**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, family member, Resident, Physician Assistant, and Medical Director interviews, the facility failed to provide supervision for Resident #1 who had a diagnosis of dementia, an addiction to cigarettes, and required supervision/touching assistance for walking 10 feet. Resident #1 left the facility unnoticed and unattended, walking along the side of a 35 mile an hour two-lane road to obtain cigarettes at a nearby store. Resident #1 was located approximately 1/2 mile away from the facility standing in a grassy field near the side of the road. The walking route to where the resident was located included an upward sloping sidewalk, a downward sloping sidewalk with a pond to the left, and then a dirt path that ended at the edge of the grassy field. Resident #1 did not have a phone, money or means to pay for cigarettes and stated she had hoped someone at the store would be kind enough to give her a cigarette and a lighter. There was a high likelihood of a serious adverse outcome for Resident #1 who had a diagnosis of dementia when she left the facility unsupervised to obtain cigarettes and was walking along the side of a 35 mile an hour two-lane road. The deficient practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Findings included:Documentation on a hospital discharge summary for the hospitalization of Resident #1 from 5/15/2025 to 5/23/2025 provided the following information. Resident #1 had the life limiting illness of progressive dementia. Resident #1 resided with Family Member #2 before her hospitalization. Resident #1 had required more help with activities of daily living over the last few months and had declining memory. Resident #1 had a fall at home resulting in fractured multiple ribs on the left side and occipital hematoma. Resident #1 was to start taking five 0.5 milligrams (mg) tablets of haloperidol (an antipsychotic medication) orally at bedtime for the treatment of agitation. Resident #1 was to stop taking 21 mg of nicotine every 24 hours, in the form of a transdermal patch.Resident #1 was admitted to the facility on [DATE] from the hospital with diagnoses of closed fracture of multiple ribs on the left side, dementia, chronic obstructive pulmonary disease, and chronic kidney disease. Resident #1 was not admitted to the facility with an initial diagnosis of agitation. Resident #1's Family Member #1 was interviewed on 6/30/2025 at 4:43 PM. Family Member #1 revealed Resident #1 had dementia and was a strong-willed person. Family Member #1 further revealed Resident #1 could not read and ambulated with a shuffling gait. An interview was conducted with the Director of Admissions on 7/1/2025 at 8:46 AM and she provided the following information. Resident #1 had previously been admitted to the facility in September 2024 for 14 days. Resident #1 did not have any issues with the non-smoking policy of the facility during her previous admission in 2024. The hospital liaison, who requested a bed offer on behalf of Resident #1 to the facility for the most recent admission, was aware the facility was a smoke free facility. The Director of Admissions reiterated and explained to Resident #1 upon admission that the facility was a smoke free facility. Resident #1 completed her own admission paperwork. In addition, the family members of Resident #1 agreed Resident #1 was cognizant enough to complete her own admission paperwork. The Director of Admissions explained all the paperwork to Resident #1, and she seemed to understand. The Director of Admissions went over the non-smoking policy of the facility with Resident #1 who responded with acknowledgment that she already knew that. The Director of Admissions revealed Resident #1 was discussed during the morning meeting when she was first admitted because she was trying to get out of the building to go outside to smoke. The Director of Admissions was not aware Resident #1 did not know how to read and felt Resident #1 had answered questions appropriately. Documentation on admission observations completed on 5/23/2025 at 1:35 PM by Nurse #2 revealed Resident #1 had no identified risks for elopement. The admission observations indicated Resident #1 did not have any diagnoses indicating cognitive impairment. In addition, admission observations noted Resident #1 was a current smoker but intended to remain non-smoking. Documentation on the baseline care plan initiated 5/23/2025 listed a care plan problem for admission of Resident #1 to the facility for skilled care. One of the approaches under this care plan problem was for wandering, stating Resident #1 would be monitored to minimize the risk of wandering or eloping. Resident #1 had a physician's order initiated on 5/23/2025 for 0.5 milligrams of haloperidol to be administered orally in the amount of 5 tablets for a total of 2.5 mg at bedtime for the diagnosis of dementia, unspecified severity, with other behavioral disturbance. An interview was conducted with the weekend Receptionist #2 on 7/1/2025 at 9:17 AM, and the following information was revealed. The first weekend Resident #1 was at the facility (5/24/2025-5/25/2025), she came to the front of the building wanting to go out the front door. Receptionist #2 did not allow Resident #1 to go outside and told her she would have to contact her nurse to make sure it was okay. Resident #1 became very argumentative and took a swing at Receptionist #1. Resident #1 left very angry to return to her room because she was not allowed outside by Receptionist #2.An interview was conducted with the Activity Director on 7/1/2025 at 11:07 AM and the following information was obtained. The only activity Resident #1 participated in while she was at the facility was the coffee and snack cart every Tuesday. The only thing Resident #1 was interested in doing was smoking. The Activity Director brought the coffee and snack cart to the room of Resident #1 on the first Tuesday (5/27/2025) she was at the facility. Resident #1 told the Activity Director that she drank a pot of coffee every morning and smoked while she drank coffee. The Activity Director stated that she saw Resident #1 in the parking lot smoking in a car with her family members the first week Resident #1 was at the facility, noting this was against the rules of the facility. An interview was conducted with the facility's Social Worker on 7/1/2025 at 10:17 AM, and the following information was revealed. The facility had an interdisciplinary meeting/care plan meeting on 5/27/2025, during which input from Resident #1 and Resident #1's family members was considered as a part of the process for new admissions. Resident #1 was reminded that she was not allowed to smoke on the facility property, but family members could come and take her off the facility property if she wanted to smoke. Resident #1 was not happy about the facility's non-smoking policy and refused the offer for nicotine patches or nicotine gum. Resident #1's family members relayed to the Social Worker that Resident #1 was a smoker, and they could not come to the facility all the time to take Resident #1 off the property to smoke. Resident #1's family members requested that an alternate placement be found for Resident #1. The Unit Manager for the hall in which Resident #1 resided, Nurse #5, was interviewed on 7/1/2025 at 3:07 PM. Nurse # 5 stated that when Resident #1 was initially admitted to the facility, it was suspected she was smoking in the bathroom because staff reported they smelled smoke in her bathroom. Nurse #5 revealed that Resident #1 told him she had been smoking since she was [AGE] years old, and she was going to die smoking because she was addicted, and it was hard to stop. Nurse #5 indicated Resident #1 was discussed in the morning clinical meetings because everyone was not sure she should be allowed outside on her own due to her cognition. Nurse #5 stated Resident #1 was usually alert and oriented to herself but had some confusion. An interview was conducted with Nurse Aide (NA #3) on 6/30/2025 at 4:11 PM. NA #3 revealed he worked the 3:00 PM to 11:00 PM shift on the hallway where Resident #1 resided. NA # 3 revealed the first week Resident #1 was in the facility, a nurse found Resident #1 with a lighter and took it away from her. NA #1 could not remember which nurse it was. NA #3 stated he recalled getting a report from a nurse aide who worked the 7:00 AM to 3:00 PM shift that Resident #1 was suspected of smoking in her bathroom because they smelled smoke in her bathroom. NA #3 reported that Resident #1 would get very frustrated at times because she wanted to try to get out the front door, but the doors lock after 5:00 PM and would not open without a code. NA #3 revealed that Resident #1 would tell him she wanted to go outside to go home to smoke. Documentation in a Situation, Background, Appearance, and Review (SBAR) dated 5/28/2025 at 3:15 PM for Resident #1, written by Nurse #4, revealed the situation or change in condition was increased agitation. The SBAR further revealed in the nursing notes portion of the document, Resident (#1) had increased agitation on wanting to smoke a cigarette. The floor nurse offered to get Resident (#1) a nicotine patch. Resident (#1) kept stating she would just leave and walk home and started to pack her belongings. Family notified and stated they would come in and talk with Resident (#1). Nurse #4 was interviewed on 7/1/2025 at 10:39 AM, and she revealed the following information. On 5/28/2025 Resident #1 was trying to get outside to smoke. Resident #1 had previously been suspected of lighting a cigarette in her bathroom on the 7:00 AM to 3:00 PM shift on that day. Staff said they smelled cigarette smoke in her bathroom, and Resident #1 was quickly flushing something down the toilet when she was confronted. A search in her belongings for cigarettes or a lighter was not conducted because Resident #1 was an alert and oriented resident. Nurse #4 explained that the Physician Assistant (PA) #1 was made aware and an order for the antipsychotic Haloperidol administered intramuscularly for Resident #1 was obtained. Resident #1 was irate and wanted to go outside to smoke. A Family Member #2 was called by Nurse #4, and she could not come to the building, so another Family Member #3 was sent to try to calm Resident #1 down. Nurse #4 had already stayed past the end of the shift, ending at 3:00 PM, to try to calm Resident #1 down, so she left before the arrival of Family Member #3. The Director of