident was weak and unable to get out of bed. She documented the resident as not having the ability to leave the facility with or without assistance devices. Therefore, Resident #1 was not assessed to be an elopement risk. Since the resident was not determined to be an elopement risk, there was no care plan developed for additional supervision for the resident. Review of camera footage, with the Administrator, on [DATE] at 2:15 PM, revealed on [DATE] at 8:31 PM, the resident was seen walking in the hallway by his/her room, room [ROOM NUMBER]. The resident walked from the far end of the hallway toward the common area. The resident disappeared from the camera at 8:34 PM toward the common area. At 8:40 PM, the resident reappeared on camera back in the hallway, again, the resident could be seen with his/her walker. Resident #1 would move his/her walker up one (1) step, would look down and would move his/her left foot up and slightly around the walker before he/she moved the other foot up. The resident had a very slow gait. Continued observation of the camera footage revealed from 9:00 PM to 9:55 PM, no staff was present in the hallway. Additional review of the camera footage, with the Administrator on [DATE] at 12:30 PM, revealed on [DATE] at 9:47 PM, Resident #1 pushed through the fire doors setting off an alarm and walked through the Dialysis Unit lobby; at 9:48 PM, entered the elevator on the second floor; at 9:49 PM, exited the elevator into the first floor lobby; and at 9:51 PM, was outside of the facility. After exiting to the outside, the resident disappeared from the camera. Interview, with Resident #1's Son, on [DATE] at 2:40 PM, revealed the resident was sent back to the facility, on [DATE], because he/she had many falls at home and increased confusion. He stated his parent required assistance to get safely to the restroom. Further interview revealed the resident got around pretty well with his/her walker, but he/she had to be very deliberate about his/her walking. He stated the resident was weak and needed supervision. Continued interview revealed the Resident's Son stated the resident's memory was really bad. He also stated he would not expect his parent to be walking around outside of the facility. Interview, with Certified Nursing Assistant (CNA) #16, on [DATE] at 6:54 PM and CNA #17 on [DATE] at 9:00 PM, revealed it was very important to follow the care plan to know how to properly care for the resident. They stated if the care plan was not followed, the resident and/or staff could be hurt in the process. They stated the care plan was created to ensure residents got the best care possible. Interview, with Registered Nurse (RN) #9, on [DATE] at 5:19 PM; RN #10 on [DATE] at 5:56 PM; and RN #13 on [DATE] at 8:51 PM, revealed the CCP was to be followed to ensure the resident received the best possible care. They stated any changes to the resident's condition would require the CCP to be reviewed and revised if the interventions in place were not working. They stated, if staff did not follow the CCP when caring for the resident, the resident could be hurt. Interview with the Director of Nursing (DON) on [DATE] at 12:54 PM, revealed the resident was not care planned for elopement risk because he/she was assessed as not being able to leave the facility on his/her own with or without an assistance device. She stated the only part of the care plan which addressed monitoring for safety was because of the resident's Dementia. She stated Elopement interventions would only have been placed on the care plan if Resident #1 had been identified as a risk. She stated once the resident's status changed where he/she became more mobile, he should have been reassessed and the care plan should have been developed more with new interventions. Additional interview with the DON, on [DATE] at 3:14 PM, revealed if a resident was able to ambulate with a walker, wheelchair, or a cane, the resident would be ambulatory. Therefore, she stated, that resident would have the ability to physically leave the facility on his/her own with or without assistive devices. She also stated if staff noticed a change in Resident #1, so he/she could ambulate, the Elopement Risk Assessment should have been redone. However, she stated she would not have made Resident #1 an elopement risk because he/she never exhibited any exit seeking behaviors. Interview with the Administrator on [DATE] at 2:00 PM, revealed the Comprehensive Care Plans (CCP) were initially created by the Minimum Data Set (MDS) Coordinator, but they were reviewed by the entire team which included leadership from each department. He said it was each department's responsibility to ensure their section was developed completely. He stated, when the care plan was being developed, input from the resident and his/her family should be involved. Continued interview revealed it was important for staff to follow the resident's care plan because when they were developed well, they were a road map to the resident's care. Also, he stated, by following the care plan, the facility would ensure each resident had the ability to maintain his/her highest practicable physical, mental and psychosocial well-being. The Administrator stated the care plan needed to be reviewed frequently to ensure the interventions still worked for the resident. However, he stated the staff did everything they should have done for this case. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan, on [DATE], that alleged removal of the IJ, on [DATE]. Review of the IJ Removal Plan revealed the facility implemented the following: 1. On [DATE], the Director of Nursing (DON) educated the Unit Managers, Staff Development Coordinator, and the Night Shift Supervisor on updating and developing the resident's care plan to be reflective of the resident's care needs; to update the resident's care plans based on the resident's change of condition; and, the Elopement Precautions Policy which included a revised Elopement Assessment. The Elopement Precautions Policy included how often to assess residents, to ensure the care plan was reflective of individualized interventions to minimize risk for elopement, where to place a wandering device (a bracelet or anklet placed on the resident and a door device that would alarm if the resident crossed the threshold used to prevent elopement) placed on their person, maintaining a list of residents at risk, and when to check the wandering devices. The deficient practice that was cited with Resident #1 was the facility's failure to complete an updated Elopement Risk Assessment when his/her functional ability improved to allow him/her to physically use a device to independently leave the facility. 2. On [DATE], all residents were reassessed by the Unit Managers and the DON to ensure that any resident identified as an elopement risk was on a secured unit and a wandering device had been placed on the resident and was intact. 3. On [DATE], the DON reviewed the elopement binders to ensure anyone who identified as an elopement risk, had a picture, a face sheet, and a listing of residents included in the binders. 4. On [DATE], the DON created a Functional/Needs Change assessment tool to be completed when a change in a resident's condition was identified. If the tool identified a change that affected the resident's elopement risk, a newly created Elopement Risk Assessment would be completed by the licensed nurse, and these were reviewed in the Clinical Meeting by the Nurse Managers. 