**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00133977. Based on observation, interview, and record review the facility failed to protect residents' right to be free from sexual abuse by another resident involving four (R40, R63, R10, and R4) of nine residents reviewed for abuse, resulting in Immediate Jeopardy to health and safety of residents when R40, a male resident, engaged in repeated inappropriate sexual contact with R4, R10, and R63, all of whom were severely cognitively impaired females who were unable to consent. Using the reasonable person concept, the sexual abuse resulted in the potential for serious psychosocial harm and/or injury to R63, R10, and R4, and it resulted in the likelihood that that additional sexual abuse would occur with vulnerable residents. Immediate Jeopardy: The Immediate Jeopardy began 01/13/2023. The Immediate Jeopardy was identified on 03/08/2023. The Administrator was notified of the Immediate Jeopardy on 03/08/023 at 4:08 PM, and a plan to remove the immediacy was requested. The immediacy was removed on 03/08/2023 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the deficient practice was not corrected and remained patterned with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Findings include: Review of a facility policy provided by the facility entitled Abuse Prevention Overview (revised on 02/2023) read, in part, Policy: It is the policy of this facility to provide the highest quality of care possible and utilize policies that protect residents from acts of abuse .Purpose: To protect the residents right to be free from verbal, sexual, physical, and psychological abuse, corporal punishment, and involuntary seclusion by anyone including, but not limited to, facility staff, other residents . Under the Prevention heading it read, 4. The facility will develop care plans, which include interventions for behaviorally challenged residents ., and under the Respond and Identity heading it read, .2. The facility will identify, correct, and intervene in situations in which abuse, neglect and /or misappropriation of resident property is more likely to occur . Review of a facility policy entitled Identification of Abuse (revised on 03/2019) read, in part, .Procedure: Facility staff will be educated according to the following definitions to assist staff to recognize and report potential abuse Definitions: .Sexual Abuse: 'non-consensual sexual contact of any type with a resident.' R40 Review of the clinical record revealed that R40 was admitted to the facility on [DATE]. Diagnoses included dementia, schizophrenia, conversion disorder with seizure (a brain disease), and high blood pressure. Per the most recent Significant Change Minimum Data Set (MDS) assessment (dated 01/19/2023), R40 required supervision with set up for bed mobility, transfers, and toileting, and R40 was significantly cognitively impaired. Review of R40's care plan found the following: .AMBULATION: Independent as tolerated with rolator walker (4 wheeled with seat) .Date Initiated: 11/21/2022 . On 03/07/2023 at 10:55 AM, R40 was observed attending an activity in the dinning room. R40 presented as confused with unclear speech, and they had a rolator walker next to them. On 03/08/2023 at 09:30 AM, R40 was observed seated in a chair by the back left window of the common room across from the Sapphire nurses' station. There were five female residents (four in wheelchairs, one ambulatory) present in the room, along with one male resident. There were no staff members present. A male CNA (Certified Nurse Assistant) entered the room at 09:30 AM, but they did not interact with R40. At approximately 9:40 AM, a housekeeper entered the room to clean tables, and the CNA left shortly after. There were no staff members at the nurses' station during this entire period. On 03/08/2023 at 09:42 AM, R40 left the common room and walked down the hall to their room-no staff were with them. R40 entered their room and sat in a chair, and at 09:42 AM, Nurse E entered the room to give medication to R40's roommate. At 09:44 AM, R40 exited their room and walked back to the common room across from the nurses' station unaccompanied by staff. There were three female residents present, all in wheelchairs, and one male resident. There were no staff members in the room, nor at the nurses' station. Staff members walked by the room but did not check on R40. At 09:54 AM, R40 again exited the common room and walked back to their room, unaccompanied by staff. On 03/08/2023 at 09:57 AM, R40 left their room and walked up the hall to the common room across from the nurses' station. R40 then sat at a table on the left side of the room. There were staff, including the DON, were in the room tending to an exit seeking resident. Staff left the room at varying times, with the DON remaining the longest. At 10:06 AM, the DON left the room, leaving no staff present with R40 and other residents, including five female residents. On 03/08/2023 at 10:09 AM, R4, who uses a wheelchair, entered the dining room and joined R40 at the table. R40 and R4's faces were in very close proximity to each other. Staff were not present for this. Staff entered the room a few minutes after and took R40 to an activity. On 03/08/2023 at 03:20 PM, R40 was observed in the main dinning room with several residents, including eight female residents, one of which was seated at the same table as R40. There were no staff members present, and staff did not enter the room until 03:23 PM when this writer called their attention to an issue with another resident. Review of the clinical record revealed a progress note dated 01/09/2023 that read, in part, Resident dx, with psychotic disturbance, mood disturbance, anxiety, schizophrenia/unspecified. Resident referred to Social Service due to increased restlessness and impulsivity. Social Worker spoke with resident verbally and through written communication. Social worker discussed personal boundaries with resident and acceptable