Nursing (DON) and Nurse #3 were assisting to try to calm Resident #1 down. Nurse #4 spoke with Resident #1 the following day, 5/29/2025. Resident #1 told Nurse #4 that she was so mad she was not allowed to go out and smoke the previous day, she threw her cell phone at Family Member #3 and broke it. Resident #1 told Nurse #4 she was sorry because she no longer had a functional phone. The DON was interviewed on 6/30/2025 at 12:15 PM. The DON revealed she witnessed part of a confrontation Resident #1 had with Family Member #3 next to the front office. The DON stated the argument was about cigarettes, and Resident #1 was being very physical. The DON indicated Resident #1 put her hands around the neck of Family Member #3, and Family Member #3 threw her hands down fast from her neck. The DON did not recall what day it was that she witnessed the confrontation. Nurse #3 was interviewed on 6/30/2025 at 12:18 PM. Nurse #3 revealed PA #1 was contacted on 5/28/2025 because Resident #1 was getting very agitated. Nurse #3 revealed the provider gave an order for 5 milligrams (mg) of haloperidol lactate to be administered intramuscularly (IM) via syringe every two hours as needed. Nurse #3 revealed Resident #1 did not receive the IM haloperidol on that day because it was decided she would be given her scheduled 2.5 mg tablets of haloperidol by mouth earlier, instead of at bedtime. Nurse #3 added that if Resident #1 had been allowed to smoke, she would have been fine. PA #1 was interviewed on 6/30/2025 at 2:04 PM. PA #1 explained that Resident #1 was having early symptoms of dementia such as sundowning while she was at the facility. PA #1 revealed she was notified by the Unit Manager, Nurse #5, that Resident #1 was showing physical aggression, agitation, and combativeness. PA #1 further explained Resident #1 did not have a formal diagnosis of dementia, but it was suspected she had underlying dementia. PA #1 stated Resident #1 was very agitated because she was not allowed to smoke so the order for haloperidol was for her suspected dementia and her agitation. Documentation on a care plan problem area initiated on 5/29/2025 revealed that Resident #1 had impaired cognitive function, impaired thought process relative to a diagnosis of dementia. The interventions were: use of simple, direct statements during communication to ensure resident understood; provision of cueing and prompting to ensure resident made attempts about own care before offering assistance; provision of a calm and relaxing environment; monitoring/observation and reporting changes in cognitive status; medication per physician orders; laboratory tests per physician orders; explanation of each activity/care procedure prior to beginning it and throughout procedure; establishment of daily routine; ensure resident's physiological needs were met; completion of BIMS (Basic Interview Mental Status) with MDS (Minimum Data Set) schedule and as needed; and anticipation of needs and observe for non-verbal cues.Documentation on a care plan problem area initiated on 5/29/2025 revealed Resident #1 had a health and safety risk relative to smoking. The interventions under this problem were to ensure Resident #1 was aware of the no smoking policy in the community, consultation with a medical professional for the possible use of transdermal nicotine patches to facilitate quitting, encouragement to express feelings/frustrations, and offering of a smoking cessation program.Documentation on the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was coded as cognitively intact. Resident #1 was coded as having non-Alzheimer's dementia, depression, and nicotine dependence on the assessment. The same assessment coded Resident #1 as having physical behaviors one to three days, verbal behaviors one to three days, rejection of care one to three days, and wandering behavior one to three days of the assessment period. Resident #1 was coded as using a walker and a wheelchair requiring supervision/touching assistance for walking 10 feet. The assessment coded Resident #1 as currently using tobacco.The Verification of Receipt of the Resident Handbook for the facility was signed by Resident #1 on 5/30/2025. The signature of Resident #1 verified she received a copy of the resident handbook that gave information pertaining to the rules of the facility, to include the no smoking policy on the facility property.Documentation on a care plan problem area initiated on 6/1/2025 revealed that Resident #1 required a supervised leave of absence related to dementia and impaired mobility. The interventions under this care plan problem were the education of the resident and/or family members on leave of absence policy/procedure, obtaining an order for leave of absence indicating either supervised or unsupervised leave of absence, and Resident #1's family/friend/responsible party to sign resident in or out and notify the nurse when leaving and returning with resident.An interview was conducted with the Speech Therapist #1 on 6/30/2025 at 4:35 PM. Speech Therapist #1 stated she knew Resident #1 had a diagnosis of dementia. Speech Therapist #1 relayed that on 6/2/2025, Resident #1 asked her to take her to the nearby store to get cigarettes. Speech Therapist #1 explained she told Resident #1 she was not allowed to take her from the building and reminded her of the facility no-smoking policy. Speech Therapist #1 stated she did not call a family member to tell her of the plan Resident #1 had to go to the nearby store to get cigarettes.Documentation in an MDS progress note dated 6/3/2025 at 9:01 AM, written by Nurse #1, revealed the following information. Resident #1 had wheeled herself independently outside to the front of the building with a cup of coffee. Nurse #1 informed Resident #1 that she would have to sign out if she was leaving the building, and she verbalized her understanding. Nurse #1 visualized Resident #1 park her wheelchair and lock the wheels. Nurse #1 made the staff aware that Resident #1 was outside.Nurse #1 was interviewed on 6/30/2025 at 9:57 AM. Nurse #1 confirmed she saw Resident #1 outside in front of the building on 6/3/2025. Nurse #1 revealed she informed the Director of Nursing and the Administrator at the morning stand-up meeting that Resident #1 was outside, sitting in the front of the building. Nurse #1 said she also sent an electronic message at 8:57 AM to alert the leadership that Resident #1 was outside, for which Nurse #5, the unit manager, reacted to the alert with a thumbs up.Nurse #2 was interviewed on 6/30/2025 at 10:18 AM and revealed the following information. Nurse #2 recalled she saw Resident #1 on the morning of 6/3/2025 with her coffee cup in her room during her morning medication administration pass. As the nurse aides were picking up the breakfast trays from the resident rooms, a therapist (Occupational Therapist (OT) #1) asked Nurse #2 where Resident #1 was. Nurse #2 told OT #1 that she did not know where Resident #1 was.OT #1 was interviewed on 6/30/2025 at 11:19 AM. OT #1 stated she was looking for Resident #1 on the morning of 6/3/2025, but she was not in her room. OT #1 stated she went on to provide therapy services to another resident and did not look for Resident #1. OT #1 revealed that later that day when she saw Resident #1, she told her she had left the building to obtain cigarettes at a nearby store. OT #1 indicated she had no knowledge of Resident #1's absence from the facility prior to that. OT #1 also indicated Resident #1 was a very independent person who was able to do all her activities of daily living but required supervision. OT #1 explained that Resident #1 was very motivated to do therapy, progressed quickly, and was cooperative.Receptionist #1 was interviewed on 6/30/2025 at 12:01 PM. Receptionist #1 explained that a part of her front desk responsibilities was to keep a written log of times the residents leave the building and the time they return inside. Receptionist #1 consulted her log and stated that on 6/3/2025, Resident #1 left the building at 8:54 AM and sat in front of the window in her view from her desk and reentered the building at 9:08 AM. Receptionist #1 stated Resident #1 told her she was going to her room to get a sweater. Receptionist #1 revealed she documented on the log that Resident #1 went back outside at 9:37 AM in her wheelchair on the other side of the front of the building so that she was not in the view of her desk.Nurse Aide (NA) #1 was interviewed on 6/30/2025 at 10:53 AM and relayed the following information as occurring on the morning of 6/3/2025 between 9:00 AM and 10:00 AM. NA #1 and NA #2 were giving a shower to a resident who required assistance from two people. NA #1 and NA #2 came out of the shower room, with the other resident, returned him to his room, and noted Resident #1 was standing at the nurses' station next to her wheelchair. NA #1 and NA #2 were in the other resident's room assisting him with care and exited his room together upon completion of care. Then, as NA #1 and NA #2 were walking down the hall, they noted Resident #1 was not in her room. NA #1 and NA #2 went to look in the therapy room to see if she was in there, and they did not find her. NA #1 and NA #2 knew that Resident #1 liked to sit outside, so they went to the front of the building. NA #1 and NA #2 asked Receptionist #1 if she had seen Resident #1. Receptionist #1 told NA #1 and NA #2 that Resident #1 was sitting outside in her wheelchair. NA #1 and NA #2 went outside and saw Resident #1's empty wheelchair in the front of the building. NA #1 and NA #2 went back into the building and ran back to the hall to tell Nurse #2 that Resident #1 was missing. After speaking to Nurse #2, NA #1 and NA #2 ran to the back of the building and out the door to look for Resident #1 in all the doorways and parking lots around the building. NA #1 stated that Resident #1 was dressed in a purple sweatsuit and shoes on the morning of 6/3/2025.NA #2 was interviewed on 6/30/2025 at 11:25 AM. NA #2 explained the same series of events as happened on the morning of 6/3/2025 that NA #1 had relayed in her interview regarding Resident #1 leaving the facility.Receptionist #1 was interviewed on 6/30/2025 at 12:01 PM and relayed the following events. NA #1 and NA #2 came to the front of the building and asked Receptionist #1 if she knew where Resident #1 was. Receptionist #1 told them she was sitting outside in the front of the building in her wheelchair. NA #1 and NA #2 hurried back into the building