**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident remained free from falls, by failing to ensure proper practices were followed while using a lift during a transfer for 1 (#1) of 2 (#1 and #2) sampled residents reviewed for incidents and accidents. This deficient practice resulted in an Immediate Jeopardy for Resident #1 on 03/27/2025 at 1:57 p.m., when Resident #1 fell from a mechanical lift onto the floor while being transferred by S3 CNA and S4 CNA. Resident #1 sustained a complete displacement fracture of the proximal left femur, and a subarachnoid hemorrhage as a result of the fall. The facility determined that S3 CNA and S4 CNA failed to use the appropriate sling size, and failed to place the sling loops appropriately on the lift to transfer Resident #1. The facility implemented corrective actions prior to the State Agency's investigation therefore, it was determined to be a Past Noncompliance citation. Findings: Review of the facility's 12/2019 policy titled [NAME]- Lift Transfer Procedure, read in part 1. Make sure you understand which size sling and which method of connecting the sling to the hanger bars is to be used to transfer patient. 13. Double check the sling loop connection to the hanger bar hooks to make sure the sling is securely attached with the loops in the bottom of the hanger bar hooks. Review of the facility's 12/2019 policy titled [NAME]- Lift -Using the Uni-fit Sling, read in part . each resident who uses the Vander-Lift for transferring should have a sling size (and color) listed on their wall care plan. The recommended sling size is what is to be used for the specific resident's transfer. Procedure Checkoff: 1. CNA correctly identified correct lift and sling size appropriate for the residents and identified sling part. 11. The CNA connects each of the shoulder sling loops to the hanger bar hooks on the mast using the same loop position on both sides of the sling. Review of Resident #1's medical record revealed an admission date of 06/20/2021, with diagnoses that included, in part .Schizoaffective Disorder, Bipolar Disorder, Diabetes Mellitus, Muscle Wasting with Atrophy, and Parkinson's disease. Review of a Quarterly MDS with ARD of 01/01/2025, revealed Resident #1 had a BIMS score of 11 (Moderate Cognitive Impairment). Resident #1 was dependent upon staff and required 2 + person physical assist for transfers. Review of Resident #1's Care Plan with a target date of 03/10/2025, revealed, in part . Resident #2 is at high risk for falls due to decreased mobility and diagnosis of Parkinson's. Interventions in place prior to incident: Vander-Lift x 2 person assist. Incident: 03/27/2025 Fall in room from Vander-Lift with head injury. Interventions: 03/28/2025 Vander-Lift x2 person assist with all transfers Medium (RED) lift pad. Observation on 04/07/2025 at 11:15 a.m. of Resident #1's wall care sheet posted in Resident #1's room, read in part .Vander-Lift x 2 person assist for all transfers. A red sticker was noted on the wall care sheet, which indicated a red (medium) sling was needed for transfers using a lift. Review of the facility incident report completed by S1 ADM, revealed on 03/27/2025 at 1:57 p.m., S5 Clinical Coordinator and S6 ADON were called into Resident # 1's room where she was found lying flat on floor between the legs of the Vander-Lift, and with blood under her head. S3 CNA and S4 CNA stated Resident #1 had fallen out of the lift sling and onto the floor during transfer. S5 Clinical Coordinator and S6 ADON applied pressure to Resident #1's head and had staff call an ambulance, the physician, and Resident #1's daughter. External rotation of the left leg was noted after the ambulance arrived, and Resident #1 was placed on the stretcher. Resident #1 was sent to the emergency room, where she was diagnosed with a subarachnoid hemorrhage, and complete displacement fracture involving the proximal left femur. The facility's investigation revealed the wrong size sling was used and the top right strap of the sling was hooked in the middle loop, rather than the loop closest to the pad, like the other 3 straps. Resident #1 was admitted to the hospital. She returned to the facility on [DATE]. Review of the employee written statement by S5 Clinical Coordinator revealed, in part .on 3/27/2025 at 1:57 p.m. Nurse stat was called to Resident #1's room. Resident #1 was observed lying on the floor between the legs of the Vander-Lift. The lift pad on the lift was a size large pad, and was trimmed in blue. Resident #1's care sheet included a red sticker, indicating her weight required the use of a red, or size medium, lift pad. All the straps were attached to the lift. The right strap at the head of the pad was attached in a higher notch further away from the sling, and the other 3 straps were attached to the bracket at the lowest level, closest to the lift pad. S3 CNA and S7 CNA were in the room at the time of the incident. S4 CNA had assisted with the transfer, but was no longer in the room. First aid was provided for Resident #1's head injury until the ambulance arrived. Review of the employee written statement by S4 CNA read in part S3 CNA hooked the lift up and she pulled it out, and Resident #1 then slipped out of the lift. Review of the employee written statement by S3 CNA read in part .Resident #1's dressed in blue jeans and a sweater with her socks and shoes with the lift pad under her. I went out to get assistance. I hooked up the 2 ends at the top, the other aide hooked up the 2 bottom ends. When lifting Resident #1 and moving her to sit her into her chair, she comes sliding out of the lift pad falling onto the floor. The sling was in her recliner chair. Review of the employee written statement by S7 CNA, read in part . I went in the room to go wait on the lift to get another resident up. S4 CNA and S3 CNA hooked the lifter pad on the lift. S3 CNA went to pull the lift from the bed and S4 CNA backed up the wheelchair to left of her bed. As soon as S3 CNA pulled the Vander-Lift out, the resident fell on her right side. S4 CNA then ran out the room while S3 CNA and I stayed with the resident'. Review of a written interview between S3 CNA and S1 ADM on 03/28/25: S1 ADM - Did you realize that you had placed one? loop higher than the other loop? S3 CNA - Yes, I do know all the loops are to be the same on each side and when hooking up the lift pad I thought they were on the same loop on each side. S1 ADM - The lift pad was large and she uses a medium size. Were you aware of this? S3 CNA - The sling was already in the room so I used the sling that was already in the room. Review of S3 CNA's personnel file revealed a new hire in-service and checkoff dated 02/27/2025 regarding use of the Vander-Lift for transfers, correct sling sizes, and attaching the hooks properly. Review of S4 CNA's personnel file revealed an in-service and checkoff dated 07/08/2024, and 10/07/2024, regarding use of the Vander-Lift for transfers, correct sling sizes, and attaching the hooks properly. Interview on 04/08/2025 at 9:55 a.m. with S5 Clinical Coordinator, revealed on 03/27/2025 at 1:57 p.m., she heard nurse stat announced