**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure a resident was free from neglect during ADL (activities of daily living) care. The facility failed to ensure S4 CNA (Certified Nursing Assistant) asked for assistance for a two person assist before providing incontinence care which resulted in a fall with injuries for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for neglect.The deficient practice resulted in an immediate jeopardy for Resident #1 on 07/25/2025 at approximately 10:30 a.m. when Resident #1 fell out of the right side of the bed during incontinent care when S4 CNA (Certified Nursing Assistant) failed to ensure a two person assist was used during incontinent care to prevent Resident #1 from falling out of the bed. S4 CNA did not ask for assistance before providing ADL care and Resident #1 fell from the bed resulting in multiple injuries. Resident #1 was sent to a local hospital on [DATE] at 10:47 a.m. via stretcher and was admitted due to his injuries. Review of the hospital records dated 07/25/2025 revealed Resident #1 was diagnosed to have a questionable non-displaced fracture to the right maxillary wall, non-displaced right posterior 12th rib fracture, and a remote T(thoracic)5 vertebral body compression fracture.The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past noncompliance citation.Findings:Abuse and Neglect Policy with a revision date of 04/02/2025.Purpose: The purpose of the Abuse/Neglect policy is to comply with the seven - step approach to abuse and neglect detection and prevention:1). Screening 2.) Training 3.) Prevention 4.) Identification 5). Investigation 6.) Protection 7.) Reporting and ResponsePolicy: It is the policy of the facility that each resident will be free from abuse. This facility will not condone any form of resident abuse or neglect. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse, including .Each resident has the right to be free from mistreatment, neglect, and misappropriation of property.Definition: Abuse and neglect exist in many forms and to varying degrees. G. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.I. Serious Bodily Injury: The term serious bodily injury is defined as any injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation. Review of Resident #1's medical record revealed an initial admission date of 03/27/2024 with diagnoses, which included in part, ataxia following other non-traumatic intracranial hemorrhage, essential tremor, muscle wasting and atrophy of left lower leg and right lower leg, weakness, contracture of muscle, multiple sites and aphasia. Review of Resident #1's Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated BIMS (Brief Interview of Mental Status) could not be completed due to resident was rarely/never understood. Further review of the Quarterly MDS assessment revealed Resident #1 had upper and lower extremity impairments to both sides, dependent with eating, oral hygiene, toileting hygiene, and shower/bathe self. Resident #1 was dependent for mobility in rolling left and right. Resident #1 was always incontinent of bowel and bladder and dependent on staff for ADL care. Further review revealed Resident #1 did not return to the facility after his hospitalization on 07/25/2025. Review of Resident #1's comprehensive care plan revealed in part, Resident #1 was at high risk for fall related to neurocognitive disorder and required total care with bedbound status. Further review of the comprehensive care plan revealed Resident #1 had an ADL deficit and required two person assist with all ADLs and transfers.Review of the facility's Incident Log for the past 3 months revealed Resident #1 had a witnessed fall on 07/25/2025.Review of S4 CNAs signed witness statement (undated) revealed: I went to Resident #1's room to check and see was he wet. He was soaked in pee and bowel movement. I looked on the hall to see if there were available aides. I didn't see any so I decided to change Resident #1. His bed was soaked with urine so I had to change, I grabbed my linen to put on his bed. I turned him and put the linen on the bed. I grabbed my pamper and pad. Resident #1 moved a little and hit the floor. I didn't have any time to catch him.Review of Resident #1's nurse's notes dated 07/25/2025 at 11:44 a.m. revealed S3 LPN (Licensed Practical Nurse) was called to Resident #1's room. Upon entering the room, Resident #1 was lying flat and face first on the floor to the right side of the bed between the air unit and bed. S3 LPN was informed by S4 CNA that while she was performing incontinent care and went to turn Resident #1, Resident #1 rolled off the bed to the floor. Redness was noted to the left cheek, left side of forehead, right cheek, right upper back, both knees, right lower leg and back of head. The ambulance was notified and Resident #1 was transferred out of the facility via stretcher to a local emergency room.Review of Resident #1's hospital record dated 07/25/2025 revealed in part, a chief complaint of Resident #1 fell out of the bed while rolled by staff. Bruising noted to left cheek and upper back. Further review revealed Resident #1 had bruising to