**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #85 was re-admitted to the facility on [DATE] with a diagnosis of cerebral infarction (disrupted blood supply to the brain). A review of his admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. He had functional limitation in range of motion on both sides of his upper and lower extremities. He required substantial/maximal assistance to roll left and right in bed. Resident #85 was always incontinent of bladder. He had no falls since his re-entry to the facility. On 6/2/25 at 3:37 PM a review of an unsigned incident report provided by the Director of Nursing (DON) dated 10/9/24 at 7:12 PM revealed at 3:30 PM on 10/9/24 staff was assisting Resident #85 with incontinence care, Resident #85 rolled out of bed face down sustaining a small skin tear on his forehead. Resident #85's family member was at his bedside, and Emergency Medical Services (EMS) was called. On 6/5/25 at 3:45 PM a telephone interview with Nurse #5 indicated she responded to Nurse Aide (NA) #4's call for assistance with Resident #85 on 10/9/24. She stated when she entered Resident #85's room, he was lying on the floor on the left side of his bed which was positioned approximately 3 feet from the floor. She reported she completed vital signs and a head to toe assessment of Resident #85 and observed a small bleeding cut on his forehead. Nurse #5 went on to say Resident #85 was sent to the hospital for evaluation. She stated NA #4 reported to her that while she had been providing Resident #85 with incontinence care, he fell off the bed. Nurse #5 reported she did not recall receiving any in-service education after this incident regarding ensuring residents were positioned in the center of the bed and turning residents towards yourself rather than away from yourself when providing care. Multiple attempts at telephone interview with NA #4 were unsuccessful. NA #4 no longer worked at the facility. A review of Resident #85's hospital record for his admission to the hospital on [DATE] revealed in part Resident #85 presented to the emergency room at approximately 3:30 PM on 10/9/24 after falling face down while being turned at the facility. He had a small cut on his forehead. Diagnostic imaging studies of his head, spine, wrists, hands and knees did not reveal any abnormalities. Resident #85 returned to the facility on [DATE]. On 6/2/25 at 3:37 PM an interview with Resident #85's family member indicated there was an instance within the last year where Resident #85 fell out of bed when someone was turning him. She stated she was outside his room at the time, and while she did not witness the incident, she saw Resident #85 on the floor in front of his bed after he fell. She reported he was not complaining of any pain, but he had a small cut on his forehead from his glasses, and she asked that he be sent to the hospital. She indicated she was not aware of any other injuries from the incident. On 6/4/25 at 9:07 AM an interview with the Director (DON) indicated she was not the DON at the time of Resident #85's fall from bed during care on 10/9/25. She stated Nurse #6, who no longer worked at the facility, was the DON at the time of the fall. She went on to say there was an incident report regarding the fall, but she did not have an investigation file for the incident. A review of a Post Fall Investigation report dated 10/12/24 at 5:51 PM completed by Nurse #6 revealed in part Resident #85 had a fall in his room on 10/9/24. There was no additional information related to what steps were taken to investigate this fall. On 6/4/25 at 10:51 AM a telephone interview with Administrator #2 indicated he was the facility's Administrator on 10/9/24. He stated he did not recall Resident #85 having a fall from bed during care. He reported this would have been a serious incident, and an investigation would have been done. Administrator #2 stated residents should not fall out of bed when staff were providing care to them. On 6/4/25 at 2:27 PM a telephone interview with Nurse #6 indicated she had been the DON at the facility on 10/9/24 when Resident #85 fell out of bed during care. She stated an investigation had been conducted but she did not know where the investigation file would be. She reported the investigation revealed NA #4 had been providing Resident #85 with incontinence care by herself, did not have Resident #85 positioned in the middle of the bed, and turned Resident #85 away from herself during the care. Nurse #6 stated Resident #85 had rolled off the left side of his bed face first onto the floor. She went on to say Resident #85 sustained a small cut to his forehead and had been sent to the hospital for evaluation. On 6/5/25 at 3:34 PM a telephone interview with the Medical Director indicated she was Resident #85's facility physician. She stated all residents should receive care in a safe manner and Resident #85 should not have experienced a fall from bed during the provision of care. On 6/6/25 at 11:33 AM an interview with the Administrator indicated she was not the Administrator on 10/9/24. She stated she had looked, but did not have an investigation file for Resident #85's fall incident on that date. She reported residents should receive care in a safe manner and should not experience a fall from bed during the provision of care. Based on observation, record review, and interviews