**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, hospital record review, pharmacy medication regimen review, interviews with staff, Medical Director #404, Pharmacy Clinical Director #406, and Family Member #500, review of information on the American Heart Association Website www.heart.org, review of the Eliquis online customer information, and consultant pharmacy contract review, the facility failed to prevent a significant medication error for Resident #105. This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #105, who had a history of atrial fibrillation (a condition of rapid heartrate), and cerebral vascular accident (CVA/stroke) did not receive physician ordered anticoagulation therapy (Eliquis) to prevent blood clot formation from [DATE] to [DATE]. On [DATE], Resident #105 was transferred to the hospital with presenting symptoms of facial droop and aphasia (difficulty speaking). The resident was admitted to the hospital on [DATE] with an embolic stroke and subsequently passed away on [DATE] with hospice services. This affected one resident (#105) of five residents reviewed for anticoagulant therapy. The census was 103. On [DATE] at 11:20 A.M., the Administrator and Clinical Services Manager (CSM) #408 were notified Immediate Jeopardy began on [DATE] when the facility failed to ensure hospital orders to increase Resident #105's Eliquis were implemented resulting in a significant medication error. The facility failed to administer the medication between [DATE] and [DATE]. On [DATE], Resident #105 was assessed to have facial drooping and aphasia (difficulty speaking). The resident was emergently transported to the hospital on [DATE] and was admitted due to suffering an embolic stroke. The resident passed away on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 5:35 P.M. Resident #105 was transferred to the hospital for a change in condition. • On [DATE] at 1:10 P.M., the daughter of Resident #105 spoke with Licensed Social Worker (LSW) #246, in person, regarding a status update on the resident and reported a concern that Resident #105 may not have been taking the correct medications (Eliquis). • On [DATE] at 10:00 A.M., Resident #105's daughter came to the facility to collect the resident's belongings and informed Receptionist #292 that the resident had passed away. • On [DATE] at 8:00 A.M., CSM #408 provided in-person and via phone education to all 24 floor nurses including Licensed Practical Nurses (LPN) #248, #250, #252, #254, #256, #258, #260, #262, #264, #266, #268, #270, #272, #274, #276, #278, #280; Registered Nurses (RNs) #298, #300, #302, #304, #306, #308, #310, and two administrative nurses, RN #296 and the DON, on the policies for order transcription and the admission process/checklist. The admission checklist was updated on [DATE] to include, but not limited to, entering orders from the hospital and admission/readmission orders to the facility. • On [DATE] at 8:00 A.M., 27 residents (#1, #2, #3, #7, #8, #11, #12, #16, #29, #38, #42, #47, #48, #58, #62, #65, #68, #72, #79, #80, #88, #94, #95, #96, #97, #98, #101) with anticoagulants orders were audited by [NAME] President of Clinical Services (VPCS) #517 and CSM #408 to ensure physicians orders were transcribed correctly with no discrepancies identified. • On [DATE] at 8:00 A.M. all current residents who had been admitted /readmitted to the facility from [DATE] through [DATE] were reviewed on [DATE] to ensure physicians orders were transcribed correctly. Thirty-three admission records were reviewed (#4, #7, #9, #16, #17, #28, #29, #30, #34, #36, #40, #43, #46, #54, #55, #56, #58, #66, #72, #76, #78, #79, #80, #83, #85 #88, #89, #92, #93, #97, #95, #98, #101) and 17 records (#7, #9, #16, #17, #28, #30, #36, #54, #55, #58, #66, #78, #79, #83, #85, #88, #97) had admission orders containing potential discrepancies. Potential discrepancies were between the hospital discharge orders and what was entered into the electronic medical record. The DON clarified these discrepancies with Nurse Practitioner (NP) #402 and orders were correctly transcribed. There were no negative outcomes because of the discrepancies. • On [DATE] at 8:30 A.M., upon Quality Review of Resident #105's medical record completed by CSM #408, the root cause analysis identified that a transcription error had occurred during the readmission of Resident #105 on [DATE]. Eliquis had been increased during Resident #105's hospitalization but the order wasn't transcribed during readmission. • On [DATE] at 10:00 A.M., an Ad Hoc Quality Assurance and Performance Improvement (QAPI) Meeting was held with the Administrator, DON, CSM #408, VPCS #517, Unit Manager #282, Assistant Director of Nursing (ADON), RN #312, and Medical Director #404 (via telephone), to review the root cause analysis completed by CSM #408 and the system in place to ensure that residents receive medications as ordered by the physician and to meet their total care needs. Policies reviewed were the electronic health record Order Entry Transcription and admission Checklist. The checklist had been updated on [DATE] to include, but not limited to, entering orders from the