**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies, it was determined the facility failed to implement a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, mental and psychosocial needs for one (1) of 29 sampled residents, Resident #1 (R1). On [DATE], Nurse Assistant (NA) #3 (Non Certified) failed to implement R1's Comprehensive Care Plan related to ensuring there were leg rests on the wheelchair and that the resident was positioned correctly in the wheelchair in regards to the pommel cushion. (A pommel cushion is designed to promote proper positioning by preventing residents from sliding forward in the wheelchair and features a raised center section that helps keep legs supported). As NA #3 propelled R1 in the wheelchair, the resident fell face first onto the floor. The facility transferred R1 to the local hospital emergency room (ER). R1's diagnoses included traumatic subarachnoid hemorrhage of the brain, fracture of the first cervical vertebrae (neck), anterior displaced type II odontoid (neck) fracture, fracture of right eye socket on right side, and fracture of right maxillary sinus (cheek). R1 expired on [DATE]. (Refer to F689) The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on [DATE], alleging removal of the Immediate Jeopardy (IJ) on [DATE]. The SSA validated the facility's IJ Removal Plan, on [DATE], and determined the deficient practice was corrected as alleged on [DATE], prior to the initiation of the investigation. Therefore, the IJ was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled Comprehensive Care Plan, dated [DATE] and revised 02/2024 revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, to meet a resident's medical, physical, mental, and psychosocial needs. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services are to be provided or arranged by the facility, as outlined by the comprehensive care plan. The comprehensive care plan will be prepared by an interdisciplinary team and will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of R1's closed medical record Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses to include Alzheimer's Disease, anxiety disorder, open wound left foot, abnormal posture, unspecified dementia, cognitive communication deficit, and depression. Review of R1's Comprehensive Care Plan (CCP), dated [DATE], revealed a category problem of Activities of Daily Living (ADL) self-care performance deficit related to Alzheimer's Disease. The goal revealed the resident would maintain current level of care of ADLs with a target date of [DATE]. The interventions included: Locomotion, assist x one (1) in standard wheelchair; position with pommel cushion for parallel thigh alignment; and bilateral elevating leg rests dated [DATE]. An additional intervention was added for Pommel cushion to wheelchair dated [DATE]. Further review of R1's Comprehensive Care Plan (CCP), dated [DATE], revealed a category problem of being at risk for alteration in skin integrity due to blindness, dementia, incontinence, generalized weakness, and arterial ulcers to the right and left heels. The goal revealed the resident would not experience any unidentified alteration in skin integrity with a target date of [DATE]. Interventions included wheelchair legs to be padded for protection twice a day at 6:30 AM and 6:30 PM with a start date of [DATE]. Review of R1's Resident Profile Care Plan ([NAME] -a care plan for nurse aides), undated, revealed interventions including assist x one (1) in standard wheelchair; position with pommel cushion for parallel thigh alignment and bilateral elevating leg rests with start date of [DATE]. In an interview with the Staff Development Coordinator on [DATE] at 2:10 PM, she stated this was the document viewed by the Nurse Aides and SRNAs in providing care for the residents. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of zero (0) out of 15. This score indicated the resident was severely cognitively impaired. Review of R1's Progress Notes, dated [DATE] at 5:45 AM, entered by Licensed Practical Nurse (LPN) #7, revealed the resident was up in the wheelchair, and slid to the floor in prone (chest down) position. An order was obtained from the Medical Doctor to send the resident to the emergency room (ER) and treat. Review of R1's hospital x-ray report, dated [DATE], revealed, Brain: acute hemorrhage in the right frontal region consistent with contusions and subarachnoid hemorrhage. Skull and facial bones: minimally displaced fracture of the right orbital roof. Suspect fracture of anterior wall of the right maxillary sinus. Orbits: external hemorrhage along the right orbital roof process. Fracture of the anterior arch of C1 (first cervical vertebra). Displaced fracture of the left posterior arch of C1 near the junction with the lateral mass in the region of the vertebral artery groove. Continued review of the hospital records, dated [DATE] and [DATE], revealed after consulting with the family, requests were made for comfort measures only. Continued review revealed the resident expired on [DATE] from injuries sustained from a fall at the Nursing Facility. Review of the facility's Incident Report titled, Incident Fall with Major Injury, dated [DATE], revealed on [DATE] at 5:45 AM, NA was pushing resident out of room after morning care. Resident noted to slide from wheelchair onto floor. Audit and interview with staff to ensure all interventions were in place at time of incident according to care plan. On the ADL care plan, the resident should be placed in a standard wheelchair with a pommel cushion for parallel thigh alignment and bilateral leg rest. Per the Incident Report, the leg rests were not used at the time of the fall. This Incident Report was completed by the Director of Nursing (DON) and Administrator. During interview on [DATE] at 9:09 AM, with State Registered Nurse Assistant (SRNA3/NA3) she stated at the time of R1's fall on [DATE], she was a NA (uncertified nurse aide) and since had become a SRNA. Per interview, she stated she had transferred R1 into the wheelchair and noticed the resident was leaning forward in the wheelchair. Further, she stated the pommel cushion was in the wheelchair to help the resident to sit in proper alignment. However, she stated R1 was not in correct alignment because her right leg was on top of the raised center portion of the pommel cushion and she did not want to hurt R1 by pushing her leg down as the resident was very rigid. SRNA #3 stated when she rolled the resident over the threshold of the door, there was a little bump at the threshold and the resident fell out of the wheelchair and went straight to the floor and did not slide out of the chair. In continued interview on [DATE] at 9:09 AM, SRNA #3 stated the leg rests were not on the wheelchair prior to the fall. During further interview related to why she did not put the leg rests on the wheelchair, she stated she had helped to take care of the resident during the last year and she did not think the resident needed the leg rests. SRNA #3 stated after the accident she was educated about the care plans, to look at them often, and if she was unsure about anything, ask a nurse. She stated she should have checked R1's care plan and followed it as it was written. SRNA3/NA3 stated she should have ensured she put the leg rests on the wheelchair and that the resident was positioned properly in the wheelchair with the pommel cushion. During interview with Licensed Practical Nurse (LPN) #7, on [DATE] at 7:41 AM, she stated she was the East Unit Charge Nurse on the night shift. She stated on [DATE] around 5:30 AM, NA #3 who was now a SRNA, came to notify her of R1's fall. LPN #7 stated she came down the hall and saw R1 was on the floor lying prone on the left side and was noted to have swelling with an abrasion to the forehead, and her nose was bleeding. She stated R1 was voicing complaints of hurting all over. LPN #7 stated NA #3 told her she was rolling the resident out to the hallway and the resident fell out of the wheelchair. The LPN stated she noticed the resident's leg rests were not on the wheelchair at the time of the fall. LPN #7 stated R1 was care planned to use the leg rests on the wheelchair and NA #3 should have followed the care plan. During an interview with MDS Coordinator #1, on [DATE] at 12:30 PM, she stated she developed/revised Comprehensive Care Plans for all residents. However, there were many staff members who also wrote care plans including Nurses, Therapists, Social Services, and Administrative staff such as the Director of Nursing (DON). She further stated the Comprehensive Care Plans were used as a guide in caring for the residents and were to be followed as written. She further stated, all nursing staff had access to the residents' profiles and their Comprehensive Care Plans. During an interview with the Staff Development Coordinator (SDC), on [DATE] at 2:10 PM, she stated during general orientation, she used a PowerPoint presentation for staff education and all information was covered regarding the Comprehensive Care Plan and how to find it. She further stated the staff also used a computerized program for training on equipment usage, floor training, care plans, and documentation. The SDC verified that all SRNAs and Nurse Aides prior to becoming SRNAs, received this training. She stated the decision to utilize leg rests on wheelchairs could be made by therapy, nurses or physicians, but typically Physical Therapy would evaluate the residents for the need for leg rests on wheelchairs. She further stated, after R1 fell, she started education and ensured 100 % (percent) of clinical staff was educated related to finding the Comprehensive Care Plans and implementing them. During an interview with the Director of Nursing (DON), on [DATE] at 9:16 AM, he stated after he was notified of R1 sustaining a fall, he immediately started an investigation. The DON stated R1 was being pushed into the hall, and had to have taken a head first fall onto the floor. He stated R1 was being pushed in a wheelchair without the leg rests and was not sitting up in the wheelchair in proper alignment as per the Comprehensive Care Plan and Resident Profile Care Plan ([NAME]). He further stated SRNA/NA #3 was educated related to following the CCP and [NAME] after the incident. During a phone interview with the Medical Director, on [DATE] at 3:48 PM, he stated on [DATE] he was notified of R1's fall. Per interview, he stated he gave staff orders to send the resident to the Emergency Department for evaluation and treatment. The Medical Director stated the executive staff had a meeting on [DATE] regarding the facility's plan for corrective action. He stated after the incident, corrective action included further education for staff. He stated staff was to follow the Comprehensive Care Plans as written. During an interview with the Administrator on [DATE] at 4:10 PM, he stated he was notified of R1's fall the morning of the incident and the facility started working on the Root Cause. Per interview, he stated education was started on [DATE] for all nursing staff related to the importance of following the care plan. He further stated he expected all staff to follow the Comprehensive Care Plans as written.