**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. a. On 11/29/2022 at 8:45 AM Medication Aide (MA) #4 was observed during medication administration. When approaching the MA's medication cart there were three pills in a clear medication cup and a nicotine patch sitting on the cart. MA#4 pulled medications for another resident and left the cart to administer those medications. The three pills in the medication cup and the nicotine patch were left unattended on her medication cart. At the time the medications were unattended, Resident #59, a severely cognitively impaired resident, was observed sitting in his wheelchair next to the medication cart. Immediately after completing the medication administration, MA #4 was interviewed. She stated the three pills and nicotine patch were for another resident who refused their medications. She further stated she should not leave medications on the cart unattended. Instead, she should have disposed of the medications or secured them in the locked cart until she had time to dispose of them. On 11/30/2022 at 4:08PM and interview was conducted with the Regional Operations Manager. She stated medications should never be left unsecured on the medication cart. 2. b. On 11/30/2022 at 10:45AM an observation of medication administration with Charge Nurse #2 was completed. Charge Nurse #2 was observed pulling Medications for Resident #325. The Charge nurse stated the resident had an order for Ferrous Sulfate solution 300milligrams (mg) per 5 milliliters (ml) but the solution on the cart was not 300mg/5ml, it was 220mg/5ml. Charge Nurse #2 asked another staff member to look in the medication storage room for Ferrous Sulfate. The staff member returned with another bottle of 300mg/5ml solution. The Charge Nurse stated she would need to call the provider prior to administering the medication for clarification. She placed both bottles on top of the medication cart and left them unattended while she went down the hall to administer medications to Resident #325. On 11/30/2022 at 11:15AM and interview was conducted with Charge Nurse #2. She stated she did not realize she left the medications on the cart unattended. She should have secured the medications prior to leaving the cart. On 11/30/2022 at 4:08PM and interview was conducted with the Regional Operations Manager. She stated medications should never be left unsecured on the medication cart. Based on record review, observation and staff interview, the facility failed to provide supervision to prevent a severely cognitively impaired resident from exiting the facility unsupervised, failed to ensure the resident was safe in the parking lot, and failed to report that a cognitively impaired resident was in the parking lot for 1 of 5 sampled residents reviewed for accidents (Resident #59). Resident #59, who was in his wheelchair, was found by Nurse Aide (NA) #1 in the parking lot unsupervised, didn't intervene and then, the resident was found to have gone out to the road. The resident was discovered by the Housekeeper on a 2-lane road where the speed limit was 55 miles per hour (MPH) west bound and was a quarter mile away from the facility's front door. In addition, the facility failed to ensure medications were not left unattended for 2 of 2 observations during the medication pass. Immediate jeopardy began on 11/22/22 when Resident #59 was observed out in the parking lot unsupervised in his wheelchair. Immediate jeopardy was removed on 12/2/22 when the facility provided and implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure the facility completes all staff training and ensure monitoring systems put into place are effective. Example #2 was cited at scope and severity of D. Findings included: 1. Resident #59 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side and dementia. Resident #59 was assessed for elopement on 11/8/22 and he did not present an elopement risk. He was not care planned for elopement risk on admission. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #59 had severe cognitive impairment. The assessment further indicated that the resident needed extensive assistance with transfer and used a wheelchair for mobility. Resident #59 was not coded for wandering. A nurse's note dated 11/22/22 at 3:22 PM and was recorded as late entry on 11/25/22 at 6:27 PM by the former Treatment Nurse revealed that Resident #59 was noted attempting to go out of the front door of facility by the staff. The staff followed the resident out and redirected back in. The staff assisted the resident back inside the door safely at which time a wander guard was placed. The Director of Nursing (DON) and the Unit Manager were present and were aware. Several attempts to interview the former Treatment Nurse via phone were unsuccessful. A new elopement assessment was completed for Resident #59 by the Unit Manager (UM). The assessment had an event date of 11/22/22 and completion date of 11/30/22. The assessment indicated that Resident #59 was found outside the front door and was redirected back in. A wander guard was applied on resident. The evaluation indicated event still open. Review of Resident #59's care plan revealed that on 11/23/22, a care plan for elopement risk was initiated. The care plan problem was resident has a wander guard secondary to wandering/elopement risk. The goal was resident will not leave secured area unattended. The approaches included check functioning of alarm every shift, check placement of alarm and monitor skin under alarm for any indication of skin breakdown, contact physician and family if resident attempts to leave facility, if resident becomes confused and attempts to exit secure unit/facility, attempts diversional activities as able, observe resident's whereabouts when out of bed, personal secure alarm (wander guard) as ordered and redirect resident as indicated and as needed. The MDS Nurse was interviewed on 11/30/22 at 10:25 AM. She stated that she had interviewed the Housekeeper who found Resident #59 outside the facility on the road. When the resident was back to the facility, a wander guard was placed on his ankle. She indicated that the administration was aware and had investigated the elopement incident dated 11/22/22 with Resident #59. She added that she initiated the care plan for elopement on 11/23/22 after the elopement incident. She stated that a new elopement assessment was completed on 11/22/22 for Resident #59 and he was added to the wander guard book. On 11/30/22 at 12:30 PM, Nurse Aide (NA) #1 was interviewed. She stated that she was familiar with Resident #59. She was assigned to him in the past. He was confused and disoriented, and wheelchair bound. She reported that on 11/22/22, she was coming in to work on 3-11 shift. She observed Resident #59 in the parking lot around 2:45 PM. There were visitors on the porch, and she thought Resident #59 was with his family. The NA stated that she did not attempt to confirm if the resident was being supervised while he was outside, and she did not report that the resident was in the parking lot. She proceeded to enter the facility to work. The Regional Operation Manager, in the absence of the Administrator, was interviewed on 11/30/22 at 11:10 AM. She reported that Resident #59 was found outside the building on 11/22/22. She stated that the incident was investigated by the [NAME] President (VP) of clinical Operation. The Regional Operation Manager provided the investigation report including the timeline, the corrective actions, and the written statements from the staff for review. On 12/1/22 at 8:20 AM, the [NAME] President (VP) of Clinical Operation, in the absence of the Director of Nursing (DON) was interviewed. She reported that she had investigated the elopement incident that occurred on 11/22/22 with Resident #59. She reported that the front door was locked from 8 PM to 8 AM every day and there was a receptionist assigned at the front desk from 8 AM to 8 PM every day. The investigation report indicated that Resident #59's elopement incident happened on 11/22/22. The resident was seen during lunch in his room by the Wellness Coordinator/Nurse Aide (NA), was seen during medication pass at 1 PM by the former Treatment Nurse, was seen between 2:45 and 3:00 PM by NA #1, and was seen at 3:15 PM by a passerby who called the facility to inform them that a resident in a wheelchair was on the road with a staff member (Housekeeper). The written statement from the Housekeeper dated 11/22/22 revealed (Name of Housekeeper) reported that when she left work on 11/22/22, she left the facility and turned left and noted a resident in his wheelchair on the road. The Housekeeper stayed with resident until additional staff came to assist the resident. On 11/30/22 at 12:20 PM, the Housekeeper was interviewed. Due to language barrier, she was interpreted by Med Aide #5. She stated that it was around 3:04 PM she was leaving from work. She was driving and when she was turning from the parking lot to the main road, she saw Resident #59 on the main road. He was in his wheelchair. She parked her car and went to the resident. She pushed the resident to the side of the road on the grass. Staff members then came and assisted the resident back to the facility. The written statement from the Business Office Manager (BOM) revealed on 11/22/22 we received a call at the front desk that there was a man in a wheelchair with a woman in scrubs on the side of the road. The caller stated that he looked like he could be one of our residents. I walked out to the road to see, and I did see a man with a woman on the side of the road, so I proceeded to go help assist. The resident is fine and alert, so I assisted nursing with pushing him back into the facility. On 11/30/22 at 2:01 PM, the BOM was interviewed. He stated that the facility had received a call from a passerby that a resident in a wheelchair was on the side of the road with a woman. He went outside to the end of the parking lot and saw Resident #59 in his wheelchair and a Housekeeper on the side of the road. The distance from the front door to where the resident was located was about a quarter of a mile. He added that the weather was partly sunny and was not cold. The resident was fine. The written statement from the Wellness Coordinator revealed that On 11/22/22, I was alerted in the hall by a staff member that there was a resident that was on the road in a wheelchair. I immediately ran down to where the resident was sitting in his wheelchair. The BOM and another staff member were already standing with him in the road. This resident was not in any kind of distress. I pushed the resident back up to the facility in his wheelchair. Once inside, a wander guard was placed on him, and he was redirected. On 11/30/22 at 1:20 PM, the Wellness Coordinator was interviewed. She reported that she was helping as a Nurse Aide (NA) on the floor on 11/22/22. She reported that she had seen Resident #59 in his room eating lunch on 11/22/22. She indicated that she was notified that the resident was outside (unable to remember exact time). When she went outside in the parking lot, she saw the resident in wheelchair, the Housekeeper, and the Business Office Manager (BOM) on the side of the road. She reported that the resident was not in any distress. He was wearing a shirt and a pair of pants. She said the weather was not cold, it was partly sunny. She indicated that the distance from the front door to where the resident was located was about a quarter of a mile. The Social Worker (SW) was interviewed on 11/30/22 at 10:30 AM. She reported that Resident #59 had eloped on 11/22/22 and was found on the road by the Housekeeper. The SW reported that the resident did not have any history of elopement or attempts of leaving the facility. On 11/30/22 at 1:35 PM, the facility's Maintenance Director was requested to measure the distance from the front door to the location where Resident #59 was located. The Maintenance Director reported that the distance was a quarter of a mile. On 11/30/22 at 3:30 PM, the location where Resident #59 was found was observed. The same location was identified by the Housekeeper, the Wellness Coordinator and by the BOM as the exact location where the resident was located. The side of the road where the resident was found was grassy. The location was not visible from the front door. Review of the www.wunderground.com revealed that the weather on 11/22/22 was partly sunny and the highest temperature was 61 degrees Fahrenheit (F). On 11/30/22 at 12:24 PM, Medication Aide (Med Aide) #5 was interviewed. She stated that she was familiar with Resident #59. She was assigned to the resident, and he would always say door, door, door. She also stated the resident was wheelchair bound and was confused and disoriented. On 11/28/22 at 12:50 PM, Resident #59 was observed up in wheelchair in his room. His speech was mumbled and hard to understand and he was unable to answer to questions appropriately. On 11/29/22 at 9:30 AM, Resident #59 was observed up in wheelchair, wheeling self-up and down the hall saying, door, door, door. He was wearing a wander guard to his ankle. Review of the education records including the sign in sheets revealed that facility had in-serviced the staff from 11/22/22 through 11/30/22 on elopement, elopement risk changes, and ensuring resident's safety when outside and wander guard book. The facility's Quality Assurance and Performance Improvement (QAPI) plan for the elopement incident that occurred on 11/22/22 was reviewed. The interventions to correct the problem included: 1. Resident was identified outside in front of the facility with an employee from housekeeping. No injuries were noted. 11/22/22 2. A facility head count was completed, and all residents were accounted for. 11/22/22 3. A 100% audit of elopement risk observation will be completed for changes in risk by the Director of Nursing (DON) and Nurse Supervisor. 11/22/22 4. Facility staff in serviced by the DON on what an elopement is, the use of the wander guard books prior to letting someone out of a locked door, and placement of the wander guard. 11/22/22 5. The Regional Clinical Manager in-serviced the DON, the Assistant DON, Nurse Supervisor, and MDS Coordinator on making sure elopement assessments are accurate and done timely. The Regional Clinical Manager in-serviced the Social Worker on accuracy of the wander guard books and placement of books. 11/22/22 6. The DON will assign quarterly wandering assessments to a specific nurse and specific shift, when due. This will be done weekly x 12 weeks. The ADON or Nurse Supervisor will complete a weekly audit on all residents with wander guards to assure orders are accurate, functionality and placement are completed daily per shift, this will be completed weekly x 12 weeks. The Social Worker Director will complete a weekly audit of the wander guard books to ensure accuracy and updated information is available. This will be done weekly x 12 weeks. 1/14/23 7. The Administrator will bring the results of these audits to the Quality Assurance Committee monthly x 3 months. The Regional Operations Manager and the Division [NAME] President (VP) of Operation were notified of the immediate jeopardy on 11/30/22 at 5:45 PM. The facility's VP of Operation provided the following credible allegation for immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to provide supervision to prevent a cognitively impaired resident from exiting the facility unsupervised (Resident #59). Resident #59 was admitted to the facility on [DATE] with diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side and dementia. Cognition score was 5, no noted behavior and used wheelchair for mobility. An elopement assessment was completed on 11/8/22 and was not identified as an elopement risk at that time. Resident #59 was observed outside in the parking lot by NA #1 on 11/22/22 at approximately 2:45 PM. NA #1 reported she thought the resident was with his family, proceeded inside the facility to work. Resident was last seen in the facility at approximately 1 PM during the medication pass. The investigation of the incident revealed Resident #59 was able to push the door and maneuver the wheelchair over the threshold. The resident demonstrated a slow steady rock to roll over the threshold. This was observed by the [NAME] President of Clinical Services. The date of this observation was 12/1/22. NA #1 failed to notify the facility that resident #59 was unsupervised in the parking lot in his wheelchair. At approximately 3:15 PM, the facility received a call from a passerby that a resident in a wheelchair was on the road with a staff member. Several staff members exited the facility to find the resident with a housekeeping staff member on the side of the road. The housekeeper was leaving work at approximately 3:00 PM when she turned out of the facility and found the resident in his wheelchair on the road, approximately a quarter mile from the facility. The housekeeper stayed with the resident until additional staff came to assist the resident. The resident was returned to the facility in his wheelchair accompanied by staff at approximately 3:30 PM. The resident was assessed for any injury and no injury was identified. Once assessed, a wander guard, a door alarm bracelet, was applied to resident. Resident information was then placed in the facility elopement books. The elopement books are located at each nurse's station and the front reception desk. These books are accessed by all staff. The elopement books contain pictures and face sheets for all residents who have triggered as an elopement risk. An elopement assessment was completed at approximately 4:05 PM by the Unit Supervisor and all notifications to Responsible Party and Medical Director were initiated. The Responsible Party did not return the phone call. Another call was placed to Responsible Party on 11/23/22 with no response. Additional calls were placed to the Responsible Party by the Director of Nursing and floor Nurse with the last attempt being on 11/25/22 and all calls left unanswered. The facility completed a census to resident count at approximately 3:45 PM. All residents were accounted for. The Director of Nursing and Nurse Supervisor initiated a 100% of all in house resident's reevaluation of elopement risk assessments. These audits were completed on 11/22/22 by the Director of Nursing and the Unit Supervisor at approximately 7:15 PM. On 11/30/22, NA #1 was educated on residents outside the facility left unsupervised and ensuring their safety. The [NAME] President of Clinical Services educated NA #1. 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 11/22/22, the Director of Nursing and Unit Manager completed a reassessment of elopement risks of all in-house residents. No other residents who were not previously an elopement risk were identified. Residents who previously triggered elopement risk were validated to have pictures and face sheets in each elopement books, care plan s were verified for wandering behaviors and interventions. On 11/22/22, the Director of Nursing initiated in-servicing on elopement and wander guard books to include locations of each book to all staff. The wander guard books are located at each nurse's stations and the front receptions desk. The Director of Nursing or designee will be responsible for keeping the elopement books up to date with all residents who trigger as an elopement risk. Any staff who did not complete the in-service prior to 11/30/22 are not allowed to work until this in-service has been completed. The Regional Operation Manager will track the in-services to ensure all staff have received. On 11/22/22, the Regional Clinical Manager in-serviced the Director of Nursing, Assistant Director of Nursing and Nurse Unit Supervisors on what an elopement is. The Director of Nursing began an in-service on 11/22/22 for all staff on elopement and completed on 11/30/22. Any staff that did not receive the in-service will not be allowed to work after 11/30/22 until the in-service has been completed. The regional Operation Manager is responsible for tracking the completion of the in-service. On 11/30/22, the Regional Operation Director in-serviced all department heads on ensuring residents safety when unsupervised outside. This in-service includes staying with a resident until staff can ensure the resident is not at risk of endangerment. 100% of staff were in-serviced on 11/30/22 by the Department heads on ensuring resident's safety when unsupervised outside and staying with resident until a staff member can ensure resident is not at risk of endangerment. Any staff member who did not receive the in-service on 11/30/22 will not be allowed to work until the in-service has been completed. The Regional Operations Manager is responsible for tracking any staff that needs to be in-serviced. This education has been added to the new hire orientation process effective 11/30/22, by the Director of Nursing. As of 12/1/22, all residents who have been identified by the nurse to be unsafe and unsupervised while outside will have a profile maintained at the receptionist desk. This profile will include picture identification. The receptionist will monitor residents, between the hours of 8AM and 8 PM, wishing to exit the facility by verifying the resident profile. Any resident who has been identified as being unsafe and needs supervision while outside will be provided with facility staff to accompany them. The receptionist will notify the nurse that the unsafe resident wishes to go outside, and a staff member will be assigned to the resident. The staff member will remain with the resident while outside. The facility will also provide education on elopement, elopement risk changes, and ensuring resident safety when outside during the monthly staff meeting x 3 months starting with the next all staff meeting. IJ removal date 12/2/22 On 12/1/22, the facility's credible allegation for immediate jeopardy removal was validated by observation of the wander guard books at each nurse's stations and at the front reception desk. The residents who were identified as elopement risk had their pictures and face sheets in the wander guard books. Multiple staff interviews including administrative staff and the receptionist were conducted and revealed that they had received in-services on elopement, wander guard books and ensuring resident's safety when unsupervised outside. Care plan of residents identified as elopement risk were initiated and reviewed and sign in sheets for the in-services were reviewed. Immediate jeopardy was removed on 12/2/22.