for Resident #1's room. Upon entering the room she observed Resident #1 lying on the floor between the legs of the lift, and with blood under her head. S5 Clinical Coordinator stated a blue-trimmed sling was attached to the lift. S5 Clinical Coordinator revealed Resident #1's wall care sheet indicated she required a red sling. S5 Clinical coordinator stated the top right strap of the sling was not hooked in the loop closest to the pad, like the other 3 straps. S5 Clinical Coordinator stated that she is in charge of ensuring the right sling size is care planned and revealed that the red sling size was appropriate for Resident #1 according to her weight. Interview on 04/08/2025 at 10:21 a.m. with S6 ADON, revealed on 03/27/2025 at 1:57 p.m., she heard nurse stat yelled loudly for Resident #1's room. S6 ADON observed Resident #1 on the floor between the legs of the Vander-Lift. She stated there was blood under Resident #1's head. S6 ADON stated Resident #1's left leg was rotated outwardly, and she complained of pain to her back and left hip. S6 ADON stated after Resident #1 was transferred to the hospital, she immediately began in-servicing staff on correct use of lifts. She required all CNAs and nursing staff be checked-off on the task prior to using the lift. S6 DON stated she continued to monitor S3 CNA, S4 CNA, and random CNAs daily. Interview on 04/08/2025 at 1:11 p.m. with S7 CNA, revealed on 03/27/2025 at 1:57 p.m. she was in Resident #1's room when the fall occurred because she was waiting on the lift. S7 CNA revealed Resident #1's lift pad was already underneath her, but she could not recall the color. S7 CNA stated S3 CNA connected the top sling straps to the lift, and S4 CNA connected the bottom sling straps to the lift. S7 CNA stated S3 CNA began lifting Resident #1. S4 CNA put her foot on the lift, turning the lift towards the wheelchair. As S4 CAN turned the lift, Resident #1 fell out of the right side of the sling, and onto the floor. S7 CNA revealed staff were to use the sling size indicated on the residents' care sheets, and ensure all straps were connected properly prior to using the lift. Interview on 04/08/2025 at 1:32 p.m. with S4 CNA, revealed on 03/27/2025, she went into Resident #1's room to assist S3 CNA with transfer of the resident. S4 CNA stated the lift pad was already under Resident #1, but she could not recall the color of the lift pad. S4 CNA connected the lower straps to the lift, and S3 CNA connected the upper straps to the lift. S4 CNA stated that as S3 CNA moved the lift, Resident #1 fell out the right side of the sling and onto the floor. S4 CNA stated she had been trained on proper use of the lift, and had been checked off on the skill. S4 CNA stated two staff members were required to use and operate the lift. She was to refer to the residents' care sheets to determine the correct size lift pad for each resident. Interview on 04/08/2025 at 1:45 p.m. with S3 CNA, revealed prior to the incident, she had gotten Resident #1dressed and had put the lift pad, that was already in the room, underneath her for the transfer. S3 CNA stated she retrieved the lift and requested assistance from S4 CNA. S3 CNA stated that S7 CNA came into the room to wait for the lift. S3 CNA stated she connected the top straps of the lift pad to the lift, and S4 CNA connected the bottom straps of the lift pad to the lift. S3 CNA stated she lifted Resident #1, and was guiding the sling to the chair when Resident #1 slid out of the sling and onto the floor. S3 CNA stated she thought the straps were hooked to the lift correctly at the time of transfer. S3 CNA stated she was to look at the resident's wall care sheet to identify what color/size sling they were to use for transfer. S3 CNA stated she did not look at the wall care sheet to determine the correct sling size, but instead used the sling that was already in Resident #1's room. She did not remember what size sling was used for the transfer. Interview on 04/08/2025 at 3:05 p.m. with S2 DON, revealed she was on vacation at the time of the incident, but had been notified by S1 ADM. S2 DON ensured all staff were trained on use of lifts since the incident. S2 DON stated all existing staff had been in-serviced, and new staff were trained upon hire. Nurses were to monitor CNAs to ensure correct lift pads and lift technique were utilized. Interview on 04/09/2025 at 9:45 a.m. with S1 ADM, revealed on 03/27/2025 she was notified that Resident #1 had been sent to the hospital after falling while being transferred with a lift. Investigation by S1 ADM and S5 Clinical Coordinator revealed the correct sling size had not been used for the transfer and one of the sling straps was not correctly connected to the lift. The facility had implemented the following actions to correct the deficient practice: 1. On 03/27/2025, the administrative team began in-servicing all CNAs and nurses on proper lift technique and correct sling use. The in-services were completed on 04/05/2025. 2. On 03/27/2025, the administrative nursing team began checking-off all CNAs and nurses on the lift and slings, using return demonstration technique. The check-offs were completed on 4/5/25. 3. On 03/27/2025, all lifts were inspected by the assistant administrators to ensure they were in safe working order. 4. On 03/28/2025, S3 CNA and S4 CNA received individual counseling and in-service. Skills check-off was completed, with follow-up questions, to ensure complete understanding. 5. Beginning 03/28/2025 and continuing × 7 days, S3 CNA and S4 CNA were to ensure a nurse was present during any transfer of a resident with a lift. The nurse completed a check-off sheet, documenting use of the correct sling size and correct connection of the sling to the lift. 6. On 03/28/2025, S2 ADON ensured all residents requiring use of the Vander-Lift had the correct sling size indicated on the care sheet in their room. To provide additional clarification, the size/color of sling to be used was added to each order for the Vander-Lift which was completed on 03/28/2025 7. On 03/31/2025, the housekeeping supervisor checked all the slings in the building, ensuring they were not frayed or torn, and were in good working condition. Completed on 03/21/2025. 8. On 03/31/2025 the medical equipment company inspected all lifts in the facility to ensure they were in safe use. 9. On 03/31/2025 S1 ADM provided an in-service to all Laundry staff regarding proper laundering of lift slings. 10. On 04/07/2025 the Assistant Administrator ensured all resident rooms provided enough space for safe transfer with a lift. 11. On 03/28/2025 the DON or designee will begin to monitor a random sample of residents being transferred with a lift to ensure the correct procedure was followed. This monitor will be completed 3x a week for 6 weeks, and then monthly until compliance is reached. Any noncompliance will be addressed. 12. On 03/28/2025 The DON or designee will begin to monitor, ensuring any lift sling in a resident's room was the correct size for the resident. This monitor will be completed on a random sample of residents with lift orders 3x a week for 6 weeks, and then monthly until compliance is reached. Any noncompliance will be addressed. 