the left side of his face, backside of his neck, right side of his shoulder, and both knees. Review of Resident #1's CT (Computed Tomography) scans revealed: questionable non-displaced fracture to the right maxillary wall, non-displaced right posterior 12th rib fracture, and a remote T5 vertebral body compression fracture. During an interview on 08/11/2025 at 8:30 a.m. S1 Corporate Nurse reported Resident #1 was sent to the hospital with major injuries due to the fall incident on 07/25/2025. S1 Corporate Nurse further confirmed Resident #1 was a two person assist and S4 CNA did not call for assistance and performed care without having another person assist her resulting in Resident #1's fall from the bed.Observations made on 08/11/2025 throughout the facility revealed resident rooms were checked for resident wall care plans and all had resident specific wall care plans located on the wall above the resident's bed, on bright orange paper and in bold letters if the resident was a one or two person assist. An observation on 08/12/2025 at 9:15 a.m. revealed S10 CNA and S12 CNA reviewed Resident #3's wall care plan and acknowledged Resident #3 was two person assist with transfers. Resident #3's wall care plan was located on the wall, above Resident #3's bed, on an orange sheet of paper with bold letters. Resident #3 was transferred from her bed to a Geri-Chair via Hoyer lift using two person assist without difficulty. Resident #3 was non-verbal but awake and looking around the room. Resident #3 was in no apparent distress during the transfer. Resident #3 was transferred safely from the bed to the Geri-chair, with 2 person assist as instructed on the wall care plan.Attempted phone calls made to S4 CNA on 08/12/2025 at 10:53 a.m., 12:26 p.m., and 2:21 p.m. were unsuccessful. During an interview on 08/12/2025 at 11:15 a.m. S3 LPN reported seeing Resident #1 face down on the floor between the air unit and the bed. S3 LPN reported Resident #1 was a two person assist with everything; he could not move his legs or his trunk. S3 LPN reported Resident #1 had tremors and could not move his arms good. S3 LPN further confirmed Resident #1's wall care plan was located on the wall above the bed stating Resident #1 required two person assist. During an interview on 08/12/2025 at 11:18 a.m. S2 DON (Director of Nursing) confirmed there was a sign above Resident #1's bed notifying staff Resident #1 was a two person assist with all ADLs. S2 DON confirmed S4 CNA did not follow the wall care plan which resulted in Resident #1's fall with injuries on 07/25/2025. Attempted phone call made to S4 CNA on 08/13/2025 at 10:48 a.m. and was unsuccessful.During an interview on 08/13/2025 at 1:20 p.m. S5 CNA Supervisor reported S4 CNA had experience working with Resident #1 and knew Resident #1 was a two person assist with all ADL care and should have asked for assistance before providing ADL care to Resident #1. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. During an interview on 08/13/2025 at 11:00 a.m., S1 Corporate Nurse confirmed the following corrective actions put into place were completed on 07/28/2025. The facility implemented the following actions to correct the deficient practice beginning on 07/25/2025 with a completion date of 07/28/2025:1. In-services were immediately started by S2 DON on 07/25/2025 on that afternoon and evening shift. S2 DON came back to the facility on the 10P-6A shift on 07/25/2025 and met with licensed and unlicensed staff to review care plans on the wall and following them with each resident encounter. 2. S4 CNA did not provide care to other residents at the facility after this event but was asked to remain at the facility to be interviewed by S2 DON and was present at the staff meeting that afternoon when topics relevant to this event were discussed at length. S4 CNA then left the facility following the meeting. S4 CNA was asked by S2 DON to return to the building on 07/26/2025 to talk with the S2 DON. At this point the facility knew the seriousness of the injuries sustained by Resident #1 and S4 CNA was officially suspended. S4 CNA had not provided care to other residents since 07/25/2025 at approximately 10:30 a.m. S4 CNA was officially terminated on 07/27/2025 for not following facility protocol with care. 3. In-services were done on following care plans on the wall began after the incident on 07/25/2025 and continued on 07/26/2025 and 07/27/2025 to licensed and unlicensed nursing staff by nursing administration.4. Staff education continued on 07/28/2025 on the following subjects: Following the care plans on the wall for resident care. Pre and post-tests to license and unlicensed nursing staff on assistance with bed mobility and following the plans on the wall was initiated on 07/28/2025. The administrator and assistant administrator also presented education to the licensed and unlicensed nursing staff beginning on 07/28/2025 regarding the seriousness of the care plans on the wall information and how not following that information could be grounds for termination. 