5. On [DATE], the Unit Managers and Minimum Data Set (MDS) Nurse reviewed and updated all residents' care plans ensuring interventions were reflective of the residents' care needs, and provided adequate supervision and monitoring to prevent elopement. 6. By [DATE], all licensed nurses were educated by the Staff Development Coordinator and the Night Shift Supervisor. The staff verbalized understanding on: updating/developing the resident's care plan to be reflective of the resident's care needs; to update/develop the resident's care plan based on his/her change in condition; and, the Elopement Precautions Policy, which included a revised Elopement Assessment. 7. By [DATE], the Staff Development Coordinator and the Night Shift Supervisor completed all education for all clinical staff including licensed nurses, Social Services, Activities, and the Registered Dietician. These staff members verbalized understanding of the education provided. This education included the implementation of a new Functional/Needs Change tool to identify residents with changed needs or a functional change. 8. The Quality Assurance Performance Improvement (QAPI) Committee, which included: Medical Directors, Administrator, DON, Staff Development Coordinator, Human Resource Director, Business Office Manager, Dietary, Activities, Housekeeping, Minimum Data Set Nurse, Director of Community Relations, Maintenance Director, Senior Vice-President (SR VP) of Risk Management/Corporate Representative, and Infection Preventionist. The QAPI Committee met on [DATE], and discussed the Comprehensive Care Plan implementation, updating and assessment processes, and the performance improvement plan. The current audit tools were agreed upon by QAPI members to be used to capture data needed to determine compliance. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Record review revealed the Current List of Residents at risk for elopement, the revised Elopement Assessment, and the revised Elopement Policy. Interview, with the DON, on [DATE] at 11:23 AM, revealed she educated the Unit Managers, the Staff Development Coordinator (SDC) and the Night Shift Supervisor on updating the residents' care plans. She stated she stressed that the care plans needed to be specific to the resident, especially his/her function. She stated she educated them on the Elopement Precautions Policy and the revised Elopement Assessment. The education was provided in the Nursing Conference room before [DATE]. Interview, with Licensed Practical Nurses (LPN) #9 and #10, and the Unit Managers, on [DATE] at 6:44 PM, revealed they were taught to update the care plan for anyone they identified as an elopement risk. Further, they stated they were educated on the Elopement Precautions Policy and the revised Elopement Assessment. The education, they said, included assessment of the resident, specifically for elopement prevention and placement of the wander guard (wandering device). Interview, with the Night Shift Supervisor, on [DATE] at 7:35 AM, revealed she was educated by the DON on updating the resident's care plan. Further, the updates needed to be specific to the resident's needs. She stated she was also educated that any changes needed to be put in the care plan. Further interview revealed the education included the Elopement Precautions Policy and the revised Elopement Assessment. She stated the policy included assessing and documenting any changes in the resident. Further, she said she was to keep a list of residents who were at risk of elopement. Interview with the SDC, on [DATE] at 11:27 AM, revealed she was educated on updating the resident's care plan, the Elopement Precautions Policy which included the revised Elopement Assessment, assessing residents for risk of elopement and wandering devices. She stated the education was provided in the Nursing Conference room prior to [DATE]. 2. Interview with the Unit Managers, LPN #9 and LPN #10, on [DATE] at 6:49 PM, revealed all residents were re-assessed using the new tools created and care plans were updated as needed. LPN #10 stated updates discovered some residents who were identified as elopement risks. They stated their care plans were revised, and they were moved to a locked unit as needed. Continued interview revealed they assisted with the assessment of all the residents for risk of elopement. LPN #9 assessed the residents in the [NAME] and [NAME] house. LPN #10 assessed the residents in the [NAME] and [NAME] Houses. They stated staff checked wander guards for each resident, per shift, and as needed and assured the device was in place. Interview, with the DON, on [DATE] at 11:34 AM, revealed all the residents had been reassessed and their care plans were updated, as needed. Interview and review of two (2) care plans with the DON revealed care plans had been updated as needed following the current process in place. Observations on [DATE] at 1:30 PM of residents that resided on the [NAME] House and [NAME] House Units, with Unit Manager #9, verified wander guards were in place for eight (8) residents, with one (1) resident asleep so verification could not be done. However, Unit Manager #9 stated this resident's wander guard was in place. The list for elopement risk residents was located in the Elopement Risk binder. 3. Review of the Elopement Binder on [DATE] revealed a total of fourteen (14) residents were identified as elopement risks. Further review revealed the binder had face sheets, pictures, and listing of the elopement risk residents. Interview, with Unit Manager/LPN #9 and Unit Manager/LPN #10, on [DATE] at 6:49 PM, revealed an elopement binder was in place on each unit, and each staff member knew the location of the binder. Interview, with the DON, on [DATE] at 11:37 AM, revealed she put most of the elopement binders together. She stated the elopement binder included a face sheet and picture of each resident at risk for elopement. Further, she stated she reviewed the binder often. 4. Review of the new Functional/Needs Change tool revealed it had a section under Alarms for Elopement Risk/Wanderguard. Interview, with LPN #7, #8, #11, #18, RN #1, and RN #8 on [DATE] at 6:15 PM, revealed they were taught to use the Functional/Needs Change tool. They stated the teaching included how to assess the resident and use the tool to identify if the resident was at risk for elopement. Further, they stated, any resident who was found to be at risk for elopement was identified in the morning clinical meetings. Interview, with LPN #12 on [DATE] at 6:38 PM, revealed he was taught by the SDC on the unit on how to use the Functional/Needs Change tool. He stated he was taught how to assess and document any changes in the resident's condition. Interview, with LPNs #26, #27, #55, and RN #18 on [DATE] at 7:37 PM, revealed they received education about the Functional/Needs Change tool which included identifying changes in a resident that could increase the risk of elopement. They stated the education was provided on the unit by the Night Shift Supervisor last month. They stated the education included assessment of the resident and how to use the tool. Continued interview revealed the Night Shift Supervisor