13. Administration was responsible for oversight of all the implemented actions, which would be reviewed during the weekly Quality Meeting for 6 weeks. As of 03/27/2025 and once the above interventions were all implemented, the past noncompliance was considered to be corrected.

Based on record reviews, observations, and interviews, the facility failed to ensure cognitively impaired residents who were wanderers, and at risk for elopement were adequately supervised and not allowed to exit the building without staff knowledge, for 3 (#1, #2, and #3) of 5 sampled residents (#1, #2, #3, #4 and #5). The facility failed to: 1. Ensure Resident #1 who was severely impaired cognitively, and required supervision, was accurately assessed for a risk of elopement. Resident #1 exited the facility unsupervised on 01/07/2023 and eloped to a local pharmacy; 2. Ensure Resident #2, a severely cognitively impaired resident who wandered, was assessed as being at risk for elopement, wore a wander alert bracelet, and was on every one hour visual checks, was supervised according to her plan of care, and not allowed to exit the building and walk across a busy 3 lane street to a gas station on 01/14/2023; and 3. Ensure Resident #3, a severely cognitively impaired resident who wandered, was assessed as being at risk for elopement, wore a wander alert bracelet, and was on every one hour visual checks, was supervised according to her plan of care and not allowed to follow a resident out a door and exit the building without staff knowledge on 01/17/2023. This deficient practice resulted in an immediate jeopardy situation on 01/07/2023 at 2:21 p.m. when Resident #1 a severely cognitively impaired resident who was inaccurately assessed and required supervision exited the facility unsupervised, and walked through a busy parking lot to a local pharmacy. A staff member shopping at the pharmacy found Resident #1 arguing and cursing a pharmacy employee, and returned Resident #1 to the facility. On 01/14/2023 at 12:31 p.m. when Resident #2, a severely cognitively impaired resident assessed and care planned as an elopement risk, wore a wander alert bracelet and was on every one hour visual checks, exited the front door of the facility when a visitor entered the door code and opened the front door. The door alarm sounded, and staff reset the door alarm without investigating. Resident #2 walked across a 3 lane street to a gas station, got into the back seat of the car of 2 gas station customers and asked them to take her home. The gas station customers assumed Resident #2 was from the facility, called the facility and asked if they were missing Resident #2, and drove Resident #2 back to the facility at 12:37 p.m. On 01/17/2023 at 2:22 p.m., Resident #3, who rarely understands/rarely understood, assessed and care planned as an elopement risk, wore a wander guard bracelet, and was on every one hour visual checks, followed a resident out a door after he entered the code to the door, and exited the building without staff knowledge on 01/17/2023. At 2:28 p.m., S15 Housekeeper looked out the kitchen/dining room window and saw Resident #3 standing outside on the side of the building directly adjacent to a busy pharmacy parking lot. S15 Housekeeper escorted Resident #3 back into the building This deficient practice continued at a potential for more than minimal harm for the 13 Residents in the facility who were identified to require supervision, and/or were assessed as being at risk for elopement and wore a wander alert bracelet, (#1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, & #14). S1 Administrator was notified of the Immediate Jeopardy on 01/31/2023 at 6:25 p.m. The Immediate Jeopardy was removed on 02/01/2023 at 6:25 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews and observations that the Plan of Removal have been initiated and/or implemented: The Facility's plan to remove the immediate jeopardy situation included: In-services were initiated for all staff by the DON and Assistant Administrator on 01/31/2023 and 02/01/2023 and will be completed by 02/03/2023 at 5 pm. The in-service covered the existing policy on Wandering or Missing Resident which covers Code W, as well. Code W includes when a resident is missing, the staff will announce Code W and repeat it twice. The charge nurse will assign staff areas to begin looking for the resident. If not located in the building or grounds within 15 minutes, the charge nurse will notify the DON and Administrator to implement a plan to locate the resident. The in-service also addressed the use of the wander alert system and protocols to follow when the alarm sounds. Staff were reminded that a list of all residents with Wander Alert Bracelets is posted at each nurses' station, at the front desk and at the time clock. All staff were informed of who the 13 wanderers are and how often they should be checked. Staff were also in-serviced about the new Wander Alert Binder that was placed at each nurses' station. Staff unable to be in-serviced by 02/03/2023 at 5 pm will not be allowed to work until they are in-serviced. Any new employees will be in-serviced on the above during their orientation process. A QAPI monitor has been implemented to monitor whereabouts of all 13 residents with orders for Wander Alert Bracelets and are wearing wander alert bracelets. This monitor was started on 02/01/2023 at 8:30 am and will be completed by the ward clerk or designee every 30 minutes around the clock for 30 days, while the facility reviews all systems and procedures related to elopement precautions. The DON or designee will supervise and monitor daily during this 30 day period to ensure that ward clerk or designee are checking on whereabouts of all 13 residents. Residents will be supervised by direct care nursing staff according to their person-centered care plans. After Resident #1 left the building on 01/07/2023, she was reassessed by nursing staff and a wander alert bracelet was put in place and she was placed on one hour visual checks. After Resident #2 eloped on 01/14/2023, she was reassessed using the Wander Collection Tool on 01/16/2023. After Resident #3 eloped on 01/17/2023, she was reassessed using the Wander Collection Tool on 01/20/2023. On 02/01/2023, the Administrator placed a sign on all doors reminding visitors, family members, staff and residents to never let a resident out of the facility without checking with a nurse first. On 02/01/2023, the Administrator notified the responsible parties of each resident using our broadcast notification system. This notification addressed the importance of protecting all residents by not letting a resident out of the facility without first checking with a nurse as some of the residents have Wander Alert bracelets and are not allowed to leave the facility. On 02/01/2023, the Assistant Administrator changed the exit door codes on the Wander Alert System on each exterior door. When a resident with a Wander Alert Bracelet approaches the door, it will remain locked. If someone enters this new code and the resident