hospital and admission/readmission orders to the facility. • Beginning [DATE], the DON/Designee will complete a comprehensive medication order review of all residents who are admitted /readmitted to the facility within 24 hours of arrival. Medication order review will include verification of accurate transcription and implementation of medications, and proper medication administration of ordered medications. Ad Hoc education will be completed as indicated. • On [DATE] at 12:30 P.M., an Ad Hoc QAPI meeting was completed with the Administrator, DON, CSM #408, VPCS #517, Unit Manager #282, RN #296, RN #312, and Medical Director #404 to re-evaluate the system implemented on [DATE] to ensure that residents received medications as ordered by the physician and to meet their total care needs. No changes were made, and policies and process remained appropriate. • On [DATE] starting at 6:45 A.M., licensed nurses were re-educated on the policies and procedures for transcription of medication orders and the admission checklist to ensure continuity of care by the DON/Designee. Education completed included 24 licensed nurses including LPNs #248, #250, #252, #254, #256, #258, #260, #262, #264, #266, #268, #270, #272, #274, #276, #278, #280 and RNs #298, #300, #302, #304, #306, #308, and #310. Agency staff will receive education prior to their next scheduled shift. All newly hired licensed nurses will receive this education during orientation. • On [DATE] at 9:00 A.M., Consultant Pharmacist (CP) #409 remotely completed a comprehensive medication regimen review for all residents admitted /readmitted from [DATE] through [DATE] which included Residents #9, #95, #101, #107, #108, #109, #110, #111 and #112 to determine medication compliance and ensure continuity of care. No discrepancies were identified. • On [DATE] at 9:00 A.M., Pharmacist #516 was educated by Chief Nursing Officer (CNO) #515 regarding the expectation of a comprehensive medication regimen review. • On [DATE] at 12:30 P.M., CNO #515, via phone, educated CP #409 regarding a comprehensive medication review and the facility will ensure all needed documents for a comprehensive review will be uploaded into the electronic health record within 24-72 hours after admission/re-admission. • On [DATE] at 12:45 P.M., an Ad Hoc Resident Council Meeting was held with Activities Director #200, the Administrator and eight residents to review the order transcription and admission checklist process. Residents in attendance were #24, #23, #12, #72, #27, #71, #94, and #25. Resident Council verbalized understanding. • Beginning [DATE], CP #409 will ensure the completion of a comprehensive medical record review to determine medication compliance, which supports continuity of care, within 24-72 hours of resident admission/re-admission to the facility. The facility will ensure within 24-72 hours of admission, the admission documents are uploaded into the electronic medical records. This will be completed by Medical Records #286/designee. All elements of the abatement plan were implemented by [DATE]. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of the closed medical record for Resident #105 revealed an initial admission to the facility on [DATE] with medical diagnoses including history of stroke, atrial fibrillation (AFib), type two diabetes mellitus, and breast cancer. Further review revealed Resident #105 was dependent on staff for activities of daily living (ADL) tasks and transfers, was non-ambulatory using a wheelchair for mobility and was verbally able to make needs known to staff. Review of Resident #105's care plan, dated [DATE], revealed anticoagulant therapy to treat arterial fibrillation with a goal of no adverse effects and interventions to administer per physician orders, and obtain vital signs as necessary. Review of the physician orders revealed an order for Eliquis, initiated on [DATE], 2.5 milligrams (mg) twice a day for atrial fibrillation. Review of Resident #105's quarterly Minimum Data Set (MDS) assessment, dated [DATE] revealed Section C - Cognitive Patterns marked as Resident #105 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (out of a score of 15), Section I - Active Diagnoses marked with an active diagnosis of longstanding persistent atrial fibrillation, and Section N - Medications marked for use of an anticoagulant medication. Review of the February 2024 Medication Administration Record (MAR) revealed Resident #105 was administered the anticoagulant medication Eliquis 2.5 mg two times daily from [DATE] to the morning dose on [DATE]. Review of the progress note dated [DATE] at 2:22 P.M., authored by Licensed Practical Nurse (LPN) #276, revealed Resident #105 had chief complaint of abdominal pain and stated she had suicidal ideations and verbalizations. LPN #276 notified the certified nurse practitioner (CNP) (unidentified) and received an order to send Resident #105 to the hospital emergency department for evaluation. LPN #276 notified Resident #105's power of attorney (POA) of the new order and transfer of Resident #105 to the hospital. The resident was hospitalized through [DATE] with Influenza A. Review of the