asked questions after the training to assess the staff's understanding of the tool. Interview, with LPN #2, RN #2, and RN #4, on [DATE] at 10:02 AM, revealed they received education about the Functional/Needs Change tool. They stated the education was about noticing changes in a resident. They stated the SDC educated them on the unit and showed the tool when she talked about it. Further, they reported they answered questions after the education. Interview, with LPNs #9 and #10 and the Unit Managers on [DATE] at 6:50 PM, revealed they were taught by the DON in the Nurse's Conference room to use the Functional/Needs Change tool. They stated they were taught how to assess the residents and if they saw a change what to do, using different examples. They stated the examples were changes in activities of daily living, cognitive changes, and other changes. They stated, if a resident had a change in function, this would be discussed in the morning clinical meetings. Interview, with the DON on [DATE] at 11:34 AM, revealed the new Functional/ Needs Change tool to identify changes in residents' condition was now being used for identification of possible behaviors that might trigger residents as elopement risks. She stated she obtained the Functional/Needs Change tool from the Vision software. The DON stated she reviewed different tools, and this was the most appropriate for the facility. She stated any change in a resident's condition would be discussed in the morning clinical meetings. 5. Review of the identified Elopement Risk Residents' Care Plans were reviewed and had the interventions put in to address elopement risk. Interview with LPN #9 and LPN #10, Unit Managers on [DATE] at 6:52 PM, revealed they were part of the process of reviewing and updating the care plans. They stated they specifically looked for elopement risks. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 11:44 AM, revealed she reviewed the residents' care plans. Further, she stated the care plans were updated as needed. She stated she especially focused on making sure the care plans were specific to each resident's functional ability and risk for elopement. Continued interview revealed she attended the morning clinical meetings, and the reviewed care plans were discussed in the morning clinical meetings. 6. Review of the sign-in sheets for training on updating/developing the resident's care plan to be reflective of the resident's care needs; to update/develop the resident's care plan based on his/her change in condition; and the Elopement Precautions Policy, which included a revised Elopement Assessment revealed training begun on [DATE] and was completed on [DATE]. Interview, with LPNs #7, #8, #11, and #18, on [DATE] at 6:16 PM, revealed they were taught to update the resident's care plan if there were any changes in the resident. Further, they stated they were taught on the Elopement Precautions Policy and the revised Elopement Assessment. They stated the training specifically talked about changes in a resident that might result in elopement. They stated the training was provided by the Night Shift Supervisor on the unit, sometime in [DATE]. Interview, with LPN #12 on [DATE] at 6:40 PM, revealed he was taught by the SDC to update the care plan if a resident had a change in condition. He stated he was also taught about the Elopement Precautions Policy. He stated the training was provided on the unit. He stated the training was provided last month, and the SDC asked questions after the training to assure they understood the training. Interview, with LPNs #26, #27, #55 and RN #18, on [DATE] at 7:45 PM, revealed they were taught to update the care plan for any change in a resident. Further, they stated the education included the Elopement Policy and the elopement assessment tool. They stated the training also included assessing and documenting changes in a resident on the elopement assessment tool. They stated the training was provided by the Night Shift Supervisor on the unit last month. They stated she asked them questions after the training. Interview, with LPN #2, RN #2, and, RN #4 on [DATE] at 10:05 AM, revealed they were educated by the SDC on updating the resident's care plan if there was a change in the function of a resident. They stated they were taught to revise the care plan if the resident's function worsened or improved. Continued interview revealed the care plan was to be specific to any elopement risk. Further, they stated the SDC provided education on the Elopement Precautions Policy which included a revised Elopement Assessment. They stated the SDC came to the unit and provided them with a handout. Further interview revealed she answered questions after the training to validate they understood what was taught. They stated the training occurred last month. Interview, with the Night Shift Supervisor on [DATE] at 7:43 AM, revealed she educated the night staff on the importance of updating the resident's care plan if there were any changes in a resident. She stated she also educated the staff on the Elopement Policy and the revised Elopement Assessment. Further, she stated she stressed the importance of identifying any resident at risk for elopement. She stated she verified that the staff understood the education by having them verbally repeat the education. Also, she stated she went to the units to provide the education last month. Interview, with the SDC on [DATE] at 11:27 AM, revealed she educated all staff. She stated she went to the units and educated the staff on updating the resident's care plan for any change in the resident's condition. She stated she stressed the importance of noticing a change in the resident's function. Further, she said she educated staff on the Elopement Precautions Policy which included a revised Elopement Assessment. Also, she stated she asked the staff members questions after the education to assure they understood the education. Further, she stated she stressed the importance of identifying any resident at risk of elopement. 7. Review of the sign-in sheets for training on the implementation of a new Functional/Needs Change tool to identify residents with changed needs or a functional change revealed training was completed on [DATE]. Interview, with CNAs #3, #9, #23, #44, #48 and #49, on [DATE] at 5:30 PM, revealed they were educated on the new Functional/Needs Change tool. They stated education was provided by the SDC on the unit last month. They stated the SDC talked about the tool and showed them the tool. They stated the tool was about noticing any changes in a resident, such as behaviors, change in mental status, and changes in ambulation. Further, they stated if there were any changes in a resident, this was to be documented on the resident's care plan. Interview with CNAs #4, #7, #41, #43, #45, #47 and #50, on [DATE] at 6:00 PM, revealed they received training on the new Functional/Needs Change tool. They stated they were taught by the SDC on the unit. Further interview revealed one (1) of the CNA's was not present on the day of the training, and she went to the SDC's office for the training. Interview, with LPNs #7, #8, #11, #18, RN #1, and RN #8, on [DATE] at 6:18 PM, revealed they were educated on the new Functional/Needs Change tool. They stated the education was done by the Night Shift Supervisor on