with family, staff, physician, Nurse Practitioner (NP), Medical Director, and the Director of Rehabilitation, the facility failed to prevent a resident with severe cognitive impairment and exit seeking behaviors from exiting the facility without supervision. On Saturday, 5/31/25, the Receptionist observed an elderly male (Resident #76) exit the facility behind a male resident who was discharging from the facility and a female family member who was moving that resident out. She did not recognize the elderly male as Resident #76, and she believed he was part of the discharging resident's family. Later that morning, as Nurse Aide (NA) #1 was driving in the community, she saw an individual who she thought looked like a resident walking without staff accompaniment approximately 0.7 miles away from the facility. She contacted the facility by phone, provided a description of the resident and staff who were working realized Resident #76 was missing. There was a high likelihood of serious harm, injury, or death for Resident #76 as the area he traversed included a well-travelled State Highway immediately outside of the facility's parking lot and multiple intersecting roads including a 4-lane intersection that was a major thoroughfare through the city. In addition, the facility failed to provide care in a safe manner when Resident #85 rolled out of bed during care and sustained a small cut to his forehead. These deficient practices affected 2 of 6 residents reviewed for accidents (Resident #76 and Resident #85). Immediate Jeopardy began on 5/31/25 when Resident #76 exited the facility without supervision. Immediate jeopardy was removed on 6/6/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Example #2 was cited at scope and severity level of D. The findings included: 1. Resident #76 was admitted to the facility on [DATE] with diagnoses which included dementia, psychotic disturbance, and anxiety disorder. A review of the elopement risk tool assessment dated [DATE] revealed Resident #76 was at low risk for elopement. A review of the care plan dated 4/28/25 revealed a focus area for Resident #76 being at risk for falls related to cognitive impairment, poor balance, and poor safety awareness and a focus area for Resident #76 being at risk for complications related to cognitive impairment with interventions that included reorienting resident as needed to person, place, time, and location. There was also a focus area also for the resident being at risk for adverse reactions related to the use of antipsychotics secondary to the diagnosis of delirium and dementia related behaviors. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #76 had severe cognitive impairment and no wandering or behavioral symptoms. He was assessed as needing moderate assistance walking 10 feet. He received antipsychotic medication and Physical Therapy services. Resident #76 found it very important to go outside to get fresh air when the weather was good. An interview with the Director of Rehabilitation on 6/4/25 at 1:41 PM revealed Resident #76 was provided with physical therapy services from 4/29/25 through 5/28/25. At the time of discharge from physical therapy, he walked 600 feet with supervision for safety. The nursing progress note written by Nurse #1 dated 5/30/25 at 10:23 PM revealed Resident #76 was exit seeking, became confused and started yelling at staff and forgot how to get back to his room. Once the resident was back in his room he began to calm down. Telephone interviews with Nurse #1 were conducted on 6/3/25 at 4:15 PM and 6/11/25 at 10:15 AM. She revealed she worked on 5/30/25 from 3:00 PM until 11:00 PM. She went on to say Resident #76 attempted to leave the facility on 5/30/25 at approximately 3:40 PM. She stated the resident was exit seeking, became confused and started yelling at staff and walking to the front exit door. Nurse #1 then placed herself between Resident #76 and the front exit door until the DON was able to redirect him and walk with him back to his room. She stated this was the first time she had witnessed his exit seeking behavior. Nurse #1 indicated she was an agency nurse and had not worked with Resident #76 often. The Director of Nursing (DON) was in the facility at the time Resident #76 exhibited exit seeking behaviors on 5/30/25. Nurse #1 reported that the DON asked Nurse #1 to call Resident #76's family to see if they would come and sit with him. The family did not answer her call. Resident #76 was in his room with a roommate, who was cognitively intact, and she (Nurse #1) checked on him often throughout her shift. Nurse #1 stated she did report Resident #76's exit seeking behaviors to the oncoming nurse. An interview with the DON was held on 6/3/25 at 4:30 PM, she revealed she did not recall Resident #76 exhibiting exit seeking behavior, but she felt he was only upset on 5/30/25. She stated Resident #27 said, I don't want to go to the pea patch. The DON then went with Nurse #1 to take the resident to his room. She added that she did not ask Nurse #1 to call the family as the facility provided one-to-one service if needed. A telephone interview with Nurse Aide (NA) #1 was conducted on 6/3/25 at 3:20 PM. She revealed on 5/31/25 she had left the facility via her car during her break and while she was enroute back to the facility she saw whom she thought might be a resident walking on