**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide proper supervision for Resident (R)97, resulting in R97 eloping from the facility. Specifically, a resident pulled a fire alarm, resulting in R97 evacuating the facility alone, without staff knowledge. This resulted in R97 falling, while in the facility's unsecured courtyard, and suffering a fractured clavical. On 12/19/24 at 12:45 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 10/05/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 12/19/24 at 5:00 PM, the facility provided an acceptable IJ Removal Plan. On 12/20/24, the survey team, validated the facility's corrective actions and removed the IJ, as of 12/20/24. The facility remained out of compliance at F689 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Recertification Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility policy titled Fire Procedures reviewed on April 2024, documented, Departmental Fire Procedures III. If Alarm Sounds from Elsewhere in Building: -close all doors in area. -remain in your area and await further instructions. If not in area, report back. -If with residents, remain with them and provide reassurance. -Account for all residents and staff in your area and be prepared to report results to Control Station. Review of R97's Face Sheet revealed R97 was admitted to the facility on [DATE], with diagnoses including but not limited to: metabolic encephalopathy, vascular dementia, unspecified severity, with mood disturbance, type 2 diabetes mellitus, unsteadiness on feet, history of falling, cognitive communication deficit. Review of R97's Physician Progress Notes dated 10/07/24, documented, Follow-up: Fall . Family at beside reports they were called by the facility where she is currently getting rehab to report she had an unwitnessed fall and they think she might have hit her head so they were sending her to the ED for evaluation . Pt had fall with significant bruising with pooling to L clavicle/ shoulder area. abnormality noted at time of exam. Will order stat xray to r/o fx . 1. Fall - Per nursing staff, s/p fall on 10/5 now with c/o Left shoulder/clavicle pain. Will order Xray 2 views Left Clavicle and Left shoulder to r/o fx post fall. Review of R97's Incidents Follow-up and Recommendation Form with an incident date of 10/05/24, documented, Summary of Investigative Facts: Resident became anxious during fire alarm and went into courtyard (locked) and layed [sic] on ground. Recommendations/Actions Taken: Resident offered non skid socks - xray obtained 10/7/24. Review of R97's Un-witnessed Fall document dated 10/05/24, documented, During a fire alarm this nurse noticed the resident lying on the ground on her left side with a blanket under her head as a pillow. Resident was dressed in pants, shirt, had on a clean dry brief with no socks or shoes. Review of R97's Trident Health Patient Visit Information dated 10/07/24, revealed, You were seen today for: Fracture of left clavicle. Collarbone Fracture received 10/07/24. Review of Accuweather.com revealed that on 10/05/24, the high was 80 degrees Fahrenheit and the low was 74 degrees Fahrenheit. During an interview on 12/17/24 at 11:17 AM, R97's Husband stated that R97 fell and fractured her shoulder the second night she was here, when she made it outside after the fire alarm went off. During an interview on 12/18/24 at 2:55 PM, Licensed Practical Nurse (LPN)3 revealed that a resident on another hall pulled the fire alarm which caused all the doors to be opened and the Certified Nursing Assistant (CNA) left the unit to go assist manning the doors on the Dayspring unit. LPN3 stated they left the unit to go to Dayspring to reset the fire alarm and once they returned to the unit, they were notified that R97 was not in their bed. LPN3 further stated that R97 was the only resident that went out during the alarm and that R97 was found outside in the courtyard, right off the unit, lying on the ground with her blanket under their head and the resident stated that they were trying to get away from the fire. During an interview on 12/19/24 at 9:16 AM, CNA1 stated that a resident on the Dayspring Unit pulled the fire alarm, and they had to leave the Pebble Creek unit to help man the doors on Daysprings. CNA1 stated that after they did their rounds on Daysprings they went back to Pebble Creek and the nurse left the unit to go turn off the alarm. CNA1 stated that it was possibly about 5 minutes before the nurse found the resident outside in the courtyard. CNA1 further revealed that they did not complete a head count on the Pebble Creek unit during the fire alarm. During an observation and interview on 12/19/24 at 9:52 AM, the Maintenance Director (MD), revealed the path used by R97 to evacuate the facility. R97 exited the facility through a secured door on the Pebble Creek Unit. The MD stated, when