the unit. Continued interview revealed the Night Shift Supervisor talked about the tool and showed them the tool. They stated the tool included significant changes, especially related to elopement. Further, they stated they were taught to document any changes on the resident's care plan. Interview, with LPNs #26, #27, #55 and RN #18, on [DATE] at 7:50 PM, revealed they had received training on using the Functional/Needs Change tool. They stated the education was provided by the Night Shift Supervisor. They stated she came to the unit and taught them to identify any change in a resident that could increase their risk for elopement. Continued interview revealed they were also taught on the Elopement Policy and the revised assessment tool. They stated they were taught to update the care plan if a resident had any change. Interview, with the night shift CNAs #51, #52, #53 and #54 on [DATE] at 7:27 PM, revealed the Night Shift Supervisor taught them about the new Functional/Needs Change tool last month. They stated the Night Shift Supervisor came to the unit and showed them a copy of the tool and explained the tool. They stated they were instructed to tell the nurse if a resident had any change in condition. Continued interview revealed changes could be an unsteady gait, an improvement in ambulation, or behavior changes, such as crying. Further, they stated they gave feedback that showed they understood the training. Interview, with LPN #2, RN #2, and RN #4 on [DATE] at 10:06 AM, revealed they received education last month by the SDC on assessing residents for any change in function. They stated the training focused on the Functional/Needs Change tool. They stated the SDC came to the unit with a cart. Continued interview revealed the cart had educational materials on how to identify a change in a resident's function. Further, they stated the education included changing the resident's care plan for any change in function, even if the change was an improvement. Interview, with the Social Services Director and Activities Director on [DATE] at 10:37 AM, revealed they were educated by the SDC to identify a functional change or mental change in a resident and to notify the resident's nurse if they noticed a change. Interview, with the Registered Dietitian on [DATE] at 10:55 AM, revealed she received education by the SDC on identifying any change in a resident. The change was to be reported to the nurse. Interview, with the Night Shift Supervisor on [DATE] at 7:35 AM, revealed she taught the night shift staff on implementing the Functional/Needs Change tool. She stated she educated the staff to identify any change in a resident's function. She stated the education included updating the care plan if a resident had a change in condition. Further interview revealed the education was provided last month prior to [DATE]. Interview, with the SDC, on [DATE] at 11:27 AM, revealed she educated all staff including the Social Services Staff, the Registered Dietitian and the dietary staff, including the Activities Director and activities staff. She stated the education included the new Functional/Needs Change tool. Continued interview revealed the staff members were taught to notify the resident's nurse if they noticed a change in a resident. She stated licensed nurses were educated on updating the care plan if a resident had a change in function or any risk of wandering. The SDC stated she asked questions after the training to assure they understood the education. 8. Review of the sign-in sheet for the [DATE] QAPI Committee meeting revealed members in attendance were Medical Directors #1 and #2, the Administrator, Director of Nursing, Staff Development Coordinator, Human Resource Director, Business Office Manager, Dietary, Activities, Housekeeping, Minimum Data Set (MDS) Nurse, Director of Community Relations, Maintenance Director, Senior Vice-President (SR VP) of Risk Management/Corporate Representative, and Infection Preventionist. Interview, with the Director of Community Relations, Infection Preventionist, Business Office Manager, Environmental Services, Central Supply, Life Enrichment, Senior [NAME] President of Risk Management, Human Resource Director, MDS Coordinator, DON, Administrator, Social Worker, Dietary Manager, and Maintenance Director, members of the QAPI Committee, on [DATE] at 10:23 AM, revealed they had attended the [DATE] QAPI meeting and discussed the need for the residents' environment to be supervised to prevent accidents, specifically elopement. They stated they agreed on the audit tools to use to evaluate the processes. Further, they stated they reviewed the new Functional/Needs Change tool and the revised Elopement Assessment. The committee members stated they all agreed the new policy and new tools to help identify possible elopement risks would be very beneficial for staff to easily identify risks. Interview, with Medical Director #2 on [DATE] at 5:20 PM, revealed she was one of the Medical Directors. She stated she did attend the QAPI meetin[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's investigation, review of the facility's camera footage, https://www.wunderground.com and review of the facility's policies, it was determined the facility failed to ensure a safe environment and failed to ensure each resident received adequate supervision and monitoring to prevent an elopement from the facility for one (1) of seventy-six (76) sampled residents (Resident #1). Resident #1 eloped from the facility, on [DATE] at 9:50 PM, and was not found by staff until 10:24 PM. When found, the resident was unresponsive, face down, with blood coming from his/her head. The resident expired at the hospital on [DATE] at 11:23 PM. On admission to the facility, on [DATE], the facility assessed Resident #1 to lack the ability to exit the facility on his/her own with or without the use of assistive devices. The facility did not assess the resident as an elopement risk. However, on [DATE] at 9:47 PM, the resident was observed on the facility's camera footage as he/she entered the lobby of the facility's second floor Dialysis Unit, boarded the elevator, and traveled to the first floor. The resident exited the elevator into the first floor lobby, walked through two (2) sliding glass doors, and exited the building at 9:50 PM. Interview with the Administrator revealed the cameras in the facility were motion activated. Once the resident stepped outside, the camera no longer picked up his/her movement and stopped recording. At approximately 10:24 PM, Certified Nursing Assistant (CNA) #8 observed an unknown person face down, bleeding and nonresponsive, on the sidewalk at the back of the facility. CNA #8 got Registered Nurse (RN) #3, who assessed the person and determined the person did not have a pulse or respirations. RN #3 began Cardiopulmonary Resuscitation (CPR) on him/her. More staff arrived on the scene, and it was not until approximately 10:36 PM when RN #11 identified the person as Resident #1, who resided at the facility. Emergency Medical Services (EMS) were called and arrived on the scene at approximately 10:36 PM. Resident #1 was taken to the hospital and was pronounced deceased at 11:23 PM. The facility's failure to ensure each resident had adequate supervision to prevent accidents and hazards has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the