behavior when feeling the need to hug others. Resident is currently on Transition Hospice. Recommendation is to have resident seen by [psychology] . A progress note dated 01/10/2023 read, in part, Spoke with [hospice]. Resident will be discharged from Hospice as of 1/12/23. Resident was not seen by [psychology] d/t (due to) patients Hospice payor source. Spoke with [psychology service], resident will be seen for a med review on 1/24/23 . Review of a Facility Reported Incident (FRI) submitted to the State Agency on 01/11/2023 read, in part, .On 1/11/23: at 11:10am, [Housekeeper F] observed [R40] and [R63] in the hallway, near the sunshine dining room. [R40] was standing with [their] walker and [R4]in her gerichair. [R40] was standing over [R63] placing closed mouth kisses to [R63's] face and neck. When [R40] saw [Housekeeper F] [R40] stood and walked with [their] walker to his room. [Housekeeper F] then went to report the encounter to the abuse coordinator, [Former Director of Nursing (DON)]. [Housekeeper F] returned to the Sapphire hallway with [Dietary [NAME] G] a few minutes later. [R40] was with [R63] once again with an open hand on top of [their] clothing on [their] breast. [Dietary [NAME] G] walked with [R40] to the dining room and [Housekeeper F] moved [R63] into the sunshine dining room. Both informed [Nurse E of the incident . Review of the FRI revealed a witness statement from Housekeeper F that read, I came around the nurse's station on Sapphire Hall, I observed [R40] standing with [their] walker, standing over [R63] who was in [their] chair. [R40] was kissing with a closed mouth to [R63's] cheek and neck. When [R40] saw me and walked to [their] room, I felt [R63] was safe to stay there until I could get help. No one was available on the hall, so I went to tell [Former DON], the abuse coordinator. I went back to the sapphire hall with [Dietary [NAME] G] a few minutes later and [R40] was standing next to [R63] in the hall again. I saw [R40's] hand placed on [R63], but I could not see where [their] hand was placed. [R40] was leaning his face toward her face again. I pulled [R63's] chair away from [R40] while [Dietary [NAME] G] walked [R40] to the main dining room. I pushed [R63] in [their] chair into the sunshine dining room and I then told [Nurse E] who was the nurse for Sapphire and [Former DON], the abuse coordinator about the second encounter. Note that Housekeeper F did not provide immediate supervision for either resident after witnessing the first encounter, thereby not safeguarding R63 from experience additional abuse, and amount of time the residents were left unsupervised was not specified. On 03/08/2023 at 05:14 PM, a voicemail was left Housekeeper F. Housekeeper F did not call back by the end of the survey. Review of the FRI revealed a witness statement from Dietary [NAME] G that read. I was coming to Sapphire Hall with [Housekeeper F] from the main dining room, [R63] was sitting in [their] chair in the hallway, [R40] was standing over [R63] leaning down with [their] open hand on [R63's] breast on top of [their] clothing and kissing [them] with a closed mouth to [their] cheek. I redirected [R40] to the main dining room and told [Nurse E], the nurse on Sapphire Hall. [Housekeeper F] helped separate them and [Attending Physician W] came from the office to assist. On 03/08/23 at 05:14 PM, Dietary [NAME] G was interviewed via phone. Dietary [NAME] G shared that they no longer work for the facility as of January. Dietary [NAME] G recounted the incident as described in their witness statement, stating that they saw R40 kissing R63 with one had on R63's breast. When asked about R40's behavior, indicated that staff all started noticing R40 doing it quite frequently after. When asked for details, Dietary [NAME] G went on to say that R40 would look for R63 and other female residents, suggesting that it was like R40 was looking for a girlfriend. When asked about specific instances, Dietary [NAME] G indicated that they did not see other instances, however they heard others talk about the behavior. R63 Review R63's clinical record revealed that they were admitted to the facility on [DATE]. Diagnoses included vascular dementia, depression, heart failure, hypothyroidism, high cholesterol, high blood pressure, and chronic obstructive pulmonary disease (a lung disease). Review of the most recent Quarterly MDS assessment (dated 01/02/2023) revealed that R63 was totally dependent, requiring the assistance of two or more people for transfers and toileting, and extensive assistance from two more people for bed mobility, and dressing. Per this assessment, R63 was not ambulatory nor were they able to move independently in their room or throughout the facility, and they were significantly cognitively impaired. Review of R63 care plan found the following: .AMBULATION: Non Ambulatory .Date Initiated 03/30/2021 . ASSISTIVE DEVICES: Geri-chair (a padded recliner on wheels) .Date Initiated: 10/06/2021 . On 03/07/2023 at 09:41 AM, R63 was observed awake, lying in bed awake. They presented as confused and lethargic with nonsensical speech. A geri chair was near their bed. Review of R63's clinical record revealed an Interdisciplinary Documentation Note dated 01/11/2023 that read, in part, Licensed staff on duty reported that today, [R40] approached [R63] and displayed impulsive, witnessed physical contact including open mouthed-quick kisses to her cheek and neck, and open-handed touching to her chest area. [R63] turned their head away and provided increased personal space reminders to [R40] with an outstretching of her right arm and hand . The note further read, .Notifications were made to [R63's family member(Family Member l)] who requested a room change since the two residents share a unit. Room change request honored and completed. Note that this was not an intervention initiated by the facility, rather a request from Family Member I due to the proximity of R63 to R40. Review of the FRI under the section Immediate