is close to the door, the door will remain locked. If someone enters the new code, and the resident is farther away, the door will unlock but the alarm will sound if the resident with the Wander Alert Bracelet approaches the door or tries to go out the door. Only staff will have access to the codes to the front door as well as the smoking door which is located at the end of (Hall A). Dietary staff will have access to the code to the exterior door of the kitchen to allow access for deliveries. The Administrator, DON, and Assistant Administrator will be the only staff to have codes to all remaining doors which are located at the end of the 100 hall, on the side of the 100 hall, at the end of the 200 hall, at the end of the 300 hall, the side of the 400 hall and the dining room doors. On 02/01/2023, the Social Service Director made Wander Alert Binders to be placed at each nurses' station as well as the front desk. This binder contains the Wandering or Missing Resident policy, the list of residents with Wander Alert Bracelets along with their pictures and face sheets. On 02/01/2023, the DON placed a list of residents with Wander Alert Bracelets orders at each nurses' station, by the medication room door, at the front desk, and by the time clock. The Wander Data Collection Tool is completed by the MDS nurse upon admission, quarterly, and with a significant change in status. This tool has a scoring system indicating a resident has a Definite Risk for elopement with a score of 3 or more yes answers and is At Risk with 1-2 yes answers. Upon completion of the Yes/No answers on the front of the page, the nurse then summarizes her findings on the back of the page and determines the most appropriate intervention needed, if any. A resident may or may not need a Wander Alert Bracelet regardless of the findings from the yes/no questions, however, additional interventions are implemented based on the needs of the resident. Things considered when deciding on need for Wander Alert Bracelet include, but not limited to; their mobility, desire to leave the building and/or exit seeking behavior. The facility will choose the least restrictive measures as interventions. If deemed at risk, the IDT will discuss the most appropriate intervention. Beginning 02/01/2023, the treatment nurse during the week and the RN on the weekend or designees will check each door daily to ensure Wander Alert System is functioning properly. If there is a concern or problem, the nurse is to notify the Administrator or DON immediately and assign someone to sit by the door until appropriate repairs can be made. The treatment nurse during the week and the RN on the weekend or designees will continue to check each Wander Alert Transmitter daily with the Transmitter Testing Device to ensure proper functioning. If a transmitter fails to function properly, the nurse stays with the resident and replaces the Wander Alert Transmitter. Once replaced, the new transmitter will be checked for proper functioning. This process will continue indefinitely. Findings: Review of the facility's policy titled, Wandering or Missing Resident revealed in part . Policy: In an effort to prevent Residents from wandering away from the facility, procedures have been developed to follow when a resident leaves the facility unsupervised or without reporting to the facility staff their time of departure and time of return. Procedures: Resident Missing From Designated Area of Facility: 1. A department or resident care staff person which identified a wandering resident is missing must notify all staff of the missing resident by announcing on the public address system Code W, Resident's Name. Repeat twice. 2. The wandering resident's charge nurse shall assign direct care staff to look for the resident. 3. If the resident is not located in the buildings or the grounds within 15 minutes, the charge nurse shall notify the DON and the Administrator to implement the plan to locate the resident. 4. Any member becoming aware of a resident not being at the designated area or activity shall proceed to notify the charge nurse, DON and the Administrator. 5. Notify the appropriate responsible party: 6. Documentation of the wandering resident: a. The care plan will be updated with diversions, approaches, and modifications that are specific to the resident's individual wandering habits. Resident #1 Review of Resident #1's medical record revealed an admit date of 02/02/2018 with diagnoses that included in part . Unspecified Severe Dementia with Behavioral Disturbance, Major Depressive Disorder, Type 2 Diabetes Mellitus and a history of Urinary Tract Infection. Review of Resident #1's Wander Data Collection Tool dated 11/10/2022 revealed the following: Instructions: Scoring: 3 or more Yes answers = Definite Risk for elopement; 1-2 yes answers = At risk for elopement. The following 4 questions were answered yes for Resident #1: Is the resident cognitively impaired with poor decision-making skills (i.e. poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes Does the resident have any visual, auditory, or communication deficits? Yes Does the resident have a diagnosis of dementia/Alzheimer's Disease, anxiety, depression, schizophrenia, OBS, delusions, or hallucinations? Yes Does the resident ambulate independently with or without the use of assistive devices (including wheelchair, scooter, walker, etc.)? Yes It was documented on the form Resident #1 had a BIMS score of 3 and based on summary of findings, Resident was not a wander/elopement risk Signed by S9 MDS and dated 11/10/2022. Review of Resident #1's Quarterly MDS with an ARD of 11/10/2022 revealed a BIMS score of 3, which indicated severely impaired cognition. The MDS revealed Resident #1 was independent with bed mobility, transferring, eating, and walking in room and corridor. Review of Resident #1's comprehensive plan of care revealed Resident #1 was not care planned for wandering or potential for prior to her elopement on 01/07/2023. In an interview on 01/30/2023 at 12:54 p.m., S6 CNA reported Resident #1 lit a cigarette in the dining room on 01/07/2023 so staff took her cigarettes away from her. S6 CNA stated Resident #1 then walked to the pharmacy next door to get some more cigarettes. S6 CNA stated one of the workers went over there for something else, saw Resident #1 and brought her back to the building. S6 CNA confirmed Resident #1 knew the door code because she was a smoker. In a telephone interview on 01/30/2023 at 2:26 p.m., S7 Laundry reported on her 30 minute break on 01/07/2023 she went to the pharmacy next door. S7 Laundry reported when she went to go check out, Resident #1 was at the register cursing loudly and arguing with the employee about getting some cigarettes. S7 Laundry reported she told Resident #1 she had her cigarettes and had to convince Resident #1 to come back to the facility with her. S7 Laundry confirmed she brought Resident #1 back into the facility and to her nurse, S8 LPN. S7 Laundry stated Resident #1 should not have been at the pharmacy unsupervised. In an interview on 01/30/2023 at 4:00 p.m., S8 LPN confirmed she did not know Resident #1 had left the building until S7 Laundry brought her back in. S8 LPN explained this happened on a Saturday and they didn't put the wander guard on until a few days later. S8 LPN confirmed Resident #1 should not have left the facility without assistance because Resident #1 was confused, and had a bad short term memory problem. S8 LPN stated Resident #1 was delusional and believed she worked in this facility for 4 years. S8 LPN reported after Resident #1 returned, staff just increased supervision. In an interview on 01/31/2023 at 1:53 p.m., S1 Administrator acknowledged Resident #1 walked to the local pharmacy without signing out or staff being aware Resident #1 had left the building. S1 Administrator stated that although Resident #1 had a BIMS of 3 and a diagnosis of Dementia, she did not consider this an elopement because Resident #1 had gone to the pharmacy in the past without supervision. S1 Administrator confirmed every one hour visual checks and a wander alert bracelet were not implemented for Resident #1 until 01/13/2023, after Resident #1's elopement on 01/07/2023. In an interview on 02/01/2023 at 9:54 a.m., S9 MDS confirmed she completed the wander data collection tool on 11/10/2022 for Resident #1. S9 MDS confirmed she marked the resident as not a wander/elopement risk although she had answered yes to 4 of the questions. S9 MDS confirmed the instructions stated 3 or more yes answers would equal definite risk for elopement, but felt like Resident #1 was not a risk for elopement. S9 MDS reported had she followed the instructions and marked Resident #1 as an elopement risk, then staff would have held a team meeting to decide if the Resident needed a wander alert bracelet. In an interview on 02/01/2023 at 10:48 a.m., the NP (Nurse Practitioner) reported she was not notified Resident #1 had left the building unsupervised until this week after the survey began. The NP reported prior to this week, she was only notified Resident #1 had lit a cigarette in the dining room so staff wanted to make Resident #1 an unsafe smoker and put a wander alert bracelet on Resident #1. The NP reported staff did not tell her that Resident #1 had left the building and went to pharmacy unsupervised, and brought it to her attention this week. The NP confirmed the Resident #1 was confused and unable to comprehend the reason the cigarettes were taken. The NP reported the facility put in a smoking schedule for Resident #1, but Resident #1 can't process that and keeps asking the NP to take her to smoke. The NP confirmed it was unsafe for Resident #1 to be out of the facility without staff's knowledge and supervision. Resident #2 Review of Resident #2's medical record revealed an admit date of 09/02/2022 with diagnoses that included in part . Severe Dementia with Behavioral Disturbance, Schizophrenia, and Major Depressive Disorder. Review of Resident #2's Quarterly MDS with an ARD of 12/13/2022 revealed a BIMS score of 5, which indicated the resident had severely impaired cognition. The MDS revealed Resident #2 required supervision with set-up help only with bed mobility, transferring, toilet use and eating. The MDS revealed Resident #2 walked in room and corridor independently. Review of the Wander Data Collection Tool for Resident #2 revealed on 09/02/2022, Resident #2 was evaluated as having a BIMS of 3 and was evaluated as a wander/elopement risk with interventions listed as: frequent monitoring - check every 1 hour, identification bracelet, exercise, wander alert bracelet, 1 hour visual checks. Completed by S9 MDS. Resident #2 was reassessed using the tool again on 09/15/2022 and 12/16/2022 and deemed a wander/elopement risk with each assessment. Review of Resident #2's physician's orders revealed the following orders: 09/02/2022 - Wander alert bracelet on resident for elopement precautions at all times. Bracelet is located on resident's left ankle. 09/02/2022 - Check wander alert bracelet daily to ensure band is intact and transmitter is functioning properly. 09/02/2022 - Visual check for resident's location every 1 hour. 09/02/2022 - Admit under the care of Dr.________ and ____________ Hospice for diagnosis of Alzheimer's disease Review of Resident #2's comprehensive plan of care revealed Resident #2 was care planned beginning 09/02/2022 for wandering and potential for elopement. Interventions included: place resident in area where frequent observation is possible, alert staff to wandering behaviors, visual check for resident's location every hour, check wander alert bracelet daily to ensure band is intact and transmitter is functioning properly, instruct visitors to inform staff when they are leaving the designated area with the resident, and wander alert bracelet on Resident's left ankle at all times. Review of S11 [NAME] Clerk's written statement dated 01/14/2023 read as follows: Around 12:30 I was at my desk I was eating and talking to S14 Housekeeper. I hear the front door alarm go off. I look up I see 2 women walking towards my desk, I did not see anyone outside the door-I assumed they had held the door open too long. I asked S14 Housekeeper to please reset alarm. She went to the door, she also saw nothing outside. 5 or 10 minutes later the phone rang and I answered and a lady said I am parked across the street and a little old lady named (Resident #2) just sat in my car and asked me to take her home, I assumed since y'all are across the street she might have come from there, and I said she crossed Texas Avenue and she said yes - she said I can drive her across the street if you want and I said yes please come to the front door. I paged Nurse (S13 RN Weekend Supervisor) and a group of us met them in the parking lot. Review of S14 Housekeeper's written statement dated 01/14/2023 read as follows: I was standing by the dining room, I could hear the alarm go off and S11 [NAME] Clerk told me to go turn the alarm off, at this time, I never saw resident inside or out, so I had reset alarm. Shortly, S11 [NAME] Clerk got phone call saying (Resident #2) was at the store, and they brought her back. In an interview on 02/01/2023 at 9:19 a.m., S14 Housekeeper revealed she worked on 01/14/2023. S14 Housekeeper stated she was talking to the ward clerk around 12:00 p.m. and Resident #2 was standing there as well. S14 Housekeeper stated the next thing she knew S11 [NAME] Clerk received a phone call stating Resident #2 was in someone's car on the way back to the facility. S14 Housekeeper stated Resident #2 slipped away while she and S11 [NAME] Clerk were talking, and they never saw her leave. S14 Housekeeper stated the video camera showed that a family member opened the door to visit and Resident #2 slipped out. Review of Resident #2's nurses' notes revealed the following entry in part . 01/14/2023 at 7:19 p.m. - At approximately 12:45 p.m., S11 [NAME] Clerk received a phone call from a concerned customer from the store across the street questioning were we missing a female resident. That there was a confused lady at the store. Resident transported to facility via private auto. This nurse along with S13 RN, weekend supervisor went outside to get resident. Assisted resident back in building as resident approached the front entrance the door alarm started sounding. Wander guard in place and properly functioning. Head to toe assessment initiated ROM WNL. VSS Stable WNL 132/67, 73, 97.5, 18. 