the sidewalk towards a fast-food restaurant. She called the facility at 9:11 AM and spoke with the Receptionist to let her know his location and described the clothes he was wearing. She indicated at that point the Receptionist identified the resident as Resident #76. Nurse Aide #1 then turned the car around and sat with Resident #76 until Nurse #2 and the Receptionist arrived to pick him up. Resident #76 was wearing black pants, a purple T-shirt and tennis shoes. He was kneeling on one knee when she saw him. Nurse Aide #1 stated he appeared very tired but not overheated. He was easily redirected into the Receptionist's car. A telephone interview was conducted with the Receptionist on 6/3/25 at 3:30 PM. She indicated that prior to working as the Receptionist, she was an NA at the facility. She revealed there were several discharges at the facility on 5/31/25, the date Resident #76 exited the facility without staff supervision. A male resident was moving out with the assistance of a female family member. The Receptionist stated she observed the male resident and the female family member exiting the facility with an elderly male behind them and did not realize that this elderly male was a resident at the facility. She explained she thought Resident #76 was part of that resident's family. The resident was wearing black pants and a purple t-shirt and walked out behind the family members of the discharged resident. The Receptionist reported that she could not recall what time this happened. The Receptionist stated she went to get Resident #76 with Nurse #2 after NA #1 contacted the facility and the resident seemed very tired but not overheated. She stated Resident #76 was severely cognitively impaired and the road he was walking on was a highly traveled main thoroughfare from downtown Greenville, NC to Falkland, NC. The door that Resident #76 used to exit was the front entrance door to the building which was unlocked every morning at 8:00 AM until 8:00 PM. She added that the facility did not utilize a wander guard system. Follow-up interviews with the Receptionist on 6/4/25 at 10:20 AM and 6/11/25 at 9:30 AM indicated the admission Nurse would verbally tell the receptionists if there was a resident that they should be on the lookout for exit seeking behaviors. She revealed there was no photo book at the reception desk to identify residents at risk for elopement. The nursing note dated 5/31/25 at 9:15 AM written by Nurse #2 revealed Resident #76 was off the premises of the facility and was returned to the facility with no injuries. An interview with Nurse #2 on 6/3/25 at 2:15 PM revealed she gave Resident #76 his medication on 5/31/25 at 8:30 AM which was the last time she saw him prior to learning of the unsupervised exit. The Receptionist notified her at approximately 9:11 AM that Nurse Aide #1 had called the facility to make them aware of a resident was walking down the road. The facility staff were unaware Resident #76 was not in the facility. She went on to say she (Nurse #2) remembered Resident #76 coming to the nurse's station prior to this day and said he wanted to go see his family. Nurse #2 went with the Receptionist at approximately 9:15 AM to pick him up and he was located on a grassy area between the sidewalk and a restaurant. Resident #76 was found kneeling on one knee, wearing black pants and a purple t-shirt. When they returned to the facility, Nurse #2 assessed him and identified no injuries noted. A follow up telephone interview was conducted with Nurse #2 on 6/11/25 at 8:45 AM. She revealed she did not know, nor did anyone tell her that Resident #76 had been exit seeking on 5/30/25, the day prior to the elopement on 5/31/25. She went on to say she did not know Resident #76 well enough to know if he would have been safe outside without facility staff supervision, but she felt the road he walked along would have been dangerous for him. A telephone interview was conducted on 6/11/25 at 8:50 AM with NA #11. He stated he worked on 5/31/25 from 7:00 AM to 3:00 PM. He indicated 5/31/25 was his first shift working with Resident #76 and he was unaware the resident had exit seeking behaviors on 5/30/25. He also stated he last saw Resident #76 when breakfast was served but did not know the time. He was not aware Resident #76 was out of the facility prior to NA #1 calling the facility to alert the staff. According to the Global Positioning System (GPS) traffic application, the location Resident #76 was found to be approximately 0.7 miles from the facility. On 6/4/25, beginning at approximately 11:45 AM, the Surveyor walked approximately 0.7 miles from the facility to the location where Resident #76 was picked up by the staff on 5/31/25. The walk revealed the resident would have to walk through the facility's parking lot that contained loose gravel and multiple potholes. Directly outside of the facility's parking lot was a well-traveled 4 lane divided State Highway, NC 43, with a speed limit of 45 miles per hour. The highway had a sidewalk. Resident #76 would then have had to cross over the following intersections: a 2-lane entrance to an apartment complex; a 4-lane intersection at [NAME] Arlington Blvd., a major thoroughfare through the city with a traffic light and a crosswalk; an apartment complex entrance road and exit road; and a gated driveway entrance and exit to an assisted