Action Taken read, in part, [R40] was placed on 1:1 observation during waking hours and 15-minute checks while sleeping. The FRI also indicated that on 01/12/2023, a referral was made to send R40 to an out of state psychiatric hospital, but on 01/14/2023, this hospital informed the facility that they could not accept R40 due to their recent discharge from hospice care. R40's record did not reveal an indication that referrals were made to other hospitals. A physician progress note revealed that R40 was seen by Physician W on 01/11/2023 for a follow-up regarding the incident between R40 and R63. This note read, in part, Plan: Medications are reviewed with no changes are this time with the exception of ABT (antibiotic) for possible UTI (urinary tract infection). Psych services .Staff to continue to monitor for any adverse repercussions or clinical changes and notify service. Review of the clinical record found no evidence that R40 was followed by psychology. Furthermore, as described above, R40 could not be seen by psychology until they discharged from hospice, and R40 did not discharge from hospice until 01/12/2023. R40 was not seen by psychology until 01/18/2023-see below for details. Documentation of the one-on-one observation was titled [Facility Name] 24 HOUR STAFFING SHEET, which was the staffing schedule for the day, broken down by unit and shift. Each schedule was dated at the top, with a date range on 01/11/2023 to 01/12/2023. Some of the CNA names on the list were highlighted. On 03/08/2023 at 01:36 PM, the DON was asked who was assigned to one-on-observation of R40. The DON indicated the CNA's highlighted were assigned to one-on-one observation of R40. However, R40's name was not on this document to indicate that this person, was in fact assigned to R40, nor was there separate documentation accounting for the one-on-one observation of R40. It should also be noted that, for some days, the CNA highlighted were not assigned to the Sapphire unit, which is where R40 resided. The DON stated that the highlighted CNAs were reassigned to the Sapphire unit to provide one-on-one observation. Documentation was not provided to indicate reassignments. Review of 15-minute check documentation dated 01/12/2023 entitled Resident Visual Observation Assessment with R40's name at the top. At 6:00 AM, 6:15 AM, and 6:30 AM, it was noted that R40 was awake in the hallway, indicating that one on one observation should have been in place, yet CNA highlighted on the 24 HOUR STAFFING sheet for the morning shift indicated that the shift did not start until 6:30 AM. Review of a progress note written on 01/24/2023 by the DON read, Note from 1/13/23 @ 1300 changed to Q (every)15 visual checks based on [R40] not displaying any behaviors while [they] had a 1:1 sitter. Review of Review of 15-minute check documentation dated 01/13/2023 revealed that the form was blank, with no indication that 15-minutes checks were completed, nor was there documentation that 15-minute checks occurred the morning of 01/14/2023. Review of a second FRI read, in part, Date of Incident: 1/14/2023 at 9:50 AM .Sequence of events: On 1/14/23 at 9:50 AM, [Cook L] witnessed .[R10] was sitting in [their] gerichair, in the sunshine dining room while [R40] stood over [R10] with [their] left head under [R10's] blouse, the placement of the hand was on [R10's] abdomen, [R10] was stating to [R40] 'don't do that.' [R40] was redirected away from [R10]. On 03/08/2023 at 05:36 PM, a voicemail was left for Dietary [NAME] L. Dietary [NAME] L did not call back by the end of the survey. On 03/08/2023 at 05:31 PM, a phone interview was conducted with Nurse E as they were the nurse assigned to the unit t the time of the incident between R40 and R10. Nurse E indicated that they did not witness the incident, but they knew it was reported. They could not recall details. R10 Review of the clinical record revealed that R10 was admitted to the facility on [DATE]. Diagnoses included vascular dementia, conversion disorders with seizures, history of stroke, high blood pressure, dysphagia (a swallowing problem), and depression. Review of the most recent Quarterly MDS assessment (dated 01/02/2023) revealed that R10 was totally dependent, requiring the assistance of two or more people for bed mobility, transfers, dressing, and toileting. Per this assessment, R10 was not ambulatory nor were they able to move independently in their room or throughout the facility, and they were significantly cognitively impaired. Review of R10's care plan found the following: .AMBULATION: Non Ambulatory .Date Initiated 09/12/2017 . ASSISTIVE DEVICES: High back reclining WC with Left arm bolster, left padded armrest, foot buddy and front and rear anti-tip bars. MECHANICAL LIFT .Date Initiated: 06/06/2017 . On 03/08/2023 at 03:47 P, R10 was observed awake, lying in bed. They were alert, but they presented as very confused. It should be noted that R10's room was directly across from R40s. Review of the FRI under the section Immediate Action Taken read, in part, in part, [R40] was placed on 1:1 observation during waking hours and 15-minute checks while sleeping On 1/14/23 a referral was sent to [an out of state psychiatric hospital] intake unit for [R40] .On 1/14/23 [Clinical Care Coordinator A] received a call from the [out of state psychiatric hospital] indicating that that they were unable to accept [R40] for care at this time related to [their] recent discharge from hospice. R40's record did not reveal an indication that referrals were made to other hospitals. Review of R40's care plan revealed Review of R40's care plan found the following: .