5. Evaluation of all the facility care plans on the wall were completed by nursing administration on 07/26/202, 07/27/2025, and 07/28/2025, even though the care plan on the wall on Resident #1's room was accurate for residents at the facility. The wall care plan updating continues when changes occur to resident abilities and medical status.6. Monitoring of CNAs staff performing care to see if they are following the care plan on the wall instructions while performing resident care was implemented on 07/25/2025 by nursing administration. This monitoring will continue 2-3 times a week for the next 6 weeks then monthly thereafter until compliance is maintained. Nursing administration is actually going into resident's rooms during care to see if the care plan on the wall is being followed by the CNA's providing care. Corrective action and immediate education is provided by nursing administration if care is not being provided according to the care plan on the wall. 7. Effectiveness of the corrective actions will be discussed weekly for 6 weeks at the QAPI (Quality Assurance and Performance Improvement) Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implement as needed.Validation of Past Noncompliance:The facility corrective actions were confirmed through onsite interviews, observations and record reviews.Review of the facility's in-services dated 07/25/2025, 07/28/2025 and 07/29/2025 revealed the facility in-serviced licensed and unlicensed staff, including CNAs, on paying attention to the resident's wall care plan in the resident's room located on the wall above the bed. The facility enforced if the wall care plan stated the resident required two person assistance, to make sure two persons assisted. Review of the Bed Mobility/ADL Care Monitor sheets revealed monitoring was put in place on 07/25/2025 after the incident. Monitoring was done by S2 DON. Further review of the Bed Mobility/ADL Care Monitor sheets revealed they continued monitoring through 07/28/2025 and then the monitoring pages were updated on 07/29/2025 to include more detailed specific information to ensure residents which required two person assist were included and if care was completed without injury. Review of the facility's QAPI meetings dated 07/28/2025, 07/29/2025, 07/30/2025, 08/05/2025, and 08/07/2025 revealed facility ensured wall care plans were discussed, the wall care plans were posted, and the staff were following the wall care plans.Observations made on 08/11/2025 throughout the facility revealed resident rooms were checked for resident wall care plans and all had resident specific wall care plans located on the wall above the resident's bed, on bright orange paper and in bold letters if the resident was a one or two person assist. Review of trainings revealed, on 07/28/2025, the facility put in place a pre-post- and answer bed mobility test and following the plans on the wall. All CNAs have taken the test and passed.During an interview on 08/12/2025 at 9:00 a.m. S10 CNA Restorative Aide, reported she attended an in-services on resident wall care plans and was aware to first review the wall care plan before care was provided. S10 CNA Restorative Aide reported the wall care plan indicated if the resident was a one or two person assist with transfers, lifts, or ADL care. S10 CNA further reported if she had any questions about a resident, she would ask a nurse and all transfers were two person when a lift was used. An observation on 08/12/2025 at 9:15 a.m. revealed S10 CNA and S12 CNA reviewed Resident #3's wall care plan and acknowledged Resident #3 was two person assist with transfers. Resident #3's wall care plan was located on the wall, above Resident #3's bed, on an orange sheet of paper with bold letters. Resident #3 was transferred from her bed to a Geri-Chair via Hoyer lift using two person assist without difficulty. Resident #3 was non-verbal but awake and looking around the room. Resident #3 was in no apparent distress during the transfer. Resident #3 was transferred safely from the bed to the Geri-chair, with 2 person assist as instructed on the wall care plan.During an interview on 08/12/25 at 9:30 a.m. S13 CNA reported she attended an in-service regarding resident wall care plans above resident beds. S13 CNA reported she knew to review the wall care plans prior to resident care and to know if the resident is a one or two person assist. S13 CNA further reported if there were any questions, the nurse would clarify. S13 CNA knew to ask assistance when a two person assist was required for any type of care. During an interview on 08/12/2025 at 9:42 a.m. S11 CNA reported she attended an in-service on resident wall care plans. S11 CNA was knowledgeable in reviewing the wall care plans upon entering a resident's room. S11 CNA reported the wall care plans, above the resident's bed, indicate whether a resident required one or two person assist with care. S11 CNA further reported if she was not sure, she would ask the nurse.During an interview on 08/12/2025 at 2:05 p.m. S15 CNA reported she was trained on the resident wall care plans. S15 CNA further reported she attended an in-service on bed mobility and the number of persons required to assist residents with ADLs. S15 CNA