living facility. Along the route there were 2 large ditches on the side of the sidewalk: one ditch approximately 3 feet deep partially covered by brush/bush-like vegetation and one ditch approximately 12 feet deep containing water and rock. There was a large volume of traffic observed during this walk. The weather underground website shows it was 66 degrees Fahrenheit in Greenville on 5/31/25 at 9:15 AM. An interview with the Medical Director was conducted on 6/4/25 at 11:07 AM. She stated the facility reported the elopement with no injuries on 5/31/25. She went on to say something failed and there were always risks of injury when someone eloped from a facility. During a follow up interview with the Medical Director on 6/11/25 at 9:05 AM she revealed the Nurse Practitioner was more familiar Resident #76 and indicated she would be able to provide further resident specific information. An interview with the NP on 6/11/25 at 9:10 AM revealed Resident #76 had dementia. She indicated she could not say whether or not Resident #76 was safe to be outside of the facility without supervision, but she did say it was concerning. She stated the roads in the area were dangerous. She reported there was not any medical reason that would have triggered the new exit seeking behavior for Resident #76. In follow-up interviews with the Director of Nursing on 6/4/25 at 2:30 PM and 6/11/25 at 10:30 AM she indicated there was a receptionist at the front desk daily Monday through Sunday from 8:00 AM until 8:00 PM. She reported that the facility did not utilize a wander guard system. She stated prior to 5/30/25, there was no system in place to identify residents that were unsafe to exit the facility unsupervised. She revealed there should have been a picture of anyone with a high risk of elopement at the reception desk to prevent a resident at risk from going outside without supervision. She stated she felt the road Resident #76 traversed would not be a safe walk for someone with cognitive issues. She went on to say it was a well-traveled road with a high volume of vehicles daily. An interview with the Administrator on 6/4/25 at 4:25 PM revealed there should have been a sign on the door asking families to check with a nurse prior to letting a resident out of the facility to prevent residents from exiting the building. She went on to say a photo book should have been created to let the staff know any resident at risk for elopement. These books should have been at all 3 nurses' stations and at the reception desk. During a follow-up telephone interview with the Administrator on 6/11/25 at 10:51 AM she stated there were not any residents at risk of elopement prior to Resident #76's elopement on 5/31/25, therefore there was not a system in place to identify residents at risk. She revealed she felt the road Residents #76 was walking on was dangerous and that it was well traveled road with a high volume of vehicles daily. The facility provided a corrective action plan that was not acceptable to the State Agency as it did not address the issue of the Receptionist not being able to distinguish between residents and visitors and not being aware of what residents were safe to be outside without supervision. It additionally did not address how the facility would ensure staff were aware of residents who were at risk for wandering and exit seeking. On 6/4/25 at 8:40 AM the Administrator was notified of immediate jeopardy. The facility provided the following Immediate Jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non-compliance: Resident #76 was admitted on [DATE] with a diagnosis of muscle wasting, muscle weakness, dysphagia, anxiety disorder, abnormalities of gait and mobility and unspecified dementia. On 4/28/2025, an initial elopement assessment was completed by the Unit Manager that resulted in the resident being at low risk for elopement (referring to the act of an older adult leaving a safe environment without supervision). On 5/30/2025, a progress note written by the hall nurse identified Resident #76 as exit seeking. He was given a snack and drink, and he returned to his room to watch TV with his roommate. The hall nurse notified the Director of Nursing. He had no further behavior throughout the shift. At approximately 9:00 a.m. on 5/31/2025, Resident #76 was identified by a staff member driving by and thought she recognized the resident walking on the sidewalk about 0.7 miles from the facility. The resident at that time had not been reported as missing. The staff member that spotted him kept him in eyesight and stayed with him and called the facility. She spoke with the Receptionist and together they realized he was resident at the facility. The Receptionist alerted the nurse and together they immediately went and brought Resident #76 back to the facility. The Receptionist is a certified nursing assistant, however, has not worked as one in this facility since 5/19/2022 and was unfamiliar with the newer residents. The Receptionist observed Resident #76 exit the facility with other individuals who were visiting the facility, but she did not identify that he was a resident and therefore did not stop the resident from exiting. A full skin assessment was performed by the hall nurse on 5/31/2025 with no negative findings. The Responsible Party (RP) and physician were notified by the hall nurse, and new orders were