*1:1 staffing when up and Q15 minute checks when in bed at night x 48 hours then reassess, due to new onset impulsive behaviors .Date initiated: 01/14/2023. [Facility Name] 24 HOUR STAFFING SHEETs were reviewed for 01/14/2023 to 01/30/2023. Again, per the DON, the CNA names highlighted indicate which staff were assigned to one-on-one observation of R40, and, again, R40's name was not listed to indicate the highlighted CNA, was in fact assigned to R40, nor was there separate documentation accounting for the one-on-one observation of R40. Also, for some dates, the highlighted CNAs were not assigned to R40's unit. Furthermore, the following dates and shifts did not have a CNA assigned to one-on-one observation: 01/18/2023, afternoon shift; 01/21/2023, afternoon shift; 01/22/2023, afternoon shift; 01/26/2023, afternoon shift; 01/30/2023, afternoon shift. No documentation to indicated that one-on-one observation continued past 01/30/2023. No interventions were added to R40's care plan. Documents entitled Resident Visual Observation Assessment were reviewed to assess 15-minute checks while R40 was in bed at night. No documentation was provided for 01/14/2023 to 01/21/2023. For 01/22/2023 at 10:00 PM, R40 was noted to be asleep, in their room at 10:00 PM, but the 15-minute check fields for 01/22/2023 at 10:15 PM to 01/23/2023 at 5:45 AM were blank. From 01/23/2023 at 08:45 AM to 09:45 PM. The Resident Visual Observation Assessment for 01/23/2023 to 01/24/2023, 15-minute check fields were completed, but R40 should have been on one-to-one observation. No documentation was provided for 01/24/2023 to 01/25/2023. The assessment dated [DATE] did not have any 15-minute check fields completed from 10:00 PM to 07:45 AM. The assessment dated [DATE] did not have any 15-minute check fields completed for 10:00 PM to 8:15 AM. The assessment dated [DATE] did not have any 15-minute check fields completed for 10:00 PM to 06:30 AM. The assessment dated [DATE] did not have any 15-minute check fields completed for 10:00 PM to 06:00 AM. The assessment dated [DATE] did not have any 15-minutes checks for the midnight shift. A physician progress note revealed that R40 was seen by Physician W on 01/16/2023. This note read, in part, Resident is seen today in follow-up to a second recent episode of inappropriate behaviors directed towards another female resident .as this is a second event in a short time, an order was given for sertraline (an antidepressant) daily with psych to follow-up regarding sexually inappropriate behaviors .Plan: Resident is off of hospice as of 01/12/2023 so psych assessment/management plan can now be put in place .further POC (plan of care) pending psych. A progress note dated 01/17/2023 read, Referred to [psychology]. To be seen on 1/18/23. Behavior packet and notes in SW (Social Worker) office. Note that this referral was placed seven days after Physician W initially indicated on 01/11/2023 that R40 should be seen by psychology and five days after R40 was discharged from hospice service on 01/12/2023. Review of a psychology consult date 01/18/2023 found the following recommendations: continuation of sertraline, a structured routine, divisional activities, and mood and behavior monitoring. Review of another FRI read, in part, Incident Summary: [R40] was observed by a staff member in the dining room, sitting in a chair next to [R4] sitting in [their] wheelchair. [R40] had one hand on the underside of [R4's] knee area and one hand up [their] blouse .[R40] placed on observations . Note that the type of observation was not provided. Review of R40's clinical record revealed a progress note dated 03/04/2023 which read, in part, [R40] was observed on this date in the dining room at 1830, engaged in physical touch with [R4], using [their] hand to touch [R4] under [their] shirt on the chest area .Increased visual surveillance checks initiated by the staff and remain ongoing. The type of visual surveillance was not reported, and additional review of progress notes did not reveal details as to what was provided. On 03/08/2023 at 04:59 PM, the Administrator reported that CNA M witnessed the incident. Review of the clinical record revealed that R4 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, and category five blindness in right eye (blindness with no light perception), and that R4 was receiving hospice services. Review of the admission MDS assessment (dated 02/06/2023) found that R4 required limited, one-person physical assistance for bed mobility, transfers, and toileting, and extensive one-person assistance for dressing. Per this assessment, R4 was severely cognitively impaired. Review of R4's care plan found the following: .AMBULATION: 1PA (a person assistance) with walker .Date Initiated: 01/30/2023 .LOCOMOTION: Independent in wheelchair .Date Initiated: 01/30/2023 . On 03/07/2023 at 11:07 AM, R4 was observed in their room, sitting up in a wheelchair. They presented as confused and very hard of hearing. On 03/08/2023 at 09:02 AM, a phone interview was conducted with R4's medical power of attorney-Family Member J. When asked about the what happened on 03/04/2023, Family Member J stated, I guess [R4] was fondled in the cafeteria by a male resident. Family Member J indicated that they were out of state at the time of the incident, and only just return the evening prior to the interview. When asked what the facility said they are doing to keep R4 safe, Family Member J stated that they were told that staff were monitoring [R40] every 15 minutes. Family Member J shared during the interview that R4's husband was physically abusive, and R4 was very leery of men. When asked, Family Member J stated that they shared this with the facility. Family Member J gave permission for Family Member K to be interviewed. On 03/08/2020 at 09:11 AM, Family Member K was interviewed. When asked what happened on 03/04/2023, Family Member K stated that they received a call from Family Member J and was told that R4 had been molested. Family Member K went to the facility to visit R4, and they spoke with an unknown staff member about how hard it is to get someone settled into a facility. Family Member K expressed to the staff member that every time they visit, R4 wants to leave, and per Family Member K, this staff member said, So do you want to transfer [R4] to another facility. Family Member