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (1) of 29 sampled residents (Resident (R1)). On [DATE], Nurse Assistant (NA) #3 (Non Certified) pushed R1 in her wheelchair from her room. However, NA #3 failed to place the leg rests on the wheelchair and failed to ensure the resident was positioned correctly in the wheelchair in regards to the cushion. R1 fell face first onto the floor. The facility transferred R1 to the emergency room (ER) for evaluation. R1 sustained injuries which included: traumatic subarachnoid hemorrhage of the brain, fracture of first cervical vertebrae (neck), anterior displaced type II odontoid (neck) fracture, fracture of right eye socket on right side, and fracture of the right maxillary sinus (cheek). R1 expired in the hospital on [DATE]. (Refer to F656) The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on [DATE], alleging removal of the Immediate Jeopardy (IJ) on [DATE], prior to the State Survey Agency's (SSA's) investigation. The SSA validated the facility's IJ Removal Plan, on [DATE], and determined the deficient practice was corrected as alleged on [DATE], prior to the initiation of the investigation. Therefore, the IJ was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Accidents and Supervision, dated [DATE] and revised [DATE], revealed the resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: (1) identifying hazards and risks; (2) evaluating and analyzing hazards and risks; (3) implementing interventions to reduce hazards and risks, and (4) monitoring for effectiveness and modifying interventions when necessary. Review of the facility's policy titled Falls, dated [DATE] and revised [DATE], revealed the facility strived to maintain a hazard free environment, mitigate fall risk factors, and implement preventative measures. Intensive efforts will be directed toward minimizing or preventing injury. Procedures include: any orders received from the physician should be noted and carried out; the resident's care plan should be updated to reflect any new interventions or change in interventions; discuss risks and interventions with resident and/or responsible party, and communicate interventions during shift report. Review of R1's Face Sheet (closed medical record) revealed the facility admitted the resident on [DATE] with diagnoses that included Alzheimer's Disease, anxiety disorder, open wound left foot, abnormal posture, unspecified dementia, cognitive communication deficit, and depression. Review of R1's Comprehensive Care Plan (CCP), dated [DATE], revealed a problem of Activities of Daily Living (ADL) self-care performance deficit related to Alzheimer's Disease. The goal stated the resident would maintain the current level of care of ADLs with a target date of [DATE]. Approaches included: locomotion, assist x one (1) in standard wheelchair; position with pommel cushion (A cushion designed to promote proper positioning by preventing residents from sliding forward in the wheelchair. It features a raised center section that helps keep the legs supported) for parallel thigh alignment; and bilateral elevating leg rests dated [DATE]. Another approach was added for a Pommel cushion to the wheelchair dated [DATE]. Review of R1's Comprehensive Care Plan (CCP), dated [DATE], revealed a problem of being at risk for alteration in skin integrity. The goal stated the resident would not experience any unidentified alteration in skin integrity with a target date of [DATE]. Approaches included wheelchair legs to be padded for protection twice a day at 6:30 AM and 6:30 PM with a start date of [DATE]. Review of R1's Resident Profile Care Plan ([NAME]) undated, revealed approaches included: assist x one (1) in standard wheelchair; position with pommel cushion for parallel thigh alignment and bilateral elevating leg rests with start date of [DATE]. During an interview with the Staff Development Coordinator on [DATE] at 2:10 PM, she stated the [NAME] was viewed by the Nurse Aides and SRNAs in providing care for the residents. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of zero (0) out of 15 which indicated the resident was severely cognitively impaired. Review of R1's Occupational Therapist Evaluation, dated [DATE], revealed the reason for the referral by nursing was due to the residents' inability for holding her feet up during transport with nursing providing elevating leg rest. However, poor lower extremity placement with the knees flexed greater than 90 degrees caused the resident's feet to slightly go inward on the foot rest and increased bilateral lower extremity adduction (move toward the midline) impacting care as well as foot placement on the foot rest. The plan was to address positioning with devices that were appropriate and least restrictive. Further review revealed the resident was dependent in areas of eating, oral hygiene, personal hygiene, toileting, shower/bath, transfers, upper body dressing, lower body dressing and putting on or taking off footwear. Review of R1's Progress Notes, dated [DATE] at 5:45 AM, entered by Licensed Practical Nurse (LPN) #7, revealed the resident was up in the wheelchair, slid to the floor in prone (face down) position, and the Certified Nurse Aide (CNA) sent for the nurse. Upon nursing assessment, the resident had a bleeding nose, knot midline that was bleeding to the forehead, and her right eye was swollen shut. R1 had complaints of pain to the head and face. Resident alert to self and pain only, normal for resident. Left pupil three (3) millimeters (mm) and reactive, and unable to assess right due to swelling. Resident's normal is stiff and ridged and unable to assess Range of Motion (ROM). Order obtained from Medical Doctor to send the resident to the emergency room (ER) and treat. Employee to be educated. Power of attorney (POA) and Director of Nursing (DON) aware. Review of R1's hospital admission Note, dated [DATE] through [DATE], revealed the resident arrived at the hospital ER on [DATE] at 6:27 AM and was transferred from a nursing home for contusion sustained from falling out of her wheelchair. Patient (resident) not very verbal. The hospital x-ray report, dated [DATE], revealed Brain: acute hemorrhage present in the right frontal region consistent with contusions and subarachnoid hemorrhage. Skull and facial bones: minimally displaced fracture of the right orbital roof. Suspect fracture of anterior wall of the right maxillary sinus. Sinuses: fluid in the right maxillary sinus which is mildly hyperdense. Mastoid air cells: small amount of right mastoid fluid without destructive changes. Orbits: external hemorrhage along the right orbital roof process. Fracture of the anterior arch of C1 (first cervical vertebra). Displaced fracture of the left posterior arch of C1 near the junction with the lateral mass in the region of the vertebral artery groove. Further review revealed the resident was admitted to the hospital and after consulting with family, requests for comfort measures only. Patient is a Do Not Resuscitate (DNR). Additional review revealed the resident expired on [DATE] from injuries sustained from a fall at nursing facility. Review of the facility's Incident Report titled Incident Fall with Major Injury, dated [DATE], revealed on [DATE] at 5:45 AM, NA was pushing the resident out of her room after morning care. The resident was noted to slide from the wheelchair onto the floor. Resident noted to be in prone position at the time. NA alerted nurse of event, nurse noted resident to be on floor with blood from nose, raised area to midline and laceration to forehead. Right eye noted to be swollen. Resident assessed for pain and voiced complaints of pain. Resident alert to self and pain, baseline for resident. Medical Director was in the facility for rounds and orders were given to send resident to the hospital ER to evaluate and treat and perform a Computed Tomography Scan (CT). Only history of falls was on [DATE] with no injury noted. Audit and interview with staff to ensure all interventions were in place at time of incident according to care plan. On the ADL care plan, resident should be placed in a standard wheelchair with pommel cushion for parallel thigh alignment and bilateral leg rest. Per the Incident Report, leg rests were not used at the time of locomotion. The Incident Report was completed by the Director of Nursing (DON) and Administrator. During an interview on [DATE] at 9:09 AM, with State Registered Nurse Assistant (SRNA) #3 (NA #3 at time of R1's fall), she stated she had worked at the facility approximately one (1) and a half months and worked the night shift. She stated she had been transferred to the facility from a sister facility. SRNA #3 stated on the morning of [DATE] she went to R1's room to perform morning care, brush R1's teeth, get her clothes on and brush her hair. In further interview, she stated she transferred the resident into the wheelchair by standing and pivoting the resident and sitting the resident down in the chair while the resident held onto her. During interview with SRNA #3, on [DATE] at 9:09 AM, she stated once R1 was in the wheelchair, she noticed she was leaning forward, but she thought the resident was just adjusting herself. SRNA #3 stated the pommel cushion was in the