after checking outside, saying Resident #1 was not in front of the building. NA #1 and NA #2 ran to the back of the building. Receptionist #1 then received a phone call from either a family member or a friend of Resident #1 telling her that Resident #1 was at a nearby store getting cigarettes. The caller also told Receptionist #1 they were going to call the police. The Business Office Manager came to Receptionist #1's desk and asked her what was happening. After telling the Business Office Manager about the phone call, the Business Office Manager told the Maintenance Director to come with her in her car and run outside to the parking lot.The Business Office Manager was interviewed on 6/30/2025 at 10:39 AM and provided the following information. The Business Office Manager overheard Receptionist #1 talking with someone with alarm and concern in her voice, so she went to Receptionist #1's desk to find out what was happening. The Business Office Manager asked Receptionist #1 if the facility had a resident at the nearby store. The Receptionist lowered the phone and told her it was Resident #1. The Business Office Manager grabbed her car keys, saw the Maintenance Director, and told him to get in her car. When the Business Office Manager got to her car she saw NA #1 and NA #2 running around the side of the building, and the Maintenance Director was still in front of the building. The Business Office Manager told NA #1 and NA #2 to get in her car, realizing that the only reason they would be outside of the building was to look for Resident #1. The Business Office Manager drove her car up the road and saw Resident #1 standing on the grass on the left-hand side of the road, approximately half a mile from the facility. The Business Office Manager parked her car in a parking lot across the street. NA #1 and NA #2 exited the vehicle, crossing the street to get to Resident #1. Resident #1 was in a good mood and confirmed she was not injured. NA #1 and NA #2 assisted Resident #1 into her vehicle, and they all returned to the facility. As they pulled into the facility, a police car pulled in after them, stopping only momentarily to make sure they had Resident #1.The following observations were made outside on 7/1/2025 at 8:25 AM of the route, walking environment, and road speed limit taken by Resident #1 to the nearby store based on the information provided by the Business Office Manager on 6/30/2025 at 10:39 AM. Resident #1 would have had to start on an upward sloping sidewalk after exiting the facility. The sidewalk passed by a downward sloped area with a pond off to the left. Directly after the pond, the sidewalk ended, and a dirt path continued next to a forest of trees close to the road. The dirt path was uneven and continued to gradually slope uphill. After approximately a 15 to 20 minute walk, the dirt path ended at the edge of a grassy field, where Resident #1 was located on the morning of 6/3/2025. Beyond the grassy field, another 10-minute walk, was a shopping center with parking lots and intersecting roads. The posted speed limit on the road next to the facility was 35 miles per hour.Documentation on a historical weather data website revealed on 6/3/2025 there was no precipitation and temperatures at 9:00 AM were 69 degrees Fahrenheit in the location of the facility.Documentation in a nursing progress note dated 6/3/2025 at 10:35 AM written by Nurse #2 revealed the following information. Nurse #2 spoke with Resident #1's daughter advising her that Resident #1 left the front part of the building to walk to the local store to obtain cigarettes. Resident #1 was transported back to the facility by staff with a police escort. Resident #1 was assessed with no acute injuries.Nurse #2 was interviewed on 6/30/2025 at 10:18 AM. Nurse #2 explained that NA #1 and NA #2 ran to her on 6/3/2025 and told her Resident #1 was missing. Nurse #2 stated she locked her medication cart and ran to the front of the building to discover the Business Office Manager was running out the door to retrieve Resident #1 from the nearby store. Nurse #2 revealed she waited outside in front of the building with Resident #1's wheelchair, and when she returned, Nurse #2 did a quick assessment to be sure she was not injured. Nurse #2 then returned Resident #1 to her room to complete a full assessment to include neurological checks, skin assessment, and vital signs. Nurse #2 revealed she had a long talk with Resident #1, who explained to her she just wanted to get some cigarettes and smoke. Nurse #2 discovered from Resident #1 that she had called somebody who was not her daughter and told them she was going to the nearby store for cigarettes despite not having any money. Nurse #2 confirmed she called Resident #1's family members to tell them of the morning events and that Resident #1 was okay.Resident #1 was interviewed on 7/1/2025 at 1:37 PM. Resident #1 confirmed she recalled the events of 6/3/2025 when she tried to walk to a nearby store from the facility. Resident #1 stated, I've lost some of my [curse word] mind, but not all of it. Resident #1 confirmed she did not have a phone, and she was not injured on that day. Resident #1 denied she called her family on 6/3/2025 and would have cussed out who notified the facility she left the faciity on that day. Resident #1 explained she was good at walking and all she wanted was a cigarette. Resident #1 acknowledged she did not have any money or means of paying for cigarettes that day, and she did not know how she was going to obtain cigarettes on that day. Resident #1 indicated she had hoped someone at the store would have been kind enough to give her a cigarette and a lighter.Family Member #1 was interviewed on 7/1/2025 at 8:28 AM. Family Member #1 revealed Resident #1 had been smoking since she was [AGE] years old, and prior to her hospitalization, she smoked a pack of cigarettes a day or every two days. Family Member #1 also revealed that Resident #1 was not allowed to smoke when she was in the hospital, but it was not a problem. Family Member #1 confirmed Resident #1 had no means of paying for cigarettes and did not have a personal phone on 6/3/2025.Family Member #2 was interviewed on 7/1/2025 at 2:43 PM. Family Member #2 revealed she was out of town when she was called by the facility on 6/3/2025, notifying her that Resident #1 had left the faciity on her own to try to obtain cigarettes. Family Member #2 said the facility asked her to come to the facility because Resident #1 was very upset that she could not go to the nearby store. Family Member #2 said Resident #1 had only one thought, and that was how she was going to get a cigarette that day.The DON was interviewed on 6/30/2025 at 8:15 AM. The DON explained that the facility was a smoke-free facility, and the family of Resident #1 was aware of this before she was admitted . The DON stated that Resident #1's family and Resident #1 both said she would not smoke while she was at the facility, or they would take her off the property to smoke. The DON further explained that staff members who smoke or residents who were smokers at the time of the transition to a non-smoking facility, had to go to the edge of the facility property and stand in a field to smoke. The DON confirmed there was no smoking on the facility property to include the parking lot. The DON acknowledged that Resident #1 was adamant about smoking cigarettes and refused any nicotine gum or patches after she was admitted . The DON also acknowledged that Resident #1 was not safe to walk by herself outside. The DON explained that Resident #1 was alert and oriented and had a strong personality, so multiple conversations were had with the family to try to resolve the issue of the facility being smoke-free.The facility Administrator was interviewed on 7/1/2025 at 1:17 PM. The Administrator stated Resident #1 had a plan and she was aware she did not have any money on 6/3/2025. The Administrator stated that Resident #1 told her she was going to have someone give her a cigarette at the local store.The facility Medical Director was interviewed on 7/7/2025 at 11:16 AM. The Medical Director stated that he saw Resident #1 one time upon admission. The Medical Director relayed that he knew cognition was an issue for Resident #1, as she had sufficient cognitive skills to leave the building undetected with a purposefully executed plan, but lacked the cognitive skills to realize it was a poor decision.The facility was notified of the immediate jeopardy on 7/1/2025 at 4:00 PM.The facility provided the following corrective action plan: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 6/3/25 Resident #1 had an unsupervised departure from the facility. She walked down the side of a two-lane road to obtain cigarettes from a local grocery store. Resident #1 was visualized going outside on to the covered porch to drink coffee around 8:54am and was observed around 9:37am going back outside after getting a sweatshirt. The receptionist received a phone call from the resident's family member stating Resident # 1 had called her to report that she was walking to the store to obtain cigarettes. The business office manager and two certified nurse assistants got into a vehicle and observed resident #1 walking on the side of the road. Resident #1 got into the vehicle with staff and returned to the facility at approximately 10:00am. A licensed nurse completed a head-to-toe assessment on resident #1 and no injuries were noted. The provider was notified, and an order was obtained to place a wander guard alarm, and resident #1 was also placed on 1:1 supervision by facility staff as an immediate intervention to keep Resident #1 safe. Resident #1 remained on 1:1 staff supervision until she was discharged on 6/5/25 to an Assisted Living Facility that allowed smoking. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 6/3/25 when the facility was made aware that resident #1 had departed the building unsupervised the director of nursing completed an immediate head count of other residents in the facility, all other residents were accounted for. The maintenance director immediately checked door alarms and the wander guard system. Doors and the wander guard system were found to be in working order. The director of nursing and nurse managers reviewed current residents with a wander guard alarm to ensure that their wander guards were in place and functioning correctly. No issues were identified. The director of nursing or designee reviewed all residents in the facility for changes in behaviors and completed another elopement assessment. There were no other residents newly identified at risk for elopement. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Beginning 6/3/25 the director of nursing or designee educated all staff in the facility on the facility elopement policy. 1. Upon discovery that a resident cannot be located a head count will be conducted. If the resident is still missing a code green is to be announced on the facility paging system to alert all staff to assist in locating the missing resident. 2. The clinical supervisor will notify the Administrator, the Director of nursing and the attending physician. 3. The highest-ranking staff member will become the team leader and coordinate the search. 4. The

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, ombudsman, family, friend, staff, the Home Health Nurse, and Adult Protective Services Social Workers interviews the facility failed to develop and implement an effective discharge planning process for 1 of 3 residents, Resident #1, by not assessing the home environment which was described as not safe by the resident and family, discharging the resident to home where the resident did not have a functional phone to contact people or 911 in the event of an emergency and arranging for individuals who would be able to obtain the resident's prescription medications and assist with basic Activities of Daily Living (ADLs) such as transfer from the couch to a wheelchair, toileting, peri-care, meal preparation, and bathing. The facility failed to realize the risk the resident was being placed at by being discharged to home without on-site assistance despite adult protective services being involved with the resident, family members stating the resident would be unable to care for himself, the resident not being able to function independently at the facility, and the resident stating he was not comfortable with being discharged to home by himself. Resident #1 lacked community resources and a dedicated support network to provide at-home support and was without assistance except for a friend delivering a meal from the time the facility dropped him off until Adult Protective Services (APS) arrived in the evening of 2/27/24. APS contacted emergency transport services to send Resident #1 to the hospital emergency department. Upon admission, Resident #1 was noted with bedbugs, weakness, lower extremity edema and high blood pressure. Resident #1 described feeling worried, humiliated, isolated, and helpless. Immediate jeopardy began on 2/27/24 when Resident #1 was discharged to his residence without caregiver support. The immediate jeopardy was removed on 03/22/24 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 a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: Resident #1 was admitted to the facility on [DATE] after a hospitalization for continuation of intravenous antibiotics for an infection following a surgical procedure. Resident #1's care plan dated 01/16/24 revealed a focused area for discharge to the community, with a goal that the resident would have a safe discharge back to the community. Interventions for the focused area included to involve specialized home health care agencies, and appropriate community support services, provide resident and family with written instructions upon discharge, periodically reevaluate resident's capabilities to return to the community, and upon discharge resident and family will receive written discharge instructions to enable a safe return to the community. A facility social worker (SW) progress notes dated 01/18/24 at 9:04 PM revealed a care plan meeting was held, and the resident's plan was to return home. The SW documented the Resident had not had home health in the past and had no equipment at home. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact with diagnoses that included infection following a procedure, hypertension, heart disease, muscle weakness, peripheral vascular disease, and presence of coronary angioplasty implant and graft (A stent graft is a small metal coil or mesh tube that is placed in an artery thickened with a buildup of plaque which has decreased the flow of blood and oxygen to the heart). The MDS indicated he had a discharge plan and the local contact agency had not been contacted. A review of the SW progress notes revealed she documented that she issued four Notice of Medicare Non-Coverage (NOMNC) with the last dates of care as 02/05/24, 02/08/24, 02/18/24, and 02/22/24. On 02/02/24 at 6:16 PM the SW documented that she and the Business Office Manager (BOM) spoke with the resident's family member. The family member stated he would not take the resident home to his house in his condition. The family member explained he could not take care of the resident. The SW documented the family member stated if the facility discharged the resident to his house, he would call adult protective services. The SW documented the resident was stand by assist (SBA) and contact guard assist (CGA - The person can do the transfer or self-care task with the caregiver providing a light touch (hence the term contact guard) for safety). The SW documented the resident was SBA to CGA in therapy as that time. The SW's note stated the resident's family member voiced he was going to do an appeal. On 02/06/24 at 10:39 AM The SW documented a NOMNC was issued with the last covered day of 02/08/24. The note revealed the resident did not want to go back to his house due to it not being safe. The note further revealed the family member was in the process of trying to find a facility closer to him where they could take the resident. The SW documented Medicaid pending. On 02/15/24 at 4:09 PM the SW documented a NOMNC was issued with the last covered day of 02/18/24. The resident's family member was notified as well. The resident was given contact information to KEPRO, the organization responsible for beneficiary review and skilled service termination appeals and a copy of NOMNC as well. On 02/20/24 at 12:53 PM the SW documented a NOMNC was issued with the last covered day of 02/22/24. The note read that the SW left a voicemail for the resident's family member. The note stated the resident, and his family member were informed that placement had not been found. The SW note further indicated the facilities she had contacted or left voicemails for the facility and the facility had declined admission, or she had not received a response from them. The SW note included she had given the resident and his family member information regarding the care patrol (a senior care advisory organization that help families find senior care solutions for their family member when living at home alone is no longer a safe option following hospitalization, a change in health, or due to the natural aging process) to help with placement. A review of the Physician's Order written on 02/26/24 at 4:16 PM revealed Resident #1 was to be discharged on 02/27/24 with Physical Therapy/Occupational Therapy evaluation and therapy as indicated, Home Health Agency to help with personal care as needed, Skilled Nurse for medication management/wound care, and a Social Worker for possible treatments/needs. On 02/26/24 at 5:08 PM the SW documented she received fax notification on the resident's reconsideration from KEPRO and the resident lost. The Resident was informed of this notification and was also told that starting on 02/23/24 he was considered as private pay. SW documented she called the resident's family member and his friend to inform them as well. The note revealed the resident, his family member, and his friend were aware he would be discharged on 02/27/24 with a transport time of 10:30 AM. The SW notes she spoke with the resident's friend about the copays that needed to be paid before his wheelchair and walker would be delivered. The note stated the friend voiced she would make the copay since she was the one who managed his money. The SW noted she would continue with discharge planning. On 03/18/24 at 10:28 AM an interview was conducted with the Adult Protective Services (APS) SW #1. She stated APS had received a report of self-harm due to Resident #1 living in an unsafe dwelling prior to admission to the facility and the facility's plan to discharge the resident back to that environment. She was informed Resident #1 resided in the facility and she entered the facility on 02/09/24 at 3:15 PM. She stated she announced herself at the front desk and she was wearing her APS SW badge. She stated she went to the nurses station where there were multiple staff at the nurse's station and was pointed in the direction of Resident #1's room. She said Resident #1 told her he wanted to go to a long-term care facility near his family. He said they had been doing therapy on his legs and it was helping but he was still very weak. The APS SW #1 stated at that time Resident #1 did not have a set discharge date . She stated multiple attempts to inform the facility SW of the open APS case by phone and voice mail were unsuccessful. The APS SW had not visited Resident #1 in his home. A review of the medication review report dated 02/26/24 at 4:25 PM revealed Resident #1 was prescribed the following medications upon discharge: -Acetaminophen ER Oral Tablet Extended Release 650 MG Give 1300 mg by mouth every 24 hours as needed for pain - Albuterol Sulfate HFA Inhalation Aerosol Solution108 Oral (90 Base) MCG/ACT (Albuterol Sulfate) 2 puffs inhaled orally every 6 hours as needed for chronic obstructive pulmonary disease - Amlodipine Besylate Oral Tablet 2.5 MG Give 1 tablet by mouth one time a day for hypertension - Aspirin Oral Tablet Delayed Release 81 MG Give 81 mg by mouth one time a day for heart health - Atorvastatin Calcium Oral Tablet 40 MG Give 40 mg by mouth at bedtime for hyperlipidemia - Bisacodyl Suppository Insert 10 mg rectally as needed for constipation - Docusate Sodium Oral Capsule 100 MG Give 1 capsule by mouth every 12 hours as needed for constipation - Sodium Phosphates enema Insert 1 application rectally as needed for constipation - Hydralazine HCI Oral Tablet 25 MG Give 25 mg by mouth three times a day for hypertension - Lasix Oral Tablet 20 MG Give 1 tablet by mouth every 24 hours as needed for edema - Metoprolol Succinate Oral Capsule ER 24 Hour Give 1 capsule by mouth one time a day for hypertension - Milk of Magnesia Suspension 400 MG/5ML Give 2400 mg by mouth as needed for constipation - Mirtazapine Oral Tablet 15 MG