K told the staff member that they thought R40 was on 15-minute checks before this incident, and the staff member said yes. Family Member K then asked, How did this happen? Family Member K stated that the staff member did not offer a response. On 03/08/2023 at 05:41 PM, a message was left for CNA M. CNA M did not call back by the end of the survey. No documentation of one-to-one supervision of R40 following the incident on 03/04/2023 was provided. Resident Visual Observation Assessment dated 03/04/2023 to 03/06/2023 were review. For the assessment dated [DATE], illegible text was written over the checks for approximately 11:00 PM to 1:15 AM-individual 15-mintue check fields were not completed. Fields from 12:30 AM to 5:45 AM were blank, as were fields from 07:15 AM to 05:45 PM. For the assessment dated [DATE], the 15-minute check fields from 10:00 PM to 06:45 AM were blank, as were the fields from 07:15 PM to 09:45 PM. No additional documentation of 15-minute checks was provided. Review of a psychology consult note dated 03/6/2023 read, in part, .Psych visit was requested as [R40] continues to exhibit inappropriate behavior problems .Plan/Monitoring outcomes/future sessions/review of Treatment Plan/Discharge from treatment/additional recommendations: Continue to meet with patient to work on goals . No interventions regarding R40's continued behaviors were recommended. Review of R40's progress notes revealed the following note dated 03/07/2023 that read, in part, Met with [R40's family member (Family Member H)] today and offered a room change to Emerald, near the Emerald lounge and in a high traffic area for supervision .[Family Member H] wants to think about it .[Family Member H] is considering moving [R40] back to the AFC (adult foster care) setting in the community . On 03/08/2023 at 11:05 AM, Family Member H was interviewed regarding the three incidents. When asked what interventions the facility provided for R40, Family Member H reported that the facility checked for a bladder infection, started sertraline, and provided more activities and supervision. Family Member H indicated that R40's mood was better when they had one-on-one observation. Family Member H stated that they were approached about moving R40 to another room, but they stated that switching rooms is not the answer. Repeatedly during this interview, Family Member H indicated that the issue is they need for more supervision. Family Member H referenced the attempt to move R40 to an out of state psychotic hospital, which Family Member H did not want to do as they would not be able to visit R40. Family Member H also stated that they do not want to move R40 to another setting as they were in very poor health before admitting to the facility and their health has greatly improved. On 03/08/2023 at 10:22 AM, an interview was conducted with Nurse E. When asked about R40's interactions with other residents, Nurse E reported that R40 has been inappropriate with women. When asked how many times this happened, Nurse E indicated that they knew of three, but could not be sure. Nurse E could not recall the incidents in January, and they indicated that they were not working during the incident on 03/04/2023. Nurse E reported that R40 was on one-on-one observation for a very long time. When asked, Nurse E could not recall a timeframe, but that R40 had been on one-to-one observation a lot. When asked about what interventions were put in place since the incident on 03/04/2023, they indicated 15 minutes checks over the weekend, though possibly one to one observation at night. Nurse E indicated that staff are doing eyes on now-meaning no one-to-one observation or 15 minutes checks. Nurse E reported that she told staff the morning of this interview to not leave R40 alone with female residents. When told about the multiple observations made of R40 being alone in the dining room with multiple female residents, Nurse E was not aware. During this interview, R4-the resident involved in the incident on 03/04/2023-attempted to enter R40's room. R40 was not in the room at the time, and Nurse E redirected R4. Nurse E indicated that they did not know the details as to which resident R40 inappropriately touched on 03/04/2023 until told by this writer. On 03/08/2023 at 11:41 AM, CNA O was interviewed. When asked about R40's contact with female residents, CNA O stated that R40 can get friendly. When asked for clarification, CNA O indicated hand holding, and that they had seen R40 try to kiss female residents. CNA O indicated that R40 had been good for a while until last weekend. When asked how many times R40 had had inappropriate contact with female residents, CNA O thought there were two, but was unsure. When asked about the incidents in January, CNA O indicated that R40 was put on one-to-one observation for a long time. They indicated that R40 had been behaving well, and was switch to 15-minute checks, then just eyes on. When asked about what interventions were in place since the incident on 03/04/2023, CNA O was not sure, but suggested one-to-one observation over the weekend, then 15-minute checks. CNA O indicated that R40 was currently eyes on for supervision. On 03/08/2023 at approximately 01:10 PM, the DON, who was also the facility's abuse coordinator, was approached to provide documentation on one-to-one observations and 15-minute checks for R40. DON mentioned the incident on 03/04/2023, and when asked why one-to-one observation was not put in place for R40, the DON reported that one-to-one observation could not be provided due to not having enough staff. When asked what interventions were put in place, the DON indicated that R40 was placed on 15-minute checks, and that these checks should still be in place. When told that the staff who were interviewed were not aware that R40 should have 15-minute checks, and that they thought he was just eyes on, the DON was not able to offer an explanation. When asked how staff were informed when residents are placed on 