100%. Resident states that she was going to get a candy bar and the store didn't have what she wanted. Resident thankful for the candy and said, I should've just asked you for the candy. S2 DON, S1 Administrator notified. Son states that this is the same issue he was having at home with 24 hour sitters that once one of the workers would turn their back resident would leave out the house and they would have to chase her. Resident ambulated with rolling walker to her room. No further issues noted. By S12 LPN. In a telephone interview on 02/01/2023 at 11:37 a.m., S13 RN Weekend Supervisor revealed she worked on 01/14/2023 when the ward clerk received a phone call asking if the facility had a resident by the name of Resident #2. S13 RN Weekend Supervisor stated the person calling then drove into the facility parking lot with Resident #2 in the car. S13 RN stated the staff got Resident #2 out of the vehicle and told her she shouldn't leave the facility. S13 RN stated Resident #2 stated she had to leave, she didn't want to be at the facility. S13 RN stated she then checked Resident #2's wander guard and discovered it was working. In an interview on 01/31/2023 at 1:53 p.m., S1 Administrator acknowledged at the time the door alarm went off on 01/14/2023, S11 [NAME] Clerk only looked up from the front desk and failed to walk over to the front door area to investigate the alarm, because S11 [NAME] Clerk assumed the alarm went off because a visitor held the door open too long. Resident #3 Review of Resident #3's medical record revealed an admit date of 01/14/2022 with diagnoses that included in part . Unspecified Dementia with Behavioral Disturbance, Type 2 Diabetes Mellitus, Primary Insomnia, Restlessness and Agitation, and Generalized Anxiety Disorder. Review of Resident #3's Wander Data Collection Tool revealed Resident #3 was assessed as a wander/elopement risk on 10/21/2022 by S9 MDS. Interventions utilized included exit alarms, frequent monitoring with checks every hour, wander alert bracelet, and staff aware of resident's wander risk. Review of Resident #3's Annual MDS with an ARD of 01/20/2023 revealed the BIMS assessment was not completed as the resident is rarely or never understood. Resident #3 was coded as requiring supervision with bed mobility, transferring, and eating; extensive 1 person physical assistance with toilet use, and independent in walking in room and corridor. Resident #3 was documented as wandering behaviors occurred 1 to 3 days during the MDS assessment period. Review of Resident #3's physician orders revealed the following orders: 01/14/2022 - Wander alert bracelet on resident for elopement precautions at all times. Bracelet is located on resident's left ankle. 01/14/2022 - Check wander alert bracelet daily to ensure band is intact and transmitter is functioning properly. 01/14/2022 - Visual checks for resident's location every 1 hour. Review of Resident #3's comprehensive care plan revealed Resident #3 was care planned for Wandering: Potential for Elopement beginning 01/14/2022. Interventions included place resident in area where frequent observation is possible, if wandering away from unit, instruct staff to stay with resident, converse, and gently persuade to walk back to designated area with them, alert staff to wandering behavior, visual check for resident's location every one hour, check wander alert bracelet placement daily to ensure band is intact and transmitter is functioning properly, wander alert bracelet on resident's left ankle at all times for elopement precautions, and note which exits resident favors for elopement from facility. Alert staff working near those areas. Observation on 01/30/2023, 01/31/2023, and 02/01/2023 revealed Resident #3 was observed multiple times each day wandering the halls and around the front of the building near the front door, and the ward clerk's desk area. Observation of the facility's video camera footage on 02/01/2023 revealed at 2:22 p.m. on 01/17/2023, a Resident in a wheelchair entered the access code to unlock the door at the end of Hall A and exited the facility. Before the door closed, Resident #3 was seen exiting the facility behind the Resident in the wheelchair. In an interview at 4:00 p.m. on 01/30/2023, S8 LPN reported she worked on 01/17/2023, but was not aware Resident #3 was found outside the building until she overheard other staff members talking about it. S8 LPN stated no one ever told her about the incident, and thought she should have known as Resident #3's nurse. S8 LPN reported Resident #3 was very confused and should not be outside without supervision. In a telephone interview on 01/31/2023 at 10:58 a.m., S15 Housekeeper reported she was in the dining room getting some water, and looked up and saw Resident #3 outside on the side of the building on the walk path. S15 Housekeeper stated she went to the side kitchen/dining room door, hit the code to unlock the door, and walked Resident #3 back in by the arm. S15 Housekeeper stated she took Resident #3 straight to S1 Administrator's office and gave Resident #3 to her. In an interview on 01/31/2023 at 1:53 p.m., S1 Administrator acknowledged on 01/17/2023 Resident #3 had exited the building without staff's knowledge, but said Resident #3 didn't go anywhere except from the smoke area to the side of the building. S1 Administrator reported she did not complete an incident report or consider this incident an elopement because Resident #3 did not leave the facility grounds. S1 Administrator reported staff had already been in-serviced after Resident #2's elopement on 01/14/2023 therefore no new in-services were done as a result of Resident #3's elopement until 01/20/2023. In an interview on 02/01/2023 at 9:34 a.m., S16 RN/ADON revealed she was working at the facility on 01/17/2023 when Resident #3 walked out the door. S16 RN/ADON stated no one notified her that Resident #3 had left the facility. S16 RN/ADON stated she became aware of Resident #3's elopement later during that week. In an interview on 02/01/2023 at 10:48 a.m., the NP confirmed she was just told this week about Resident #3 being found outside the building. The NP reported Resident #3 had severe dementia and should not be outside without supervision. In an interview on 02/01/2023 at 3:00 p.m., S18 CNA reported she was pulled to work Resident #3's hall after another CNA left at 1:00 p.m. S18 CNA reported she did not know Resident #3 was to be checked every hour, and thought it was supposed to be every 2 hours. S18 CNA stated Resident #3 walks non-stop, and she did not see her go outside on her shift. S18 CNA confirmed she did not know that the resident eloped that date. S18 CNA reported Resident #3 was difficult to keep up with because she was always on the move.