hospital discharge summary and hospital discharge orders, dated [DATE], revealed an order to increase the anticoagulant medication dose of Eliquis to 5 milligrams (mg) two times daily for atrial fibrillation. Review of Resident #105's progress notes, dated [DATE] at 8:05 P.M. and authored by LPN # 256, revealed Resident #105 was re-admitted from the hospital with the diagnosis of influenza A. All admission conditions and orders were reviewed and clarified by the on-call physician (unidentified). Review of the MAR dated [DATE] through [DATE] revealed no evidence the anticoagulant medication Eliquis for either the previous dosage of 2.5 mg twice a day or for the new increased dosage of 5 mg twice a day was noted as ordered upon discharge from the hospital on [DATE]. Review of the pharmacy dispensing report for February 2024 revealed Eliquis 5 mg was not delivered by the facility pharmacy during the time span from [DATE] through [DATE]. Review of Resident #105's quarterly MDS Assessment, dated [DATE] revealed Section C - Cognitive Patterns marked as Resident #105 was cognitively intact with a BIMS score of 15, Section I - Active Diagnoses marked with an active diagnosis of longstanding persistent atrial fibrillation, and Section N - Medications was not marked for use of an anticoagulant medication. Review of Resident #105's MAR dated [DATE], [DATE], and [DATE] revealed there were no orders for Eliquis at either the previous dosage of 2.5 mg or the new ordered dose of 5 mg. Review of the Pharmacy Medication Regimen Review dated [DATE] revealed CP #409 reviewed Resident #105's medication orders since readmission to the facility on [DATE] to [DATE]. There were no recommendations or clarifications requested for the physician to address or recommendations for the facility nursing department to address. There was no indication CP #409 identified Resident #105 was not receiving either the previous dose or the newly ordered dose of Eliquis, even though Resident #105 had the diagnosis of arterial fibrillation and had been previously ordered the medication. Review of the Pharmacy Medication Regimen Review dated [DATE] revealed CP #409 had two recommendations. First, for a gradual dose reduction for Resident #105's prescription for Ambien (medication to treat insomnia). The recommendation was declined by Medical Director (MD) #404. Second, for a laboratory test for lipids and for liver function tests, which was approved by MD #404. There was no indication CP #409 identified Resident #105 was not receiving either the previous dose or the newly ordered dose of Eliquis, even though Resident #105 had the diagnosis of atrial fibrillation or had been previously ordered the medication. Review of the Resident #105's annual MDS assessment dated [DATE] revealed Section C - Cognitive Patterns marked as Resident #105 was cognitively intact with a BIMS score of 15, Section I - Active Diagnoses marked with an active diagnosis of longstanding persistent atrial fibrillation, and Section N - Medications was not marked for use of an anticoagulant medication. Review of Resident #105's progress note dated [DATE] at 7:50 P.M., authored by LPN #252, revealed Resident #105's daughter was visiting, and Resident #105 was having difficulty responding to conversation during the daughter's visit. At the time of the transfer (to the hospital) Resident #105's blood pressure was 148/106 millimeters of mercury (mmHg), blood oxygen saturation level was 91 percent (%) with two liters of oxygen in place, and heart rate was 73 beats per minute. Review of the Stroke Network Virtual Neurology Assessment note dated [DATE] at 9:19 P.M. authored by Neurology Physician #512 (part of the resident's hospital record beginning on [DATE]) revealed Resident #105 with history of left frontal lobe ischemic infarction (stroke) with hemorrhage in 2018 resulting in aphasia (inability to speak) which has resolved, and diagnosis of arterial fibrillation prescribed Eliquis but unclear if Resident #105 is receiving the medication or not. Per the nursing facility, Resident #105 was taken off the Eliquis for reason as being unsafe for Resident #105 to be on the Eliquis. There was no additional information about what unsafe meant. Review of the Neurocritical Care History and Physical progress note dated [DATE] at 5:12 A.M. authored by hospital Neuro-physician #510 revealed Resident #105 arrived at the emergency department on [DATE] presenting with right facial droop, right sided weakness, non-verbal, and left gaze preference. Multimodal imaging results showed occlusion of the distal left internal carotid artery and occlusion in the left and proximal left branches of the internal carotid artery. Resident #105 was not a candidate for thrombolytic (clot buster) interventions due to unclear if Resident #105 was receiving Eliquis prior to emergency department transfer. Further review of the hospital record revealed the resident was taken to the cardiovascular laboratory (lab) for a thrombectomy (removal of the clots), but the catheters were unable to be advanced for removal and the procedure was aborted. Review of the hospital progress note dated [DATE] at 10:16 A.M., authored by Hospital Physician #410, revealed Resident #105 experienced an acute ischemic stroke with Computed Tomography (CT) Scan results which showed large left hemispheric region of the brain with ischemia (an area of the body that is not receiving blood and oxygen due to an occlusion) and associated swelling. Resident #105 also had acute metabolic encephalopathy (a change in the brain which affects how thinking and reasoning occurs and can be caused by a stroke), and acute hypoxic respiratory failure likely related to the ischemic stroke. Resident #105 was placed on palliative and comfort care due to her critical condition and worsening mental status. Resident #105 ultimately expired on [DATE]. Interview on [DATE] at 10:20 A.M. with Family Member #500 revealed Resident #105 had been ordered Eliquis for the treatment of atrial fibrillation since Resident #105's previous stroke which occurred in 2018. Family Member #500 was unsure why Resident #105 had not been placed back on the Eliquis when she was readmitted to the facility on [DATE]. Family Member #500 verified, prior to the stroke team attempting thrombolytic interventions, the emergency room physician questioned if Resident #105 was receiving Eliquis at the facility, but the family member was unsure as to why the resident was not receiving the Eliquis. Interview on [DATE] at 2:15 P.M. with Pharmacy Clinical Director #406 revealed there was no readmission order received from the facility for Resident #105's anticoagulant medication Eliquis when the dose was increased. Pharmacy Clinical Director #406 stated the last fill and dispense for Resident #105's anticoagulant medication, Eliquis 2.5 mg, was on [DATE]. There was no further filled or dispensed anticoagulant medications for Resident #105 from [DATE] to when Resident #105 was admitted to the hospital on [DATE]. Interview on [DATE] at 3:03 P.M. with the DON revealed the expectation for the nurses was to review and clarify medication orders with the physician upon admission or readmission to the facility. Once the orders had been reviewed and approved, the nurses were to transcribe the orders into Point Click Care (the computerized medical record). The DON confirmed there was not an anticoagulant medication order for Resident #105 since readmission to the facility on [DATE] despite the hospital order upon the resident's discharge from the hospital. The DON confirmed Resident #105 had been receiving Eliquis at 2.5 mg since the initial admission on [DATE] and there was no clarification or reasoning for the discontinuation of the Eliquis of the previous dose or on the new dose ordered upon readmission on [DATE]. Interview on [DATE] at 2:25 P.M. with Medical Director (MD) #404 revealed, on admission or re-admission of residents, MD #404 would review the admitting orders from the hospital, which was the source for approving, clarifying, or discontinuing medication orders. The physician shared the only reason he could think of the resident's Eliquis was being held or not administered would be for a breast biopsy due to her recent diagnosis of breast cancer but, even then the Eliquis would have been resumed and not held for three months. Resident #105 should have been on the Eliquis just due to history of an ischemic stroke and having atrial fibrillation. MD #404 shared there was a 20% chance of developing an embolus (clot) once the medication has been discontinued. Interview on [DATE] at 3:14 P.M. with CP #409 revealed completion of the monthly pharmacy medication regimen review involved the review of what the facility had uploaded or documented in the computerized medical record. CP #409 stated diagnoses and medications were reviewed and if there was a diagnosis of atrial fibrillation then the review would involve a more in-depth look at the ordered medications for appropriateness and accuracy. CP #409 confirmed Resident #105 did have a diagnosis of atrial fibrillation, but the pharmacy review did not have documentation to support further review of the resident's cardiac history and no anticoagulant use. Interview on [DATE] at 3:35 P.M. with LPN #256, the admitting nurse for Resident #105 on [DATE], revealed LPN #256 did not recall the details of Resident #105's readmission to the facility on [DATE]. Interview on [DATE] at 3:55 P.M. with CSM #408 revealed the facility missed the order on readmission for Resident #105 on [DATE] and the facility's check and balance systems and consultants did not identify the lack of the Eliquis order for Resident #105, even though she had been receiving the medication prior to the hospitalization on [DATE]. CSM #408 verified the resident returned to the hospital on [DATE] due to experiencing a stroke and expired in the hospital on [DATE]. Review of the consulting pharmacist contract dated [DATE] revealed, review each resident's clinical record monthly and evaluate for appropriateness of the therapy according to current medical practice standards. Review of the American Heart Association website, www.heart.org, defined atrial fibrillation as a quivering or irregular heartbeat, or arrhythmia. Atrial fibrillation, also known as AFib or AF, can lead to blood clots, stroke, heart failure and other heart-related complications. Normally, your heart contracts and relaxes to a regular beat. In AFib, the upper chambers of the heart, or the atria, beat irregularly. Because not enough blood is being pumped out of the atria, blood pools in the area. The pooled blood can clot - which can be extremely dangerous. If a blood clot forms, it can be pumped out of the heart to the brain. This blocks the blood supply to the brain and causes a stroke. About 15% to 20% of people who have strokes have this heart arrhythmia. The clot risk is why patients with this condition are prescribed blood thinners. Some medications are commonly called blood thinners because they can help reduce a blood clot from forming. There are two main types of blood thinners that patients commonly take: anticoagulants such as warfarin, dabigatran (Eliquis) and rivaroxaban (Xarelto), and antiplatelet drugs such as aspirin or clopidogrel. Each type of medication has a specific function to prevent a blood clot from forming or causing a blocked blood vessel, heart attack or stroke. Untreated AFib doubles the risk of heart-related deaths and is associated with a fivefold increased risk for stroke. Yet many people are unaware that AFib is a serious condition. Review of the Eliquis Customer Website, www.eliquis.bmscustomerconnect.com, revealed Eliquis use can reduce the risk of stroke and blood clots in people who have atrial fibrillation (AFib), a type of irregular heartbeat, not caused by a heart valve problem. For patients taking ELIQUIS for atrial fibrillation: stopping ELIQUIS increases your risk of having a stroke. Do not stop taking ELIQUIS without talking to the doctor who prescribed it to you. This deficiency represents non-compliance investigated under Complaint Number OH00154096.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interviews with facility staff and the resident, interviews with the local police, review of hospital documentation, review of the police report, review of the facility ' s investigation, review of the National Weather Service report and review of the facility ' s policy on missing residents, the facility failed to ensure staff provided adequate supervision to prevent a resident, with a history of exit seeking behavior, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (#85) was placed at potential risk for serious life-threatening harm and injury when she eloped from the facility without staff knowledge. The resident was missing for approximately three hours when she was finally found by a police helicopter in a wooded area and was subsequently transported to the hospital for evaluation and treatment. The resident was diagnosed with hypothermia. This affected one (#85) of three residents reviewed for elopement. The facility identified seven current residents at risk for elopement. The facility census was 107. On 05/15/19 at 1:18 P.M., the Administrator and Regional Director of Operations #110 were notified that Immediate Jeopardy began on 03/19/19 at 8:30 P.M. when Resident #85 exited the building activating the door alarm, which an unidentified staff member turned off without initiating a resident search. Resident #85 was previously assessed as being at risk for wandering and elopement and a wanderguard (a bracelet type device worn to alert staff of unauthorized exits through doors equipped with an alarming system) was in place to ensure resident safety. On 03/19/19 at 11:45 P.M., Resident #85 was found about 100 feet from the facility in the southeast wooded area by the local police and was taken to the local hospital. The ambient air temperature outside was 28 to 30 degrees Fahrenheit on 03/19/19. At the time of discovery, the resident was noted with a wanderguard in place to her right ankle and was not wearing any shoes. She was treated in the hospital for hypothermia. The Immediate Jeopardy was removed on 05/17/19 when the facility implemented the following corrective actions: • On 03/19/19 at 11:45 P.M., Resident #85 was located by the police and the resident was taken to the local hospital. The resident was admitted to the hospital and returned to the facility on [DATE]. Upon readmission to the facility, Resident #85 was reassessed for wandering and a wanderguard was applied. • On 03/20/19 at 1:00 A.M., Former Director of Nursing #112 initiated education with all staff on emergency management and exit seeking behaviors. • On 03/20/19 at 1:00 A.M., Former Administrator #111 completed a door audit for the entire facility and found all doors to be in working order. • On 03/21/19 at 6:30 P.M., the door code distribution process was changed by admission Director #03. Door codes will now expire when a resident is formerly discharged from the facility. In addition, a red sign was posted at the front door alerting visitors to not assist residents out of the facility. • On 05/15/19 at 10:00 A.M., the residents will be evaluated and reviewed for elopement risk upon admission, readmission or change in condition by the licensed nurses, and quarterly by the Interdisciplinary Team (IDT) and the plan of care updated as indicated. • On 05/15/19 at 10:00 A.M., the Director of Nursing (DON) will review new and readmitted residents at risk for elopement Monday through Friday during the IDT team meetings noting residents that need a secure care bracelet and to ensure they have appropriate interventions in place. • On 05/15/19 at 10:00 A.M., the DON will begin to monitor compliance by completing Exit Seeking audits weekly for four weeks. • On 05/15/19 at 2:00 P.M., the Administrator/designee and the DON/designee began staff education on emergency management of missing residents, exit seeking behaviors, and door alarms. As of 05/17/19 at 9:00 A.M., 143 staff were in-serviced, and 49 staff remain to be in-serviced. Any staff not educated by 05/17/19 would be unable to work until the in-service was completed. The total number of facility staff was 192. In addition, the DON will educate new hires on emergency management of missing residents and exit seeking behaviors. • On 05/15/19 starting at 2:16 P.M., the Administrator initiated missing resident drills, including door alarm response time. The missing resident drills will continue each shift for one week, then every shift three times per week for one week, then once per week on every shift and will continue then monthly on every shift. Drills will be conducted by the DON, Maintenance Director or Designee. • On 05/15/19 at 6:00 P.M., the Admissions staff were educated by the Administrator on door code distribution process and the alert sign posted at the front door stating not to assist residents from the facility. • On 05/15/19, record reviews for two additional residents (#29 and #356), identified at risk for elopement, revealed they were assessed to be at risk for wandering and had wanderguards in place. There were no concerns identified. • On 05/16/19 at 12:30 P.M., an observation revealed an unnamed male resident with a wanderguard was attempting to go out the front door. He pushed on the door and the alarm immediately sounded and three staff members came to the door. One male staff member took the resident's hand and had him walk away from the door with him. There were no issues with this encounter. • On 05/16/19 at 4:39 P.M., an observation of the drill for missing persons with the Administrator revealed the Unit Manager pushed on the café door for 15 seconds and went out the door. The alarm sounded immediately. An aide was at the door when he left and followed him, there were also four other staff members on site. The staff were at the door within five to ten seconds. There were no identified issues observed with this drill. • On 05/17/19 from 8:00 A.M. to 8:56 A.M., interviews with State Tested Nursing Aide (STNA) #170 and #230, Registered Nurse (RN) #311 and Housekeeper #172 revealed knowledge of proper procedures for resident elopement, and what to do if a door alarms. Although the Immediate Jeopardy was removed on 05/17/19, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #85 revealed an initial admission date of 01/07/19. Diagnoses included cerebral aneurysm, difficulty in walking, muscle weakness, epilepsy, encephalopathy and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/16/19, revealed Resident #85 had intact cognition with signs and symptoms of delirium. The resident was also assessed to have wandering behavior that occurred on four to six days. Review of the care plan, dated 01/09/19, revealed the resident to be at risk for elopement and exit seeking related to cognitive impairment. Interventions included an alert bracelet to the resident's left ankle, redirection to an appropriate area of the facility, education of family and visitors to advise staff when leaving, encourage socialization, administer medications per physician's order and observe for mental status and behavior changes. Review of the physical restraint assessments, dated 01/13/19, 02/15/19 and 03/16/19, revealed the resident was assessed to be an elopement risk. The assessments stated a wanderguard was in place. Review of the nursing progress notes dated 01/12/19 through 03/25/19 revealed Resident #85 had a wanderguard bracelet placed to her left ankle due to continued roaming and attempts to exit the building. Documentation dated 03/19/19 revealed the resident was alert and oriented but confused. On 03/20/19, with a late entry time of 2:29 A.M., Licensed Practical Nurse (LPN) #150 documented Resident #85 had exited the facility, a search was conducted, the DON, the Administrator and the family were notified and emergency nine-one-one (911) was contacted. No further documentation concerning the elopement was documented in the nursing notes. Review of the police incident/investigation report, dated 03/19/19, revealed the facility notified the police Resident #85 was missing. The police searched the open local businesses and were unable to locate the resident. At an unknown time, the police requested additional police to assist with the search. The resident was found by a police helicopter at 11:30 P.M. on 03/19/19 in the southeast wooded area by the facility. Review of Resident #85's hospital emergency room report, dated 03/20/19 