15-minute checks, the DON stated that they were informed verbally. On 03/08/2023 at approximately 12:25 PM, an interview was conducted with Social Services [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00133117 and MI00132321. Based on observation, interview, and record review the facility failed to respond to an alarming door after one (R801) of three residents reviewed for elopement who had exit seeking behaviors and severely impaired cognition, exited the front door, held open by a visitor, without staff knowledge. This resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident when R801 was found by an off-duty staff member crossing a heavily trafficked road with no sidewalks and was eventually found walking on the side of the road toward oncoming traffic approximately a quarter mile away from the facility. This had the likelihood to cause serious harm, serious injury, and/or death. Findings include: Review of a Facility Reported Incident (FRI) submitted to the State Agency on 11/26/22 and a complaint received on 11/30/22 revealed R801 eloped from the facility. An unannounced, onsite investigation was conducted from 12/14/22 through 12/20/22. On 12/14/22, an observation of the outside of the facility revealed the facility was located on the corner of two heavily trafficked roads that intersected, one going east and west that the front of the facility faced, and one that went north and south that the side of the facility faced. There were no sidewalks on either side of both roads. There were no crosswalks at the intersections of the roads. A narrow shoulder was observed on both sides of each road. To the side of the road that ran east and west, a ditch was observed on the south side of the road and uneven ground sloping on an incline was observed on the north side of the road. A wooded area with tall trees was observed alongside the road that ran east to west. The speed limit of both roads was fifty miles per hour (MPH). On 12/14/22 at 2:32 PM, R801 was not in his room. It was explained by staff that R801 was on a leave of absence with his family member. On 12/15/22 at 8:18 AM, R801 was not in his room. At 9:12 AM, the Director of Nursing (DON) assisted with finding R801. After searching for R801, it was discovered that R801 was with the dentist. On 12/15/22 at approximately 3:30 PM, Nurse 'E' was asked where R801 was located as he was not in his room. Nurse 'E' reported R801 wandered throughout the facility, visited with certain residents in their room, used the bathroom on another unit, and was rarely in his room. After approximately five minutes, R801 was observed pushing another resident in a wheelchair. R801 was observed to be independently ambulatory. Review of R801's clinical record revealed R801 was admitted into the facility on 6/1/22 with diagnoses that included: Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had severely impaired cognition and was independent with no assistance needed for transfers and walking. Review of R801's Wandering Risk Assessment Scale forms dated 6/1/22, 6/13/22 and 9/12/22 revealed R801 was at high risk for wandering. Review of R801's care plans revealed a care plan initiated on 6/3/22 and revised on 6/27/22 that documented, He (R801) will often wander throughout the facility looking for exit doors .he finds comfort in going outside with staff . Review of a psychosocial care plan initiated on 6/8/22 and revised on 9/9/22 revealed, Family report exit seeking but easily redirectable .Behavior monitoring utilize log for patterning and intervention revision as indicated . Review of R801's progress notes revealed a note dated 11/26/22, written by Nurse 'E', that documented, Writer received phone call from staff member (Certified Nursing Assistant - CNA 'M') who was calling from her car but still at the facility after having finished her shift. (CNA 'M') informed this writer that (R801) was walking down (street name that facility was located on) Resident stated, 'I thought my wife would be home by then but evidently she was not done grocery shopping. I waited around then I wanted to give myself some time to think.' When writer asked resident how he was able to get out of the facility, resident stated, 'Actually, there were quite a few people walking out and they were holding the door, so I went for a walk to do some thinking.' Staff immediately retrieved (R801) and returned him to this facility .Writer checked resident's exit seeking transmitter device for proper functioning; device on his ankle is properly functioning but the bracelet was loose, so writer replaced the bracelet with a new one. Resident was immediately placed on 1:1 direct supervision with a staff member .This writer tested all exit doors in this facility for proper functioning of alarm system with a new exit seeking transmitter device that was verified to be working by using a (wander alert device) tester. All exit doors tested positive for proper alarm sounding when triggered by properly functioning (wander alert device) within range of exit doors . Further review of R801's progress notes revealed R801 was assigned one to one supervision in June 2022 due to wandering. Review of a progress note dated 8/5/22 revealed, Patient attempted to exit the building without assistance. (Wander alert device) in place and alarm sounded. Staff followed the patient outside and he was retuned within one minute . Review of a progress note dated 11/19/22 revealed, (R801) has been exit seeking this evening, going from the exit door on Sapphire to the exit door on [NAME] and opening the exit door in the Sunshine dining room. He was quickly diverted after opening the Sunshine dining room by staff. The door did alarm, however the door opened easily for him . On 12/15/22 at 8:34 AM, an interview was conducted with CNA 'M'. When queried about the day (11/26/22) R801 got out of the facility, CNA 'M' reported she left her shift around 3:00 PM and noticed she left her purse at the facility. CNA 'M' returned to