the fire alarm is activated, the doors are no longer secured. The door leads to a gated courtyard. Further observation revealed, two gates located to the left and right of the courtyard. Both gates were not secured. The MD stated the gates are never secured. During an interview on 12/19/24 at 8:53 AM, the MD revealed there are fire alarm pull stations next to the exit doors. The resident room doors as well as the hallway doors are three-hour fire doors. There is an employee stationed on every door. There is enough staff to man each door even at night. The MD stated all staff report to the location of the fire. All staff are assigned a job at this point. No staff member is preassigned a particular door to be stationed at. The MD further stated no one is going to fuss at the staff if they choose to evacuate the hall. They may choose to take the residents behind the fire doors, or they may choose to evacuate the residents outside the facility. The MD further stated, the only incident that I am aware of in October occurred on October 12, 2024 at 9:30 AM, when a resident pulled the pull station outside of room [ROOM NUMBER]. There have been no other Incidences in October. The MD concluded, I was not informed that a resident was found outside during this incident on 10/05/24. On 12/19/24 at 5:00 PM, the facility provided an acceptable IJ Removal Plan, which included the following: 1. How correction action will be accomplished for those residents found to have been affected by the deficient practice. On 10/5/2024 resident MR#209959 exited the facility unsupervised sustaining a fracture. The resident ambulated with the Charge Nurse back inside the facility denying any pain. On 10/5/2024, the Charge Nurse completed a skin assessment with no injuries or bruising. On 10/5/2024, an Incident Report and notifications were made to the family and MD. On 10/5/2024, a Fall risk evaluation was completed and the patient identified as a risk with a score of 16. The Executive Director, Director of Nursing and Interdisciplinary Team completed a Root Cause Analysis (RCA) on 12/19/2024. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice. On 10/5/2024, the Charge Nurses completed a head count for all patients inside the facility. All patients were accounted for. 3. What measure will be put into place or systemic changes made to ensure that the deficient practice will not recur? During the monthly PI committee meetings, the following will be reviewed: -The Executive Director and Maintenance Director will be responsible for ensuring compliance with supervision when drills/fire alarm sounds. -The Director of Nursing will be responsible for reviewing the Event Management System for trends and patterns. -The Staff Development Director will be responsible for reviewing the education completion of associations on: Departmental Fire Procedures policy, Incident and Reportable Event Management Policy, and Fall Management Policy. On 12/19/2024, the Regional Director of Clinical Services provided education to the Executive Director (ED) and the Director of Nursing (DON) on the following: Departmental Fire Procedures policy, Incident and Reportable Event Management Policy, and Fall Management Policy. The ED, DON, Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC) and/or licensed nurse will provide education to all facility staff on the following: Departmental Fire Procedures policy, Incident and Reportable Event Management Policy, Fall Management Policy. Any associate who has not completed training by 12/19/2024 will not be allowed to provide direct resident care until training is completed. The Executive Director (ED), Director of Nursing (DON), Staff Development Coordinator (SDC), and/or licensed nurse will provide education to all new associates upon hire during orientation. Medical Director reviewed and agreed with this plan of removal on 12/19/2024. AD Hoc QAPI meeting was held 12/19/2024 regarding this plan of removal. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The ED and/or Maintenance Director will complete fire drills weekly x8 weeks. The DON will review Event Management System for trends and patterns daily x8 weeks. Associate Education will be continued until all associates have been educated on Departmental Fire Procedures policy, Incident and Reportable Event Management Policy, and Fall Management Policy. 5. Date when corrective action will be completed. 12/20/2024

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review and interviews, the facility failed to prevent accidents/hazards for 1 of 3 Residents (R)1 reviewed. Specifically, on 8/30/23, R1 had a successful elopement from the facility. R1 was placed at an increased risk of serious harm with the potential of being struck by a vehicle and/or suffering a heat related illness. On 08/31/23 at 3:35 PM the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 08/31/23 at 3:35 PM, the Administrator was notified that the failure to protect Resident (R)1 from having a successful elopement from the facility constituted Immediate Jeopardy (IJ) at F689. On 08/31/23 at 3:35 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 08/30/23. The IJ was related to 42 CFR 483.25 Quality of Care. On 09/01/23 at 11:23 AM, the facility provided an acceptable IJ Removal Plan. On 09/01/23 at 11:23 AM, the facility provided an acceptable IJ Removal Plan. On 09/01/23, the survey team, validated the facility's corrective actions and determined the facility made good faith attempts at correcting the non-compliance before the start of the survey. The IJ is considered at Past Non-Compliance as of 08/31/23. The survey team concluded all corrective actions were put into place prior to their arrival onsite. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility policy titled Unsafe Wandering and Elopement Prevention with a reviewed date of 09/29/22 revealed, The facility will ensure that residents are assessed to determine risk for elopement in accordance with current standards and implement interventions as appropriate to mitigate the risks identified. Definitions. Elopement- this occurs when a resident leaves the premises or a safe area without authorization (i.e., and order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential too experience) heart or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Unsafe wandering - It can be associated with an increased risk for falls and injuries. Wandering may become unsafe when a resident becomes overly tired or enters and area that is physically hazardous or that contains potential safety hazards (e.g., chemicals, tools, and equipment, etc.) entering into another resident's room may led to an altercation or contact with hazardous items. Wandering if random or repetitive locomotion. This movement may be goal-directed (e.g., the person appears to be searching for something such as an exit0or [sic] may be non-goal-directed or aimless. Review of the facility policy titled Missing Residents/Actual Elopement Event with a revised date of 04/05/23 revealed, It is the responsibility of all associates to report any resident who is suspected of being missing to the nurse manager immediately. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to dementia, coronary artery disease, cardiovascular accident/transient ischemic attack, hypertension, diabetes mellitus and hyperlipidemia. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/09/23 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 5 out of 15, which indicated R1 has severe cognitive impairment. Review of R1's Elopement assessment dated [DATE] and 06/23/23, revealed R1 was not at risk for wandering and elopement. Review of a facility statement dated 08/30/23 revealed, Registered Nurse (RN)1 stated R1 had been out of her room in the day room at 11:30 PM and came to the nursing desk at 12:15 AM because of nausea. R1 sat at the nursing station with another resident for approximately 30-45 minutes and around 1:30 AM I pushed her back to her room. R1 came out of room again at approximately 2:30 AM, back to the day room and I pushed her back to her room. RN1 stated she last saw R1 around 4:30 AM in dayroom. RN1 further stated while doing my final rounds and checking blood sugars she went into R1's room and she was not in her room or bathroom. RN1 rechecked the day room and went through all rooms and bathrooms on Morning Star and Day Spring units and still could not find R1. All other units came to assist with the search. RN1 concluded she went outside the perimeter of the facility and noticed R1 was in the parking lot and returned R1 to the unit. A body assessment was conducted with no injuries. Review of a facility statement dated 08/30/23, revealed Certified Nursing Assistant (CNA)1 stated R1 was in tv room around 2:00 AM and went to nursing station. I went on break at 2:30 AM and nurse had pushed her back to her room. The resident self-propelled herself back to day room around 4:30 AM, nurse was looking for resident and unable to locate on Morning Star or Dayspring. R1 was found sitting in parking lot at around 5:00 AM and returned to facility. Review of a facility statement dated 08/30/23, revealed CNA2 stated I saw [R1] last at 2:40 AM at nursing station before I started doing rounds. [R1] had been alternating between watching TV in day room and the nursing station since 12:30 am. During an interview on 08/31/23 at 10:30 AM, the Administrator stated R1 was a resident on the Morning Star unit and was last seen at approximately 4:30 AM in the Morning Star Day Room across from the nursing station. R1 was found in the parking lot near the main entrance in her wheelchair at approximately 4:50 AM and had been outside approximately 20 minutes. The