area of 42 CFR 483.25 Quality of Care (F689) Free of Accident Hazards/Supervision/Devices at a Scope and Severity (S/S) of a J. The facility submitted an acceptable Immediate Jeopardy (IJ) Removal Plan on [DATE], alleging the Immediate Jeopardy's removal and substantial compliance, on [DATE]. The State Survey Agency validated the IJ Removal Plan, prior to exit on [DATE], and determined the facility implemented corrective actions and was in substantial compliance on [DATE], as alleged, before the State Survey Agency's investigation. Therefore, it was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Accidents and Supervision Prevention, last revised 10/2020, revealed the facility would utilize an Interdisciplinary Team (IDT) to identify solutions to keep all residents safe; would identify additional resources to address safety concerns, and demonstrate a commitment to safety at all levels within the organization. The facility was to provide a process that would identify hazards and risks to include supervision, evaluations and analysis of the hazards and risks. Per the policy, implementation of interventions was to include adequate supervision and monitoring. The policy also stated the facility would provide comprehensive assessments for each resident upon admission, quarterly, and with any change in the resident's condition. Per the policy, the Administrator and Quality Assurance (QA) team would conduct environmental rounds to ensure the environment would remain free from hazards. The policy stated QA was to identify issues, develop and implement a plan of action to make corrections, and put interventions in place to reduce potential for accidents and hazards. Review of the facility's policy titled, Elopement, last reviewed 07/2022, revealed residents were to be assessed upon admission, readmission, quarterly, with a significant change, and as needed to determine a resident's elopement risk. Per the policy, if the resident was determined to be at risk, the elopement form would be printed and placed in the elopement binder. The policy stated the Medical Director would be informed, and the resident would be moved to a secured unit or have a wander guard device (a system used to prevent elopement that had a bracelet or anklet on the resident and a door device that would alarm if the resident crossed the threshold) placed on their person. The resident's care plan would be updated, and he/she would be monitored. Per the policy, if an elopement occurred, staff was to immediately contact security, the Director of Nursing (DON), and the Administrator and start a full facility search. Review of the facility's Investigation and Five Day Follow-Up Report, dated [DATE], revealed the facility provided the following explanation for Resident #1 leaving the facility on [DATE]: (Resident #1) was admitted to [NAME] House on [DATE] for short term rehab services and had a prior stay from [DATE]-[DATE] and this room was directly across from the current room he/she was residing at the end of the hall. The unit is a short term rehab unit and is only for those individuals who do not need a more secure environment. (Resident #1) did not require a special type of supervision based on his/her assessments and interactions with staff. (Resident #1) had purpose with his/her day-to-day engagements like going to ride the exercise bike, and use of the public restroom. It appeared (Resident #1) had left the unit to go outside for a walk on the premises properly dressed in a safe area of the campus which was a sidewalk. (Resident #1's) actions were self-initiated and driven as an alert and oriented resident, and staff responded appropriately and followed proper plan of care for this resident during his/her entire stay. Review of Resident #1's closed record review revealed the facility admitted the resident, on [DATE], for Rehabilitation Services related to increased weakness, increased confusion, and a high number of falls while at home. The resident's diagnoses included Wernicke Encephalopathy, Vascular Dementia without Behaviors, Unspecified Convulsions, Insomnia, and Alcohol Dependence with Withdrawal. Review of Resident #1's Quarterly Risk Assessment completed by RN (Registered Nurse) #13 on [DATE], revealed the facility assessed Resident #1 to be at high risk for falls with a total score of twenty-two (22), in which a ten (10) or higher was determined to be high risk. Continued review revealed the facility assessed the resident as having behaviors present; moderately impaired vision; independent and incontinent; ambulated with problems and with the use of a device; and gait was unsteady, slow, and lurching. RN #13 also noted the resident was not steady on his/her feet and only stabilized with physical assistance. The resident received a score of twenty-two (22) and anything above ten (10) made the resident high risk for falls. Review of the facility's developed Elopement Risk Assessment, dated [DATE] revealed because the resident was assessed not to be able to exit the facility on his/her own, with/without assistive devices the elopement assessment ended. Interview with the Director of Nursing (DON), on [DATE] at 12:54 PM, revealed the resident should have been reassessed once he/she was up and walking again. Interview, with RN #13, on [DATE] at 8:51 PM, revealed when she completed Resident #1's assessment, he/she was unable to sit up in the bed and was very weak. She stated that was why she marked the resident as unable to leave the facility on his/her own. Interview with the DON, on [DATE] at 12:54 PM, revealed even if the resident had been reassessed when he/she was up and walking, she would not have identified him/her as an elopement risk because the resident did not show any exit seeking behaviors. However, based on the Elopement Risk Assessment, the resident should have been identified as an elopement risk with a score of two (2); one (1) point for being newly admitted to the facility (less than three (3) days); and one (1) point for exhibiting periods of confusion. Review of the Hospital Discharge summary, dated [DATE], revealed the hospital treated Resident #1, from [DATE] to [DATE], for multiple falls and worsening confusion with underlying dementia. Review of the Geriatrics History and Physical, completed by the Primary Care Physician (PCP), dated [DATE], revealed the PCP assessed Resident #1 with decreased mobility, used a wheelchair, required assistance, and had previous falls. The resident was also noted with weakness, seizure disorder, mild memory loss, and unsteady gait. Review of the Five (5) Day admission Minimum Data Set (MDS) Assessment, dated [DATE], but created on [DATE], revealed Resident #1 required supervision-oversight; and encouragement and/or cueing for dressing, eating, toileting and personal hygiene as well as bed mobility, transfers, walking in the room, and walking in the corridor and locomotion on the unit. The MDS assessment revealed the resident completed locomotion off the unit one (1) or two (2) times only, during the assessment. Resident #1 was also assessed to walk ten (10) feet and walk fifty (50) feet with two (2) turns with touch assistance/supervision provided. Review of the facility's camera footage (from [DATE]) with the Administrator, on [DATE] at 12:30 PM, revealed on [DATE] at 9:47 