Give 15 mg by mouth at bedtime for sleep - Omeprazole 20mg Capsule Give 1 capsule by mouth one time a day for gastroesophageal reflux disease - Trazodone HCI Oral Tablet 100 MG Give 100 mg by mouth at bedtime for sleep On 02/26/24 at 5:36 PM the SW's Social Service Summary revealed the resident was discharged in stable condition with home health and his primary care physician follow-up appointment was scheduled for 03/06/24 at 2:00 PM. The note indicated the resident was also set up with a social worker through home health to be able to help him at home with further services. Resident #1's Discharge Instruction Form dated 02/26/24 at 5:36 PM indicated in Section II under the Pharmacy heading written prescriptions were provided to the Resident, no prescriptions were called in to a pharmacy. Additionally, under the Nursing heading Resident #1 had a bilateral groin wound which required a dry dressing. The Therapy heading of the Discharge Instruction Form revealed a home evaluation was not completed and a wheelchair and walker were ordered by the SW. The Rehab heading indicated Resident #1 needed continued therapy with bathing, dressing, toileting, transfers, and stairs. On 02/27/24 at 3:00 AM Physician's Assistant Note read the resident was seen for their discharge summary. The note revealed the resident had remained at the facility since 1/15/24 and appealed discharge several times. He received and completed intravenous antibiotics for a groin infection. The resident was followed by infectious disease. His pain control continued to be an ongoing issue, but narcotics had been able to be deescalated to a non-narcotic pain reliever. The note further revealed Resident #1 received physical therapy and occupational therapy. He continued to have concerns about functioning at home on his own but would have his brother and home health. On 03/17/24 at 1:40 PM an interview was conducted with the Director of Therapy, and she stated Resident #1 often verbalized to her he wanted to go back to his own home, and he had a neighbor friend who helped him out. The Resident's family member was made aware of his wish to return to his own home. She further stated Resident #1 was alert and oriented and was his own responsible person. She stated Resident #1's family member voiced concerns about the resident's safety and was interested in taking resident to his house. She stated she offered opportunities to train the family on assisting the Resident with hygiene care since Resident #1 did need some assistance with bathing and hygiene after toileting. She stated the family declined and told her they were not skilled to provide that level of care to Resident #1. She stated she told the family member home health would be available for the first couple weeks after discharge. The Director of Therapy stated the Resident was able to walk with a walker independently and transfer independently. She stated it was very difficult to get the resident and the family member to commit to a discharge plan because of their wish to appeal the discharge. They won several appeals but when their last appeal was denied. The facility offered Resident #1 a private pay room, but the Resident declined and said he was going to go back to his own home. She stated she did not conduct a home assessment. On 03/18/24 at 4:51 PM an interview was conducted with Resident #1's family member and he stated the Resident had been admitted to the facility after having a couple of surgeries on his legs which had become infected. He stated he tried to get the Business Office Manager to help file for Medicaid and she said, Oh, we can't do that and the Social Worker said she could not help either. He stated Resident #1 was discharged from the facility to home and unfortunately, he was living in a terrible living environment. The family member stated Resident#1's home environment was not good due to rotting floors, holes in the floor, and an infestation of bed bugs. He stated Resident #1's trailer was falling apart. He stated that he thinks Resident #1's wounds initially got infected because of the bed bugs. The family member said that is why the Resident went back to the hospital and was then admitted to the facility. He added that before Resident #1 went to the hospital he had fallen and was unable to get up for a couple of days. The family member said Resident #1 was in the hospital for 34 days. He stated Resident #1 had an infection in his blood and they started him on intravenous antibiotics. The family member said Resident #1 was sent to the facility to finish his antibiotic regimen and for physical therapy and occupational therapy. He stated when he was discharged from the hospital, the hospital only requested rehabilitation to Medicare for the 23 remaining days and his antibiotics were not considered rehab. The family member said he repeatedly appealed each time the facility tried to discharge Resident #1. He said he ran out of appeals at the 4th level, but it did gain the Resident about two more weeks of therapy. Resident #1's family member stated that the Resident was up walking with a walker with the help of PT. The family member stated Resident #1 could not change his own brief when he was incontinent. The family member stated he was out of town when the resident received the third discharge notice, and they discharged Resident #1 home. The family member stated that resident #1 told the facility that his home was unsafe for him, and he told them he did not want to go there. The family member stated that facility staff transported Resident #1 to his home, wheeled him into home. set him on the couch, and just left him there. He stated Resident #1 was unable to get up and go to the bathroom, unable to prepare a meal for himself, and could not make any phone calls. The family member stated Resident #1's phone had started malfunctioning while he was hospitalized and had stopped working completely by the time he was admitted to the facility. He stated Resident #1 used the facility phone when he wanted to make a call. The family member stated a neighbor called him and told him Resident #1 had been dropped off at his home and had not been able to get up off the couch. He stated he told the neighbor to call APS for assistance. He stated APS tried to find Resident #1 emergency placement in a safe environment but there were none available, so she called an ambulance to take him to the hospital. He stated the resident was covered in bed bugs again. He stated the facility should never have dropped his brother off at his home. It was not a safe discharge to take him to his home. He stated Resident #1 said he had had his brief changed that morning but by the time he got to the hospital he had urinated in that brief about six times. On 03/18/24 at 5:10 PM an interview was conducted with Resident #1's friend who was also his neighbor in the mobile home park. She stated she visited the Resident about every week. She stated on 02/05/24 she fell and could not visit the resident as often. She said she went to a care plan meeting in February for Resident #1 to talk about his discharge plan. She stated an appeal was filed because they were going to send him to an unsafe home. She stated at that discharge care plan meeting she told them the resident had nowhere to go because his home was not safe. She said she showed the SW pictures of the condition of the home. She stated there were holes in the floor, black mold in the bathroom and the ceiling was falling down in the bathroom. She said she told the SW Resident #1 couldn't go to his family member's home because he said Resident #1 had to be self-sufficient and the SW said Well, we'll have to discharge him back to his own home then. The friend stated she informed the SW that she nor the Resident's family member would provide transportation back home for Resident #1. She stated they left him on his couch, unable to get up and walk for himself, go to the bathroom or anything else. She added that unfortunately, when she turned the heat back on and the place heated up, the bed bugs came out. She stated he sat on the couch, unable to get up, and covered in bed bugs. She stated she took him a plate of food that evening. The friend stated, I was hot when I saw him sitting there, even with a walker he couldn't have maneuvered in there the way the floors were rotted out and the boards on the floor. She stated Resident #1's trailer park manager came to visit him in hospital, and the Resident signed his trailer over to him. She stated Resident #1 did not have a home phone and his cell phone had not worked since he was admitted to the hospital in December. An interview was conducted on 3/17/24 at 1:03 PM with the Administrator and she stated Resident #1 was able to transfer and walk independently with wheelchair. She stated he had been admitted to the facility for short term rehabilitation due to a wound that required intravenous antibiotics through a peripherally inserted central catheter (PICC line). A PICC line is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart. She further stated Resident #1 was only supposed to be in the facility for the duration of the antibiotic therapy. The Administrator explained Resident #1 filed an appeal for each NOMNC he received to the higher level until it was denied for the last time. She added Resident #1 had no skilled needs and was given a 30-day notice. The Administrator stated Resident #1's family member initially said they were willing to allow the Resident to discharge to their home. The Administrator stated later the family member changed his mind and said the Resident could not discharge to their home because Resident #1 required assistance with hygiene. The Administrator stated she told the SW they needed to talk to the Ombudsman to make sure they were doing the right thing. The Administrator relayed the Ombudsman confirmed discharging the resident home was appropriate. She stated the Ombudsman said the facility was not responsible for repairing the Resident's home if that was the condition it was in prior to his admission. The Administrator said it was explained to Resident #1's family that he would have home health services when he was discharged . She added referrals were made to other facilities, but they declined Resident #1 due to his payor source. The Administrator stated a home assessment and review for barriers to a successful discharge was not conducted. The Administrator stated they felt the need to contact the Ombudsman