Based on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 3 Residents (#1, #2 and #3) of 5 sampled residents (#1, #2, #3, #4 and #5). The facility failed to: 1. Have an effective system in place to ensure Residents (#1, #2, and #3) who were known to require supervision, were wanderers, and were assessed as being at risk for elopement and/or wore a wander alert bracelet, were adequately supervised to prevent them from exiting the building without supervision; 2. Ensure staff were effectively trained and competent in supervising Residents (#1, #2, #3) who were identified as wanderers and were at risk for elopement; and 3. Ensure staff accurately assessed Resident #1 using the Wander Data Collection tool and implemented interventions to prevent Resident #1 from exiting the building without supervision. This deficient practice resulted in an immediate jeopardy situation on 01/07/2023 at 2:21 p.m. when Resident #1 a severely cognitively impaired resident was inaccurately assessed and required supervision exited the facility unsupervised, and walked through a busy parking lot to a local pharmacy. A staff member shopping at the pharmacy found Resident #1 arguing and cursing a pharmacy employee, and returned Resident #1 to the facility. On 01/14/2023 at 12:31 p.m. Resident #2, a severely cognitively impaired resident assessed and care planned as an elopement risk, wore a wander alert bracelet and was on every one hour visual checks, exited the front door of the facility when a visitor entered the door code and opened the front door. The door alarm sounded, and staff reset the door alarm without investigating. Resident #2 walked across a 3 lane street to a gas station, got into the back seat of the car of 2 gas station customers and asked them to take her home. The gas station customers assumed Resident #2 was from the facility, called the facility and asked if they were missing Resident #2, and drove Resident #2 back to the facility at 12:37 p.m. On 01/17/2023 at 2:22 p.m., Resident #3, who rarely understands/rarely understood, assessed and care planned as an elopement risk, wore a wander guard bracelet, and was on every one hour visual checks, followed a resident out a door after he entered the code to the door, and exited the building without staff knowledge on 01/17/2023. At 2:28 p.m., S15 Housekeeper looked out the kitchen/dining room window and saw Resident #3 standing outside on the side of the building directly adjacent to a busy pharmacy parking lot. S15 Housekeeper escorted Resident #3 back into the building. This deficient practice continued at a potential for more than minimal harm for the 13 Residents in the facility who were identified to require supervision, and/or were assessed as being at risk for elopement and wore a wander alert bracelet, (#1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, & #14). S1 Administrator was notified of the Immediate Jeopardy on 01/31/2023 at 6:25 p.m. The Immediate Jeopardy was removed on 02/01/2023 at 6:25 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews and observations that the Plan of Removal have been initiated and/or implemented: The Facility's plan to remove the immediate jeopardy situation included: S19 Corporate Nurse in-serviced the Administrator, Assistant Administrator, DON, and ADON on 02/01/2023 on the policies and procedures related to elopement as well as internal protocols. Corporate Nurse will monitor for compliance two times per month for two months and then monthly until compliance is maintained. The DON and Administrator in-serviced the ADON, Maintenance, Activity Director, Dietary Manager, Admissions Coordinator, Business Office Manager, Human Resources, Therapy Department, Charge Nurse, and MDS nurses on 02/01/2023 on policy and procedures related to elopement as well as internal protocols. In-services were initiated for all staff by the DON and Assistant Administrator on 01/31/2023 and 02/01/2023 and will be completed by 02/03/2023 at 5:00 p.m. The in-service covered the existing policy on Wandering or Missing Resident which covers Code W, as well. Code W includes when a resident is missing, the staff will announce Code W and repeat it twice. The charge nurse will assign staff areas to begin looking for the resident. If not located in the building or on the grounds within 15 minutes, the charge nurse will notify the DON and Administrator to implement a plan to locate the resident. The in-service also addressed the use of the wander alert system and protocols to follow when the alarm sounds. Staff were reminded that a list of all residents with Wander Alert Bracelets is posted at each nurses' station, at the front desk and at the time clock. All staff were informed of who the 13 wanderers are and how often they should be checked. Staff were also in-serviced about the new Wander Alert Binder that was placed at each nurses' station. Staff unable to be in-serviced by 02/03/2023 at 5:00 p.m. will not be allowed to work until they are in-serviced. Any new employee will be in-serviced on the above during their orientation process. A QAPI monitor has been implemented to monitor whereabouts of all 13 residents with orders for Wander Alert Bracelets and are wearing wander alert bracelets. This monitor was started on 02/01/2023 at 8:30 am and will be completed by the ward clerk or designee every 30 minutes around the clock for 30 days, while the facility reviews all systems and procedures related to elopement precautions. On 02/01/2023, the Administrator placed a sign on all doors reminding visitors, family members, staff and residents to never let a resident out of the facility without checking with a nurse first. On 02/01/2023, the Administrator notified the responsible parties of each resident using our broadcast notification system. This notification addressed the importance of protecting all residents by not letting a resident out of the facility without first checking with a nurse as some of the residents have Wander Alert bracelets and are not allowed to leave the facility. On 02/01/2023, the Assistant Administrator changed the exit door codes on the Wander Alert System on each exterior door. When a resident with a wander alert bracelet approaches the door, it will remain locked. If someone enters this new code, and the resident is close to the door, the door will remain locked. If someone enters the new code, and the resident is farther away, the door will unlock but the alarm will sound if the resident with the wander alert bracelet approaches the door or tries to go out the door. Only staff will have access to the codes to the front door as well as the smoking door which is located at the end of Hall A. Dietary Staff will have access to the code to the exterior door of the kitchen go allow access for deliveries. The Administrator, DON, and Assistant Administrator will be the only staff to have codes to all remaining doors which are located at the end of the 100 hall, on the side of the 100 hall, the end of the 200 hall, the end of the 300 hall, the side of the 400 hall, and the dining room doors. On 02/01/2023, the Social Services Director made Wander Alert Binders to be placed at each nurses' station as well as the front desk. This binder contains the Wandering or Missing Resident policy, the list of residents