PM, Resident #1 appeared on the camera as he/she entered the lobby on the second floor Dialysis Unit. At 9:48:52 PM, the resident got on the elevator and closed the door. At 9:49:38 PM, the resident got off the elevator on the first floor. At 9:50:21 PM, Resident #1 exited the first set of electronic sliding glass doors and entered a byway. At 9:50:46 PM, the resident exited the second electronic sliding door to the outside. The resident disappeared off camera. Per the Administrator, the cameras in the facility were motion activated, and once the resident stepped outside, the camera no longer picked up his/her movement and stopped recording. The time on the camera skipped forward to 10:20 PM. A different camera showed, on [DATE] at 10:25:23 PM, which revealed a staff member entered the [NAME] House running for help. At 10:26:07 PM, that same staff member (an aide) and two (2) other aides ran and exited the building. Another staff member could be seen walking in the hall slowly, heading toward the door. That staff member exited the building at 10:26:28 PM. Another camera angle to the outside revealed emergency lights, and the fire truck arrived at 10:36:18 PM. Per the footage, movement could be seen in the upper right hand corner of the screen, but nothing was identifiable except the fire truck's arrival. The resident was outside of the facility for thirty-five (35) minutes before being discovered. Review of a weather report from https://www.wunderground.com, for [DATE] revealed at the facility at 8:56 PM it was thirty-six (36) degrees Fahrenheit (F) but felt like twenty-four (24) degrees F with south winds blowing at five (5) miles per hour (mph) with cloudy skies. At 9:56 PM, it was thirty-five (35) degrees F, but felt like twenty-four (24) degrees F with southeast winds blowing at five (5) mph and with cloudy skies. Review of the facility's camera footage (all from [DATE]) with the Administrator, on [DATE] at 2:15 PM, revealed at 7:10 PM, LPN #6 took the medication cart to the end of the hall toward room [ROOM NUMBER], Resident #1's room. At 7:24 PM, Resident #1 was seen in the hallway by room [ROOM NUMBER]. At 7:50 PM, the resident was seen in the hall and then disappeared. At 8:01 PM, LPN #6 was seen at the end of the hall near room [ROOM NUMBER]. At 8:19 PM, LPN #6 went into a room at the end of the hall. There was no activity in the hall again until 8:31 PM, when LPN #6 was seen at the end of the hall across from room [ROOM NUMBER]. Also, at 8:31 PM, the resident was seen in the hallway next to LPN #6. Resident #1 had the walker and moved up the hall toward the common area. At 8:34 PM, the resident disappeared out of the view of the camera into the common area. At 8:40 PM, LPN #6 was seen in the hallway and moving up toward the common area with the medication cart. At 8:44 PM, Resident #1 entered the hallway from the common area and headed toward the end of the hall where his/her room was. At 8:52 PM, the resident disappeared off the camera as he/she walked back to the room. The Administrator explained since the cameras were motion censored, it stopped recording because of the resident's slow movement and neutral colored clothes. From 9:00 PM until 10:00 PM, no staff was seen in the hallway, neither up toward the common area or at the end of the hall near room [ROOM NUMBER]. The fire door was noted to be thirteen (13) feet from the resident's room door. The camera footage skipped from 9:35 PM to 9:55 PM, after the resident had exited the building. Observation, on [DATE] at 8:50 AM, with the Administrator, revealed the path Resident #1 took when he/she left the building on [DATE] at 9:47 PM. Resident #1 was expected to be in his/her room, on the second floor, before pushing through the egress doors at the end of the [NAME] Hall. This door was noted to require a badge to open or it could be bypassed by pushing the fire lock for fifteen (15) seconds until the door released. Once through that door, there was a hallway to the left which led to a lobby in the upstairs Dialysis Unit. Per the observation, the Dialysis Unit had a large glass door which had a push button intercom. The lobby also had an elevator that was unlocked without any restrictions. The State Survey Agency (SSA) Surveyor and the Administrator entered the elevator and traveled down to the first floor. Exiting the elevator, there was another lobby, toward the right that had two (2) sliding glass doors. Those doors were locked from the outside only. Continued observation on [DATE] at 8:50 AM, with the Administrator, revealed based on where Resident #1 was found, he/she took a right out of the sliding glass doors and walked down the sidewalk almost making it to the flag pole at the back of the building. At the beginning of this sidewalk there was a wheelchair access dip. Walking down the sidewalk, there was an area that split because a road, which ran through it. This was a surface change from a regular sidewalk surface to a black road surface. Observation, on [DATE] at 1:00 PM, with the Maintenance Director, revealed he used a rolling counter to count out the distance Resident #1 traveled from his/her room to where the resident was found on [DATE]. From the resident's room to the first fire door was thirteen (13) feet; from that door to the elevator was fifty-nine (59) feet; from the elevator on the first floor to outside was fifty-four (54) feet; and to the spot on the sidewalk where the resident was found was four hundred and thirty-two (432) feet to the back side of the facility. Resident #1 was found unresponsive with no respirations or pulse, thirty-five (35) minutes after he/she exited the facility. Additional review of the camera footage, from [DATE], with the Administrator on [DATE] at 11:20 AM, revealed on [DATE] at 8:40 PM, LPN #6 left the hallway. At 9:33 PM, a visitor was seen exiting a door towards the front of the hall by the common area, to the right. At 10:09 PM, a staff member came out of the second door on the right of the hallway. The Administrator did not identify the staff member but said it was either CNA #16 or #17. At 10:13 PM, the visitor returned to the same room she had exited. At 10:17 PM, an Aide walked up the hall to the Nurses' Station. Per the interview with LPN #14, this was when CNA #17 notified the nurse she could not locate Resident #1. The facility confirmed the fire door alarm was on from 9:46:54 PM until 10:28:40 PM; however, camera footage did not show staff interact with the door at any time during this period. Review of the facility's Badge Transaction Report revealed the egress door which led out to the dialysis lobby was pushed open, causing the door fire alarm to sound on [DATE] at 9:46:54 PM; and the door closed at 9:47:16 PM. The report revealed the door was opened with LPN #6's badge at 10:28:40 PM. Continued review of the camera footage (all from [DATE]) with the Administrator on [DATE] at 11:20 AM, revealed LPN #6 took the same path Resident #1 had taken on [DATE] at 10:28:40 PM; however once outside, she did not locate the resident and returned to the unit. Review of the Emergency Medical Services (EMS) Incident Report #E22123538, dated [DATE], revealed dispatch was called at 10:28:11 PM, and EMS arrived on scene at 10:37:00 PM. The call came in as unknown problem and person down. The report stated CPR (cardiopulmonary