at 1:56 A.M., revealed Resident #85 arrived via medic. She was reported found by police helicopter wondering about a block and half away from the facility. The resident was observed wearing a coat but no shoes. A wanderguard was noted on the resident's right ankle. Resident #85 reported not being outside more than three hours. Vital signs were reported for rectal temperature at 93.2 degrees Fahrenheit (F), blood pressure was 137/97, the resident pulse was 58 and her oxygen saturation was 98 percent. The resident was stated to be initially hypothermic and a Bair Hugger (external warming device) was placed on the resident. Review of the National Weather Service Report for the night of 03/19/19 revealed the outside temperature was 28 to 30 degrees F. Review of the facility's investigation, dated 03/19/19, revealed Resident #85 was last seen by STNA #151 and #160 on 03/19/19 at 7:00 P.M. LPN #150 reported seeing Resident #85 around 7:15 P.M. sitting on her bed. Between 8:30 P.M. and 8:45 P.M., STNA #151 observed that the resident was not in her room as she was collecting dinner trays. STNA #151 proceeded to search the hallways of the unit but was unsuccessful in finding the resident. During the same time, LPN #150 could not find Resident #85 for evening medications. Between 8:45 P.M. and 9:00 P.M., STNA #151 let LPN #150 know that she was unable to locate Resident #85, and a Code Green (missing resident) was initiated. The facility staff started a building wide search. At 9:30 P.M., the DON was notified by the facility staff of the missing resident, at 9:32 P.M. the resident's family was notified, at 9:35 P.M. the DON notified the Administrator, the resident's physician and the police of the missing resident. The local police arrived at the facility at 9:45 P.M. and assisted in the search. A complete head count of the facility's resident population was completed at 11:30 P.M. On 03/19/19 at 11:30 P.M., Resident #85 was located by the police. The facility investigation of the elopement was initiated on 03/20/19 at 12:00 A.M. with staff interviews. On 03/20/19 at 1:00 A.M., the Administrator completed a door audit of the entire facility and all doors were found to be in working order, and the DON initiated education with all nursing staff on emergency management and exit seeking. The door code distribution process was changed, and a sign placed by the front door alerting visitors not to assist others out the door. On 03/25/19 Resident #85 returned from the hospital and was reassessed for elopement with a wanderguard placement. On 05/14/19 at 7:11 P.M., an observation and interview with Resident #85 revealed she had no memory of the elopement. She denied knowing when or how she left or what she was wearing. Resident #85 stated no one had checked her wanderguard bracelet that day and couldn't remember having it checked for a long time. She stated she was thinking of cutting it off to see how long it would take for someone to notice she didn't have it on. The wanderguard was observed to be on the resident's left ankle. On 05/14/19 at 7:40 P.M., an observation of the exit door next to room [ROOM NUMBER] was conducted with the Administrator. The exit bar was pushed, and the alarm was activated. The bar was held for 15 seconds until the door unlocked. Several front office staff came to see about the alarm within five seconds. No other staff working in that area came to respond to the alarm. On 05/14/19 at 7:42 P.M., STNA #204 opened the resident's door next to the exit door. She confirmed she had heard the alarm but was in the middle of resident care. On 05/14/19 at 7:43 P.M., STNA #151 opened the resident's door across from the exit door. She confirmed she had heard the alarm but was in the middle of resident care. On 05/14/19 at 7:48 P.M., an interview with LPN #150 revealed the LPN had last seen Resident #85 during shift report around 7:15 P.M. on 03/19/19. LPN #150 stated around 9:00 P.M., she noticed the resident was missing when she went to give her evening medications. At that point, the LPN stated she asked STNA #151 and #160 to help search the facility for Resident #85. LPN #150 stated she called the DON around 9:15 P.M. and was told to do another search of all rooms. The LPN called a Code Green after that search and she also called 911. The police arrived quickly, but unknown time, and helped search the facility again. They also searched outside and couldn't find her. She was notified later that the police found her at 11:55 P.M. On 05/14/19 at 8:00 P.M., an interview with STNA #151 revealed she learned that Resident #85 was missing when she came back from her break the night of 03/19/19 around 7:30 P.M. She started searching every room and upstairs, then outside with STNA #160. She stated she heard the door alarms multiple times that night, one was before 8:00 P.M. and one was at 8:00 P.M. She stated she went and checked both times and didn't see anyone. She stated she does not do head counts every time she checks the sounding door alarm. On 05/14/19 at 8:19 P.M., an observation and interview with LPN #150 revealed she couldn't find the alert bracelet test monitor at this