because the SW had put so much time and effort into researching available resources for this resident. She said the Ombudsman told the SW that the resident is alert and oriented and the facility is not a prison. The Administrator stated Resident #1, or his family member never voiced concerns that the Resident's house was not safe to live in or that there was any type of insect infestation. Record review revealed no evidence a 30-day discharge notice was issued. An interview was conducted with the Transportation Aide on 03/17/24 at 1:30 PM and she stated she had only transported one resident into their home and that was Resident #1 02/27/24 at 10:45 AM. She further stated she was accompanied by Nurse #1. She explained she wheeled Resident #1 up the ramp in a facility wheelchair and through the unlocked door of his mobile home. She said the living room was at the entrance and Resident #1 transferred himself independently from the wheelchair onto the couch. She stated she folded the wheelchair up and pushed it out the door. She added the nurse who had accompanied her in the transportation van brought two boxes of Resident #1's personal items into the home. She stated the Resident asked the nurse to set one box on the television tray table by couch and one on the island between the living room and kitchen. She stated she did not go any further beyond the living room into the home. She stated his phone was on the table beside him and she thought it worked. She further stated it was not plugged into a charger. An interview was conducted on 03/17/24 at 2:10 PM with Nurse #1 who accompanied the Transportation Aide during Resident #1's discharge home. She stated the Transportation Aide pushed Resident #1 up the ramp in a wheelchair and went in the unlocked mobile home. She stated Resident #1 transferred himself from the wheelchair to the couch. Nurse #1 explained she brought in two boxes of the Resident's belongings. She said he asked to place the box that contained soft drinks on the table beside him and told her to place the other box on the counter between the kitchen and living room. She stated the box which she put on the counter contained his written prescriptions. Nurse #1 added the trailer was warm, cluttered, and smelled of old cigarette smoke. She added as she walked from the living room to the kitchen counter, she did not feel any weak spots or holes in the floor. She stated she did not see any rodents or insects. Nurse #1 said Resident took his cell phone from his pocket and put it on the tray table. She stated she assumed the phone worked but did not check it and did not see a charging cord. Nurse #1 added while in the facility she observed Resident #1 ambulate with a walker and a wheelchair. She stated he only needed some assistance with hygiene. She did not observe Resident #1 get up and ambulate after he sat down on the couch. On 3/17/24 at 4:26 PM an interview was conducted with the facility Social Worker, and she stated Resident #1's discharge process began on his admission to the facility. She explained a form called Your Path was used which allowed for input from the Minimum Data Sets (MDS) Nurse, Therapy, Nursing, SW and Business Office Manager input. Each discipline had a piece of the Your Path form to fill out that assessed the Resident's needs so they could be addressed. She stated the Your Path form provided a baseline to work from. Nursing for education, Therapy for physical/occupational needs and for SW to know where the resident came from, where he planned to discharge to and any equipment or services he may need. She explained Resident #1 was ordered home health, physical and occupational therapy, a home health aide, and skilled nursing for medication management. She stated home health usually visited within 24 to 48 hours after discharge. The SW stated the only concern voiced about the Resident #1's home environment was from the Resident's family member who said the floor had areas without carpet. She stated on 02/06/24 she called the Ombudsman to make sure the facility was doing the right thing because Resident #1's family member was concerned about the flooring in Resident #1's home. The SW stated the Ombudsman told her if the Resident lived in his home prior to admission then could be discharged back to his home from the facility. The SW added the Ombudsman stated it was not the facility's responsibility to fix anything that was wrong with Resident#1's home. The SW stated the Ombudsman said if the facility set up Resident #1 with a home health aide, a skilled nurse and a social worker, discharge was appropriate. The SW stated Resident #1's neighbor told her she would be responsible for getting Resident #1's prescriptions filled and assisting him in his home. She stated the Home Health Agency would provide a Home Health Aide to assist Resident #1 with his needs for a period of time. The SW stated she would not send a resident to an unsafe environment and that is why she called the Ombudsman for clarification. On 03/18/24 at 9:15 AM an interview was conducted with the Ombudsman, and she stated the facility SW said Resident #1's family member had said he was going to take the Resident home with them but then declined. The Ombudsman stated the SW said that Resident #1's family member had voiced concerns regarding the flooring in the Resident's home. The Ombudsman said she spoke with her colleagues, and they advised that if the Resident's home was in the condition he left it then he could return to it. She stated she relayed that information to the facility social worker. She stated she told the SW that if the Resident was to be discharged back to his home, to make sure he had home health services and a social worker. An interview was conducted on 03/18/24 at 7:34 AM with the Home Health Nurse and she stated she received the referral for Resident #1 on 02/27/24. She explained she called his number on the evening of 02/27/24 to set up a time to visit him. She stated the phone number did not work. She said she tried the family member's and friend's number listed in his file and didn't get an answer, so she went out on 02/28/24 to check on the Resident. She said she drove out to his house and knocked for several minutes and couldn't get an answer. She stated she was able to finally reach Resident #1's friend by telephone who informed her Adult Protective Services had been called the evening prior and the Resident was sent by ambulance to the hospital. On 03/18/24 at 10:39 AM an interview was conducted with the APS SW #2, and she stated she called the facility SW on 02/27/24 and did not get an answer, left a voicemail but did not receive a call back from the SW. She stated she called and spoke with Resident #1's family member on the 2/27/24. She stated the family member was very frustrated with the facility. She said Resident #1's family member had filed an appeal three times and it had been approved those three times for the Resident to have an extended stay for therapy. He said that the facility told him Resident #1 needed an assisted living level of care. The APS SW #2 stated the Resident's family member told her Resident #1 was unable to use a wheelchair or walker due to his physical limitations and the poor condition of his home. The family member told APS SW #2 the Resident was incontinent and he needed help with dressing, bathing, grooming, meal prep, and medication assistance. He reported to the APS SW #2 that the facility said Resident #1 needed 24-hour care however there's no one in Resident #1's home to provide that care. The APS SW #2 stated she called the facility SW multiple times and left multiple messages which were unanswered. An interview was conducted with Resident #1 on 03/18/24 at 10:45 AM from his hospital room phone and he stated he was at the facility on 1/15/24 to continue antibiotic therapy for a wound he had. He stated he also received PT and OT. He stated that the final appeal was not granted, and he was going to be discharged . He stated he told the facility SW his house was not safe. He stated he told them that the floors had holes in them and that it was infested with bedbugs. He stated after being in the hospital for a month in December 2023 his health had declined, and his muscles had weakened to the point he needed physical therapy at the nursing home to help him get enough strength back to walk with a walker. He stated prior to going in the hospital in December he could walk to the store, or his friend would take him to get whatever he needed from town. He stated they told him that if he stayed at the facility, he would be private pay. Resident #1 stated he could not afford $500 a day so he felt his only choice was to be discharged back to his unsafe home. He stated he did not apply for Medicaid in the facility. Resident #1 said the facility transportation aide and a nurse took him to his house, they rolled him up the wheelchair ramp into the house and he transferred himself onto the couch. He stated the nurse put a box of soft drinks next to him on the table and a box with his prescriptions in it on the island between the kitchen and living room. Resident #1 stated he urinated on himself about six times because he could not pull himself up to the walker to go to the bathroom. He stated he did not have a working phone to call anyone to help him. He stated he felt worried, humiliated, isolated, and helpless. Resident #1 stated his neighbor stopped by to visit him, saw the condition he was left in and called his family member. She called APS and they came to his home and sent him to the hospital. Resident stated he was unable to call anyone because his phone had not worked since his admission to the hospital in December. He added when he wanted to make a phone call he used the room phone. On 03/18/24 at 12:22 PM an interview was conducted with APS SW #3, and she stated APS received a phone call on 2/27/24 at 4:45 PM Related to Resident #1 discharge to an unsafe home. She stated the call was from a neighbor who was very concerned about Resident #1 being left alone in an unsafe home. She stated she walked into the house, and he was sitting on his couch by the door with a plate of food that his neighbor had brought him. She stated she asked him if he could get up and he said he wasn't able to stand on his own. She stated she asked him if he felt safe in his home, and he stated he did not feel safe in his home. She said she asked if he had moved since he had been dropped off at his home and he stated he was not able to move from the couch on his own. She stated she asked him how he had been going to the bathroom and he said that he had on an adult diaper the whole time and he had used it three or four times. Resident #1 also advised the APS SW #3 that there had been no one at the home to help him until the friend came by to check on him. APS SW #3 stated that Resident #1 had hundreds of bed bugs crawling on him. She stated they were very visible, and he was spraying some kind of chemical on him every time one would bite him. She stated the mobile home had a horrible smell of chemicals related to Resident #1 spraying himself. She stated his walker was in reach, but he was unable to stand to use it. She stated there was a wheelchair on the other side of the room folded closed. She stated she called the emergency medical services (EMS) to transport Resident #1 to the hospital. She said the EMS team had to assist Resident #1 to stand because his legs were like wobbly sticks. The APS SW #3 had Resident #1 transported to the hospital by (EMS) for evaluation. The neighbor stated Resident #1 had a cell phone, but it had not worked since he had been admitted to the hospital in D