resuscitation) had been and was performed. Further review revealed the clinical impression of the first responder was cardiac arrest and secondary impression was respiratory arrest. Per the report, the protocol used was for cardiac arrest. The person was noted to have bleeding to the face and was unconscious. The report stated at 10:40 PM, the person was still unresponsive, no blood pressure was observed and pulse was zero (0). The stats were noted as the same at 10:43 PM, 10:52 PM, and 11:00 PM. Per the report, before the person was taken away in the ambulance it was determined he/she was Resident #1, who could not be located within the [NAME] House at the same time. Review of Emergency Department Encounter Report ([NAME]), dated [DATE] at 11:24 PM, revealed Resident #1 arrived to the hospital in full cardiac arrest. It was noted the resident was found outside of the facility unresponsive. The total amount of time down was unknown and the report revealed a bystander performed CPR upon finding the resident. Per the [NAME], it was thought the resident might have been in fine ventricular fibrillation, and he/she was given five (5) rounds of intravenous (IV) Epinephrine (given to stimulate the heart to beat), IV Amiodarone (given as an antiarrhythmic during cardiac arrest), as well as being defibrillated numerous times. The report also revealed the resident had multiple facial abrasions with blood present. Per the [NAME], ACLS protocol was continued; however, on [DATE] at 11:23 PM, the resident was pronounced deceased . Interview with the Chief Information Officer (CIO) on [DATE] at 1:50 PM, revealed he was responsible for monitoring the badging system, reports, and camera footage. He stated the door at the end of the [NAME] Hall required a badge to silence the alarm, once it was triggered. He stated, based on the report provided, the alarm was not silenced until 10:28:40 PM by LPN #6. The CIO stated when the staff member badged out at 10:28:40 PM, that would have been the time the alarm on the door was silenced, and staff went out to look for the resident. He verified that the alarm sounded from 9:46 PM to 10:28 PM. Interview, with Resident #1's Son, on [DATE] at 2:40 PM, revealed the facility contacted the resident's spouse via telephone at approximately 12:30 AM to inform him/her the resident had been taken to the hospital. He stated he was called by his sister at 1:09 AM and she told him their father/mother was dead. The resident's son explained it was the hospital that told the family the resident was found outside, and EMS tried to get his/her heart started on the sidewalk and on the way to the hospital. He explained the resident was not in a wheelchair when he/she arrived at the facility. Further interview revealed the resident was put in a room all the way at the end of the hall. The resident's son explained the resident's walking was very deliberate because he/she had had many falls. He stated the resident used a double cane, which he described as two (2) canes held together by a bar. He stated the resident got around okay, but just could not move without thought. Continued interview revealed the resident's memory was bad. He stated the resident had been in the hospital because of falls, and he would not expect his father/mother to be out walking around, outside the facility. The Resident's son stated, the resident was not even supposed to go to the restroom alone. Interview, with Certified Nurse Aide (CNA) #8 on [DATE] at 4:18 PM, revealed she went on break at the back parking lot of the facility and was gone for only five (5) minutes. CNA #8 stated on her way back into the facility she saw a person down on the sidewalk. She stated she called out to him/her and asked, Are you okay?, but the person did not respond. CNA #8 stated she did not see the person when she started her break. Further interview revealed she ran to the second floor, to the unit where she worked, to get help. She stated she returned with RN #3, but they did not recognize the person as a resident. Review of the camera footage showed CNA #8 running to get help and three (3) staff members going back outside with her, on [DATE] from 10:25 PM to 10:26 PM. Interview, with CNA#16 on [DATE] at 6:54 PM, revealed she worked the night of [DATE]. She stated CNA #17 informed her she could not locate Resident #1 and they both started to search for him/her. CNA #16 stated Resident #1 was ambulatory and could have been in any room, so they searched the entire floor. She said she thought it was about that time she heard the Code Blue (a code given when someone needed cardiopulmonary resuscitation (CPR)). CNA #16 stated she continued to look for the resident but did not locate him/her. She stated she did not hear an alarm sounding during this time. Interview, with CNA #17 on [DATE] at 9:00 PM, revealed she provided care for Resident #1 on [DATE]. She stated she took the resident a snack and a drink between 7:00 PM and 7:30 PM. CNA #17 stated she went back to check on the resident around 8:00 PM. She stated she guessed it was about 9:00 PM or 9:30 PM when she noticed the resident was not in his/her room. She stated she went and found the other Aide, and they started to look for the resident. Continued interview revealed she did not hear any alarm coming from the hallway door next to the resident's room. She also stated she had never heard an alarm on that door. CNA #17 reported she thought the last time she saw the resident he/she was seated in his/her wheelchair, but she could not recall what clothes the resident was wearing. Additionally, she stated she only had cared for the resident one (1) other time. CNA #17 stated she thought resident dressed himself/herself for bed, so she did not assist him/her on [DATE]. Interview, with Certified Medication Technician (CMT) #1 on [DATE] at 8:25 PM, revealed on [DATE], CNA #8 came in the facility yelling for help. She stated when someone called for help, one had to move quickly. She stated staff followed CNA #8 outside, saw a person down, and the nurse with them told her to get more help. She stated she went back into the facility and got additional staff. CMT #1 stated she did not know the identity of the person who was down. She said it was hard to tell who was a resident and who just walked through the neighborhood. CMT #1 stated it was not until more staff started to show up that it was determined it was Resident #1. Interview, with LPN #14 on [DATE] at 6:32 PM, revealed CNA #17 informed her she could not locate Resident #1 and asked her to pass it on to LPN #6 upon her return. LPN #14 stated CNA #17 and the other Aides on duty started to look for the resident. She stated they searched all the common areas, looked in other rooms, covered the entire floor, but they did not locate the resident. LPN #14 stated she did not hear an alarm sounding during the search. She stated LPN #6 called the code for a missing person, and then it seemed right after that a Code Blue was called for an unresponsive person outside. LPN #14 stated she did not put the two (2) together and thought the facility just had a very busy night. Further interview revealed the process for the missing person was to call a Code Green, state the resident's name, and ask the resident to return to his/her hall. She stated this was done three (3) times, which