time, but then had located it on the second floor. LPN #150 was then observed to test Resident #85's wanderguard bracelet. The wanderguard was observed on the resident's left ankle. LPN #150 was observed to wave the test monitor over the resident's bracelet with no response. The LPN repeated this process two more times without response. The monitor was observed by the surveyor to be turned off. LPN #150 then realized the monitor was not turned on and turned the dial to test. LPN #150 then waved the monitor next to the resident's bracelet and it tested positive. A positive response indicated the bracelet was working. On 05/14/19 at 8:36 P.M., an observation of the front door alarm activation by the Administrator revealed the door alarm was activated when pushed and held. The alarm sounded for approximately 15 to 20 seconds before the DON arrived. A floor nurse arrived to check out the front door alarm approximately 22 to 25 seconds after the door alarm was initiated. On 05/15/19 at 8:18 A.M., an interview with the Administrator and Regional Director of Operations #110 verified head counts were not performed when the doors alarm. Head counts were done when a Code Green was called. They confirmed a wanderguard will activate a door alarm when it was within three feet of an exit door. If the door was closed, it will lock, but if it was opened already just the alarm will sound. The staff were to respond and check the area each time the alarm sounds. The Regional Director of Operations (#110) confirmed the building did not have video surveillance of the doors. On 05/15/19 at 11:18 A.M., an interview with LPN #257 revealed she will check the door and surrounding area every time she hears the alarm go off. She stated she turns off the alarm and then will make sure all her residents are accounted for. She denied having any education concerning response to missing residents following the elopement on 03/19/19. On 05/15/19 at 11:50 A.M., an interview with Admissions staff #03 revealed the front door was locked from 8:00 P.M. to 8:00 A.M. and a code must be manually entered to unlock the door. He stated a unique code was given to residents to share with their families. He also stated residents who were deemed not cognitively competent do not receive the code. He stated their Power of Attorney or family will receive a code. On 05/15/19 at 11:51 A.M., an interview with Receptionist #123 revealed she was at the front desk from 8:00 A.M. to 4:00 P.M. and had not seen any resident leave on 03/19/19. She also stated the desk was occupied by an evening receptionist from 4:00 P.M. to 8:00 P.M., but after that the doors were locked. On 05/15/19 at 11:53 A.M., an observation with the Administrator with a wanderguard in hand, revealed when she was close to the front door, the alarm sounded, and the door locked. In a second test, at the same time, a visitor exited through the front door. The Administrator walked behind the exiting visitor and the door alarm sounded but the door did not lock. Several staff members came within 15 seconds to check the alarm. The Administrator also activated the alarm and put a working family code in, but the alarm continued to sound. The alarm was silenced by Receptionist #123 on a second key pad, only accessible to staff. On 05/20/19 at 7:41 P.M., an interview with Police Dispatcher #300 revealed the police received the initial call from the facility about a missing person on 03/19/19 at 10:07 P.M. and the police were dispatched to the facility at 10:08 P.M. The representative stated there were a lot of police involved in this missing person incident. This timeline was noted to be different from the facility's investigation. On 05/20/19 at 7:54 P.M., an interview with Police Officer #400 revealed the first police officer to arrive at the facility was at 10:14 P.M. and he was one of the first officers to arrive at the nursing home. He stated they checked the entire facility and were unable to locate the resident. They dispatched four more police officers at 10:19 P.M., and at 10:33 P.M., more police officers arrived, including a police helicopter to aide in the search. He stated the facility seemed confused with their timeline and could not give them the accurate timeline of events. He stated the facility said they had a lot of false alarms and assumed this was a false alarm as the resident would have sounded the alarm when she left the facility. He stated the resident was located by the police helicopter and he was the first officer to arrive on scene where the resident was, which was at 11:45 P.M. She was in the wooded area about 100 feet from the facility and he found the resident kneeling down on the ground. She was wearing a light coat, socks, no shoes and had a bowling bag with her. She seemed very confused and not familiar with her surroundings. She was put in a police cruiser due to the cold weather until the medics arrived. Review of the facility's policy titled Missing Patients, dated 11/2017, revealed the facility's procedure was to account and search for missing residents, and to communicate with outside agencies when a resident is discovered missing.