reported each resident had a wall care plan on the wall above the bed and CNAs were to follow that wall care plan. S15 CNA further reported a CNA should always ask for assistance if a resident was a two person assist with ADLs. During an interview on 08/12/2025 at 5:00 p.m. S14 CNA reported she attended in-services on resident wall care plans and knew to look at the sign on the wall to see if the resident was a one or two person assist. S14 CNA understood to never attempt to move or transfer a resident alone if the resident was a two person assist.During an interview on 08/13/2025 at 8:32 a.m. S7 CNA reported she attended the in-service on Bed Mobility and turning schedule. S7 CNA further reported the meeting included how important it was to use two person assist if the wall care plan indicated two person assist. If there was not another CNA to help, she would call the nurse or a supervisor to help and never attempt two person assist care alone. During an interview on 08/13/2025 at 8:33 a.m. S8 CNA reported he attended the in-service regarding wall care plans and the importance of following the wall care plans. S8 CNA further reported he checked the wall care plans upon entering a room and checked if the resident was a one or two person assist. If the resident was a two person assist, S8 CNA reported he would ask for assistance and never attempt to move or change a resident without another person to assist. During an interview on 08/13/2025 at 8:39 a.m. S9 LPN reported she attended the in-service on bed mobility and wall care plans which included to check residents wall care plans located above the resident's bed. S9 LPN reported she would assist CNAs when needed for residents requiring two person assist patient care. During an interview on 08/13/2025 at 8:59 a.m. S2 DON reported S4 CNA was suspended right after the incident. S4 CNA stayed for the in-service on wall care plans and left after that. S2 DON reported S4 CNA did not care for any residents after the incident with Resident #1. S2 DON further reported S4 CNA was called to the facility the next day to sign papers on termination for not following the company policy.

Based on interviews, record reviews, and observations the facility failed to provide adequate supervision for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents reviewed for risk of elopement. The deficient practice resulted in Immediate Jeopardy for Resident #1 on 07/31/2023 at 8:00 p.m. when Resident #1 exited through the dining room door of the facility. On 7/31/2023 the facility was notified by a concerned community citizen that Resident #1 was found outside approximately 300 feet from facility near a railroad track 12 minutes after Resident #1 exited the facility. On 07-31-2023 at 8:21 p.m., Resident #1 returned to the facility assisted by S3 [NAME] Clerk and S4 LPN (licensed practical nurse). Facility staff immediately notified S2 DON (Director of Nursing), Resident #1's doctor, and S1 Administrator of incident. Resident #1 was assessed and had no injuries when found by S4 LPN. The Immediate Jeopardy continued for 12 other residents who were at risk for wandering until 08/10/2023 when the dining room door hinge was repaired to ensure the door closed completely. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Finding: Review of the facility's Wandering or Missing Resident Policy dated 05/2023 revealed in part, a department or resident care staff which identified a wandering resident is missing must notify all staff of the missing resident by announcing on the public address system, Code W and residents name. Any staff member becoming aware of a resident not being at a designated area or activity shall proceed to notify the charge nurse, director of nursing and the administrator. Review of resident #1's medical record revealed an admit date of 08/17/2021 with a diagnosis of but not limited to Depressive Episodes, Dementia, History of Falling, Cognitive Communication Deficit. Review of the resident #1's Yearly MDS (Minimum Data Set) dated 07/21/2023 revealed in part, resident #1 had a BIMS (Brief Mental Status Interview) score of 3 indicating severe impairment and wandering behavior occurred 7 days of the 7 day look back period, and resident #1 received anti-depressant medication for 7 days of the 7 day look back period. Review of resident #1's August 2023 Physician's Orders revealed in part: 08/17/2021-Visual Checks for resident location every 1 hours 08/17/2021-Wander alert bracelet on resident for elopement precautions at all times, bracelet located on residents right leg 08/17/2023- Check Wander alert bracelet daily to ensure band is intact and transmitter is functioning properly. Review of Resident #1's current Comprehensive Care Plan revealed Resident #1 was care planned for wandering and use of wander alert bracelet with interventions including visual check for resident location every hour, wander alert bracelet on resident for elopement precautions and check wander alert bracelet daily to ensure band is intact and transmitter is functioning properly. Review of Resident #1's elopement risk assessment with start and end date of 