with wander alert bracelets along with their pictures and face sheets. On 02/01/2023, the DON placed a list of residents with wander alert bracelet orders at each nurses' station, by the medication room door, at the front desk and by the time clock. The Wander Data Collection Tool is completed by the MDS nurse upon admission, quarterly, and with a significant change in status. This tool has a scoring system indicating a resident has a Definite Risk for elopement with a score of 3 or more yes answers and is At Risk with 1-2 yes answers. Upon completion of the yes/no questions on the front of the page, the nurse then summarizes her findings on the back of the page and determines the most appropriate interventions needed, if any. A resident may or may not need the wander alert bracelet regardless of findings from the yes/no questions, however additional interventions are implemented based on the needs of the resident. Things considered when deciding on need of a wander alert bracelet include, but not limited to; their mobility, desire to leave the building and/or exit seeking behavior. The facility will choose the least restrictive measures as interventions. If deemed at risk, the IDT team will discuss the most appropriate intervention. Beginning 02/01/2023, the treatment nurse during the week and the RN on the weekend or designees will check each door daily to ensure the Wander Alert alarm is functioning properly. If there is a concern or problem, the nurse is to notify the Administrator or DON immediately and assign someone to sit by the door until appropriate repairs can be made. The treatment nurse during the week and the RN on the weekend or designees will continue to check each Wander Alert Transmitter daily with the Transmitter Testing Device to ensure proper functioning. If a transmitter fails to function properly, the nurse stays with the resident and replaces the Wander Alert Transmitter. Once replaced, the new transmitter will be checked for proper functioning. This process will continue indefinitely. This deficient practice continued at a potential for more than minimal harm for the 13 Residents in the facility who were assessed to be wanderers and/or an elopement risk. Findings: Cross Refer to F689 Review of the facility's policy titled, Wandering or Missing Resident revealed in part . Policy: In an effort to prevent Residents from wandering away from the facility, procedures have been developed to follow when a resident leaves the facility unsupervised or without reporting to the facility staff their time of departure and time of return. Procedures: Resident Missing From Designated Area of Facility: 1. A department or resident care staff person which identified a wandering resident is missing must notify all staff of the missing resident by announcing on the public address system Code W, Resident's Name. Repeat twice. 2. The wandering resident's charge nurse shall assign direct care staff to look for the resident. 3. If the resident is not located in the buildings or the grounds within 15 minutes, the charge nurse shall notify the DON and the Administrator to implement the plan to locate the resident. 4. Any member becoming aware of a resident not being at the designated area or activity shall proceed to notify the charge nurse, DON and the Administrator. 5. Notify the appropriate responsible party: 6. Documentation of the wandering resident: a. The care plan will be updated with diversions, approaches, and modifications that are specific to the resident's individual wandering habits. Resident #1 In an interview on 01/31/2023 at 1:53 p.m., S1 Administrator acknowledged Resident #1 walked to the local pharmacy without staff being aware Resident #1 had left the building. S1 Administrator stated that although Resident #1 had a BIMS of 3 and a diagnosis of Dementia, she did not consider this an elopement because Resident #1 had gone to the pharmacy in the past without supervision. S1 Administrator confirmed every one hour visual checks and a wander alert bracelet were not implemented for Resident #1 until 01/13/2023, after Resident #1's elopement on 01/07/2023. In an interview on 02/01/2023 at 9:54 a.m., S9 MDS confirmed she completed the wander data collection tool on 11/10/2022 for Resident #1. S9 MDS confirmed she marked the resident as not a wander/elopement risk although she had answered yes to 4 of the questions. S9 MDS confirmed the instructions stated 3 or more yes answers would equal definite risk for elopement but reported she felt like the Resident #1 was not at risk for elopement. S9 MDS further reported had she followed the instructions and marked Resident #1 as an elopement risk, then staff would have held a team meeting to decide if the Resident needed a wander guard. In an interview on 02/01/2023 at 10:48 a.m., the NP (Nurse Practitioner) reported she was not notified Resident #1 had left the building unsupervised until this week after the survey began. The NP reported prior to this week, she was only notified Resident #1 had lit a cigarette in the dining room so staff wanted to make Resident #1 an unsafe smoker and put a wander alert bracelet on Resident #1. The NP reported staff did not tell her that Resident #1 had left the building and went to pharmacy unsupervised, and brought it to her attention this week. The NP confirmed the Resident #1 was confused and unable to comprehend the reason the cigarettes were taken. The NP reported the facility put in a smoking schedule for Resident #1, but Resident #1 can't process that and keeps asking the NP to take her to smoke. The NP confirmed it was unsafe for Resident #1 to be out of the facility without staff's knowledge and supervision. Resident #2 In an interview on 01/31/2023 at 1:53 p.m., regarding Resident #2, S1 Administrator acknowledged at the time the door alarm went off on 01/14/2023, S11 [NAME] Clerk only looked up from the front desk, and failed to walk over to the front door area to investigate the alarm, because S11 [NAME] Clerk assumed the alarm went off because a visitor held the door open too long. Resident #3 In an interview on 02/01/2023 at 9:34 a.m., S16 RN/ADON revealed she was working at the facility on 01/17/2023 when Resident #3 walked out the door. S16 RN/ADON stated no one notified her that Resident #3 had left the facility. S16 RN/ADON stated she became aware of Resident #3's elopement later during that week. In an interview on 02/01/2023 at 10:48 a.m., the NP confirmed she was just told this week about Resident #3 being found outside the building. The NP reported Resident #3 had severe dementia and should not be outside without supervision. In an interview on 01/31/2023 at 1:53 p.m., S1 Administrator acknowledged Resident #3 had exited the building without anyone's knowledge, but said Resident #3 didn't go anywhere except from the smoke area to the side of the building. S1 Administrator reported she did not consider this an elopement because the resident never left the facility grounds. S1 Administrator acknowledged staff were not notified of the elopement or in-serviced on elopement precautions for 3 days following Resident #3's elopement.