wheelchair, which was to help the resident to sit in proper alignment. However, she stated R1 was not in correct alignment because her right leg was on top of the raised center portion of the pommel cushion and she didn't want to hurt R1 by pushing her leg down as the resident was very rigid. She stated the resident did not respond much during conversation due to her dementia diagnosis. In further interview, SRNA #3 stated when she rolled the resident over the threshold of the door, there was a little bump at the threshold and the resident fell out of the wheelchair and went straight to the floor. She stated R1 did not slide out of the chair. In interview with SRNA #3, on [DATE] at 9:09 AM, she stated on [DATE], the R1's leg rests were leaning against the wall behind the wheelchair at the time she transferred the resident to the wheelchair. She stated the leg rests were not on the wheelchair prior to the fall. SRNA #3 state she did not put the leg rests on the wheelchair, she stated she did not think the resident needed the leg rests. She further stated she had helped to take care of the resident during the last year and had not used them. SRNA #3 stated she had not reviewed the resident's Comprehensive Care Plan or [NAME] prior to the transfer. She stated she was unaware of the interventions related to the leg rests on the chair and making sure R1 was correctly positioned in the chair with the pommel cushion. She stated she had since been educated related to ensuring the Care Plan was followed. During an interview with Licensed Practical Nurse (LPN) #7, on [DATE] at 7:41 AM, she stated she was the East Unit Charge Nurse on night shift. She further stated on [DATE] around 5:30 AM NA #3, who was now a SRNA, came to get her. LPN #7 stated she came down the hall and saw R1 on the floor. She stated she told NA #3 to go find the charge nurse. LPN #7 stated R1 was lying prone on her left side on the floor. She further stated the resident had swelling with an abrasion to the forehead, and her nose was bleeding. LPN #7 stated there were no visual injuries to R1's arms or legs. She stated R1 was talking and voicing complaints she was hurting all over. LPN #7 stated NA #3 told her she was rolling the resident out to the hallway and the resident fell out of the wheelchair. The LPN stated the resident's leg rests were not on the wheelchair at the time of the fall. She further stated she had placed the leg rests in the seat of the resident's wheelchair earlier in the night prior to NA #3 assisting the resident to the wheelchair in the morning. In continued interview, LPN #7 stated R1 was care planned for locomotion to use the leg rests on the wheelchair prior to the fall. During a phone interview with SRNA #5, on [DATE] at 9:10 AM, she stated she had been NA #3/SRNA #3's preceptor/trainer since she started. She stated she was not there the night of R1's fall. However, SRNA #5 stated NA #3/SRNA #3 had been trained fully on transfers, reading and following the care plans and finding help if she did not understand or remember how to follow a task. She further stated she had told NA#3/SRNA #3 to always ask her trainer or another person/nurse/SRNA if she needed help with any task. During a phone interview, on [DATE] at 9:30 AM, with SRNA #7, she stated she was working on [DATE] and NA #3 was supposed to come to her if she needed help or had questions. She denied that NA #3 had asked her any questions on [DATE]. SRNA #7 stated she came out of a resident's room and saw R1 on the floor with NA#3 and the charge nurse with the resident. During an interview with the Director of Nursing (DON), on [DATE] at 9:16 AM, he stated he received a phone call related to R1 sustaining a fall and when he arrived at the facility an investigation was initiated. He stated, R1 was being pushed into the hall, and had to have taken a head first fall onto the floor. He further stated R1 was an AM get up which meant the night shift assisted her out of the bed to get her ready for breakfast prior to the end of the shift. The DON stated on the morning of R1's fall, she was being pushed in a wheelchair without leg rests even though it was safer for her to have leg rests on the wheelchair. He stated the resident had not been sitting properly in the wheelchair at the time of the fall. He stated these safety measures were on the resident's Comprehensive Care Plan and Resident Profile Care Plan ([NAME]) prior to the fall. During a phone interview with the Medical Director, on [DATE] at 3:48 PM, he stated he had just left the faciity on [DATE] and was called by the facility to advise related to R1's fall. He stated he gave staff the orders to send the resident to the Emergency Department at the local hospital for evaluation and treatment. He further stated he was aware of the resident's outcome. He stated the executive staff had a meeting the day of R1's fall regarding the facility's plan for corrective action which included further education for staff. During an interview with the Administrator, on [DATE] at 4:10 PM, he stated he was aware of R1's fall and it was an unfortunate occurrence. He further stated after the fall, the facility started working on the Root Cause of the incident and education was started immediately for all nursing staff related to the need to follow the care plans, as this was important for the safety of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to review and revise the resident's Person-Centered Comprehensive Care Plan for one (1) of six (6) sampled residents reviewed for elopement (Resident #1). Interviews with facility staff revealed Resident #1 frequently searched for and asked staff about the whereabouts of family members. However, this behavior was not reflected in Resident #1's care plan. Additionally, the Administrator stated the resident frequently left the facility with his/her family, which was a trigger for the resident to leave the facility unsupervised; however, the resident's care plan was not revised to reflect the Administrator's concerns. On 09/17/2023, while ambulating throughout the facility independently, Resident #1 exited the facility without staff's knowledge. The facility's failure to have an effective system to ensure residents' care plans were revised to reflect the residents' healthcare needs, has caused or is likely to cause serious injury, serious harm or death to residents. Immediate Jeopardy (IJ) was identified on 09/29/2023 and was determined to exist on 09/17/2023, with deficiencies cited at 42 CFR 483.21, Comprehensive Resident Centered Care Plans, (F657); and 42 CFR 483.25, Quality of Care, (F689); both at a Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25, Quality of Care, (F689). The facility was notified of the Immediate Jeopardy on 09/29/2023. An acceptable IJ Removal Plan was received on 10/12/2023, which alleged removal of the Immediate Jeopardy on 10/01/2023. The State Survey Agency (SSA) validated the removal of the IJ, as alleged, on 10/14/2023, prior to exit on 10/14/2023. IJ was removed at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, (657); and 42 CFR 483.25, Quality of Care, (F689); both were lowered to a S/S of a D, while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. (Refer to F689) The findings include: Review of the facility's policy, Comprehensive Care Plans revised 08/25/2023, revealed the facility would develop and implement a comprehensive, person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframe to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the resident's comprehensive assessment. The care planning process would include an assessment of the resident's strengths and needs and would incorporate the resident's personal and cultural preferences in developing goals of care. The comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Further review of the policy revealed the comprehensive care plan objectives would be utilized to monitor the resident's progress. Alternative interventions would be documented as needed. Qualified staff responsible for carrying out interventions specified in the care plan would be notified of their roles and responsibilities for carrying out interventions specified in the care plan initially and when changes were made. Review of the facility's policy, Elopement and Wandering Residents, revised 01/02/2023, revealed the facility would ensure that residents who exhibited wandering behavior and/or are at risk for elopement receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility should establish and utilize a systematic approach to monitoring and managing residents at risks for elopement or unsafe wandering to include identifying and assessing residents of risk, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness, and modifying interventions when necessary. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or minimize risks associated with hazards would be added to the resident's care plan and communicated to appropriate staff. Closed record review revealed the facility admitted Resident #1, on 11/01/2021 with diagnoses which included: Unspecified Dementia, Generalized Anxiety Disorder, and Major Depressive Disorder. Further review of the record revealed Resident #1 was discharged home with family on 09/20/2023. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 08/22/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating the resident was severely cognitively impaired. Review of Resident #1's Elopement Assessment Risk dated 08/22/2023, revealed the facility assessed Resident #1 as being at risk for elopement based on him/her being ambulatory, cognitively impaired, having poor decision-making skills, and history of wandering. Review of the Facility's Investigation, completed by the Administrator and Director of Nursing on 09/20/2023, revealed on 09/17/2023 at 2:40 PM, a caller notified facility staff that Resident #1 was found outside the facility approximately six hundred (600) feet from the front entrance. Resident #1 was escorted back into the facility by two (2) staff members at 2:45 PM. Review of Resident #1's elopement care plan revealed Resident #1 was care planned for interventions which included Resident #1's room was decorated with items from his/her home with pictures of his/her family so when he/she wandered, he/she would see something familiar. Additional interventions included to check the placement and functioning of his/her safety monitoring device every shift and distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. Further review of the care plan revealed staff were to identify patterns of wandering based on whether the wandering was purposeful or aimless and if the resident was looking for something. Staff would intervene as appropriate, observe for fatigue and weight loss, and for his/her wander alert device. Review of the facility's in-coming call log, revealed Caller #1 had called the facility on 09/17/2023 at 2:46 PM, to inform staff that Resident #1 was outside the facility. In an interview with Certified Nurse Aide (CNA) #12 on 10/05/2023 at 10:32 AM, she stated she was familiar with Resident #1 and he/she would walk the halls constantly. She stated Resident #1 would be looking for his/her family members. CNA #12 stated she would usually tell Resident #1 his/her family members had left for the day and other times she would just redirect Resident to an activity in the dining room. She stated these diversions seemed to help distract the resident. In an interview with CNA #2 on 09/23/2023 at 7:14 PM, he stated Resident #1 was a wanderer and would often wander the facility asking where certain family members were. He stated staff would redirect the resident by offering snacks or an activity. CNA #2 stated that these interventions were effective for him when caring for Resident #1. In an interview with CNA #3 on 09/27/2023 at 8:06 PM she stated Resident #1 was a wanderer and would constantly look for his/her family members. She stated that when Resident #1 would display this behavior she would divert the resident by offering a snack, toileting him/her, taking the resident back to his/her room, or by taking the resident to an activity if one was being held at that time. CNA #3 stated most times these interventions were effective. In an interview with Certified Nurse Aide (CNA) #5 on 09/27/2023 at 9:07 AM, she stated Resident #1 always walked the facility and would ask where his/her family was. In an interview with Licensed Practical Nurse ( LPN) #2 on 09/26/2023 at 1:43 PM, she stated it was normal behavior for Resident #1 to wander the facility. She stated on 09/17/2023 she witnessed Resident #1 walking towards the nurse's station on the East Hall, holding a baby doll and asking, Where's momma? then turned and began walking towards the living room area. Per the interview, LPN #2 stated she let Resident #1 continue to walk towards the living room area, as requesting for the resident's family members was normal behavior for Resident #1. She further stated she did not feel anything needed to be added to Resident #1's care plan at that time. She stated after Resident #1 eloped she assumed the Social Services Director (SSD) may have updated the care plan because she was the manager on duty. In an interview with the Social Services Director (SSD) on 09/22/2023 at 4:40 PM, she stated after Resident #1 eloped on 09/17/2023 his/her care plan was updated to reflect the intervention of fifteen (15) minute checks for seventy-two (72) hours and initiated a psychosocial assessment. She stated the next day she completed the psychosocial assessment on Resident #1 to see how the elopement had affected him/her afterward and there were no changes. The SSD stated nursing would update the care plan for interventions related to the elopement because the resident had already been assessed to be at risk for elopement. She further stated she didn't add any new interventions for mood or behaviors because Resident #1 was assessed to be unaffected by the event. During additional interviews with the SSD on 09/28/2023 at 11:53 AM and 2:10 PM, she stated it was normal everyday behavior for Resident #1 to ask where his/her momma was and that he/she would also ask where his/her sisters and brother were as well. When this behavior occurred, staff would always redirect Resident #1 with an activity. If church services were being offered, staff would take Resident #1 to the church service because he/she liked music and singing. The SSD further stated because this was normal everyday behavior for Resident #1 that it should have been added to the resident's care plan as an intervention, so all staff was aware that it was not a new behavior. The SSD stated the resident's wandering behavior and request for his/her family was such a constant behavior, that staff knew how to intervene when he/she displayed the behavior. She stated staff were basically informed of the resident's behavior by word of mouth, but it would have been nice if it was added to his/her care plan. In an interview with the Minimum Data Set (MDS) Nurse on 09/28/2023 at 10:52 AM, she stated she added the fifteen (15) minute checks to Resident #1's care plan after the elopement. She stated Resident #1 was discharged from the facility shortly afterward because the resident's family was going to be providing his/her care. The MDS Nurse stated after an event they would re-evaluate the residents' care plans and revise them as needed. During an additional interview with the MDS Nurse, on 09/28/2023 at 12:19 PM, she stated that potentially a resident seeking a family member could become agitated and potentially violent if they were left unsupervised and ended up not finding their family member. She stated Resident #1's care plan was not updated because all his/her current interventions seemed to be adequately working and staff reported the resident was easily redirected when seeking family members. The MDS Nurse further stated that they were open to feedback from staff about any resident behaviors so the care plan could be reviewed and revised if needed. In an interview with the Assistant Director of Nursing (ADON) on 09/22/2023 at 11:39 AM, she stated during morning meetings the interdisciplinary team (IDT) and Administrator reviewed resident care plans. She stated the MDS Nurse was ultimately responsible for updating resident care plans based on staff's feedback and assessments. She further stated that if staff were to observe something at a specific time they could add it to the care plan and notify the MDS Nurse for review. In an interview with the Director of Nursing (DON) on 10/05/2023 at 3:38 PM, he stated all resident care plans were updated with changes and any pertinent information that staff needs to be aware of. He stated he felt the interventions on Resident #1's care plan were sufficient enough regardless of the resident calling out and looking for his/her momma or daddy. In an interview with the Administrator on 10/04/2023 at 4:14 PM, he stated updating a resident's care plan was a team approach and not just the responsibility of one person. He stated he did not feel that Resident #1's care plan needed to be updated because he/she said a lot of things. The Administrator stated Resident #1 went out of the facility with family at least three (3) to four (4) times a week and was used to going out the front door frequently. He stated visitors knowing the door code and holding the door open for others were the root cause of why Resident #1 eloped from the facility on 09/17/2023. He further stated that Resident #1's care plan interventions would not change because he/she was already care planned for wandering, and he had mentioned the frequent trips out of the facility being a trigger for wandering with family in previous care conferences. However, a review of the resident's care plan revealed no revised interventions to address the resident's trigger for wandering due to frequent trips outside of the facility with his/her family. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 10/12/2023 that alleged removal of the Immediate Jeopardy (IJ) on 10/01//2023 as follows: 1. Resident #1 was discharged home on [DATE]. 2. On 09/17/2023 and 09/18/2023, the Assistance Director of Nursing (ADON), DON, Unit Managers, Staff Development Coordinator, and SDC, conducted a one-time 100% record review for residents who may have increased/unsafe wandering behaviors and/or were increased elopement risk for the past thirty (30) days. The record reviews included but were not limited to physician's orders, care plans, and treatment administration records (TAR). Plans of care for identified residents were reviewed and revised as needed to reflect the resident's status. 3. On 09/19/2023 the DON and ADON reviewed residents' physician orders, progress notes, plans of care, and Elopement Risk Assessments to ensure care plans were accurate. 4. On 09/19/2023 the DON and ADON reviewed residents with wander alert bracelets to ensure proper placement and function, with no concerns noted. Additionally, care plans for identified residents were reviewed and revised as needed to reflect the resident's status. 5. Further corrective action on 09/19/2023 included, the DON and ADON reviewed the Facility Assessment to ensure the number of residents at risk for unsafe wandering/elopement was accurate. 6. The Administrator, Assistant Director of Nursing, Social Services Director, and Staff Development Coordinator were educated on documentation of behaviors and care planning with effective interventions by the Area Director of Clinical Services. The Director of Nursing would be educated upon return from vacation. 7. On 09/29/2023 the Staff Development Coordinator educated all current Registered Nurses, Licensed Practical Nurses, and all nursing assistants to include PRN (as needed) staff. The education was on documenting resident behaviors that included increased wandering/ elopement and repetitive verbalizations in the nurse's notes and point of care. 8. On 09/29/2023 the Staff Development Coordinator (SDC)and Assistant Director of Nursing (ADON) educated all non-nursing staff on reporting observations of resident behaviors such as increased wandering and repetitive verbalizations, and to notify a licensed nurse immediately. During education, the Elopement Risk Assessment and plans of care for any residents reported by staff as exit-seeking or having repeated verbalizations, not already identified by the IDT, were reviewed and revised as needed. All staff voiced understanding of the material presented as well as a post-test with an overall score of 100%. Beginning 09/30/2023 the education would be included in the orientation of newly hired staff. 9. Starting on 09/30/2023 the Director of Nursing (DON) and Assistant Director of Nursing (ADON) would audit nurse progress notes daily seven (7) days a week for documentation of residents who have behaviors including increased wandering/elopement risk and repetitive verbalizations. If identified the DON/ADON would ensure the resident's care plan was up to date with personalized interventions. This process would occur Monday through Friday in the daily clinical meeting ongoing and would be done every Saturday and Sunday for twelve (12) weeks by the DON/ADON. 10. Starting on 09/30/2023 the Social Services Director or Social Services Assistant would audit Point of Care documentation with the DON/ADON daily x 7 days per week for documentation of residents who have behaviors including increased wandering/elopement risk and repetitive verbalizations. The process would occur Monday through Friday and was ongoing in the daily clinical meeting. On Saturday and Sunday, this would done for twelve weeks by the DON/ADON/SDC. 11. Starting on 09/30/2023 the Administrator/DON/ADON/UM/SS would interview five random staff members a week on various shifts to ask if any resident had behaviors including increased wandering/elopement and or repetitive verbalizations for twelve weeks, then monthly for three (3) months. 12. Starting on 09/30/2023 the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers, and Social Services would review all residents identified as at risk for elopement to ensure personalized care plan interventions were in place to prevent elopement daily for twelve (12) weeks then once per month for three (3) months. 13. A Quality Assurance meeting was held on 09/29/2023 to discuss. The Administrator, Assistant Director of Nursing, Area Director of Clinical Services, and Medical Director were in attendance. ***The State Survey Agency validated the facility had taken the following actions: 1. Closed record review revealed Resident #1 was discharged from the facility to home with family on 09/20/2023. In an interview with the Administrator on 09/22/2023 at 4:00 PM, he stated Resident #1 was discharged on 09/20/2023 and the family wished to provide care for the resident. 2. In an interview with the Social Services Director (SSD) on 09/22/2023 at 4:40 PM, she stated she reviewed care plans for residents at risk for increased/unsafe wandering. She stated the reviews were comprehensive to ensure the residents' care plans accurately reflected the residents' needs. In an interview with the Minimum Data Set (MDS) Nurse on 09/28/2023 at 10:52 AM, she stated she reviewed care plans for residents at risk for increased/unsafe wandering and updated them if needed. 3. In an interview with the Director of Nursing (DON) on 10/05/2023 at 3:38 PM, he stated he performed a review of all current residents to ensure their current Elopement Risk Assessments and care plans were accurate. He further stated if they were not he would update them at that time. In an interview with the Assistant Director of Nursing (ADON) on 09/22/2023 at 11:39 AM, she stated she checked residents' wanderguard bracelets for placement and function. The ADON further stated care plans were reviewed and revised if needed. 4. In an interview with the Assistant Director of Nursing (ADON) on 09/22/2023 at 11:39 AM, she stated she reviewed the wanderguard orders for the at-risk residents and assisted with checking their placement and function. In an interview with the Director of Nursing (DON) on 10/14/2023 at 10:24 AM, he stated care plans for identified residents were reviewed and revised by himself and the ADON to reflect the status of those residents. 5. In an interview with the DON on 10/14/2023 at 10:24 AM, he stated he and the ADON reviewed the facility assessment and verified the number of residents with unsafe wandering was correct. 6. In an interview with the Area Director of Clinical Services on 10/13/2023 at 5:02 PM, she stated she provided education to the Administrator, Assistant Director of Nursing, Social Services Director, and Staff Development Coordinator on documentation of behaviors and care planning with effective interventions and that she educated the DON upon his return from vacation. Review of the Staff Education/In-service Document, dated 09/29/2023, revealed ADON, SSD, and SDC were educated on documentation of behaviors and care planning with effective interventions. 7. In an interview with the Staff Development Coordinator (SDC) on 10/12/2023 at 3:55 PM, she stated she educated all current RN's and LPN's including PRN's on documenting resident behaviors to include increased wandering/elopement and repetitive verbalizations in the nurse's notes. During an interview with the Staff Development Coordinator on 10/13/2023 at 3:52 PM, she stated besides administering a post-test to staff after they received their education, she typed a syllabus and then reads it to staff. She stated she then asked if they understood, and had staff recite specific parts of the education given, like the names of the residents. In interviews with Licensed Practical Nurse (LPN) #8 on 10/13/2023 at 4:36 PM, LPN #2 on 10/13/2023 at 4:45 PM, LPN #9 on 10/09/2023 at 4:43 PM, and LPN #6 on 10/03/2023 at 2:26 PM, they stated they were educated by the SDC on documentation of resident behaviors to include increased wandering/elopement and repetitive verbalizations and took a post-test. In an interview with the Staff Development Coordinator (SDC) on 10/12/2023 at 3:55 PM, she stated she educated all current nursing assistants including PRN (as needed) staff on documenting resident's behaviors that included increased wandering/elopement and repetitive verbalizations in Point of Care. In an interview with the Staff Development Coordinator (SDC) on 10/12/2023 at 3:55 PM, she stated she educated all current nursing assistants including PRN (as needed) staff and gave post tests on documenting resident behaviors that included increased wandering/elopement and repetitive verbalizations in Point of Care. In interviews with Certified Nurse Aides (CNAs) #5 on 10/09/2023 at 2:49 PM, CNA #16 on 10/09/2023 at 3:35 PM, they stated the SDC provided education documenting resident behaviors to include increased wandering/elopement and repetitive verbalizations in Point of Care. CNA #5 further stated, on 10/09/2023 at 2:49 PM, in her interview that the Administration would randomly quiz them while they were out on the floor from time to time. 8. In an interview with the Staff Development Coordinator (SDC) on 10/12/2023 at 3:55 PM, she stated she educated all current non-nursing staff to notify a licensed nurse immediately if they had observed a resident with behaviors including increased wandering and repetitive verbalizations. In an interview with the Director of Rehabilitation Services on 10/05/2023 at 9:57 AM, she stated she received education from the SDC about when to notify licensed nursing staff if she observed any increased wandering or repetitive behaviors in a resident. During an interview with the Activities Director on 10/13/2023 at 3:28 PM, she stated she received education from the SDC about when to notify licensed nursing staff if she observed any behaviors in residents such as an increase in wandering or repetitive behaviors. In an interview with Certified Nurse Aide (CNA) #11 on 10/03/2023 at 3:24 PM, he stated he had been employed at the facility for approximately two weeks (2). He stated he received education and training during his orientation on elopement and documentation of resident behaviors in Point of Care from the Staff Development Coordinator (SDC). 9. Review of audits dated 09/30/2023 and completed by the ADON and DON, revealed audits of nurse progress notes and review of resident care plans were completed. In an interview with DON on 10/14/2023 at 10:24 AM, he stated that he along with the ADON had been reviewing the resident's care plan to ensure they included personalized interventions and were up to date. 10 In an interview with the Director of Nursing (DON) on 10/14/2023 at 10:24 AM, he stated that he along with the ADON and SSD, had been reviewing the Point of Care documentation to ensure they were up to date with personalized interventions. 11. In an interview with the DON on 10/14/2023 at 10:24 AM, he stated that he along with the ADON were conducting interviews with five (5) random staff members a week on various shifts and asked if any resident has had behaviors including increased wandering/elopement and or repetitive verbalizations. In an interview with Certified Nurse Aide (CNA) #6 on 10/10/2023 at 1:29 PM, she stated she had been interviewed by the ADON regarding resident behaviors. CNA #5 on 10/09/2023 at 2:49 PM, stated the Administration would randomly quiz them while they were out on the floor from time to time. In an interview with the ADON on 10/12/2023 at 5:07 PM, she stated she performed random audits on behaviors with staff. 12. In an interview with the Director of Nursing (DON) on 10/14/2023 at 10:24 AM, he stated he and other disciplines were reviewing care plans for those residents identified as at risk for elopement weekly and the reviews would continue. He stated these reviews were to ensure the residents had appropriate and personalized interventions in place to prevent elopement. In an interview with the ADON on 10/12/2023 at 5:07 PM, she stated she reviewed care plans for those residents identified as at risk for elopement. 13. Review of the Quality Assurance Performance Improvement (QAPI) meeting minutes dated 09/29/2023, revealed the results of on-going audit results of nurse progress note, Point of Care documentation of. and employee interviews were being discussed. In an interview with the Administrator on 10/14/2023 at 11:15 AM, he stated the committee was going over the documentation of the audits and employee interviews in QAPI. The team has also been addressing these topics items in the daily morning meetings in an effort to prevent further non-compliance. In an interview with the Area Director of Clinical Services on 10/13/2023 at 5:02 PM, she stated that documentation of the audits and employee interviews had been brought to QAPI and was being discussed. A review of the facility's Allegation of Correction on 10/12/2023 revealed documentation of QAPI meetings that occurred on 09/29/2023 included the audits and employee interviews.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to provide effective monitoring and supervision to prevent elopement for one (1) of six (6) sampled residents assessed for elopement risk (Resident #1). The facility assessed Resident #1 to be at risk for elopement on 08/22/2023. Staff observed the resident to wander throughout the facility searching for his/her family members; however, the staff were not alerted to provide increased supervision to the resident as this was the resident's normal behavior. Therefore, on 09/17/2023, the resident exited the facility undetected by staff. The resident was found approximately six hundred (600) feet outside of the facility by a citizen in the community. The facility's failure to have an effective system to ensure the resident's environment remained free of accident hazards and failure to ensure each resident received adequate supervision to prevent accidents has caused or is likely to cause serious injury, serious harm or death to residents. Immediate Jeopardy (IJ) was identified on 09/29/2023 and was determined to exist on 09/17/2023, with deficiencies cited at 42 CFR 483.21, Comprehensive Resident Centered Care Plans, (F657); and 42 CFR 483.25, Quality of Care, (F689); both at a Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25, Quality of Care, (F689). The facility was notified of the Immediate Jeopardy on 09/29/2023. An acceptable IJ Removal Plan was received on 10/12/2023, which alleged removal of the Immediate Jeopardy on 10/01/2023. The State Survey Agency (SSA) validated the removal of the IJ, as alleged, on 10/14/2023, prior to exit on 10/14/2023. IJ was removed at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, (657); and 42 CFR 483.25, Quality of Care, (F689); both were lowered to a S/S of a D, while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. (Refer to 657) The findings include: Review of the facility's policy titled, Accidents and Supervision, revised 03/20/2023, revealed the resident's environment would remain as free of accident hazards as possible. Continued review of the policy revealed each resident would receive adequate supervision and assistive devices to prevent accidents. This included identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The facility policy further stated that supervision was an intervention and a means of mitigating accident risk. The facility would provide adequate supervision to prevent accidents. Adequacy of supervision was defined by type and frequency and was also based on the individual resident's assessed needs and identified hazards in the resident environment. Review of the facility's policy titled, Elopement and Wandering Residents, revised 01/02/2023, revealed the facility utilized a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering to include identifying and assessing residents at risk, evaluation, and analysis of hazards and risks, implementing interventions to reduce hazards and risks, monitoring for the effectiveness and modifying interventions when necessary. Further review of the policy revealed interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards would be added to the resident's care plan and communicated to appropriate staff. Closed record review revealed the facility admitted Resident #1 on 11/01/2021 with diagnoses which included: Unspecified Dementia, Generalized Anxiety Disorder, and Major Depressive Disorder. Further review of the record revealed Resident #1 was discharged home with family on 09/20/2023. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 08/22/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) which indicated the resident was severely cognitively impaired. Review of Resident #1's elopement care plan initiated on 02/16/2023 revealed, interventions to include: Resident #1's room was to be decorated with items from his/her home and had pictures of his/ her family so when the resident wanders, he/she would see something familiar; check placement and function of safety monitoring device every shift; and distract the resident from aimless wandering by offering food, pleasant diversions, structured activities, conversation, television, or book. Review of Resident #1's Elopement Assessment Risk dated 08/22/2023, revealed the facility assessed Resident #1 as being at risk for elopement based on him/her being ambulatory, cognitively impaired, having poor decision-making skills, and history of wandering. Review of a Progress Note dated 09/17/2023 at 3:00 PM, completed by Unit Manager #1 revealed the facility was notified that Resident #1 was outside the facility. Further review of the Note revealed Resident #1 was escorted back into the facility by staff with his/her wanderguard bracelet in place and it was in working order as Resident #1 entered the building. The Note revealed Resident #1 was assessed by staff with no injuries noted. Review of the Facility's Investigation, completed by the Administrator and Director of Nursing (DON) on 09/20/2023, revealed on 09/17/2023 at 2:40 PM, the facility was notified that Resident #1 was found outside the facility at approximately six hundred (600) feet from the front entrance. Resident #1 was escorted back into the facility by two (2) staff members at 2:45 PM. In an interview with Licensed Practical Nurse (LPN) #7, on 10/05/2023 at 10:55 AM, she stated she was working on 09/17/2023. She stated she had seen Resident #1 the morning of the elopement as she was walking by the [NAME] Side nurse's station. LPN #7 stated Resident #1 did not say anything at that time. She further stated Resident #1 would normally walk the halls and talk about his/her baby doll, or would ask when his/her family was coming to get him/her. In an interview with Certified Nurse Aide (CNA) #2, on 09/23/2023 at 7:14 PM, he stated he last saw Resident #1 on 09/17/2023 at 2:30 PM, walking down the East Long Hall. CNA #2 stated shortly after seeing Resident #1, he was then informed that he/she had been found outside and that two (2) staff members had gone to retrieve Resident #1. CNA #2 further stated he had never known Resident #1 to attempt to make attempts to exit the facility; however, the resident wandered around the facility asking staff where his/her brother was located. CNA #2 stated he did not believe the resident needed increased supervision because the resident had never tried to exit the facility before. In an interview with CNA #3, on 09/27/2023 at 9:45 AM, she stated she was assigned to Resident #1's hall on 09/17/2023. She stated she last saw Resident #1 around 2:40 PM-2:45 PM, in the living area after church services ended, and was walking on the East Short Hall asking staff if they had seen his/her momma. CNA #3 stated she was in another resident's room providing care when Licensed Practical Nurse (LPN) #2 informed her that Resident #1 had exited the facility. She stated it was normal for Resident #1 to walk the halls and ask for his/her family members or sit in the living area. Review of the facility's in-coming call log revealed Caller #1 had called the facility on 09/17/2023 at 2:46 PM, to inform staff Resident #1 was outside of the facility. In an interview with Caller #1, on 09/27/2023 at 11:00 AM, she stated she was on her way from the grocery store when she saw Resident #1 at the end of the street near a daycare close to the highway. She stated she immediately called the facility because she recognized the resident, adding she had a family member who was also a resident of the facility. Caller #1 stated the resident was holding a baby doll and was observed walking down the street as she parked her car. She stated she got out of her car and then walked with Resident #1. Caller #1 stated two (2) staff members came to escort the resident back to the facility. In an interview with CNA #1, on 09/23/2023 at 6:49 PM, she stated on 09/17/2023 as she was walking by the receptionist's desk the telephone rang so she answered it. The caller stated, Resident #1 was outside the facility. CNA #1 stated she immediately hung up the phone, went and got LPN #1 and both of them went outside and found Resident #1 walking back towards the facility. She stated Resident #1 told her, A weird lady opened the door so I left with her. She further stated upon entering the facility Resident #1's wanderguard sounded the door alarm and she escorted the resident back to his/her unit. In an interview with Licensed Practical Nurse (LPN) #2, on 09/26/2023 at 1:43 PM, she stated she was the nurse caring for Resident #1 on 09/17/2023. She stated she last saw Resident #1 in front of the East Hall Nurse's station about ten (10) minutes prior to his/her elopement. LPN #2 stated Resident #1 asked her, Where's Momma? before she proceeded to walk towards the living area where they were having church services at the time. LPN #2 stated the Weekend Receptionist came running down the hall towards her unit to alert her that Resident #1 had eloped. She stated someone found Resident #1 walking down the street and called the facility to alert staff. She stated CNA #1 and LPN #1 had gone to get Resident #1 and escorted him/her back into the facility. LPN #2 stated she and another CNA went outside to help look for Resident #1. Per the interview, she stated that once they were outside, they saw CNA #1 and LPN #1 heading back toward the facility with Resident #1. The LPN stated she performed an assessment on Resident #1 and noted the resident had no injuries. LPN #2 stated she notified the Unit Manager of the event, and the resident was placed on increased supervision. In an interview with LPN #1, on 09/26/2023 at 10:10 AM, she stated she saw Resident #1 around lunchtime, as he/she was walking down [NAME] Hall. She further stated CNA #1 told her a caller had reported Resident #1 as being outside of the facility. She stated she and CNA #1 found Resident #1 outside about 600 feet from the facility. LPN #1 stated the resident was holding his/her baby doll and talking to him/herself. She stated she asked Resident #1 why he/she left the facility and Resident #1 stated, A weird lady wanted to talk to me, so I left and went with her. LPN #1 further stated she asked Resident #1 if he/she had punched in any numbers to get out of the door and the resident stated, No. In interviews with the Weekend Receptionist on 09/26/2023 at 2:45 PM and 09/27/2023 at 10:20 AM, she stated she had stepped away from the front desk to fix a television (TV) for another resident. She stated she saw Resident #1 walking through the living area towards the [NAME] Side of the facility. The Receptionist stated this must have been around 2:30 PM because she had let a visitor out at that time. Per the interview, she stated she returned to the front desk and a staff member ran by her and stated Resident #1 got out. The Receptionist stated she went to the door and saw Resident #1 with CNA #1 and LPN #1 walking towards the facility, and she went to notify Resident #1's nurse. She further stated she should have ensured someone relieved her prior to leaving her post. In an interview with the Minimum Data Set (MDS) Nurse, on 09/28/2023 at 10:52 AM; and 12:19 PM, she stated Resident #1 would normally wander the facility searching for his/her family members. In an additional interview, the MDS Nurse stated the potential for harm was that the resident would be successful with exiting the facility or the resident could have become agitated and potentially violent, when left unsupervised, if he/she could not locate his/her family. In an interview with the Maintenance Director on 09/27/2023 at 9:57 AM, he stated the facility had over nine (9) exit doors which he checked daily to ensure they were operational and functioning properly. He stated Resident #9 had a wander guard bracelet and would not have been able to exit the facility without overriding the door alarm. Further, he stated that when the system detected the wanderguard, the doors would not unlock. In an interview with the Social Services Director (SSD) on 09/22/2023 at 4:40 PM, she stated that on 09/17/2023 she was the weekend Manager on duty. She stated staff reported to her that a caller had notified the facility of seeing Resident #1 walking down the street, a short distance from the facility. She stated the resident returned to the facility by staff and was assessed to have no injuries. The SSD stated the resident was dressed appropriately and had on a shirt, pants, and shoes She stated Resident #1 was asked why he/she left the facility and the resident replied, I left with a crazy lady. The SSD further added this was the first time Resident #1 had exited the facility. She stated she had notified all levels of management so an investigation could be initiated. In an interview with the Director of Nursing (DON) on 09/26/2023 at 10:40 AM, he stated he was notified of the resident's elopement by the SSD. He stated he went to the facility immediately and directed staff to start an investigation of the elopement. Per the interview, the DON stated that the root cause of the resident exiting the facility was related to visitors leaving from attending the church service and that by no staff were present when Resident #1 exited the facility. The DON stated someone turned the alarm off because they did not see a resident at the door, but they were unable to determine from their investigation who the staff member was that reset the door alarm. In an interview with the Administrator on 09/22/2023 at 4:00 PM, he stated the Social Services Director (SSD) informed him of Resident #1's elopement on 09/17/2023 and had initiated an investigation. The Administrator stated he felt Resident #1 was at risk for elopement because he/she was independent with ambulating and blended in easily with visitors. He stated the facility investigation determined the root cause of the resident's elopement was he/she walked out with a group of visitors and that the resident's trigger for wandering was frequent visits outside of the facility with his/her family. ****The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 10/12/2023 that alleged removal of the Immediate Jeopardy (IJ) on 09/20/2023 as follows: 1. Resident #1 was returned to the facility on [DATE] and was immediately assessed for injuries by the Assistant Director of Nursing (ADON), with no injuries noted. 2. A resident head count was completed by the Social Services Director (SSD) and charge nurses on 09/17/2023. All other current residents were accounted for at the facility. 3. On 09/17/2023, Resident #1's wanderguard was checked for placement and function by the Maintenance Director, with no irregularities noted. 4. The Unit Manager checked 6 (six) current residents who had an order for wander guards for placement and functioning with other alarmed doors. No were issues noted. 5. Resident #1 was assisted to his/her room and placed on fifteen (15) minute checks. 6. Unit Manager notified Resident #1's physician and guardian on 09/17/2023. No new orders were received. The written plan of care for Resident #1 was reviewed and updated by the Interdisciplinary Team to reflect his/her increased supervision. 7. On 09/17/2023 the Maintenance Director assessed the wanderguard door system and alarmed doors for functioning with no irregularities noted. All the exit door codes were changed. 8. Beginning 09/17/2023, the Maintenance Director would change all exit door codes monthly and as needed. The Maintenance Director would complete a door code audit monthly and as needed. Further he would report monthly to Quality Assurance Performance Improvement (QAPI) team. 9. A QAPI meeting was held on 09/17/2023 with the Administrator, Director of Nursing (DON), and the Medical Director to discuss Resident #'1's elopement, the root cause of the incident, elopement policy and procedure, and elopement drill scheduling for all shifts. The Maintenance Director would conduct the elopement drills, and staff education would be provided by the Social Services Director (SDC). Additional QAPI meetings were scheduled once a week for four (4) weeks. 10. On 09/17/2023 and 09/18/2023, the Assistant Director of Nursing (ADON), DON, Unit Managers, Staff Development Coordinator, and SDC, conducted a one-time 100% record review for residents who may have increased/unsafe wandering behaviors and/or were increased elopement risk for the past thirty (30) days. The record reviews included but were not limited to physician's orders, care plans, and treatment administration records (TAR). Plans of care for identified residents were reviewed and revised as needed to reflect the resident's status. 11. On 09/19/2023 the DON reviewed current residents to ensure Elopement Risk Assessments and care plans were accurate. 12. On 09/19/2023 the DON and ADON reviewed residents with wander alert bracelets to ensure proper placement and function, with no concerns noted. Additionally, care plans for identified residents were reviewed and revised as needed to reflect the residents' status. 13. On 09/19/2023, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) reviewed the facility assessment to ensure the number of residents with unsafe wandering was correct. 14. On 09/17/2023, the ADON, DON, and SDC initiated re-education on policy and procedure for elopement prevention and management for staff on duty. The re-education continued for all other staff, with a completion date of 09/19/2023. Re-education included but was not limited to checking of immediate surrounding area when responding to an alarm, and notification of the Licensed Nurse, DON, and the Administrator. All licensed nurses, Certified Nurse Aides (CNA's), current CNA students, Maintenance, housekeeping, dietary, and therapy, and included as needed (PRN) staff. any PRN staff. Staff completed a post-test with an overall score of 100%. No staff were allowed to work until they received the education. The information would also be included in the orientation of newly hired staff. The facility had no agency staff. 15. Signage informing visitors to not assist residents in exiting the facility was verified to be in place at the front door on 09/17/2023 by the Director of Nursing (DON) and the Administrator. Additional signage would be added as necessary. 16. The placement and function of resident wanderguards would be checked every shift by a licensed nursing staff and/or medication tech and documented in the electronic medical record on the treatment administration record (TAR) and/or the medication administration record (MAR). 17. The Maintenance Department and/or Manager on Duty would test exit doors and wander guard system daily. The Maintenance Director and/or the Administrator would change the door alarm codes monthly. 18. Wanderguard books were reviewed on 09/17/2023 by the SSD and were found to be up to date. Medical Records would be responsible for updating the Wanderguard books as needed. 19. Elopement drills would be conducted by the Maintenance Director or Maintenance Assistant 5 days per week, across all shifts and including weekends times 2 weeks, then 3 days per week, across all shifts and including weekends x 4 weeks; and then monthly times 3 months and then quarterly thereafter and will be documented on elopement drill sign-in sheets. 20. Any identified non-compliance with facility policy and procedure would result in 1:1 re-education with staff and repeat non-compliance resulting in progressive disciplinary action per facility policy. 21. The Door Code and elopement drills audit would be brought to QAPI by the Maintenance Director. They would be reviewed weekly for four (4) weeks and then monthly for five (5) months in the QAPI meeting by the Administrator and Director of Nursing (DON). ****The State Survey Agency validated the facility had taken the following actions: 1. During an interview with the Assistant Director of Nursing (ADON) on 09/22/2023 at 11:39 AM, she stated when staff escorted Resident #1 into the facility after his/her elopement on 09/17/2023, she assessed the resident for injuries. The ADON stated Resident #1 had no injuries and was appropriately dressed. 2. During an interview with the Social Services Director (SSD) on 09/22/2023 at 4:40 PM, she stated on 09/17/2023, after staff were informed that Resident #1 had eloped, she and other staff completed a full head count of facility residents. The SSD stated all residents were accounted for. 3. During an interview with the Maintenance Director on 09/27/2023 at 9:57 AM, he revealed when he was made aware of Resident #1's elopement he went to the facility and checked to ensure all facility doors were secure and functioning. Observations with the Maintenance Director on 09/27/2023 at 10:00 AM revealed all facility exit doors were checked and were in operating order. The Unit Manager checked 6 (six) current residents who had an order for wanderguards for placement and functioning with other alarmed doors. No issues were noted. 4. In an interview with the Unit Manager and Director of Nursing (DON) on 10/05/2023 at 3:38 PM, they stated they had performed checks on the six residents currently wearing wanderguards and found they were functioning properly. 5. Record review revealed Resident #1 was placed on fifteen (15) minute checks after the elopement. In interviews with Certified Nurse Aide (CNA) #3 on 09/27/2023 at 9:45 AM, Unit Manager #1 on 09/26/2023 at 3:46 PM, and Licensed Practical Nurse (LPN) #2 on 09/26/2023 at 1:43 PM, they stated 15-minute observation checks were conducted on Resident #1. 6. Review of a Progress Note dated 09/17/2023 at 3:00 PM, revealed Unit Manager #1 notified Resident #1's guardian and the resident's physician of the elopement. In an interview with Unit Manager #1 on 09/26/2023 at 3:46 PM, she stated she notified Resident #1's guardian and physician about the elopement on 09/17/2023. In an interview with Resident #1's physician/facility Medical Director, on 10/13/2023 at 2:03 PM, he stated he was notified of Resident #1's elopement by facility staff and provided with updates on the investigation by DON. In interviews with the Administrator on 09/22/2023 at 4:00 PM and the DON on 10/05/2023 at 3:38 PM, both stated they provided the Medical Director with updates on Resident #1 and the facility investigation. They further stated Resident #1's care plan had been reviewed and updated by the Interdisciplinary Team (IDT) to reflect his/her increased supervision. 7. In an interview with the Maintenance Director on 09/27/2023 at 9:57 AM, he stated that he observed the SSD check the doors on the morning of 09/17/2023, prior to the elopement. He further stated he performed checks on the doors on 09/17/2023, after Resident #1's elopement to ensure all doors were functioning properly. Review of the facility's door log on 09/27/2023 at 11:16 AM, revealed the SSD had signed off on all the door checks for 09/17/2023 at 9:00 AM. 8. Review of the Quality Assurance Performance Improvement (QAPI) meeting minutes dated 09/19/2023, revealed the door code audits were completed by maintenance were reviewed and discussed, with no concerns noted. Further review of the meeting minutes revealed the facility identified the Root Cause Analysis to be not responding properly to the door alarm and visitors knowing the door code. 9. Review of the QAPI minutes dated 09/17/2023, revealed the Administrator, Director of Nursing (DON), and the Medical Director attended the meeting. The QAPI team discussed Resident #'1's elopement, the root cause of the incident, elopement policy and procedure, and elopement drill scheduling for all shifts. In an interview with the Administrator on 09/22/2023 at 4:00 PM he stated a QAPI meeting was held on 09/17/2023 with himself, the DON, and Medical Director to discuss Resident #1's elopement. He stated the team further discussed the root cause of the elopement and the next steps to ensure all staff were educated on the elopement policy and procedure. The Administrator stated they have continued to have weekly meetings to discuss the events. In an interview with the facility Medical Director on 10/13/2023 at 2:03 PM, he stated they had a QAPI meeting by telephone. In an interview with the DON on 10/12/2023 at 5:23 PM, he stated he, the Administrator held a QAPI meeting after the elopement with the Medical Director by telephone. 10. In an interview with the Social Services Director (SSD) on 09/22/2023 at 4:40 PM, she stated she reviewed care plans for residents at risk for increased/unsafe wandering. She stated the reviews were comprehensive to ensure the residents care plans accurately reflected the residents needs. In an interview with Minimum Data Set (MDS) Nurse on 09/28/2023 at 10:52 AM, she stated she reviewed care plans for residents at risk for increased/unsafe wandering and updated them if needed. 11. In an interview with the Director of Nursing (DON) on 10/05/2023 at 3:38 PM, he stated he performed a review of all current residents to ensure their current Elopement Risk Assessments and care plans were accurate. He further stated if they were not he would update them at that time. 12. In an interview with the Assistant Director of Nursing (ADON) on 09/22/2023 at 11:39 AM, she stated she checked residents' wanderguard bracelets for placement and function. The ADON further stated care plans were reviewed and revised if needed. In an interview with the DON on 10/14/2023 at 10:24 AM, he stated care plans for identified residents were reviewed and revised to reflect the current status of those residents. He stated he checked those residents with wanderguard bracelets for placement and function. 13. In an interview with the DON on 10/14/2023 at 10:24 AM, he stated he and the ADON reviewed the facility assessment and verified the number of residents with unsafe wandering was correct. He stated this would be updated if concerns were noted with a resident having new wandering behaviors. 14. Review of staff education including post-tests and sign-in sheets revealed all staff disciplines had been educated by DON, ADON, and SDC. The education topics included policy & procedure for elopement prevention and management and the checking of the immediate surrounding area when responding to an alarm, and notification of the Licensed Nurse, DON & the Administrator. Interviews with Registered Nurse (RN) #1 on 10/02/2023 at 8:58 AM, Licensed Practical Nurse (LPN) #5 on 10/02/2023 at 8:56 AM, and Certified Nurse Aide (CNA) #3 on 09/27/2023 at 9:45 AM, revealed they received education on elopement from the SDC and took post-tests to demonstrate understanding of the information. In interviews with [NAME] #1 on 10/02/2023 at 4:45 PM, Environmental Services Manager on 10/02/2023 at 4:29 PM, and the Business Office Manager on 10/06/2023 at 10:19 AM, they all stated that they had received education on Elopement and took a post-test from the Staff Development Coordinator. In an interview with the Staff Development Coordinator on 10/02/2023 at 4:20 PM, she stated that she provided education to therapy, environmental services, and dietary services on elopement. 15. Observation of the front entrance on 09/21/2023 at 11:55 AM, revealed signage in place informing visitors to not assist residents in exiting the facility. Further observations revealed additional signage was posted on front exit doors of the main lobby of the facility. Additionally, signage informing visitors to not assist residents in exiting the facility was verified to be in place at the front door on 09/17/2023 by the Director of Nursing (DON) and the Administrator. 16. Review of Treatment Administration Records (TARs) of residents at risk for elopement revealed wanderguards were checked by nursing staff and documented. In an interview with Unit Manager #1 on 09/26/2023 at 3:46 PM, she stated she, along with the unit nurses, checked the placement of the residents' wanderguard bracelets every shift. 17. In an interview with the Maintenance Director on 09/27/2023 at 9:57 AM, he stated he was responsible for completing daily wanderguard system checks on all exit doors. If he were not working, the assigned manager on duty would complete the checks. He further stated he changes the door codes monthly to ensure visitors do have the door codes. 18. In an interview with the Social Services Director (SSD) on 09/22/2023 at 4:40 PM, she stated she reviewed the Wanderguard books and ensured they were up to date. She stated if any resident were newly assessed to be a wanderer the book would be updated immediately. 19. Record review of the Elopement drill logs and sign-in sheets on 09/27/2023 at 3:00 PM, revealed staff members participated in elopement drills given by the facility maintenance director. Observation of an elopement drill conducted by the Maintenance Director, on 09/29/2023 at 3:15 PM, revealed no concerns. Facility staff responded appropriately by calling alarms and providing prompt responses to door alarms. Staff were observed to have followed facility policy and procedure on a resident elopement event. Staff were observed walking the building perimeter and an all-clear was given on 09/29/2023 at 3:18 PM. 20. In an interview with the Director of Nursing (DON) on 09/26/2023 at 10:40 AM, he stated facility staff were educated on no longer giving out the door codes to vendors, and visitors. He stated the vendors and visitors have been educated by facility staff as they come to the facility. They were informed that they would now be let in and out of the facility by staff members because the door code would no longer be given out. The DON stated any staff member who violates this practice would face disciplinary action. 21. Review of the Quality Assurance Performance Improvement (QAPI) meeting minutes dated 09/22/2023, revealed the Administrator, DON, ADON, Area Director of Clinical Services, Maintenance Director, and Medical Director attended. The members discussed the elopement situation, the door codes, and the audits of elopement drills. In an interview with the Administrator on 10/14/2023 at 11:15 AM, he stated the door audits and elopement drills have been reviewed during weekly QAPI meetings and there have been no identified issues. He stated all interventions remained in place and seemed to be effective. In an interview with the DON on 10/14/2023 at 10:24 AM he stated that they were still discussing the Elopement in QAPI and evaluating to see if it was going well.