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview of staff, physician, resident, the facility failed to protect Resident #1 from rolling out of bed during the provision of personal care. Resident #1 fell from her bed to the floor. Resident #1 was sent to the emergency room and was diagnosed with a distal femur fracture (fractures of the thighbone that occur just above the knee joint) of both legs. The fractures resulted in hospitalization, treatment with Heparin (blood thinner) to prevent blood clots in the lower legs and Fentanyl (a controlled substance used to treat severe pain) for pain. The resident had to wear knee braces to both legs for stability until healed which can cause skin breakdown and significantly limit her ability to move/transfer during care, dialysis, or simple shifting herself in the bed. This deficient practice affected one of two sampled residents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses of a history of falling, and muscle and right-sided weakness, diabetes, neuropathy, and renal failure. Resident #1 had a quarterly Minimum Data Set (MDS) dated [DATE] that documented she had severely impaired cognition. The resident required one-person physical assistance with bed mobility. The active diagnoses were end-stage renal disease dependent on hemodialysis, diabetes, cognitive communication deficit, dementia, and muscle weakness. The resident had scheduled and as needed pain medication. Her pain was occasional and mild. She was not coded for anticoagulant and coded no falls since the prior assessment. Resident #1's care plan dated 10/7/23 documented she had an activity of daily living deficit and required assistance with hygiene by one staff, impaired mobility, pain, and was at risk for falls. On 1/10/24 at 12:20 pm an interview of Resident #1 was completed. The resident was alert and oriented to self and situation. She remembered falling from her bed by herself. She did not remember staff being present. The resident stated that she had very bad pain when the staff tried to move her after the fall (does not remember how many days after). The pain with movement was a 10 (scale of 1 to 10, with 10 being the worst), the worst she ever had. The resident had no pain at this time and no other concerns. A review of Resident #1's Medication Administration Record for December 2023 which documented the resident was assessed for pain each shift. Her pain level was none or below a 4 from 12/1/23 to 12/8/23. On 12/9/23 the pain level had increased to a 10 (the resident was sent to the Emergency Department). A nurses' note dated 12/7/23 at 7:36 am by Nurse #2 (night shift) documented she was called to Resident #1's room by Nursing Assistant (NA) #1. NA #1 informed Nurse #2 that during peri care, the NA rolled the resident over onto her right side and the resident rolled out of bed. According to NA #1, the resident will sometimes continue to roll when being turned for peri care but not out of bed. The resident was assessed, and her range of motion did not change per the resident's baseline, and she had no pain. The resident was known to moan and groan often, but no injuries were noted at this time. There was no swelling, deformity, discolorations, or redness noted. The resident's vital signs were unchanged from her normal baseline. The resident was assisted back up and into bed. The bed was elevated for care when the resident fell out of the bed. A message was left for the on-call medical service. The call bell was within reach and bed was in low position. On 1/10/24 at 4:11 pm Nurse #2 was interviewed. Nurse #2 stated NA #1 informed her Resident #1 had fallen out of the bed when the NA was changing her on night shift 12/6/23. The accident occurred close to the end of shift. The NA rolled the resident to the right side in the center of the bed and the resident held onto the quarter rail as usual, but she rolled out of bed. Nurse #2 stated she and NA #1 had taken care of the resident before and had no problems. The resident's right side was weaker, and the resident rolled over from time to time but not out of the bed. Nurse #2 stated she assessed the resident and there were no injuries, and the resident had no pain. The resident's extremities were moved and checked with no change. There was no head injury. Resident #1 informed Nurse #2 she fell out of bed. Nurse #2 stated she assisted the resident off the floor and put her back in the bed using a mechanical lift. There was no redness, swelling, or deformity of the extremities. There was a fall committee (date unknown) that evaluated the incident. The resident was changed to a larger/wider bed for safer rolling. NA #1 was called and left a detailed message to return the call on 1/10/24 at 3:50 pm and again on 1/11/24 at 10:30 am. The NA was unable to be contacted. On 1/11/24 at 10:30 am an interview was attempted with NA #3 but was unsuccessful. NA #3 was assigned to Resident #1 on 12/7/23 day shift. A nurses' note dated 12/7/23 at 3:51 pm written by Nurse #5 documented follow up for Resident #1's fall. The blood pressure was 131/69 position was lying taken on the left arm. The pulse was 75 and regular, respirations were 19, temperature was 98.1 taken on the forehead, and oxygen saturation was 97.0 %. The resident was oriented to room location and was pleasant. Neurological checks were within normal limits. The resident had no complaint of pain. The pain level was 0 (pain score 0 to 10 with 10 being the worst). The resident's skin tone was normal, warm, and dry. The respirations were unlabored and lung sounds were clear. The resident had no edema, and pedal pulses were present. The resident required two-person physical assistance with transfers and bed mobility after the fall. On 1/10/23 at 2:40 pm an interview was conducted with NA #2. NA #2 stated she was assigned to Resident #1 on day shift 12/7/23, 12/8/23, and 12/9/23. She stated the resident had no pain on 12/7/23 or 12/8/23 during care or assistance with her meals. On 12/9/23 the resident complained of acute pain in her left leg when moved and Nurse #1 was informed. Nurse #1 called the doctor and an x-ray was ordered. When she returned to work and was assigned to Resident #1 days later, she had been to the hospital and was wearing splints to both her legs and had no pain during care. On 1/10/24 at 4:30 pm an interview was conducted with Nurse #5. Nurse #5 stated she was familiar with Resident #1. The resident had an accident on 12/7/23 and had no pain until 12/9/23. The resident had an x-ray and was sent out to the Emergency Department. The resident was able to inform staff if she had pain. The resident had an assessment on each shift twice a day for two days and on the third day after the accident she had pain and was sent out. The resident had neurological assessments each shift. The resident had gone to dialysis on Friday 12/8/23, the date she completed the head-to-toe form (assessment of the resident's body) after the resident returned. She had no pain, and her neuro check was negative. A facility Head to Toe Evaluation form was completed by Nurse #2 dated 12/8/23. Nurse #2 documented Resident #1 had no swelling, discolorations, or redness noted on her body. The resident's vital signs were taken and at her baseline. The resident was assessed for pain and had none, score of a 0. Nurses' note dated 12/8/23 at 5:44 pm written by Nurse #1 documented Resident #1's blood pressure was 117/62, pulse was 77 and regular, respirations 20 and non-labored, temperature was 97.8, and oxygen saturation was 98%. Neurological check was within normal limits for the resident. The resident had no complaints of pain, and the skin tone was normal. The staff will continue to monitor the resident. Nurses' note dated 12/9/23 written by Nurse #1 documented Resident #1 had new onset pain to the left knee and the physician was called and tramadol 50 milligrams one time only for pain was ordered and administered. Resident #1's Medication Administration Record documented on 12/9/23 her pain score level was 10. Resident #1 had a medication order dated 12/9/23 for Tramadol 50 milligrams one time only for pain and for radiographs of the left knee, leg, and hip. Resident #1 had a medication order dated 12/9/23 for Tylenol 650 milligrams every 6 hours as needed for pain. Resident #1's radiograph reading of the left knee, leg, and hip dated 12/10/23 reported a left acute distal femur fracture that was comminuted (more than 2 breaks) and closed. The bony structures appear osteopenic (weak bones) . The knee and hip joints were in place and unaffected. Resident #1's hospital Discharge summary dated [DATE] documented the resident was seen in the Emergency Department on 12/10/23 for a history of falling and knee pain and radiographs were completed. The resident was admitted for fractures. The resident's radiographs reported she had closed bilateral (both legs) closed distal femur fractures that were managed non-surgically. The resident was to be non-weight bearing with knee immobilizers. Heparin (blood thinner) was added to prevent deep vein thrombosis (clots of the lower legs). The resident was evaluated by an orthopedic physician and pain management medication and immobilizers were initiated for the fractures. Resident #1 had a new pain medication order upon