obtained for urinalysis and a psychiatry consultation. The urinalysis resulted negative on 5/31/2025. The psychiatry visit was completed on 6/2/2025 with no new orders. Resident #76 was placed on one-on-one supervision until further notice while the social worker / discharge planner work with the family members to find a memory care unit. On 5/31/2025 the Administrator met with the Assistant Director of nursing, floor nurse and Receptionist and determined staff did not intervene with the resident's exit seeking behavior, nursing staff did not follow up on exit seeking behaviors the night prior to the elopement, and there was no wandering book at the front desk or nursing stations with residents with exit seeking behaviors pictures. The floor nurses completed a 100% head count of all residents; all were present and accounted for. On 5/31/2025, the Director of Nursing (DON) initiated an audit of resident progress notes to include Resident #76 for the past 14 days. The audit was completed with no other residents' issues identified. On 5/31/2025, the Assistant Director of Nursing (ADON) completed an audit of all wandering assessments to ensure assessments were completed accurately and to ensure all residents who triggered as at risk were care planned for wandering risk. No other residents were identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 5/31/2025, the Administrator & ADON initiated an in-service with all nurses regarding initiating an intervention if residents are exhibiting wandering behaviors or statements about seeking exit and notify the DON/ADON. On 5/31/2025 an in-service was also initiated by the ADON & Administrator with all staff, including agency staff, regarding not assisting any person known or unknown outside of the facility without checking with nursing staff to ensure the resident is safe to be outside unsupervised. The DON created on 6/4/2025 wandering books for all nurses' stations and the front desk with pictures and resident demographics for any resident identified to be an elopement risk. The Activity Director has placed pictures of residents from the wandering book on the bulletin board in the employee dining room to assist staff in identifying residents with exit seeking behaviors. The DON started all staff in-services on 6/5/2025 on the wandering books at the nurses' stations and the front desk and the notification board in the employee break room. Any new residents identified with exit seeking behaviors will be added to the wandering books and bulletin board along with being added to the Kardex used by the certified nursing assistants for charting care given. The Minimum Date Set (MDS) nurse will update the Kardex as residents are identified to be exit seeking. This in-service will be completed by 6/5/2025 and any staff who are not in serviced will be in serviced prior to their next shift. The ADON will be responsible for updating the wandering books at the nurses' station and front desk and updating the bulletin board in the employee dining room. The nursing staff that identifies the exit seeking behaviors will complete the Elopement Assessment in the electronic medical record as directed by the DON/ADON upon notification. The Regional Clinical Director in serviced the DON/ADON on 6/5/2025 on steps to direct the nursing staff upon any notification of exit seeking behaviors, these steps will include completing an Elopement Assessment. The ADON will then notify the MDS nurse to update the Kardex. All in-services will be completed by 6/5/2025. The Staff Development Coordinator (SDC) and Scheduler will be responsible for tracking staff needing an in-service prior to working. All in-services will be added to the orientation for all new staff to be completed by the SDC. A sign was placed on the front door on 6/4/2025 by the Administrator to alert any visitors or other family members not to assist anyone outside and to seek help from the receptionist. The Social Worker has drafted a letter to the families of current residents to remind them not to assist residents outside without checking with the nursing staff or the receptionist. This letter will be post marked 6/5/2025 and will be mailed on 6/5/2025 by the Social Worker. Alleged date of immediate jeopardy removal: 6/6/2025 Onsite validation of the immediate jeopardy removal plan was completed on 6/6/25 as follows: Review of the facility documentation revealed the facility completed an audit of resident progress notes for the past 14 days. Review of the facility education materials and sign-in sheets were reviewed to confirm that education was provided as indicated in the removal plan. Interviews were conducted on 6/6/25 with facility staff to confirm that education was received regarding elopement risk residents. Observed the elopement risk photo binders located on all 3 nurses' stations and at the reception desk. Observed the signs posted on the interior and exterior of the front door asking all visitors to check with a nurse prior to assisting residents outside. Observed the residents' photos at risk for elopement that were posted in the staff break room. Reviewed evidence of the letters that were sent to the families of current residents asking them not to assist residents outside without checking with a nurse or the receptionist. The facility's immediate jeopardy removal date of 6/6/25 was validated.