the facility and left again at approximately 3:20 PM. CNA 'M' explained as she approached the corner in her vehicle, she observed R801 waiting to cross the intersection. At that time, CNA 'M' turned left, pulled into the back parking lot of the facility, parked her car, and contacted Nurse 'E' who was R801's assigned nurse at that time. CNA 'M' stated, By the time I got to him, he crossed the street. CNA 'M' reported she initially could not see R801 and thought he entered the wooded area on the side of the road, but found him approximately a quarter mile away, walking on the side of the road (there was a small gravel strip on the side of the road) toward oncoming traffic. CNA 'M' further reported at that time, Nurse 'E' and Nurse 'B' caught up to R801 and all three assisted R801 back to the facility. CNA 'M' reported it took approximately 10 minutes from the time she parked the car and walked back to the facility with R801. When queried about whether R801 exhibited any exit seeking behaviors during her shift, CNA 'M' reported R801 was ripping at the alarm on his ankle and tried to remove it. CNA 'M' reported she reported the behavior to Nurse 'L', but the ankle bracelet remained on R801's ankle when she left her shift at 3:00 PM. On 12/15/22 at 1:08 PM, an interview was conducted with Nurse 'E'. When queried about the day (11/26/22) R801 eloped from the facility, Nurse 'E' reported she was seated at the nurses' station located between the Sapphire and [NAME] hallways. Nurse 'E' received a phone call from CNA 'M' who recently left the facility when her shift was over. Nurse 'E' explained that CNA 'M' told her she saw R801 walking down (the street the facility was located on). Nurse 'E' explained she notified Nurse 'B' who was assigned to the [NAME] hallway, and they ran out of the break room door and down the road until they caught up to R801 and CNA 'M'. Nurse 'E' reported R801 had crossed the road at the intersection and was walking on the gravel strip on the side of the road going toward oncoming traffic when herself and Nurse 'B' caught up to the resident. Nurse 'E' explained she found out R801 was missing from CNA 'M' and left the building to get the resident due to the phone call. Nurse 'E' explained she was not responding to a door alarm and stated, I don't even know if I heard an alarm, but when we returned to the building an alarm was going off and (CNA 'C') had to let us in. On 12/15/22 at 10:07 AM, a telephone interview was conducted with Nurse 'B'. Nurse 'B' was asked to explain the facility's protocol for responding to an alarming door. Nurse 'B' explained if an alarm was sounding, you would go to the nearest exit to respond to the door. Nurse 'B' further explained if you noticed a resident was missing, you would announce it on the overhead speaker and conduct a head count of residents. Nurse 'B' explained that residents who were at risk of elopement generally had a wander alert device which would alarm if they attempted to leave through one of the doors. When queried about the incident of R801 eloping from the facility on 11/26/22, Nurse 'B' reported he was assigned to the [NAME] hallway and was passing medications when Nurse 'E' summoned him to help find R801 who was outside of the building. Nurse 'B' explained that himself and Nurse 'E' immediately ran out of the break room door and saw R801 across the road that ran north and south alongside the building. Nurse 'B' reported that CNA 'M' had already caught up to R801 and they all brought the resident back to the facility. When queried about whether there was an alarm sounding at the time he was alerted of R801's elopement, Nurse 'B' reported he could not remember and that he might not have heard it if he was at the end of the [NAME] hallway. Nurse 'B' explained he responded to R801 being outside because Nurse 'E' notified him, not because he responded to a door alarm. On 12/15/22 at 10:09 AM, a phone interview was conducted with CNA 'C'. When queried about what happened the day R801 eloped from the facility on 11/26/22, CNA 'C' reported she worked second shift from 2:30 PM until 11:00 PM on that date. CNA 'C' explained that she thought R801's wife came to the facility and was going to take him out but ended up staying at the facility and R801 received a shower. CNA 'C' stated, I honestly did not know he left the building until I let him and the nurses and aide back into the building. CNA 'C' reported she had to let them in because the alarm needed to be disengaged. CNA 'C' further explained that she saw him at some point prior to finding out he left but did not know he left. CNA 'C' explained there was a monitor at the nurses' station that had view of the front door of the facility and the monitor would also show which door was alarming if it was set off. CNA 'C' stated, From what I recall, the door was alarming but there was a group of family leaving so she did not notice the resident. On 12/15/22 at approximately 9:15 AM, an observation was made of the front door wander alert system with the DON, as the Maintenance Director was not working that day. The front door required a code to be entered on a keypad to exit that door. When the wander alert device was at a close distance from the front door, the lock engaged, and the door could not be opened. If the wander alert bracelet device was further back from the door, the code allowed the door to open. If the door was held open after the code was entered and the wander alert device was passed through the doorway, an alarm sounded and could clearly be heard at each nurses' station and faintly in the hallways in between. The alarm could only be disengaged by entering the code at the door that was alarming. On 12/15/22 at approximately 10:20 AM, review of the video footage of the facility's front door on 11/26/22 was conducted with the Administrator. Review of the video footage revealed on 11/26/22 at 3:23 PM, R801 exited the front door to the outside of the building while an unknown person