return from the hospital dated 12/14/23 for Norco 5-325 milligrams every 6 hours as needed for pain for 7 days. On 1/10/24 at 12:00 pm an interview was conducted with Nurse #1. Nurse #1 stated she was assigned to the resident for a 12-hour day shift on 12/9/23 after the fall that occurred on night shift 12/6/23. It was on Sunday morning and the resident complained of left leg pain, score level of 10 when staff moved her for care. This was the first time the resident had complained of leg pain that Nurse #1 was aware of. The on-call medical practitioner was called and he ordered an immediate x-ray of the leg which was taken at the facility and pain medication. The x-ray result reported a distal fracture of the left femur on 12/10/23. There was no deformity, bruising, or edema of the legs or knees at this time (12/9/23). The resident was sent to the Emergency Department for evaluation on 12/10/23. Nurse #1 stated she readmitted the resident on 12/14/23 and the Emergency Department diagnosis was distal fracture of bilateral femurs. The resident was ordered a Fentanyl patch on 12/20/23 (a controlled substance used to treat severe pain) for pain because she attended hemodialysis. With the patch, pain would be more continuously controlled with dialysis and pain was under control. Nurse #1 stated the resident required one person assist for in bed care and was able to hold the quarter mobility rail for care and had no prior history of not being able to hold the rail and falling from the bed before the accident. On 1/14/24 the resident was changed to a two-person bed mobility assist to prevent falls. Nurse #1 also stated she thought the resident was now unable to hold the rail and balance when rolled was a change. Nurse #1 stated the resident now had knee immobilizers and was unable to bend her knees and move freely in her bed and the immobilizers had to be removed to check for skin breakdown. The immobilizers placed the resident at risk for skin breakdown. The resident was non-weight bearing and had to be transferred using a mechanical lift after the accident. Nurse #1 stated she was not aware of any other incidence where a resident rolled out of bed onto the floor. Resident #1 had a change in pain medication dated 12/20/23 from Norco to Fentanyl transdermal (through the skin) patch 12 micrograms/hour change every 72 hours due to uncontrolled pain. On 1/10/24 at 12:20 pm an observation of Resident #1 was completed. The resident was lying in a pressure reduction air mattress bed that was wider than the traditional foam mattress she was on prior to the fall. She had knee imobilizers in place to both legs. On 1/10/24 at 1:10 pm an interview was conducted with the Administrator and Director of Nursing (DON). The accident was investigated, and the outcome determined was the resident had a large bottom and abdomen in comparison to the extremities which slid off the bed from the center when turned/rolled during care and hit her knees to the floor. The resident was still holding on to the bed mobility rail when she fell. There was a full investigation, education, and plan of correction. The Quality Assurance Committee was involved, and the Medical Director was informed. After the accident, NA #1 was observed to provide bed mobility for Resident #1 by the Administrator and Physical Therapist. No concerns were identified with the technique at this time. On 1/10/24 at 3:00 pm an interview was conducted with the Physician. The Physician stated on 12/7/23 he examined Resident #1 in the late morning of the day she fell previously on night shift, approximately 2:00 am. The resident was fully examined and there was no deformity, edema, redness, or pain. The resident had been able to verbalize pain or concerns in the past and on 12/7/23 during the exam the resident had no pain or concerns. The Physician stated the resident had normal vital signs (within her usual range) and no facial grimace or body language that would show pain. The Physician further stated Resident #1 had diabetes, neuropathy, and renal failure usually have decreased sensation and the diagnoses contribute to osteoporosis. The resident had no bone scan to diagnose osteoporosis, it was suspected. The Physician stated that the pain showing two days later was not unusual and the nursing staff had documented an assessment each shift of no pain or changes. The Physician stated that pain would cause increased vital signs and the resident's vital signs were normal and at her baseline until 48 hours later when the resident verbalized pain. The resident went to dialysis during the two days after the fall before she had experienced pain. The Physician stated the fall was an accident, the staff handled the situation appropriately, it was investigated, and shared at QA (quality assurance). The clinical staff also participated in education for bed mobility and falls. On 1/10/24 at 3:40 pm an interview was conducted with the Physical Therapist (PT) Director who investigated Resident #1's fall. The PT volunteered to be a subject in the bed and evaluated the width and determined the root cause of the accident, observed NA #1 complete bed mobility with the PT as the resident, and provided education with return demonstration to all clinical staff, including therapy. The PT stated the morning of Resident #1's fall, the risk management morning meeting included the fall/incident, and the staff reviewed the plan of intervention for recurrence. The resident was handled by NA #1 and the resident fell out of the bed while being rolled to her right side for incontinence care. The resident had no pain until two days later, on the weekend. PT and the Administrator interviewed NA #1 and she provided a demonstration of bed mobility that was used for Resident #1 with the PT as the resident in the bed. It was determined the root cause for the accident was the resident was rolled from the center of the bed, held the mobility rail and was stable on one side but not the other. The second rollover of the resident to the right side was a weaker side and the resident could not hold her core muscles and leaned over and rolled out of bed. The NA overestimated the space and ability of the resident to remain on her side in the center of the bed, which had not occurred in the past. The resident was provided a wider bed for bed mobility and to prevent any further accident. Resident #1 was initially evaluated upon admission for use of the mobility rail by PT staff and then entrapment evaluation by nursing staff. PT stated this incident was isolated to one NA. There had not been this type of accident before or after the 12/7/23 accident. The NA took the proper steps after the fall and was forthcoming. All clinical staff, including therapy, were educated with return demonstration. The resident had a communication deficit and dementia. The fracture pain seemed to have shown when the swelling increased post injury two days later. The resident required maximal assistance for transfer. Resident #1's PT note dated 12/15/23 documented the resident had minor generalized pain with movement before the fall at a level of 4 and had a level of 10 after the fall. The resident was sit to stand transfer before the fall and non-weight bearing after the fall which required maximum assistance for transfer. The 12/20/23 significant change MDS assessment revealed that sit to stand, chair to bed, toilet and shower transfers were not attempted due to medical condition or safety concerns. The Administrator was notified of immediate jeopardy on 1/17/24 at 4:20 PM. The facility provided the following corrective action plan with a completion date of 12/19/23: F689 1.Corrective action for resident(s) affected by the alleged deficient practice: On 12/10/23 the Resident was transferred to the hospital for evaluation and treatment. She returned to the facility on [DATE] with bilateral knee immobilizers. 2. Corrective action for residents with the potential to be affected by the alleged deficient practice: One on one education with the staff member identified in the incident was provided on 12/11/23 by the facility Rehab Director. To identify other residents with this same issue on 12/18/23 the Director or Nursing or Designee audited all residents who have had a fall in the last 7 days for issues related to bed mobility and for injuries related to the fall. No other issues were identified. 3. Measures/Systemic changes to prevent reoccurrence of alleged deficient practice: To prevent this from recurring on 12/18/23 the Director of Nursing, Assistant Director of Nursing and Rehab Director designee educated all licensed nurse, certified nurse aides and therapists on resident handling with bed mobility. As the training was being completed, the facility rehab director made unannounced in room visits while resident care was being provided by staff to observe for any safety concerns. None were observed. All agency and new licensed nurses, certified nurse aides and therapist will receive this same education prior to working with residents. 4. Monitoring Procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements. To monitor and maintain ongoing compliance beginning 12/25/23 the Director of Nursing or designee will audit 3 residents per week with falls for injuries and issues related with bed mobility, and will observe 3 staff providing care with bed mobility x 12 weeks. Compliance Date: 12/19/23 Validation of the corrective action plan was completed on 1/10/24: There was a signed roster of 120 clinical staff who received in-service for the fall incident of a resident who rolled out of bed onto the floor during care. 97 staff members were educated onsite and 23 staff were educated by telephone completed by 12/19/23. There were 81 staff who signed a check off procedure for return demonstration of proper bed mobility of a resident to include rolling a resident during care. There was documentation of on-going monitoring of random bed mobility observation for 3 clinical staff per week for the past 2 weeks (1/10/24) as part of the quality assurance plan. On 1/10/24 Nurses #1, #2, and #5 and NAs #2 and #5, the Director of Nursing, Physical Therapy Director, and the Physician were all interviewed during validation and were able to state nursing and therapy staff received education for resident safety, care, and bed mobility. The Director of Nursing provided documentation of the on-going audits of staff provide care and bed mobility. The completion date of 12/19/23 was validated.