Based on interview, facility policy review, and record review, the facility failed to timely report an instance of elopement involving a resident with a history of hallucinations for one (1) of four (4) residents reviewed for accidents and hazards (Resident #55). Resident #55 was observed inside the facility at approximately 4:00 AM on 5/31/25 and was found unsupervised in the facility parking lot by dietary staff at approximately 4:30 AM. Facility staff were unaware the resident had left the facility through an alarmed door, which staff failed to investigate despite hearing the audible alarm. This event was not reported to the State Agency until 6/2/25. The delay in reporting placed this resident and other residents at continued risk for exiting the facility unsupervised which increased the likelihood of serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 5/31/25, when Resident #55 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 6/4/25 at 11:30 AM and provided an IJ Template. The State Agency (SA) validated the Removal Plan on 6/5/25 and determined that the IJ was removed on 6/5/25, prior to exit. Therefore, the scope and severity for CFR 483.12 (c)(1) Reporting of Alleged Violations (F609) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's policy, Incident Investigation & Reporting reviewed 05/24 revealed, Purpose: To provide guidance to the Facility for .reporting incidents of abuse, neglect, exploitation, misappropriation of property and or other reportable incidents .When must it be reported All alleged violations .2) Not later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property and does not result in serious bodily injury .5. Additional items that .may require reporting .G. Elopement . A record review of the admission Record revealed the facility admitted Resident #55 on 4/4/25 with the diagnoses including Parkinson's Disease with Dyskinesia, with Fluctuations, Hallucinations, and Dementia. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/25 revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A record review of the facility's investigation, dated 6/4/25, revealed, .Resident .did in fact exit the facility via a secured door .The (State Agency) entered the facility on June 2, 2025 .Surveyors are aware of the incident/allegation and are currently investigating . During an interview on 6/2/25 at 11:02 AM, during an interview, Resident #55 stated that on 5/31/25, she felt threatened by a nurse and decided she needed to leave the facility. The resident explained that she observed staff and checked multiple doors until she located an unlocked door in the kitchen area. She reported that she exited the facility through the unlocked kitchen door and hid behind a vehicle in the parking lot. During an interview on 6/2/25 at 1:00 PM, Dietary #1 explained that on 5/31/25 at approximately 4:27 AM, she was arriving for work and, upon turning into the facility parking lot, observed an individual coming from around a black jeep parked outside. She stated that as she looked closer, she realized it was a resident of the facility, who was walking down the driveway toward the main road. She reported that when she stopped her car, Resident #55 approached and stated, I'm so glad you came. I need help getting out of here. A lady threatened me in the facility. Dietary #1 stated that the resident appeared confused and reported feeling tired. She assisted the resident into her car on the passenger side and immediately called the facility to notify staff that the resident was outside requesting help. Dietary #1 stated that a nurse and three (3) Certified Nursing Assistants (CNAs) came out of the building with a wheelchair to assist the resident back inside. She further noted that the resident's shirt and hair were wet from the humidity. Dietary #1 stated that she told the facility staff that came to get the resident from her car that Resident #55 had told her that she left the facility because she was threatened by staff. During an interview on 6/2/25 at 6:00 PM, Licensed Practical Nurse (LPN) #5 stated that on 5/31/25, between 4:00 AM and 5:00 AM, the alarm sounded on both the 300 and 400 hall exit doors. She explained that she was not familiar with the code required to stop the alarm from sounding. While the door was alarming, she received a phone call from a kitchen staff member who reported that Resident #55 was outside in the facility parking lot. LPN #5 stated that she and three CNAs exited the front door with a wheelchair and assisted the resident back into the building. She reported that she contacted the Administrator to inform her that the door alarm was sounding, and the Administrator provided her with the code to silence the alarm. LPN #5 stated that she informed the Administrator that all residents were accounted for at that time but could not recall if she had specifically told the Administrator that the resident had been found outside by dietary staff, as she was focused on addressing the alarm. The nurse was unable to recall if she received any information regarding why the resident left the facility. During an interview on 6/4/25 at 10:00 AM, the Administrator stated that she received a call around 5:00 AM on 5/31/25 from LPN #5. She reported that LPN #5 informed her that Resident #55 had exited through the 400 hall door and was seen by staff, but had been brought back into the facility. The Administrator stated that she was not made aware at that time that the resident had exited the facility and had been found by dietary staff. She reported that she did not learn those details until she returned to work on 6/2/25, when Resident #55 reported that she had left the building because she felt threatened and physically abused by a staff member. The Administrator stated that she subsequently contacted the weekend nursing staff for clarification and was informed that dietary staff had called the facility to report that Resident #55 was outside. The Administrator stated that she had not been provided that information during the initial call on 5/31/25 and was under the impression that staff had observed the resident as she pushed the door open and immediately escorted her back inside. She further stated that she was not aware the resident had exited the building and that staff were initially unaware of the resident's whereabouts until notified by Dietary #1. During an interview on 6/4/25 at 1:00 PM, the Director of Nursing (DON) stated that Resident #55 is delusional, confused, and experiences hallucinations. She reported that she was not aware the resident had eloped from the building until Monday, 6/2/25, after the State Agency (SA) entered the facility. The DON confirmed that she did not report the alleged abuse or elopement at the time of the incident because she was unaware of the situation until 6/2/25, more than two (2) days after the event occurred. The facility provided the following removal plan: On June 4, 2025, at 11:30 AM the State Agency notified the Administrator that the facility was in Immediate Jeopardy (IJ) related to failure to ensure adequate supervision and a safe environment to prevent an elopement, timely report, and initiate an investigation and provided the templates. Removal Plan - Corrective Action Plan 1. On May 31, 2025, at approximately 5:00 AM, Licensed Practical Nurse #1 notified the Nursing Home Administrator the 400 hall door alarm was alarming and the staff was not able to silence the alarm. The Nursing Home Administrator asked Licensed Practical Nurse #1 what was the cause of the 400 hall door alarming. License Practical Nurse #1 stated Resident #55 had exited the 400 hall door. The Nursing Home Administrator inquired about the length of time Resident #55 had exited through the 400 Hall door and License Practical Nurse #1 stated it had only been a few minutes. Resident #55 was found in the parking lot by Dietary employee #1 that was arriving to work. Dietary employee #1 notified facility nursing staff that Resident # 1 was outside of the facility. Resident #55 re-entered the facility with multiple staff members at approximately 4:33 AM 2. On June 2, 2025, facility Nursing Home Administrator reviewed video surveillance. At approximately 4:08 AM on May 31, 2025 Resident #55 exited her room and ambulated down the 400 hall. Camera's do not show the entire hallway. It is not definitive what time Resident # 55 exited the facility via 400 hall door. At 4:33 am on May 31, 2025 Resident # 55 re-enters the facility via the facility dining room door with multiple facility staff members. 3. On May 31, 2025 at approximately 4:45 am Licensed Practical Nurse # 2 assessed Resident #55 with no injuries noted. A wander guard bracelet was applied to Resident #55 on May 31, 2025. 4. On June 2, 2025 at approximately 11:35 am facility Director of Nursing interviewed Licensed Practical Nurse #1. Licensed Practical Nurse # 1 stated that she heard the alarm go off but did not investigate nor did any other staff member. 5. On June 2, 2025 at approximately 11:35 am, the State Department of Health was notified of the initial report via telephone of the incident by facility Nursing Home Administrator and Corporate personnel #1. June 2, 2025 at approximately 12:11 PM, an initial report was submitted to local law enforcement. 6. At the time of the incident Resident #55 BIMS score was 15. Resident was reassessed on June 3, 2025 with a BIMS score of 12. 7. A facility Quality Assurance Committee meeting was held at approximately 4:00 PM, June 2, 2025 to include facility Quality Assurance Committee members which consisted of the facility Administrator #1, Director of Nursing, Assistant Director of Nursing, Dietary Manager, Nurse Case Manager, Admissions coordinator, Infection Preventionist and Medical Director via telephone. Topics discussed included: Elopement policy to include Supervision, Wander guard system, Resident Right, Investigation and Reporting with no changes to policy. 8. The facility corrective actions were reviewed and initiated June 2, 2025 to include the following: in-service training, code drills, medical record audits, and monitoring systems ongoing. On June 2, 2025, at approximately 1:30 pm in-service training was initiated by Staff Development Nurse to include all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department on the following: (a) Incident/Accident Reporting (b) Incident/Accident Reporting to include investigation (c) Wandering/Elopement to include Supervision. On June 3, 2025, at approximately 3:30 pm an in-service on Incident/Accident Investigation and Incident/Accident Reporting was conducted by Corporate Nurse to include facility Administrator and Director of Nursing. Facility staff and agency staff if utilized will not be allowed to work until the proper in-service training has been conducted. 9. On June 3, 2025 at approximately 11:00 am the facility elopement binder was reviewed and updated by Medical Records Nurse #1. 10. On June 4, 2025, at approximately 12:45 pm Wandering/Elopement Code Drills were initiated by the facility Administrator to include Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department. The staff were in-serviced on how to distinguish between the wander guard alarm and the fire alarm. Staff will not be allowed to work until participation in a code drill has been conducted. Code drill exercises will be performed daily until all staff have participated in at least one exercise, and then code drills will continue as outlined below. 11. On June 4, 2025 at approximately 12:45 pm Wandering/Elopement Code Drills were initiated by the facility Administrator which included a complete facility head count 65 of 65 residents were identified. 12. On June 4, 2025 at approximately 6:00 pm care plans were reviewed of 3 residents identified as an elopement risk by Corporate Nurse. 13. On June 4, 2025, an outside vendor inspected 9 of 9 facility doors and identified 2 of 9 doors with delayed egress enabled. The two effected doors were deactivated and tested for proper functioning. 14. On June 4, 2025 at approximately 3:30 pm the completion for all incident/accident reports for the last 90 days were audited by the facility Administrator to ensure proper investigation and reporting. 66 of 66 reports were audited. The results of this audit showed no issues with reporting or investigation. 15. On June 4, 2025 monitoring systems were put in place to sustain compliance. (a) All Incident/Accident Reports will be reviewed by the facility Administrator and Director of Nursing to ensure proper investigation is complete. 16. On June 4, 2025 monitoring systems were put in place to sustain compliance. (a) All Incident/Accident Reports will be reviewed by the facility Administrator and Director of Nursing to ensure timely reporting daily. (b) the facility began monitoring wandering/elopement code drills on all three shifts, weekly times (x) 4 weeks, monthly x 3 months, then per facility protocol thereafter (every 4 months rotating shifts). 17. On June 4, 2025 at approximately 12:45 pm monitoring systems were put in place to sustain compliance. The facility began monitoring wandering/elopement code drills on all three shifts, weekly x 4 weeks, monthly x 3 months, then per facility protocol thereafter (every 4 months rotating shifts). 18. The facility Administration will have a follow up Quality Assurance Meeting on June 5, 2025 and monthly times two months and then quarterly thereafter to ensure sustained compliance. 19. The facility alleges that all corrective actions to remove the IJ were completed on June 4, 2025 and the Immediate Jeopardy was removed as of June 5, 2025. Validation: The SA validated on 6/5/25, through interview and record review, that actions to remove the immediacy were completed on 6/4/25, and the IJ was removed on 6/5/25, prior to the SA's exit on 6/5/25.

Based on interview, facility policy review, and record review, the facility failed to initiate an investigation timely when Resident #55, who had a history of hallucinations, exited the facility for one (1) of four (4) residents reviewed for accidents and hazards (Resident #55). Resident #55 was observed inside the facility at approximately 4:00 AM on 5/31/25 and was found unsupervised in the facility parking lot by dietary staff at approximately 4:30 AM. Facility staff were unaware the resident had left the facility through an alarmed door, which staff failed to investigate despite hearing the audible alarm. This event was not investigated by the facility until 6/2/25 in which the Administrator stated she was unaware of the elopement and believed the resident had been returned by staff immediately, indicating that no internal investigation was initiated as required. The facility's delayed investigation prevented timely identification of root causes, such as the failure to respond to the alarm, the door's egress function, and the lack of staff awareness, which placed Resident #55 and other residents in a situation to elope and experience serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 5/31/25, when Resident #55 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 6/4/25 at 11:30 AM and provided an IJ Template. The State Agency (SA) validated the Removal Plan on 6/5/25 and determined that the IJ was removed on 6/5/25, prior to exit. Therefore, the scope and severity for 42 CFR 483.12(c)(2) Investigation/Prevent/Correct Alleged Violation (F610) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Cross Reference F609, F689 Findings include: A review of the facility's policy, Incident Investigation & Reporting reviewed 05/24 revealed, Purpose: To provide guidance to the facility for investigation .incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents .5. Additional incidents that must have a thorough investigation .G. Elopement .6. The facility will investigate all alleged violations under the direct supervision of the Administrator . A record review of the admission Record revealed the facility admitted Resident #55 on 4/4/23 with the diagnoses including Parkinson's Disease with Dyskinesia, with Fluctuations, Hallucinations, and Dementia. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/25 revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A record review of the facility's investigation, dated 6/4/25, revealed, .Resident .did in fact exit the facility via a secured door .The (State Agency) entered the facility on June 2, 2025 .Surveyors are aware of the incident/allegation and are currently investigating . On 6/2/25 at 11:02 AM, during an interview, Resident #55 reported that on 5/31/25, she became fearful after feeling threatened by a nurse and made the decision to leave the facility. She stated that she watched staff and checked several doors before finding one in the kitchen area that was unlocked. The resident stated that she went through the kitchen door and hid behind a vehicle in the facility's parking lot. On 6/2/25 at 1:00 PM, during an interview, Dietary #1 stated that at approximately 4:27 AM on 5/31/25, she was arriving for work when she saw someone walking from behind a black jeep parked outside the building. As she got closer, she recognized the individual as Resident #55, who was walking down the driveway toward the main road. She stated that when she stopped her car, the resident approached her and expressed relief that she had arrived, stating that she needed help getting out because she had been threatened by a staff member in the facility. Dietary #1 stated that the resident appeared confused, tired, and her clothing and hair were damp from the humidity. She helped the resident into her car and immediately contacted facility staff to report that the resident was outside and requested assistance. Dietary #1 stated that a nurse and three Certified Nursing Assistants (CNA) came outside with a wheelchair to assist the resident back into the building. She further stated that when the staff arrived at her vehicle, she informed them that Resident #55 had reported leaving the facility due to feeling threatened by staff. On 6/2/25 at 6:00 PM, during an interview, LPN #5 explained that on 5/31/25, between 4:00 AM and 5:00 AM, the alarms on both the 300 and 400 hall exit doors activated. She stated that she did not know the code needed to silence the alarm. While the alarm continued to sound, she received a call from a kitchen employee notifying her that Resident #55 was outside in the parking lot. Licensed Practical Nurse (LPN) #5 reported that she and three CNAs went outside through the front entrance with a wheelchair to bring the resident back into the facility. She stated that she then contacted the Administrator to report that the alarm was sounding, at which time the Administrator provided her with the code to turn off the alarm. LPN #5 recalled informing the Administrator that all residents were accounted for but was unsure if she specifically mentioned that the resident had been located outside by dietary staff, as she had been focused on silencing the alarm. The nurse stated she could not recall receiving any information regarding the reason the resident exited the building. LPN #5 also acknowledged that she did not conduct an investigation or interview the dietary staff member who observed the resident in the parking lot. On 6/4/25 at 10:00 AM, during an interview, the Administrator stated that she was contacted by LPN #5 at approximately 5:00 AM on 5/31/25. She reported that during the call, LPN #5 informed her that Resident #55 had exited through the 400 hall door and was seen by staff before being brought back into the building. The Administrator stated that at the time of the initial call, she was not told that dietary staff had located the resident outside. She explained that she first became aware of those details on 6/2/25, after returning to work and speaking with Resident #55, who reported leaving the facility due to feeling threatened and physically abused by a staff member. The Administrator stated that after learning this information, she began contacting the weekend staff involved for clarification and was informed that dietary staff had notified the nurses when the resident was found outside. She confirmed that during the initial call on 5/31/25, she had believed staff observed the resident as she pushed open the door and immediately escorted her back inside, and was not aware that staff were initially unaware of the resident's whereabouts until notified by Dietary #1. The Administrator acknowledged that she and facility staff did not initiate an investigation into the elopement until 6/2/25, after the State Agency arrived. She reported that at that point, she began reaching out to the weekend staff who had worked the night of the incident and reviewed surveillance footage to determine when Resident #55 was last seen inside the hallway. On 6/4/25 at 1:00 PM, during an interview, the Director of Nursing (DON) stated that Resident #55 is confused, delusional, and experiences hallucinations. She explained that she was not made aware that the resident had eloped from the facility until 6/2/25, when the State Agency (SA) arrived. She stated that once she and the Administrator learned that dietary staff had contacted nursing to report the resident was found outside wandering in the parking lot, they initiated an investigation into the incident. The facility provided the following removal plan: On June 4, 2025, at 11:30 AM the State Agency notified the Administrator that the facility was in Immediate Jeopardy (IJ) related to failure to ensure adequate supervision and a safe environment to prevent an elopement, timely report, and initiate an investigation and provided the templates. Removal Plan - Corrective Action Plan 1. On May 31, 2025, at approximately 5:00 AM, Licensed Practical Nurse #1 notified the Nursing Home Administrator the 400 hall door alarm was alarming and the staff was not able to silence the alarm. The Nursing Home Administrator asked Licensed Practical Nurse #1 what was the cause of the 400 hall door alarming. License Practical Nurse #1 stated Resident #55 had exited the 400 hall door. The Nursing Home Administrator inquired about the length of time Resident #55 had exited through the 400 Hall door and License Practical Nurse #1 stated it had only been a few minutes. Resident #55 was found in the parking lot by Dietary employee #1 that was arriving to work. Dietary employee #1 notified facility nursing staff that Resident # 1 was outside of the facility. Resident #55 re-entered the facility with multiple staff members at approximately 4:33 AM 2. On June 2, 2025, facility Nursing Home Administrator reviewed video surveillance. At approximately 4:08 AM on May 31, 2025 Resident #55 exited her room and ambulated down the 400 hall. Camera's do not show the entire hallway. It is not definitive what time Resident # 55 exited the facility via 400 hall door. At 4:33 am on May 31, 2025 Resident # 55 re-enters the facility via the facility dining room door with multiple facility staff members. 3. On May 31, 2025 at approximately 4:45 am Licensed Practical Nurse # 2 assessed Resident #55 with no injuries noted. A wander guard bracelet was applied to Resident #55 on May 31, 2025. 4. On June 2, 2025 at approximately 11:35 am facility Director of Nursing interviewed Licensed Practical Nurse #1. Licensed Practical Nurse # 1 stated that she heard the alarm go off but did not investigate nor did any other staff member. 5. On June 2, 2025 at approximately 11:35 am, the State Department of Health was notified of the initial report via telephone of the incident by facility Nursing Home Administrator and Corporate personnel #1. June 2, 2025 at approximately 12:11 PM, an initial report was submitted to local law enforcement. 6. At the time of the incident Resident #55 BIMS score was 15. Resident was reassessed on June 3, 2025 with a BIMS score of 12. 7. A facility Quality Assurance Committee meeting was held at approximately 4:00 PM, June 2, 2025 to include facility Quality Assurance Committee members which consisted of the facility Administrator #1, Director of Nursing, Assistant Director of Nursing, Dietary Manager, Nurse Case Manager, Admissions coordinator, Infection Preventionist and Medical Director via telephone. Topics discussed included: Elopement policy to include Supervision, Wander guard system, Resident Right, Investigation and Reporting with no changes to policy. 8. The facility corrective actions were reviewed and initiated June 2, 2025 to include the following: in-service training, code drills, medical record audits, and monitoring systems ongoing. On June 2, 2025, at approximately 1:30 pm in-service training was initiated by Staff Development Nurse to include all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department on the following: (a) Incident/Accident Reporting (b) Incident/Accident Reporting to include investigation (c) Wandering/Elopement to include Supervision. On June 3, 2025, at approximately 3:30 pm an in-service on Incident/Accident Investigation and Incident/Accident Reporting was conducted by Corporate Nurse to include facility Administrator and Director of Nursing. Facility staff and agency staff if utilized will not be allowed to work until the proper in-service training has been conducted. 9. On June 3, 2025 at approximately 11:00 am the facility elopement binder was reviewed and updated by Medical Records Nurse #1. 10. On June 4, 2025, at approximately 12:45 pm Wandering/Elopement Code Drills were initiated by the facility Administrator to include Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department. The staff were in-serviced on how to distinguish between the wander guard alarm and the fire alarm. Staff will not be allowed to work until participation in a code drill has been conducted. Code drill exercises will be performed daily until all staff have participated in at least one exercise, and then code drills will continue as outlined below. 11. On June 4, 2025 at approximately 12:45 pm Wandering/Elopement Code Drills were initiated by the facility Administrator which included a complete facility head count 65 of 65 residents were identified. 12. On June 4, 2025 at approximately 6:00 pm care plans were reviewed of 3 residents identified as an elopement risk by Corporate Nurse. 13. On June 4, 2025, an outside vendor inspected 9 of 9 facility doors and identified 2 of 9 doors with delayed egress enabled. The two effected doors were deactivated and tested for proper functioning. 14. On June 4, 2025 at approximately 3:30 pm the completion for all incident/accident reports for the last 90 days were audited by the facility Administrator to ensure proper investigation and reporting. 66 of 66 reports were audited. The results of this audit showed no issues with reporting or investigation. 15. On June 4, 2025 monitoring systems were put in place to sustain compliance. (a) All Incident/Accident Reports will be reviewed by the facility Administrator and Director of Nursing to ensure proper investigation is complete. 16. On June 4, 2025 monitoring systems were put in place to sustain compliance. (a) All Incident/Accident Reports will be reviewed by the facility Administrator and Director of Nursing to ensure timely reporting daily. (b) the facility began monitoring wandering/elopement code drills on all three shifts, weekly times (x) 4 weeks, monthly x 3 months, then per facility protocol thereafter (every 4 months rotating shifts). 17. On June 4, 2025 at approximately 12:45 pm monitoring systems were put in place to sustain compliance. The facility began monitoring wandering/elopement code drills on all three shifts, weekly x 4 weeks, monthly x 3 months, then per facility protocol thereafter (every 4 months rotating shifts). 18. The facility Administration will have a follow up Quality Assurance Meeting on June 5, 2025 and monthly times two months and then quarterly thereafter to ensure sustained compliance. 19. The facility alleges that all corrective actions to remove the IJ were completed on June 4, 2025 and the Immediate Jeopardy was removed as of June 5, 2025. Validation: The SA validated on 6/5/25, through interview and record review, that actions to remove the immediacy were completed on 6/4/25, and the IJ was removed on 6/5/25, prior to the SA's exit on 6/5/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure supervision and implement adequate safety interventions to prevent accidents for two (2) of four (4) residents reviewed for accidents and hazards (Resident #55 and Resident #47) as evidenced by: 1) failing to monitor door alarms and failing to immediately investigate an active exit alarm to prevent Resident #55 exiting the facility unsupervised and 2) failing to ensure safe transfer techniques when staff manually lifted Resident #47 without the use of the required stand lift, resulting in the resident's foot becoming caught under the wheelchair and causing a right ankle injury. On 5/31/25, at approximately 4:00 AM, Resident #55 exited the facility through the 400 hall exit door, which caused the door to alarm. The alarm was ignored by staff and resulted in the resident being found outside in the parking lot at approximately 4:33 AM by a dietary staff member arriving at work. The facility's failure to immediately investigate an active alarm and provide adequate supervision for Resident #55, put this resident and all other residents at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 5/31/25, when Resident #55 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 6/4/25 at 11:30 AM and provided an IJ Template. The State Agency (SA) validated the Removal Plan on 6/5/25 and determined that the IJ was removed on 6/5/25, prior to exit. Therefore, the scope and severity for CFR 483.25(d)(1)(2) Accidents/Hazards - F689 was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A record review of the facility's policy Elopement/wandering-General Policy, with reviewed date of 01/23, revealed . Elopement occurs when a resident who is incapable of adequately protecting themselves leaves the premises without necessary supervision to do so . Resident #55 A record review of the admission Record revealed the facility admitted Resident #55 on 4/4/25 with the diagnoses including Parkinson's Disease with Dyskinesia, with Fluctuations, Hallucinations, and Dementia. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/25 revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A record review of the facility's investigation, dated 6/4/25, revealed, .Resident .did in fact exit the facility via a secured door .The State Agency entered the facility on June 2, 2025, .Surveyors are aware of the incident/allegation and are currently investigating . Record review of the facility's Interviews, dated 6/3/25, revealed Resident #55's BIMS score was a 12, which indicated her cognition was moderately impaired. Record review of the local weather report from www.weatherunderground.com revealed the local weather was 70 degrees at 4:00 AM on 5/31/25. An interview with Resident #55 on 6/2/25 at 11:02 AM, she stated that on 5/31/25, she felt threatened by a nurse and decided she needed to leave the facility. The resident explained that she observed staff and checked multiple doors until she located an unlocked door in the kitchen area. She reported that she exited the facility through the unlocked kitchen door and hid behind a vehicle in the parking lot. The resident stated that shortly afterward, a woman driving a car stopped and assisted her back into the building. The resident further reported that she was tired and thirsty at the time. Observation on 6/2/25 at 11:15 AM of the area where Resident #55 was located outside of the facility revealed the resident was in the parking lot approximately 15 yards from the 400 Hall exit door. There was a wooded area across from the exit door and a highway in front of the facility. An interview on 6/2/25 at 1:00 PM, Dietary #1 explained that on 5/31/25 at approximately 4:27 AM, she was arriving for work and, upon turning into the facility parking lot, observed an individual coming from around a black jeep parked outside. She stated that as she looked closer, she realized it was a resident of the facility, who was walking down the driveway toward the main road. Dietary #1 described the resident as wearing a pink shirt, capri jeans, socks, and shoes. She reported that when she stopped her car, Resident #55 approached and stated, I'm so glad you came. I need help getting out of here. A lady threatened me in the facility. Dietary #1 stated that the resident appeared confused and reported feeling tired. She assisted the resident into her car on the passenger side and immediately called the facility to notify staff that the resident was outside requesting help. Dietary #1 stated that a nurse and three (3) Certified Nursing Assistants (CNA) came out of the building with a wheelchair to assist the resident back inside. She further noted that the resident's shirt and hair were wet from the humidity. An interview on 6/2/25 at 4:30 PM, CNA #5 stated that she was assigned to care for Resident #55 on 5/31/25. She reported that she had not observed the resident attempting to exit the facility. CNA #5 explained that while she was on break, another CNA informed her that Resident #55 had been observed outside the building. CNA #5 stated that she, along with two additional CNAs and Licensed Practical Nurse (LPN) #5, went outside to assist the resident and escorted her back into the facility. She reported that the last time she saw the resident prior to the incident was at approximately 3:00 AM, when she and the nurse provided the resident with a peanut butter sandwich because the resident had been awake and wandering in the hallway. CNA #5 stated that the resident often ambulated in the hallway at night and required redirection. She reiterated that she had not previously observed the resident attempting to exit the facility and stated that the resident was in her room when she went to lunch. An interview on 6/2/25 at 5:30 PM, LPN #4 stated that on 5/31/25, an exit door alarm sounded sometime during the morning hours, but she could not recall the exact time. She explained that staff conducted a quick scan of the area and observed that everything appeared to be in place; however, they did not check each resident's room to verify all residents were accounted for. LPN #4 stated that she believed the exit door alarm was faulty and assumed it was beeping as it frequently did. She reported that a staff member from the dietary department later called the facility to inform them that Resident #55 was outside in the parking lot. LPN #4 stated that she exited the 300-hall door while one of the CNAs exited from another door with a wheelchair to assist in bringing the resident back into the building. She reported that she did not know how long the resident had been outside and was unsure who initially received the call from the dietary staff. LPN #4 stated that she believed LPN #5 notified the Administrator of the incident. She also reported that she typically worked only on Friday and Saturday nights and was not familiar with facility policies regarding alarms and elopements. LPN #4 stated that the last time she had seen the resident prior to the incident was when she arrived for her shift at 11:00 PM. An interview on 6/2/25 at 6:00 PM, LPN #5 stated that between 4:00 AM and 5:00 AM on 5/31/25, the alarm on the 400 hall exit door sounded. She reported that staff looked outside the door and scanned the immediate area but did not observe any residents out of place at that time. LPN #5 confirmed that room-to-room checks were not conducted to verify that all residents were present. She also stated that staff did not know the code required to silence the exit door alarm. LPN #5 reported that she later received a phone call from Dietary #1, who informed her that Resident #55 was outside in the facility parking lot. LPN #5 stated that she, along with three CNAs, exited the building through the front door with a wheelchair to assist the resident back into the building. She recalled that Resident #55 had been up and walking around near the nurse's station earlier that morning. LPN #5 explained that the only possible exits the resident could have used were the doors on either the 300 or 400 hall. She confirmed that staff was unaware the resident had exited the building until notified by Dietary #1. LPN #5 stated that once the resident was returned to the building, she was assessed, and a head count of all residents was conducted. She reported that Resident #55 was found sitting in the passenger seat of the kitchen staff member's car when staff arrived to assist. LPN #5 further stated that she contacted the Administrator to report that the door alarm would not stop sounding, and the Administrator provided her with the code to disable the alarm. She also informed the Administrator that the resident had been located and that all residents were accounted for. LPN #5 stated that Resident #55 did not sustain any injuries during the incident. An interview on 6/3/25 at 12:30 PM, CNA #6 stated that she was working on the 100 hall on 5/31/25. She reported that the CNA assigned to the 400 hall was on break at the time. CNA #6 stated that when the alarm sounded, staff initially believed it was the fire alarm in the nutrition room, which had been intermittently sounding for the past two days. She explained that after realizing it was not the fire alarm, staff checked the 400 hall and discovered that the exit door was open following notification from kitchen staff that a resident was outside. CNA #6 reported that she retrieved Resident #55's wheelchair and brought it outside to assist the resident. She further stated that the door was unlocked, and she was able to push it open and exit the building. An interview on 6/3/25 at 9:00 AM, Resident #55's significant other stated that the resident reported to him that she had been threatened by facility staff and feared that they were going to harm her. He stated that the resident told him she exited the facility through the kitchen door and ran down the street. The resident also reported that it was raining and cold at the time. According to the significant other, the resident stated that a woman stopped her vehicle, assisted her into the car, and brought her back to the facility. The significant other reported that the resident had not previously been this confused and expressed concern that her condition may be declining due to her Parkinson's disease. He further stated that the resident's hallucinations had increased lately. On 6/4/25, during interviews with multiple residents on the 400 hall, several reported hearing alarms sounding over the weekend. At 8:30 AM, Unsampled Resident A in room [ROOM NUMBER] stated he remembered the alarm going off during the night for approximately 20 minutes or longer, though he was unsure if it was a door or fire alarm. At 8:40 AM, Resident #26 in room [ROOM NUMBER]-A reported hearing the alarm late over the weekend, stating it sounded longer than usual, but she was unsure if something was wrong. At 9:00 AM, Resident #163 in room [ROOM NUMBER] stated he heard alarms during the night over the weekend, estimating the alarm sounded for approximately 30 to 45 minutes. He was unsure if someone was trying to exit the facility. At 9:10 AM, Resident #33 in room [ROOM NUMBER] stated that alarms had gone off approximately five or more times since his admission and recalled being awakened by the alarm on at least one occasion, though he could not recall the exact time. At 9:30 AM, Unsampled Resident B in room [ROOM NUMBER] stated that the alarm sounded for a long time over the weekend, and due to the length of time it sounded, she thought something might be wrong with the alarm system. An interview on 6/4/25 at 9:00 AM, the Maintenance Director explained that the door alarm on the 400 hall is the only door that will release and open if the push bar is held down for 10 seconds. He stated that the alarm will sound immediately upon the door being pushed. The Maintenance Director reported that he has provided education to staff on multiple occasions regarding the difference between fire alarms and door alarms. He stated that staff have also received inservice training from the Administrator on how to respond when alarms sound and the appropriate actions to take. The Maintenance Director reported that on several occasions he has arrived at the facility to find alarms sounding without staff responding to them. He further stated that he has conducted one-on-one training with various staff members but does not have any signed documentation verifying completion of those individual trainings. An interview on 6/4/25 at 10:00 AM, the Administrator stated that she was contacted by staff around 5:00 AM on Saturday morning, 5/31/25, and informed that Resident #55 had exited the building through the 400-hall door but was returned to the facility immediately. She reported that the resident was brought back into the building and that a body audit and head count were completed to ensure all other residents were accounted for. The Administrator further stated that when she arrived at work on Monday morning, a therapy staff member informed her that Resident #55 stated she did not understand why the facility had placed a WanderGuard (a type of monitoring device) bracelet on her leg. The Administrator reported that she spoke with both the resident and her significant other to explain that the WanderGuard device was being used to help staff monitor her location and ensure her safety. During this conversation, the resident reported feeling unsafe, stating that a staff member with orange fingernail polish had threatened and physically abused her. The Administrator stated that after hearing this, she contacted facility staff for clarification and was provided with additional details. She reported that LPN #5 informed her that Dietary #1 had called the facility to notify staff that Resident #55 was outside. LPN #5 also reported that she and three CNAs brought the resident back into the building. The Administrator confirmed that a body audit and head count were completed following the incident. She further stated that she reviewed the facility's surveillance footage from 5/31/25 but was unable to determine the exact time the resident exited the building. The Administrator explained that the surveillance cameras do not capture the 400 hall exit door; however, based on the resident's location and the facility layout, she determined that the 400 hall door was the only exit the resident could have used, as access through the kitchen was not possible. The footage showed the resident was last observed inside the facility at 4:06 AM and was next observed returning to the building at 4:34 AM. An interview on 6/4/25 at 1:00 PM, the Director of Nursing (DON) stated that Resident #55 is delusional, confused, and experiences hallucinations. The DON reported that she was not aware the resident had exited the building until Monday (6/2/25), after the State Agency (SA) arrived onsite. She confirmed that both she and the Administrator began investigating the incident after learning that a dietary staff member had notified nursing staff that the resident was outside the building. Resident #47 A record review of the facility's Lifting Policy, revised 10/23, revealed, .This facility will strive to provide a safe work environment by providing and requiring the use of safety materials, equipment and training designed to help prevent personnel and resident injury .Failure to utilize a mechanical lift when the use of this equipment is indicted in resident's plan of care, unless exception is met, could result in disciplinary action up to and including termination of employment .*Exception: Although the mechanical lift, if indicated by screening, is the preferred method of transfer it is recognized it may not always be possible due to certain circumstances. Circumstances to include emergencies, residents care needs, mechanical failure, and some areas in which mechanical lifts do not fit. In these circumstances it would be acceptable to transfer a resident manually with the assistance of one (1) or more staff as indicated . A record review of the admission Record revealed the facility admitted Resident #47 on 12/20/24 with diagnoses including Right Femur Fracture. A record review of the Quarterly MDS with an ARD of 3/20/25 revealed Resident #47 had a BIMS score of 15, which indicated she was cognitively intact. A record review of the facility's incident report, dated 2/17/25, revealed Resident #47 informed therapy that she had pain in her right ankle following a transfer and the resident stated that two aides transferred her to the wheelchair and her foot got caught under the chair. The report indicated that the CNAs were educated on transfer/lift status. A record review of a consultation for Resident #47, dated 2/20/25, revealed Findings of a right ankle sprain. Recommendations including non-steroidal anti-inflammatory drugs (NSAIDs) as needed for ankle pain and ice as needed to the right ankle. New Orders included an air cast to the right ankle and elevate the right ankle. On 6/2/25 at 12:04 PM, during an interview, Resident #47 reported that in February 2025, a male CNA picked her up and transferred her into a chair without using a mechanical lift. She stated that during the transfer, her foot became caught under the wheelchair, resulting in a sprained ankle. Resident #47 confirmed that a lift was not used during the transfer. On 6/4/25 at 9:14 AM, during an interview, the Rehabilitation Director/Speech Therapist stated that the Physical Therapist Assistant (PTA) had worked with Resident #47 during a therapy session on 2/17/25. She reported that during the session, the PTA observed that the resident's right ankle was swollen. When asked about the swelling, the resident informed the PTA that a CNA had lifted her by the arms during a transfer instead of using the designated mechanical lift. The resident stated that during the transfer, her foot became caught under the wheelchair. On 6/4/25 at 12:32 PM, during an interview, the Director of Nursing (DON) stated that she was informed by the Physical Therapist Assistant that Resident #47 had sustained a sprained ankle. She reported that the resident was subsequently examined and underwent an X-ray, which revealed no evidence of a fracture. The DON stated that the CNAs involved in the improper transfer were agency staff who are no longer employed at the facility. She further explained that CNAs have since been re-educated on proper lift procedures and the importance of following each resident's assigned lift status. The DON confirmed that an incident report documenting the event was completed on 2/17/25. On 6/5/25 at 11:40 AM, during a follow-up interview, the Director of Nursing (DON) stated that agency CNAs receive an orientation similar to facility staff, although it is typically an abbreviated version, which includes a review of client charts and care plans. The DON reported that Resident #47 had requested to get up in order to attend therapy, and the CNAs informed her that no mechanical lift was available at that time. She stated that the CNAs appeared to assume the resident could assist during the transfer. The DON further stated that she believed the footrest on the wheelchair had been removed prior to placing the resident into the chair but was unable to determine to how the resident's foot became caught under the wheelchair. The DON stated that according to the facility's policy, CNAs are allowed to determine whether a manual transfer may be used in certain situations, including for resident care needs. She also stated she understood that the resident was reportedly in a hurry to get to therapy that day. The DON further explained that the facility did not consider the transfer to be neglectful because, under the facility's policy, the transfer was permissible and no significant injury, such as a fracture, occurred. The DON agreed that the incident report regarding the injury did not include an Exception reason as to why the CNAs chose to manually lift her instead of using the mechanical lift. On 6/5/25 at 12:03 PM, during an interview, the Physical Therapy Assistant (PTA) stated that Resident #47 was unable to fully participate in physical therapy for several weeks after the reported incident on 2/17/25 due to swelling in the right ankle. She reported that while the resident was restricted from performing weight-bearing exercises involving the affected ankle, she was able to continue participating in therapy. On 6/5/25 at 12:13 PM, in an interview with LPN #6 (Care Plan Nurse), she explained that a yellow sticker on Resident #47's bulletin board and the care plan both indicated the resident required a stand-assist mechanical lift. She emphasized CNAs are not permitted to determine lift methods. On 6/5/25 at 12:50 PM, during an interview with Charge Nurse/LPN #7, she stated the facility is a no-manual-lift environment and confirmed Resident #47 had required a stand-assist lift for several months. She confirmed that the CNAs involved in the incident on 2/17/25 admitted not using a lift and did not provide justification for their actions. On 6/5/25 at 12:17 PM, during an observation and follow-up interview, Resident #47 provided additional details regarding the incident that occurred on 2/17/25. She stated that there was no footrest on the wheelchair during the transfer and noted that her knee was not functioning well at the time. The resident reported that she was wearing slippers and was unsure how her foot became positioned underneath the wheelchair. She explained that she did not refuse the lift and was not rushing the staff. She said she knew the lift was available for use because the CNAs brought the lift to the door of her room when they came in for the transfer. She stated that there were two or three CNAs present in the room at the time of the transfer, and they did not explain to her why they were not using the mechanical lift. There was a yellow circle observed on the bulletin board in her room above the headboard. On 6/5/25 at 2:48 PM, during an interview, the Administrator acknowledged Resident #47 was transferred without a lift on 2/17/25 that resulted in the resident having a sprained ankle. On 6/5/25 at 3:20 PM, during an interview with Agency CNA #1, he stated he and another CNA manually transferred Resident #47 from the bed to the wheelchair. He believed a two-person assist was appropriate for Resident #47 and was unable to provide a reason or exception as to why they did not use the mechanical lift. The facility provided the following removal plan: On June 4, 2025, at 11:30 AM the State Agency notified the Administrator that the facility was in Immediate Jeopardy (IJ) related to failure to ensure adequate supervision and a safe environment to prevent an elopement, timely report, and initiate an investigation and provided the templates. Removal Plan - Corrective Action Plan 1. On May 31, 2025, at approximately 5:00 AM, Licensed Practical Nurse #1 notified the Nursing Home Administrator the 400 hall door alarm was alarming and the staff was not able to silence the alarm. The Nursing Home Administrator asked Licensed Practical Nurse #1 what was the cause of the 400 hall door alarming. License Practical Nurse #1 stated Resident #55 had exited the 400 hall door. The Nursing Home Administrator inquired about the length of time Resident #55 had exited through the 400 Hall door and License Practical Nurse #1 stated it had only been a few minutes. Resident #55 was found in the parking lot by Dietary employee #1 that was arriving to work. Dietary employee #1 notified facility nursing staff that Resident # 1 was outside of the facility. Resident #55 re-entered the facility with multiple staff members at approximately 4:33 AM 2. On June 2, 2025, facility Nursing Home Administrator reviewed video surveillance. At approximately 4:08 AM on May 31, 2025 Resident #55 exited her room and ambulated down the 400 hall. Camera's do not show the entire hallway. It is not definitive what time Resident # 55 exited the facility via 400 hall door. At 4:33 am on May 31, 2025 Resident # 55 re-enters the facility via the facility dining room door with multiple facility staff members. 3. On May 31, 2025 at approximately 4:45 am Licensed Practical Nurse # 2 assessed Resident #55 with no injuries noted. A wander guard bracelet was applied to Resident #55 on May 31, 2025. 4. On June 2, 2025 at approximately 11:35 am facility Director of Nursing interviewed Licensed Practical Nurse #1. Licensed Practical Nurse # 1 stated that she heard the alarm go off but did not investigate nor did any other staff member. 5. On June 2, 2025 at approximately 11:35 am, the State Department of Health was notified of the initial report via telephone of the incident by facility Nursing Home Administrator and Corporate personnel #1. June 2, 2025 at approximately 12:11 PM, an initial report was submitted to local law enforcement. 6. At the time of the incident Resident #55 BIMS score was 15. Resident was reassessed on June 3, 2025 with a BIMS score of 12. 7. A facility Quality Assurance Committee meeting was held at approximately 4:00 PM, June 2, 2025 to include facility Quality Assurance Committee members which consisted of the facility Administrator #1, Director of Nursing, Assistant Director of Nursing, Dietary Manager, Nurse Case Manager, Admissions coordinator, Infection Preventionist and Medical Director via telephone. Topics discussed included: Elopement policy to include Supervision, Wander guard system, Resident Right, Investigation and Reporting with no changes to policy. 8. The facility corrective actions were reviewed and initiated June 2, 2025 to include the following: in-service training, code drills, medical record audits, and monitoring systems ongoing. On June 2, 2025, at approximately 1:30 pm in-service training was initiated by Staff Development Nurse to include all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department on the following: (a) Incident/Accident Reporting (b) Incident/Accident Reporting to include investigation (c) Wandering/Elopement to include Supervision. On June 3, 2025, at approximately 3:30 pm an in-service on Incident/Accident Investigation and Incident/Accident Reporting was conducted by Corporate Nurse to include facility Administrator and Director of Nursing. Facility staff and agency staff if utilized will not be allowed to work until the proper in-service training has been conducted. 9. On June 3, 2025 at approximately 11:00 am the facility elopement binder was reviewed and updated by Medical Records Nurse #1. 10. On June 4, 2025, at approximately 12:45 pm Wandering/Elopement Code Drills were initiated by the facility Administrator to include Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department. The staff were in-serviced on how to distinguish between the wander guard alarm and the fire alarm. Staff will not be allowed to work until participation in a code drill has been conducted. Code drill exercises will be performed daily until all staff have participated in at least one exercise, and then code drills will continue as outlined below. 11. On June 4, 2025 at approximately 12:45 pm Wandering/Elopement Code Drills were initiated by the facility Administrator which included a complete facility head count 65 of 65 residents were identified. 12. On June 4, 2025 at approximately 6:00 pm care plans were reviewed of 3 residents identified as an elopement risk by Corporate Nurse. 13. On June 4, 2025, an outside vendor inspected 9 of 9 facility doors and identified 2 of 9 doors with delayed egress enabled. The two effected doors were deactivated and tested for proper functioning. 14. On June 4, 2025 at approximately 3:30 pm the completion for all incident/accident reports for the last 90 days were audited by the facility Administrator to ensure proper investigation and reporting. 66 of 66 reports were audited. The results of this audit showed no issues with reporting or investigation. 15. On June 4, 2025 monitoring systems were put in place to sustain compliance. (a) All Incident/Accident Reports will be reviewed by the facility Administrator and Director of Nursing to ensure proper investigation is complete. 16. On June 4, 2025 monitoring systems were put in place to sustain compliance. (a) All Incident/Accident Reports will be reviewed by the facility Administrator and Director of Nursing to ensure timely reporting daily. (b) the facility began monitoring wandering/elopement code drills on all three shifts, weekly times (x) 4 weeks, monthly x 3 months, then per facility protocol thereafter (every 4 months rotating shifts). 17. On June 4, 2025 at approximately 12:45 pm monitoring systems were put in place to sustain compliance. The facility began monitoring wandering/elopement code drills on all three shifts, weekly x 4 weeks, monthly x 3 months, then per facility protocol thereafter (every 4 months rotating shifts). 18. The facility Administration will have a follow up Quality Assurance Meeting on June 5, 2025 and monthly times two months and then quarterly thereafter to ensure sustained compliance. 19. The facility alleges that all corrective actions to remove the IJ were completed on June 4, 2025 and the Immediate Jeopardy was removed as of June 5, 2025. Validation: The SA validated on 6/5/25, through interview and record review, that actions to remove the immediacy were completed on 6/4/25, and the IJ was removed on 6/5/25, prior to the SA's exit on 6/5/25.