08/17/2021 revealed Resident #1 was found to be at risk for elopement. Review of resident #1's progress notes revealed in part: 07/31/2023 at 11:24 p.m. by S4 LPN. Writer was notified by [NAME] Clerk that a lady noticed a person walking down ___ Rd and asked if we were missing a resident, she described the resident that fit her description. Writer and [NAME] Clerk left the facility and found resident standing a couple of feet past the rail road tracks. Lady that notified us about resident came and offered to transport resident back to facility. [NAME] clerk accompanied resident back to the facility. Head to toe assessment done, administrator notified, director of nursing and nurse practitioner notified. During an observation on 08/16/2023 at 3:45 p.m. of the facility's surveillance video from 07/31/2023, revealed Resident #1 walking out of the facility's dining room door alone on at approximately 8:00 p.m. Further review of facility surveillance video revealed at 8:12 p.m. a concerned community citizen walked into the facility's front door and alerted staff of a resident out of the facility and staff ran out of the facility. At 8:21 p.m. resident #1 was seen being assisted back into the facility by staff. During an interview on 8/14/2023 at 2:15 p.m. S3 [NAME] Clerk reported on 07/31/2023 at approximately 8:00 p.m. the dining room door alarm went off and she overhead paged for a staff member to go and check the dining room door alarm. S3 [NAME] Clerk further reported S5 Front Door Screener checked the dining door and reset the alarm. A few minutes later a visitor came in the front door and described a resident who was outside of the facility walking on the street. I (S3 [NAME] Clerk) recognized the resident by the visitor's description. S4 LPN and I (S3 [NAME] Clerk) left the facility and located the resident down the street near the railroad track in some bushes unharmed and assisted the resident back inside of the facility. During an interview on 08/15/2023 at 1:35 p.m. S5 Front Door Screener stated, I was sitting at the front door when the ward clerk said to check the dining room door alarm. I went to the dining room door and looked out the door and did not see any resident. I closed the door and reset the alarm on the door and went back to my station at the front door. A few minutes later a visitor came into the facility and described a resident who was outside of the facility walking down the street. We immediately went to search for the resident. During an interview on 08/14/2023 at 2:30 p.m. S4 LPN reported, a lady had come to the facility and reported seeing a possible resident on the street out by the railroad tracks. We (S4 LPN and S3 [NAME] Clerk) went out and located the resident on the road near the railroad track and assisted the resident back inside of the facility. S3 [NAME] Clerk notified the administrator, and I (S4 LPN) notified the director of nurses. During an interview on 08/15/2023 at 8:30 a.m. S2 DON reported resident #1 had been assessed to be a wanderer and was at risk for elopement and wandered in the facility daily. S2 DON confirmed resident #1 had eloped from the facility through the facility's dining room door on 07/31/2023 at approximately 8:00 p.m. S2 DON confirmed the facility's dining room door did not close completely after a staff member had entered and required repairing for safety and supervision of residents. During an interview on 08/15/2023 at 2:00 p.m. interview with S5 Maintenance Supervisor and S1 Administrator reported upon examining the dining room exit door after resident #1's elopement, it was noted that the door did not close completely and remained about one-half inch open after being closed. S1 Administrator and S5 Maintenance Supervisor confirmed the dining room door had to be repaired to ensure resident safety and supervision. On 07/31/2023, the facility implemented the following actions to correct the deficient practice with completion on 08/10/2023: 1. Resident #1 was placed on close supervision and visual check every 1 hour. 2. Daily census checks on each resident. 3. All residents assessed for elopement risk and wandering risk. 4. Staff in-services regarding: monitoring door alarms to include checking outside and inside to find out who activated the alarm, door alarm audit sheet, wandering and missing resident policy and procedures and wander alert bracelet check and documentation. Emphasis on answering door alarms and assuring all wandering resident with and wander alert bracelet are accounted for. 5 All facility door codes were changed and staff were instructed only to enter and exit the facility through the front door. 6. 8/10/2023 the dining room door was repaired to ensure complete closure for safety. 7. A mock drill was completed by administrative staff in which door alarms were triggered and staff were observed following the facility protocol. 8. Monitoring of each door alarm is tracked daily by the ward clerk or nurse at the nurse's station. 9. This plan is monitored in the facility's daily Quality Assurance meetings with indefinite monitoring, changes will be made to current monitoring if issues arise.