notified other staff to report to that floor to help look for the resident. She stated the person who called the Code [NAME] was responsible to notify management. Interview, with LPN #6 on [DATE] at 8:55 AM, revealed once CNA #17 informed her Resident #1 could not be located, all staff present on the floor started to look for the resident. She stated they checked where the exercise bike was located, the activity room, and the dining room. LPN #6 stated it was the facility's protocol to check the entire floor before calling a code for a missing person. She said to call the missing person alert, staff was to call the resident's name over the loud speaker, three (3) times, and ask the resident to return to his/her house. LPN #6 stated when she was near Resident #1's room, she could hear the alarm going off, which she identified as a soft hum. She stated she only heard it when she stood directly next to the door. The LPN stated that door required a badge to get in and out. She stated she badged out, took the elevator to the first floor, and went outside to look for the resident. Continued interview revealed she did not see the resident so she returned upstairs. LPN #6 stated once she got back to the floor, she heard a Code Blue being called, and it was about that time she announced the missing resident code, Code Green. She stated she talked with the Director of Nursing (DON), and they realized the Code Blue person and the missing person was the same person. Interview, with LPN #5 on [DATE] at 6:30 PM, revealed she was the nurse in charge on [DATE]. She stated she was charting on [NAME] House, another unit within the facility, when CNA #35 ran in and informed her of the incident happening at the back of the facility and that RN #3 needed help. She stated she initially ran out of the facility to determine what was going on, and once she arrived on the scene, RN #3 was doing CPR on a person he told her was not responsive. LPN #5 stated she ran into the facility to grab the crash cart and the Ambu bag. She stated they used the Ambu bag on the person. LPN #5 stated there was a lot going on at the time, and it was hard to keep track or time and/or people. She stated she did not render CPR, but another staff member switched off with RN #3. The LPN stated she did not recognize the person as a resident. LPN #5 stated EMS arrived on the scene and took over doing CPR. She stated RN #11 was on the scene too, and she recognized the person as Resident #1. LPN #5 stated she informed the DON of the situation. Interview, with Unit Manager (UM) #1 on [DATE] at 4:25 PM, revealed if staff was aware a resident was missing, management should be notified immediately of the situation and not wait until the floor was searched. She stated that would be best for resident safety so staff could find the resident quickly. Continued interview revealed the quicker staff knew about the situation, the quicker the response. The UM state the announcement (Code Green) should be made over the intercom so other staff was made aware of the situation and could help in the search. Interview with RN #3, on [DATE] at 4:24 PM, revealed on [DATE] he was on his floor charting when one of the Aides came running in and screaming for help. He stated he responded to the request. RN #3 stated he exited the facility to the back and found an unresponsive person, lying face down with blood coming from the head. He stated he rolled the person over and checked for a pulse and for breathing and found none, so he started to perform CPR. Continued interview revealed additional staff started to arrive on the scene, and they discussed if anybody knew the person and if he/she was a resident. He stated nobody recognized the person. RN #3 stated the facility grounds had a high number of people from around the community who walked in the area, and there was no way for him to know if the person was a resident or not. Prior to EMS arrival, he stated, staff determined the person was Resident #1. He stated EMS arrived on the scene, took over CPR, and transported the resident to the hospital. Interview, with RN #9 on [DATE] at 5:19 PM, revealed she was familiar with Resident #1, and he/she was not exactly independent. She stated the resident had a gastrostomy tube (G tube, an opening in the stomach with a tube inserted to receive liquid nutrition) during his/her prior visit and was in the facility for a stroke. She stated the resident ambulated with the use of a walker and was generally pretty steady on his/her feet. RN #9 stated it was not uncommon for a resident to be missing from their room. She stated many times therapy had taken the resident off the floor. Continued interview revealed if it was determined to truly be a missing resident, all staff would search the floor, and an announcement would be made over the intercom for the person to return to their house. She stated, if the resident still was not located, management and security would be notified. The RN stated the resident's family would be contacted and the police, if necessary, until the resident was found. RN #9 reported Resident #1 regularly went outside with his/her spouse to sit in the courtyard, but she did not know the resident to go out on his/her own. She stated it was not normal for any resident to be outside at 10:20 PM. She explained, even if family took a resident to the courtyard, she liked for them to take a wheelchair just for backup. Continued interview, with RN #9 on [DATE] at 5:19 PM, revealed she had heard the alarm on the fire door go off several times. She stated it was usually therapy students who would forget to badge out. RN #9 stated the only way to shut the alarm off, once it had been activated, was to use the badge to stop it. She stated the alarm, prior to the new louder alarm, could not be heard on the back hall. Interview with the Maintenance Director on [DATE] at 9:50 AM, revealed he put in the louder fire alarms on the doors on [DATE], after the [DATE] incident. Interview with RN #10 on [DATE] at 5:56 PM, revealed she was an agency staff member and had worked in the facility since [DATE]. She stated she was not aware there was a code for a missing person. Interview, with RN #11 on [DATE] at 7:04 PM, revealed on [DATE] she heard a Code Blue come across the intercom and then shortly after heard LPN #6 announce for Resident #1 to return to his/her room. She stated when she arrived at the location of the Code Blue, EMS was already present and doing CPR. She stated Resident #1 had a different kind of a walker, and she recognized it on the ground. She stated it took her a few minutes to actually see the resident, but when she saw his/her face, she recognized the person to be Resident #1. Continued interview with RN #11 on [DATE] at 7:04 PM, revealed she recalled the alarm on the [NAME] House door sounding one (1) time. She stated she could not recall what caused it to sound. The RN stated the alarm was not very loud, and staff members did not hear it going off until they were present in that hall. She said the alarm had to be turned off with the use of her badge. RN #11 stated she thought the alarm might have been louder on the outside of the door on the Dialysis side. Interview with RN #13 on [DATE] at 8:51 PM, revealed she was an agency staff and had worked in the facility since [DATE]. RN #13 ex[TRUNCATED]