held the first door open and then the second door. R801 is observed going to the left. The Administrator pointed to the light on the key code box and reported the light meant the alarm was engaged and sounding. A visitor is observed in the lobby near the front door. No staff are observed coming to the front door. At approximately 3:26 PM, two people (identified as Nurse 'B' and Nurse 'E' by the Administrator) are observed running past the front door of the facility on the outside. At 3:31 PM, Nurse 'B', Nurse 'E', and CNA 'M' are observed with R801. They entered the first door from the outside of the building and CNA 'C' disengaged the alarm using the code box to let them into the facility. At that time, the Administrator was asked what the facility did because of R801's elopement on 11/26/22. The Administrator reported they checked all the wander alert devices for placement and functioning, checked the door alarms, conducted a missing resident drill, and posted a sign on the door to alert visitors not to let residents out. When queried about what was done about the lack of staff response to the alarming door, the Administrator reported Nurse 'B' and Nurse 'E' responded to the alarm and that was why they were running outside. It should be noted that during surveyor interviews, staff indicated they did not respond to an alarm on 11/26/22 and they either were unsure if an alarm was sounding or did not respond to the alarm. Nurse 'E' indicated they went outside after alerting Nurse 'B' because they were alerted by CNA 'M' who happened to come back to the facility to get her purse and left again and saw R801. On 12/15/22 at 1:27 PM, a telephone interview was conducted with CNA 'A' who worked on 11/26/22 on a different unit than where R801 resided. When queried about whether she was aware of R801's elopement on 11/26/22, CNA 'A' reported she worked that day, but did not hear about it until the following day. When queried about the facility's protocol for responding to door alarms, CNA 'A' explained the alarms went off quite a bit when visitors leave and they leave the door open, so we are always running up to shut off the alarm. CNA 'A' further reported that R801's wife took him out of the building often and did not always sign him out or left staff know. On 12/15/22 at 1:55 PM, an interview was conducted with Nurse 'I' who was assigned to the Emerald Unit on 11/26/22. The Emerald Unit was located to the right of the front lobby. When queried about their response to the door alarm on 11/26/22, Nurse 'I' reported she did not recall an alarm going off and stated, If the front door alarm goes off, usually someone gets it. Nurse 'I' then reported that she thought she heard an alarm but it is such a common occurrence for it to go off and I was passing medications so I just figured someone would do their job and turn off the alarm. Nurse 'I' reported she did not respond to the alarm and assumed someone else did because it was eventually cleared. Nurse 'I' explained she was not aware of R801's elopement until the following Monday when Administration called her for an interview. On 12/15/22 at 2:04 PM, an interview was conducted with the Administrator. When queried about the required timeframe to respond to a door alarm, the Administrator reported it should be addressed immediately. When queried about who was responsible to respond, the Administrator reported all staff are responsible to respond. Review of the facility's Elopement Drill Log forms for 2022 revealed a minimum of one drill on each shift was conducted on a quarterly basis. The log revealed drills were conducted on all three shifts in March 2022 and September 2022. Review of an Elopement Drill Record dated 3/24/22 at 12:56 PM (first shift) revealed, Nursing leadership to receive additional training. Temp. (temporary) staff needs additional training. Review of an Elopement Drill Record dated 3/30/22 at 3:38 PM (second shift) revealed, Additional Training needed. Review of an Elopement Drill Record dated 3/31/22 at 6:12 AM (third shift) revealed, Additional Training needed. Review of an Elopement Drill Record form dated 9/14/22 at 4:54 PM (second shift), revealed, Poor response - Ended with a round-table discussion of responsibilities. More drills needed. There was no evidence provided by the facility of any additional drills conducted after the poor response to the 9/14/22 elopement drill. The next documented drill was conducted after R801 eloped from the facility. Review of the investigation conducted by the facility into R801's elopement on 11/26/22 revealed CNA 'C' heard the front door alarm on 11/26/22 but could not respond right away because she was transferring another resident. Additional statements from witnesses did not indicate the staff responded to the door alarm but responded to the call from the off-duty CNA (CNA 'M') who found R801 outside. There was no indication in the facility's investigation that addressed the lack of response to the door alarm until nine minutes later when CNA 'C' let Nurse 'B', Nurse 'E', and CNA 'M' back into the facility with R801. Review of a facility policy titled, Wandering Residents Exit Seeking Management revised 2/2021, revealed, in part, the following: .RESPONSE TO A SOUNDING DOOR ALARM .Check the alarm panel to determine which door has been triggered. DO NOT ASSUME someone else has already done this .Check the exit door for any exiting resident by means of a visual check .If an exit door alarm is triggered, the cause is evaluated and re-set after the resident is re-directed, and their safety is assured . The IJ began on 11/26/22, it was identified by the survey team on 12/15/22 and the facility was notified of the IJ on 12/15/22, and a removal plan was requested. On 12/17/22, the State Agency completed onsite verification that the Immediate Jeopardy was removed on 12/15/22, however the facility remained out of compliance at a scope of pattern and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency.