**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff, police dispatch, physician, and responsible party (RP) interviews the facility failed to prevent a severely cognitively impaired resident (Resident #71) with known wandering behaviors and poor safety awareness from becoming trapped alone in a locked administrative staff's office with the lights off without staff's knowledge. The facility also failed to provide evidence that a thorough investigation of the incident was conducted and to put corrective measures in place after the incident to prevent a potential recurrence. This deficient practice had a high likelihood of causing Resident #71 serious physical and psychosocial harm. Resident #71 did not have the cognitive capacity to express an adverse outcome. A reasonable person would have suffered feelings of fear, anxiety, and/or helplessness from the incident. This was for 1 of 11 residents reviewed for the provision of supervision to prevent accidents. Immediate Jeopardy began on 7/26/23 when Resident #71 became trapped alone in a staff office. Immediate Jeopardy was removed on 10/15/23 when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. Findings included: Resident #71 was admitted to the facility on [DATE] with diagnoses including dementia, generalized muscle weakness and unsteadiness on feet. A review of the Physical Therapy discharge summary for Resident #71 dated 6/21/22 completed by Physical Therapist (PT) #1 revealed the discharge recommendation was for staff to continuously monitor Resident #71 and to keep Resident #71 in line of sight of staff due to her high fall risk. A review of a nursing progress note for Resident #71 dated 11/21/22 at 6:36 PM revealed in part she was found on the floor in the hallway. She had no injuries. A review of a nursing progress note for Resident #71 dated 11/27/22 at 12:59 PM revealed in part she was found on the floor in a kneeling position. She had no injuries. A review of a nursing progress note for Resident #71 dated 12/2/22 at 6:56 PM revealed in part she was found sitting on the floor in the dining room. She had no injuries. A review of a nursing progress note for Resident #71 dated 4/13/23 at 6:23 PM revealed in part Resident #71 was found on the floor in the dining room. She had no injuries. A Fall Risk Assessment for Resident #71 dated 4/14/23 revealed in part she had a history of falls. It further revealed she overestimated her abilities and forgot her limitations. It concluded Resident #71 was at high risk for falls. Resident #71's comprehensive care plan revealed in part a focus area last updated on 4/22/23 of at risk for further falls and injury related to weakness, impaired mobility, potential side effects of medication, poor safety awareness and history of falls. It further revealed Resident #71 had actual falls with no injury on 7/29/22, 8/12/22, 8/17/22, 8/19/22, 11/21/22, 11/27/22, 12/2/22 and 4/13/23. The goal was for Resident #71 to remain free from falls with injury through the next review. Interventions included the following: 8/12/22 referral to Occupational Therapy for wheelchair positioning, 8/17/22 a non-slip mat to seat of wheelchair, 8/19/22 staff education to ensure resident is wearing non skin {sic} footwear when OOB (out of bed), 12/2/22 anti-tippers to wheelchair, and 4/13/23 frequent monitoring during mealtimes. There was no care plan focus area in place for wandering. A review of Resident #71's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. She displayed inattention and disorganized thinking continuously. She displayed no behavioral symptoms, rejection of care or wandering behavior. Resident #71 required the extensive assistance of 2 people for transfers and set-up assistance for locomotion on and off her unit. She did not walk. She was not steady when moving from a seated to standing position and was only able to stabilize with human assistance. She was not steady during transfers from surface to surface (between bed to chair or wheelchair) and was only able to stabilize with human assistance. She had no functional impairment of range of motion in her upper or lower extremities. She used a wheelchair for mobility. She had one fall with no injury since her prior MDS assessment. She did not use a wander/elopement alarm. A review of an Elopement Risk Tool for Resident #71 dated 7/15/23 completed by the Director of Nursing (DON) revealed Resident #71 was found to be at risk for elopement. It further revealed her wandering behavior affected her safety and well-being. On 10/10/23 a review of the physician's orders for Resident #71 revealed an order dated 7/15/23 for a wanderguard (a type of elopement alarm) to be placed to her right ankle. A nursing progress note dated 7/27/23 at 7:58 AM written by Nurse #2 revealed in part Resident #71 was reported missing around 9:00 PM to 11:00 PM (7/26/23). All open doors were searched multiple times including outside in the courtyard and around the facility and she was not found. Management and law enforcement were notified, and law enforcement came to the facility. Resident #71's family was notified. She was found in the MDS (Minimum Data Set) office in the dark seated on the sofa facing the door. The door was locked and needed a code to enter. She was assessed for injury at that time with none noted. Her family was notified that she had been found safe. On 10/10/23 at 11:19 AM a telephone interview with Nurse #2 indicated she was familiar with Resident #71. She stated Resident #71 often self-propelled herself round in the facility by wheelchair. She stated she was assigned to care for Resident #71 from 7:00 PM to 7:00 AM on 7/26/23. She went on to say about 7:30 PM to 8:00 PM on 7/26/23 she had some residents including Resident #71 gathered around her medication cart in the hallway. She further indicated around 8:20 PM Resident #71 refused her medications and her vital signs, and she told Resident #71 she would try again later. Nurse #2 stated this was the last time she had seen Resident #71 herself prior to her being identified as missing. Nurse #2 stated around 9:20 PM she went to find Resident #71 in her room, but she wasn't there. She went on to say she found Nurse Aide (NA) #4 to ask her where Resident #71 was. She stated NA #4 had not known and NA #4 went to look for Resident #71. Nurse #2 stated when NA #4 reported back to her that NA #4 was not able to locate Resident #71 after looking on all the halls Nurse #2 let all staff know to begin looking for her. She went on to say they searched everywhere inside the facility and outside that they could access for about 30 minutes but could not locate Resident #71. She further indicated at that point she knew it was time to notify her chain of command and the police. She stated when she spoke with the Administrator by telephone, the Administrator told her to call the police, so she did. She went on to say the Director of Nursing, the Admissions Director, and the police had all arrived at the facility about the same time Nurse #2 further indicated the police asked for the codes to the locked doors in the facility. She went on to say the Admissions Director then went to the MDS office door, entered the code, opened the door, and Resident #71 was there alone in the dark seated on a couch with her wheelchair facing the door and the brakes to her wheelchair locked. She stated Resident #71 was smiling and asked if the police were going to arrest her. She further indicated when she arrived to work on 7/26/23 at 7:00 PM she walked past the MDS office and recalled the office door being closed like it usually was in the evening. Nurse #2 stated there was no way Resident #71 could have gotten out of there by herself due to the heavy door, and the codes that were needed. She stated Resident #71 was thin, not very strong, and could not walk. She further indicated she had assessed Resident #71 for injuries and there had been none. On 10/11/23 at 2:43 PM an interview with Police Dispatch #1 indicated the [NAME] Varina Police Dispatch first received the call for a missing resident at the facility on 7/26/23 at 10:23 PM. A review of the local Police Department Call for Service report dated 7/26/23 for a missing person verified the call was initially received from the facility at 10:23 PM. On 10/10/23 12:00 PM an observation of the MDS office was conducted with MDS Nurse #2. She stated she had been working in this MDS office for over a year. She went on to say she was not working on 7/26/23. She stated the current arrangement of the MDS office was the same as it had always been. On entrance to the office there was observed to be one desk to the right of the door facing towards the back of the room. There was a second desk on left of the office which faced the door. There was a short, narrow Z shaped path between the opposing corners of desks leading to the back wall of the office. There were 2 chairs at the front of the desk on the right which were pushed together and facing the desk on the left. The door to the office did not atomically shut and had to be manually pushed to close. On 10/10/23 at 5:21 PM an observation was conducted with the Director of Nursing (DON) of the MDS office including the key code door locking mechanism. The MDS office was observed to be at the end of the 400 Hall past where resident rooms were located. A numerical push button keypad was located on the outside of the door below the door handle which required entering the correct numerical code to open the door if it were locked. There was also a keyhole. The interior aspect of the locking mechanism on the inside of the office door was observed to have a knob. If this knob was turned one way, it disabled the need to enter a numerical code to unlock the door if the door were closed. When this knob was turned the opposite way it enabled the keypad lock which locked the door requiring the correct keypad code be entered to unlock the door if it were closed. On 10/11/23 at 11:04 AM a telephone interview with NA #4 indicated she was familiar with Resident #71 and had been assigned to care for her at the time of the incident on 7/26/23. She stated Resident #71 was at baseline that night and did not have any behaviors. She stated Resident #71 liked to propel herself around the facility in her wheelchair and everyone kept an eye on her for safety reasons. NA #4 went onto say around 8:30 PM on 7/26/23 she had gone to look for Resident #71 to help her get ready for bed and could not find her. She stated she notified Nurse #7 who was the Supervisor that night. NA #4 stated Nurse #7 said she had seen Resident #71 earlier and Nurse #7 instructed everyone to keep looking. NA #4 stated when Resident #71 could not be found, the DON, Administrator and police were notified. She stated the police arrived and wanted all the locked doors opened. She went on to say the Admissions Director arrived at the facility and had gone straight to the MDS office and opened the door. She went on to say she had no idea how Resident #71 could have gotten locked in the MDS office by herself. A review of a written statement from Nurse #7 dated 7/26/23 (provided by the facility on 10/11/23) revealed in part she last saw Resident #71 at around 8:30 PM in the facility. Around 9:00 PM NA #4 reported to her she could not find Resident #71 after she looked everywhere in the facility. All staff were notified of the situation, and they began to look for Resident #71. On 10/10/23 at 8:36 PM a telephone interview with Nurse #7 indicated she was very familiar with Resident #71. She stated Resident #71 liked to self-propel herself around the facility in her wheelchair and so everyone kept an eye on her for safety. Nurse #7 stated the last time she saw Resident #71 on 7/26/23 was around 8:30 PM near the nurse's station. She reported she told Resident #71 to head back towards her hall which she usually did when you told her to. She stated around 9:00 PM that night NA #4 came to her and told her they had been looking for Resident #71 and could not find her. Nurse #7 went on to say she had become very concerned and immediately got all the staff together to begin looking for Resident #71. She stated Resident #71 was not steady enough to transfer herself without falling. She went on to say Resident #71 had a wanderguard and there were no alarms going off so everyone really felt she must still be in the building. Nurse #7 stated she was fuzzy about the time, but she thought it was about 10:00 PM when she called the DON. She stated she did not think the DON had known yet about Resident #71 being missing. She went on to say she was fuzzy about who called the police or when but the reason the police were not notified sooner was everyone thought Resident #71 would not have been able to get out of the building unless someone let her out and there were no alarms going off, so she had wanted to be sure Resident #71 was not in the building before the police were called. She went on to say it took time to look everywhere. Nurse #7 stated she got in her car and began driving around to look for Resident #71. She went on to say when she got back to the facility the Admissions Director was there getting out of her car. She stated she followed the Admissions Director into the building and the Admissions Director went straight to the MDS Office. Nurse #7 stated the Admissions Director, the DON, and the police were all there at the same time, the Admissions Director put the key code in and opened the MDS office door and found the resident. She further indicated that door had been checked during the search earlier and it had been locked. She went on to say when the door was opened initially, the room was dark. She stated Resident #71 had been sitting in a chair and her wheelchair was in the back of the room facing the door. In an interview on 10/10/23 at 12:06 PM MDS Nurse #1 stated she left for the day on 7/26/23 between 3:00 PM and 4:00 PM. She went on to say she had locked the office door when she left like she always did and checked to make sure it was locked. She stated the last thing she did every day was make sure the lights in the office were off and the door was locked. MDS Nurse #1 stated she had never shared the door code with anyone. On 10/12/23 at 8:28 AM MDS Nurse #1 stated the only thing in the MDS office at the time of the incident she could think of that would have posed any risk to Resident #71 would have been a bottle of hand sanitizer. A review of a written statement dated 7/31/23 from NA #5 (provided by the facility on 10/11/23) revealed in part she spoke with the Admissions Director by phone and told her Resident #71 had been missing for over an hour and a half and neither the Administrator nor the DON had been notified. It further revealed NA #5 told the Admissions Director Nurse #7 had said she was going to drive around the block to look for Resident #71 and if she didn't see her, she would come back and call the Administrator, DON, and the police. On 10/10/23 at 1:23 PM a telephone interview with NA #5 indicated she was familiar with Resident #71. She stated Resident #71 was confused and did not walk. She went on to say Resident #71 required 1 person to assist her with standing and transferring to the wheelchair. NA #5 stated Resident #71 liked to self-propel herself throughout the facility in her wheelchair. She went on to say everyone knew this and kept an eye on her to ensure Resident #71 stayed safe. She further indicated Resident #71 had a couple of favorite places she liked to sit which included the glass door at the end of the 400 Hall where Resident #71 liked to look out. NA #5 stated she had been working on the 400 Hall on 7/26/23 from 3:00 PM until 11:00 PM. She further indicated Resident #71 had been at baseline that evening with no unusual behaviors. She stated she had last seen Resident #71 about 7:00 PM looking out the 400 Hall exit door with another resident when she was picking up supper trays. She went on to say she recalled the MDS office door being shut during her shift that evening. NA #5 stated about 8:30 PM she came in from her break and NA #4 told her they couldn't find Resident #71. She went on to say she participated in looking for Resident #71 from about 8:30 until 10:00 PM. She further indicated she had been present when the police arrived about 10:00 PM. NA #5 stated when she had been on her break that evening, the Admissions Director called her about an issue with another resident in the facility. She went on to say when she called the Admissions Director back that evening, she told her she couldn't talk because Resident #71 was missing, and they were looking for her. She stated she had no idea how Resident #71 could have gotten locked into the MDS office. A review of the written statement provided by the Admissions Director dated 7/31/23 (provided by the facility on 10/11/23) revealed in part that at 9:52 PM she received a call from NA #5 who told her Resident #71 had been missing for about 2 hours. NA #5 told her that the nurse had not called to notify the DON or the Administrator. NA #5 reported staff had been looking for Resident #71 all over the building, in the parking lots, out behind the dumpster and near the woods. NA #5 told her the nurse had said she was going to get in her car and look around the neighborhood and if she still couldn't find Resident #71, she was going to notify the Administrator and DON. The Admissions Director told NA #5 she would call the Administrator herself immediately. At approximately 10:35 PM the Admissions Director arrived at the facility. There were 3 police cars at the facility. The DON provided her with the code to unlock the MDS office door. Initially she entered the wrong code and was unable to open the door. When she opened the door, the lights were off, and it was totally dark in the office. She flipped on the lights due to not being able to see clearly without the lights on and saw Resident #71 sitting on the edge sofa chair. To prevent Resident #71 from being scared or upset, the Admissions Director spoke with her. Resident #71 noticed the police officers in the hallway and muttered something about being arrested and going to jail. The Admissions Director sat down beside Resident #71 and told her the police had not come because of her. Resident #71's wheelchair was not extended all the way out (the seat was pulled up in the middle). The wheelchair was beside Resident #71 facing the door. The Admissions Director assisted with getting Resident #71's wheelchair out of the very small office space between the desks. She noticed Resident #71 had her bedroom shoes under a file cart near the door. At 10:43 PM she sent the Administrator a text to let her know the resident had been located. On 10/10/23 at 12:13 PM an interview with the Admissions Director indicated she had been made aware by telephone that Resident #71 was missing at the facility on 7/26/23 around 10:00 PM when NA #5 called her. She went on to say NA #5 told her the nurse had tried to give Resident #71 her medication but Resident #71 had refused. She went on to say NA #5 reported that the nurse had gone back to try again, and they couldn't find Resident #71. The Admissions Director stated she immediately went to the facility to assist with the search. She went on to say when she arrived at the facility, the police were there. She further indicated the Director of Nursing (DON) gave her the code for the MDS office and she went there while the DON went to open the beauty shop door. She stated she initially entered the wrong code to the MDS office, and the door wouldn't open but she tried again and was able to open the door. She went on to say the lights were off in the office and when she flipped on the lights, she saw Resident #71 seated in a chair. The Admissions Director further indicated when Resident #71 saw the police standing in the open doorway Resident #71 asked her if the police were there to arrest her. She stated she reassured Resident #71 the police were not. On 10/10/23 at 2:04 PM an interview with the DON indicated she received a telephone call about 10:00 PM on 7/26/23 from the facility saying that Resident #71 was missing, staff had looked in all the rooms in the facility and outside and still couldn't find her. She stated she told staff to keep looking. She went on to say the police had already been called. She further indicated she had the code to the office doors, and she immediately went to the facility. The DON stated when she arrived at the facility, she checked the beauty salon and then opened the door to the MDS office. She went on to say when she opened the MDS office door the lights were off. She further indicated she flipped on the lights and saw Resident #71 seated on a chair in the office. She stated Resident #71 was calm, kind of laughed because she could see the police and said, Y'all call the police on me?. The DON went on to say Resident #71 was assessed for injury and none was found. On 10/10/23 at 5:22 PM a follow-up interview with the DON she stated other staff had already tried to open the MDS office door earlier when looking for the resident on 7/26/23 and found it to be locked. She further indicated the door had been locked when she first tried it. In an interview on 10/10/23 at 2:41 PM the Regional Nurse Consultant #1 stated there were no cameras and there was no video footage or any pictures from the incident on 7/26/23 to be reviewed. On 10/10/23 at 5:51 PM an interview with the Maintenance Director indicated he received a call in the evening on 7/26/23 regarding a missing resident. He stated he could not recall who called him or the exact time. He further indicated he thought it was from the DON. He went on to say by the time he arrived at the facility the resident had been found. The Maintenance Director stated it was reported to him that Resident #71's wheelchair had been backed into the MDS office. He stated he was familiar with Resident #71 because he often saw her in the halls. He went on to say at times he would see Resident #71 with her wheelchair brakes locked but she wouldn't realize it and she would be just rocking the wheelchair back and forth trying to get it to move and he would have to go over and help her unlock them. He went on to say he immediately changed all the door codes that night. He stated he felt like if that was the issue, he would fix that. The keypad code locking mechanism on the MDS office door was discussed with the Maintenance Director. He confirmed if the door's inner knob was turned one way when the office door was closed, the door would not be locked and no keycode would be required to open the closed door. He further confirmed if the inner knob was turned the opposite way when the door was closed, the entry of the correct code on the keypad would be required to open the door. He stated there was no physical key for the keyhole in the MDS office door. On 10/11/23 at 8:33 AM an additional interview with the DON indicated an investigation of the incident had been conducted which included interviews with the staff present in the facility at the time of the incident. She went on to say the investigation was inconclusive regarding how it could have occurred. She further indicated education had been provided to staff that they were to immediately notify administration when a resident was missing. She stated if administration had been immediately notified, staff would have been instructed to call the police then. She went on to say she did not consider an hour to be immediately and felt staff should have notified administration and the police sooner than they did. She went on to say staff had been educated on the missing resident policy and all the door codes had been changed to ensure only certain people had access. On 10/11/23 Regional Nurse Consultant #1 provided the investigation information of the 7/26/23 event which did not include written statements from Nurse #2, MDS Nurse #1, or therapy staff. On 10/13/23 at 10:22 AM a follow-up interview with the Regional Nurse Consultant #1 indicated she was not aware of any written statement from MDS Nurse #1 or therapy staff. As of this survey's exit (10/18/23) the facility provided no written statements from Nurse #2, MDS Nurse #1, or therapy staff. On 10/11/23 at 8:47 AM an interview with the Administrator indicated she received a phone call from the Admissions Director between 9:30 PM and 10:00 PM on 7/26/23 letting her know that Resident #71 was missing. She stated she immediately called Nurse #2 who told her they were looking for Resident #71. She went on to say she immediately called the DON who went to the facility and found Resident #71 in the locked MDS office. The Administrator stated when she came to the facility the next day (7/27/23), they did an investigation by talking to the people familiar with the incident to see if they could determine how Resident #71 was able to get into the office. She went on to say their investigation had been inconclusive. She further indicated because Resident #71 could have a conversation with her some days and somedays not she felt that maybe the door to the MDS office had been unlocked and Resident #71 had been able to get herself in there. On 10/12/23 at 10:27 AM an interview with Physical Therapist (PT) #1 indicated he was familiar with Resident #71 from treating her in PT. He stated Resident #71 was a high fall risk due to her impaired safety awareness. He went on to say being unsupervised in a locked office alone would place Resident #71 at high risk for a fall and injury. On 10/12/23 at 2:57 PM an interview with the Therapy Manager indicated she was familiar with Resident #71 from treating her in speech therapy. She stated Resident #71 was severely cognitively impaired as the result of her dementia. She went on to say while there had been a telephone in the administrative office, she would not think Resident #71 would have the cognitive ability to use the phone to call for help. The Therapy Manager stated she had never seen Resident #71 use a telephone. She went on to say based on what she knew of Resident #71, one of her biggest concerns was the simple fact that Resident #71 did not have the cognitive ability to move about in the space and she would just be sitting there. On 10/13/23 at 10:03 AM the Corporate MDS Consultant discussed reviewing the event of 7/26/23 involving Resident #71 this week. She stated in thinking about things, she recalled Resident #71 visited the MDS office at times before the event. She stated she felt this made it very plausible Resident #71 entered the MDS office herself on 7/26/23. On 10/13/23 at 10:31 AM in an interview Occupational Therapist (OT) #1 stated she was familiar with Resident #71. She went on to say residents with dementia had fluctuating cognition and while on one day they might not be able to do something, another day they could. She further indicated for residents with dementia, while their short-term memory might be impaired their long-term memory could be intact. OT #1 stated she felt that given enough time Resident #71 could have wiggled herself into the MDS office and done a squat pivot transfer. She stated she felt Resident #71 would have the cognition to try to move something that was in her way. On 10/12/23 at 3:15 PM a telephone interview with the Medical Director indicated he was familiar with Resident #71 and had been notified of her being missing on 7/26/23. He stated for residents with advanced dementia like Resident #71 it was common for them to go in and out of rooms. He stated the same way that these residents did not recognize family members anymore he did not think Resident #71 knew which room was hers and which room was not. He stated because Resident #71 would not have known the difference regarding whether she was in an office or her room, he did not feel it would have been psychologically upsetting for her. He stated his biggest concern was that staff had been unaware of where Resident #71 was. He stated this would not have been safe for Resident #71. The Medical Director further indicated because staff had been unaware of Resident #71's location, anything could have happened to Resident #71 including falls and other injuries. On 10/16/23 at 8:43 AM a telephone interview with Resident #71's Responsible Party (RP) indicated the facility had notified her on 7/26/23 that Resident #71 was missing. She stated they called her back later that evening to let her know Resident #71 had been found safe. She further indicated it was very upsetting for her to find out that Resident #71 had been locked in an office. She stated Resident #1 did not have the ability to lock or unlock doors and would not have been able to get out. The RP went on to say this would not have been safe for Resident #71 to be trapped alone where staff were not monitoring her. The Administrator was notified of Immediate Jeopardy (IJ) on 10/13/23 at 12:40 PM. The facility provided the following credible allegation of IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non- compliance: Resident #71 was found in the MDS office on 400 hall behind a locked door at 10:45 PM on 7/26/23 by the DON and local police. The facility administrator and Director of Nursing (DON) began an investigation into this incident on 7/26/23. Upon review by the Regional Clinical Nurse on October 11, 2023, this investigation was missing statements from MDS Nurse and Physical Therapist, Occupational Therapist, and Therapy Manager. These statements were obtained on 10/13/23. The results of this re-investigation concluded that the MDS door was not secured, and the resident did have the physical ability to enter the unlocked office. The resident was immediately assessed for physical injuries by the Director of Nursing. There were no identified injuries. Resident was laughing when the door was opened. Her psychosocial well-being was assessed by the in-house mental health provider, on 8/14/23. The facility social worker completed a trauma informed assessment on 8/9/23. The resident's psychosocial well-being was not affected and is still at baseline. The Regional Clinical Nurse and DON completed a review of facility investigations to ensure that the investigation was thorough on 10/13/23. This included a review of the incident logs and state reportables for the past 30 days. The facility administrator re-opened 1 investigation, 10/13/23 related to a reportable, as a result of the review. No other issues were identified. The Regional MDS Nurse reviewed Brief Interview of Mental Status (BIMS) scores for all current residents to determine who was classified as cognitively impaired. Of those residents, the facility therapy manager identified residents who are able to locomote independently. These residents have been identified as at risk of being behind an unlocked office door to include conference room, therapy gyms, kitchen, and other common storage rooms. This was completed on 10/13/2023. The facility licensed nurses, Nurse Aides, including agency, and administrative staff were educated on 10/13/23 by the Staff Development Coordinator and the DON that all office doors must be closed, locked, and secured when not occupied, in order to keep residents who are cognitively impaired safe. They were also educated on residents who are cognitively impaired and move independently about the facility are at increased risk of entering into unsupervised, unsecured areas. When a resident is identified in one of these areas, the resident will be encouraged to go to a more common, higher trafficked area for increased supervision. A review of the incident log for the last 30 days on 10/13/2923 by the Regional Clinical Nurse revealed no similar incidents in the facility. Specify action the fac[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident, staff, Physician, and pest control technician interviews the facility failed to control the presence of ants in the facility, maintain an effective pest control program, and to protect a vulnerable resident from having ants crawling on him while in bed. The resident sustained multiple ant bites/stings to his arms, torso, and upper back which resulted in the resident experiencing the discomfort of stinging and itching. Furthermore, the resident stated having ants in his bed, on him, and having been stung/bitten made him feel upset and like No one cared. The facility also failed to implement effective pest reduction measures when the ants were first observed on the resident by staff on 10-6-23. This occurred for 1 of 4 residents (Resident #1) observed for pest control. Immediate Jeopardy began on 10-6-23 when NA #1 first discovered red colored ants crawling on Resident #1's bed and person but had not reported the incident. Immediate Jeopardy was removed on 10-13-23 when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included paraplegia (which included numbness below the waist), bilateral above the knee amputation, and diabetes. The quarterly Minimum Data Set (MDS) revealed Resident #1 was cognitively intact and required total assistance with two people for bed mobility, total assistance with one person for dressing, toileting, and personal hygiene. Resident #1 was interviewed in conjunction with an observation on 10-9-23 at 12:13pm. The resident stated, I would be doing good if they would get these ants out of my room, so they quit crawling on me. Resident #1 discussed since last Monday (10-2-23) he had been reporting to staff ant activity in his room and told them the ants had been crawling on him and the bed. The resident stated no one had done anything except for one NA (NA #2) who, he stated, placed hot sauce in an area of the wall by the bathroom where the NA thought the ants maybe coming from and then placed a washcloth over the hot sauce to try and kill the ants. He explained he could not feel anything below his waist but had seen the ants crawling on his torso and arms. The resident also stated the ants had bit/stung him several times you can see the one on my arm and I have felt the stinging when they bite my back. Resident #1 stated he had also told the nurses (could not remember any names) since Sunday (10-8-23) he was itchy but said he had not received any medication to relieve his itching. Resident #1 voiced being frustrated and feeling like no one cares. During an observation of the resident, there was a small round reddened area on his upper left arm. There were no ants observed in the resident's room at the time of the observation and interview. A telephone interview was conducted with NA #1 on 10-10-23 at 3:15pm. NA #1 confirmed she had been assigned to Resident #1 on 10-6-23 during the 7:00pm to 7:00am shift. The NA discussed when she had gone into Resident #1's room to provide him care she had observed red ants crawling on the resident's bed and on the resident's torso and arms. She stated she wiped' the ants off the resident onto the floor and changed his linens. The NA stated she had seen ants a few weeks ago in the living room area and said she had reported it to the nurse on duty (could not remember which nurse). NA #1 said she had not seen any ant bites/stings on Resident #1 and stated she had reported the ants to the nurse (Nurse #2). NA #2 was interviewed by telephone on 10-10-23 at 3:19pm. NA #2 confirmed he had been assigned to Resident #1 on 10-7-23 and the evening of 10-9-23 from 7:00pm to 7:00am. The NA discussed Resident #1 informing him of having ants in his room and stated on 10-7-23 while in Resident #1's room providing care he saw red ants crawling on the resident's bed and body. NA #2 stated he cleaned the ants off Resident #1 by wiping them onto the floor with a washcloth and changed his linens. He also explained he thought the ants were coming from an area of the wall by the bathroom, so he stated he placed some hot sauce and a washcloth on the area of the wall in hopes to kill the ants. The NA stated it was after hours and he did not have access to any sprays to try and kill the ants. The NA stated on 10-9-23 he again saw ants on Resident #1's bed and body. NA #2 explained he washed Resident #1 and changed his linens. NA #2 said he did not observe any ant bites/stings on the resident and that he had reported the ant sighting on 10-7-23 to the nurse (Nurse #2). During a telephone interview with Nurse #2 on 10-10-23 at 3:33pm, the nurse confirmed she had been working the 7:00pm to 7:00am shift on 10-6-23 and 10-7-23. Nurse #2 also confirmed she had been made aware and saw the red ants on Resident #1's bed, torso, and arms both days. The nurse discussed assisting NA #1 in wiping the ants off the resident's bed, torso, and arms onto the floor. She said she had not seen any ant bites/stings on the resident's arms or torso, so she did not inform the Physician or provide any medical care. Nurse #2 stated she had not completed a full skin assessment but had just assessed Resident #1's arms and torso. The nurse stated she also had not informed anyone in management or maintenance of the presence of ants in Resident #1's room because I did not know who I was supposed to report to. Observation of wound care for Resident #1 occurred on 10-10-23 at 1:17pm with Nurse #4 and NA #3. Upon pulling back Resident #1's sheet, several red ants, too many ants to count, were seen crawling on the resident's bed and the resident's body. The red ants were crawling on Resident #1's arms, torso and into and out of his brief. Nurse #4 left the room to get the Maintenance Director and NA #3 left the room to get the Director of Nursing (DON). Upon return of the DON, Resident #1 was assessed for ant bites/stings and revealed a bite/sting to his left arm that was round, bright red approximately a centimeter in diameter and 4-5 ant bites/stings to the resident's upper back that were red and raised. Resident #1 stated he had felt the ants stinging/biting his back but that he was not currently itchy or in pain. Staff were observed to place the resident in his wheelchair and remove him from his room. The Maintenance Director was interviewed on 10-10-23 at 1:26pm. The Maintenance Director explained there was a maintenance logbook at each nursing station to record any pest concerns and/or maintenance issues. He stated he checked the logbook two times a day and said there had not been any reports of ants in Resident #1's room. The Maintenance Director discussed there were ants found over the summer in a resident room on the other side of the building and in the living room area a few weeks ago. He stated he had called the pest control company both times and they came and treated the areas. The Maintenance Director discussed the pest control company coming every 2 weeks to treat pests (not just ants) however he explained he did not have any invoices to confirm the treatments. Review of the maintenance logbook from August 2023 through October 2023 revealed no reports of ants in Resident #1's room however there had been reports of ants on 8-29-23 and 10-8-23 in other areas of the building. A follow up interview was conducted with the Maintenance Director on 10-10-23 at 1:45pm. The Maintenance Director discussed calling the pest control company and said they were on their way to treat Resident #1's room. Observation/interview of Resident #1 occurred on 10-10-23 at 5:23pm. Resident #1 was observed back in his room sitting in his wheelchair. Resident #1 stated he had not been back in his room long and that he had not seen any ants. He stated he had wheeled himself back into his room after activities and stated he was unaware he was supposed to go to another room until his room was treated. The resident also stated he was concerned about staying in the room because he did not know if the ants would return. Observation of the facility's center courtyard occurred on 10-10-23 at 5:27pm. There were 5 active ant mounds observed. There were 2 located by the door to the courtyard and 3 along the walkways in the courtyard. The ant mounds were not located near Resident #1's room. The Maintenance Director was interviewed on 10-10-23 at 5:37pm. The Maintenance Director stated the pest control company was not coming to treat Resident #1's room until 10-11-23. He stated he was not aware Resident #1 was back in his room and confirmed other than cleaning the room there had not been any treatment provided. During an interview with the DON, Assistant Director of Nursing (ADON) and the Corporate Nurse Consultant and Administrator on 10-10-23 at 5:43pm, the DON, ADON and the Corporate Nurse Consultant all stated they did not know who placed Resident #1 back into an un-treated room. The Administrator explained Resident #1 was supposed to be moved to another room. Nurse #3 was interviewed on 10-10-23 at 5:51pm. Nurse #3 stated she saw Resident #1 wheel himself back into his room. She said she had been told by maintenance or housekeeping (could not remember who) that the room had been treated so she allowed the resident to stay in his room. Review of Resident #1's medical record revealed a late entry note for 10-10-23 by Nurse #5. The nurse documented she had contacted the Physician regarding Resident #1's ant bites. She wrote there were no new orders, and the resident did not have any discomfort. The Maintenance Director and the pest control Account Manager were interviewed on 10-11-23 at 12:00pm. Upon observing Resident #1's room, where the ants had been seen, there were no ants present. The Maintenance Director stated he had treated the room on 10-10-23 with an over-the-counter ant killer. He clarified he had treated the room after he had been informed Resident #1 had returned to the room and stated he had not treated it beforehand because he knew the pest control company was coming to treat. The pest control Account Manager explained he could not know for certain what kind of ants were in Resident #1's room as there were no ants currently present. He did clarify that fire ants were the only ants that would bite without provocation. The pest control Account Manager discussed plans on treating the room on 10-11-23 and speaking with the facility on expanding their contract to cover the several active ant hills on the property. He stated he had observed the exterior of the building and had found 5 active ant hills in the courtyard and 7 active ant hills around the facility's perimeter. A nursing note written by Nurse #5 dated 10-11-23 at 6:48pm documented Resident #1 was itching a little and she observed 2 circular scabbed areas to the resident's upper chest. Nurse #5 wrote that she called the Physician and obtained new orders. Review of the Physician orders for Resident #1 revealed an order for Hydroxyzine (antihistamine medication) 25 milligrams by mouth every 8 hours as needed for itching. During a telephone interview with the Medical Director on 10-12-23 at 7:50am, the Medical Director discussed being informed by the facility on 10-10-23 of the ants and the ant bites on Resident #1. He explained when he spoke with staff on 10-10-23 Resident #1 was not having any itching or reaction to the ant bites, so he had not ordered any medication at that time. The Medical Director said on 10-11-23, staff had contacted him regarding Resident #1 complaining of itching and discomfort which was unrelated to the ant bites/stings, so he stated he ordered medication. The Medical Director said he would have expected staff to report the ant issue as soon they were aware and that there was a possibility of harm if Resident #1 had been allergic to the ant bites. The DON was interviewed on 10-13-23 at 10:03am. The DON discussed feeling there was a lack of education with staff on knowing who to report issues to and where the maintenance communication book was located. She stated if staff saw an infestation of ants in Resident #1's room on 10-6-23 and 10-7-23, staff should have contacted her and moved Resident #1 to another room. The DON said she expected staff to ensure residents safety and notify her of any situation involving the safety of residents if they do not know who to report to. On 10-10-23 at 7:15pm the Administrator was informed of the Immediate Jeopardy. The facility provided a credible allegation of Immediate Jeopardy removal on 10-13-23. The allegation of Immediate Jeopardy removal indicated: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non- compliance: On October 10, 2023, at approximately 2:30pm, it was reported by the survey team that an observation was made that resident #1 had ants in his bed. Resident #1 stated he reported the ants on 10/6/2023 and 10/7/2023 to a nursing assistant. CNA #1 (10/6) said last Friday she observed ants in his bed and on the floor. She said she changed the sheets, provided Activities of Daily Living (ADL) care, cleaned the floor, and did not notice any reddened areas on the resident. She indicated that she reported it to Nurse #1. CNA #2 stated on 10/7/23, she alerted Nurse #2 of the sighting of ants. Nurse #2 assisted CNA #2 in providing care and changing the sheets. Nurse #2 stated she was alerted to the ants by CNA #2 on 10/7/23. On exam, neither Nurse #1 nor Nurse #2 found reddened areas on Resident #1 that could be interpreted as a bite and the resident had no complaints of itching or discomfort on his upper extremities or lower torso. Nurse #1 nor Nurse #2 reported the sighting of ants to the Maintenance Director or facility Administrator after the incidents. Complete skin assessments were completed on all current residents on 10/10/2023 by the Director of Nursing and administrative nurses. No other abnormalities were found. Interviews were conducted by the facility Social Worker on 10/11/2023 with the alert and oriented residents and no further pest sightings were reported. Resident #1 was relocated from his room to another room on 10/10/23 by his assigned nursing staff. The Maintenance Director completed a treatment for Resident #1's original room with an approved pesticide for indoor insect elimination on 10/10/23 in late afternoon. Any resident had the potential to be affected by this alleged deficient practice. Specify action the facility will take to alter the process or system failure to prevent a serious outcome from occurring or recurring and when the action will be completed: A facility notification was mailed to each resident representative on 10/11/2023 to alert them to make sure all food brought in the facility to residents will need to be placed in a sealed container to prevent further sightings. Corporate Contractor completed a reeducation with the facility maintenance director on timely follow up of work orders, including pest control sighting logbook, on 10/12/23. The facility administrator will be completing a weekly review of maintenance work orders & pest control sighting logbook to confirm that all work orders and pest treatments have been completed in a timely manner. This will include at the time of a pest sighting the facility nursing staff will contact the maintenance director and/or assistant maintenance director; they will also add the pest/ant sighting in the pest control log located at each nursing station. The Director of Nursing (DON) and Maintenance Director met with the current facility staff, including clinical agency and contract (HK/Laundry/Rehabilitation) staff on 10/10/2023 to discuss reporting pest sightings and no other sightings were reported by staff. Current facility staff, including clinical agency and contract (HK/Laundry/Rehabilitation) staff will receive this training prior to being able to work on their next assignment. The Director of Nursing and Administrative Nurses ensures this education is being completed prior to employees being able to work at the facility. The Maintenance Director and the contracted pest control provider inspected the perimeter of the building on 10/11/23 for signs of active ant mounds, and any areas identified were treated with approved pesticides. On 10/11/23, the contract pest control company provided an inspection of the facility and was not able to identify the type of ant. This was evident in their report on 10/11/23. The Corporate Contractor and Maintenance Director completed an observation inspection of the interior and exterior of the facility on 10/12/23 and identified 5 active ant mounds in the courtyard and 7 on the exterior of the facility. The Corporate Contractor and Maintenance Director completed treatment of these areas. Also, the contracted pest control company provided additional treatment. The Maintenance Director developed Pest Sighting Logbooks on 10/10/2023 for each nurse's station so the staff can document any sighting. If there were any sightings noted on residents or in rooms, the Director of Nursing and Administrator will be notified immediately by the staff member upon discovery and the resident will be removed from the identified area. The Pest Sighting Logbook will be reviewed by the Maintenance Supervisor to assure the area where the sighting occurred has been treated. The DON and Maintenance Supervisor educated all staff beginning 10/10/23 on the pest sighting logbooks. All staff can document in the logbooks as they are available at each nurse's station. Current facility staff, including clinical agency and contract (HK/Laundry/Rehabilitation) staff will receive this training prior to being able to work on their next assignment. The Director of Nursing and Administrative Nurses are monitoring that this education is being completed prior to employees being about to work at the facility. The Maintenance Director and/or the Assistant Maintenance Supervisor initiated weekly pest control rounds on 10/10/2023 to include room, bed, bath and building perimeter. There were no other sights inside the building on 10/10/23. The facility has a contract with a pest control company. The pest control company will be providing weekly observations to ensure there are no further ant or pest issues. The pest control company was onsite 10/11/2023 to complete interior and exterior treatments. The pest control company found no further live ant activity in the facility in their report that was provided by the Maintenance Director on 10/11/23. They treated the facility for pests to include acrobat ants, American cockroaches, ants, [NAME] ants, Black widow spiders, brown banded cockroaches, cockroaches, German cockroaches, odorous house ants, oriental cockroaches, pavement ants, Pharoah ants and smoky brown cockroaches. The Director of Nursing and Maintenance Director provided education on 10/10/2023, for all staff, including agency, regarding reporting ant sightings immediately to facility supervisors and assessing residents for bites. If bites are found, the resident will be immediately relocated, and the identified room treated for infestation by the Maintenance Director or Assistant Maintenance Director. Employees will not be able to work until they receive this education from the director of nursing, administrative nurse and/or maintenance director. Any employee who does not receive this education will not be able to work until education is completed by DON, Administrative Nurse and/or Maintenance Director. The DON and/or administrative nurses will be responsible for ensuring that the employees receive this required education prior to working. Allegation of Immediate Jeopardy removal date: 10/13/23 On 10-13-23 the facility's plan for Immediate Jeopardy removal was validated by the following. Multiple residents had been interviewed and confirmed they had not seen ant activity in their rooms. Observation of resident rooms revealed no current ant activity. There were pest sighting logbooks located at each nursing station. Upon interviewing staff, staff stated they had received education on the pest sighting logbooks and reporting any pest sightings immediately. Verification of completed skin assessments on all residents were completed. The pest control company was observed on 10-11-23 and 10-12-23 as explained by the exterminator, to be treating ants in the building and on the facility grounds outside. The facility's Immediate Jeopardy removal date of 10-13-23 was validated.