Administrator further stated R1 passed through the main hallway into the Lobby and exited through the front door which will open when pushed because it is an egress door. It was a warm night and it was not raining. During an interview on 08/31/23 at 11:12 AM, the Director of Nursing (DON) stated R1 had been on the dementia unit and had been transferred to the Morning Star unit several months ago because the other residents on the dementia unit were bothering her. The DON further stated R1 was last assessed for elopement risk on 06/23/23 and found not to be at risk for elopement. During a follow up interview on 08/31/23 at 11:33 AM, the Administrator stated there is no video footage since the system does not work. The Administrator further stated R1 had recently been started on Trulicity once a week and staff and her daughter had noticed some changes in her behavior and nausea. During an interview on 08/31/23 at 2:52 PM, the Maintenance Director (MD) stated the front entrance door through which R1 eloped does not presently signal elsewhere in the facility when it is opened. On 08/31/23, attempts were made to contact the Resident Representative, Licensed Practical Nurse (LPN)1, Certified Nursing Assistant (CNA)1 and CNA2 with no success. The facility's Removal Plan for included the following: Life Care Center of [NAME] takes quality assurance and quality control very seriously. It is extremely important that we provide a safe, clean environment for our residents, family members, staff, and the community we serve. On August 30, 2023, Life Care Center of [NAME] notified DHEC of an event pertaining to the elopement of resident # I (MR#206990). Immediate risk mitigation started with a Root Cause Analysis (RCA) which was completed the same day, August 30, 2023. l. On 8/30/23, resident# l (MR #206990) was assisted back into the facility by a licensed nurse. A skin assessment, pain assessment, and an elopement risk assessment were completed by a licensed nurse and no injuries were noted. Resident was placed on l: l supervision by a licensed nurse. A licensed nurse completed an event management report. A licensed nurse notified the physician, responsible party, Director of Nursing and Executive Director. A licensed nurse reviewed and updated resident #1 'scare plan and [NAME]. Resident was placed on the secure unit and assessed by the attending physician. New medication orders were received. 2. On 8/30/23, The Executive Director reported the incident to the Medical Director, SC DHEC, and the Tri-County Regional Ombudsman. 3. On 8/30/23, a licensed nurse completed head count of all residents and all residents were in facility. A licensed nurse completed elopement risk assessments for all residents and updated all care plans and [NAME]'s for residents identified at risk for elopement. A licensed nurse updated At Risk for Elopement notebooks. The At Risk for Elopement notebooks were placed at the nurse's stations and the reception desk. The Director of Nursing also placed signage for awareness of exit seeking residents at nurses' stations and reception desk. 4. On 8/30/23, the Interdisciplinary team completed a Root Cause Analysis (RCA) on the elopement to re-evaluate the systemic approached to resident elopement. 5. On 8/30/23, the Maintenance Director ensured the front door was secured/locked and will remain secured unless receptionist or staff is present. 6. On 8/30/23 , the Director of Nursing (DON), Assistant Director of Nursing (ADON), Director of Rehab (DOR) and/or Infection Preventionist (IP) nurse-initiated education to all associates on: · Abuse Policies · Unsafe Wandering and Elopement Prevention · Missing Residents/Actual Elopement Event · Resident Assessment Instrument and Care Plan Any Associate that did not complete training on 8/30/23, will receive training before working their next shift. 7. On 8/30/23, the Maintenance Director conducted an elopement drill and provided educational overview for the participants. The Maintenance Director will conduct Elopement Drills monthly for three months. Results will be presented by the Director of Maintenance to the monthly QAPI committee. Then resume to quarterly schedule. 8. A licensed nurse will review elopement risk assessment (UDA's) to ensure residents at risk for elopement are appropriately care planned and a picture is placed in elopement notebooks. This will be completed 5 times/week for 4 weeks, 3 times /week for 4 weeks and 1 time/week for 4 weeks. Results will be presented by the DON to the monthly QAPI (Quality Assurance and Performance Improvement) committee for 3 months. QAPI committee members may make recommendations as appropriate for changes to managing this clinical system. All corrective actions were completed on 8/30/23. The facility alleges compliance on 8/31/23 as a past noncompliance immediate jeopardy. Timeline of events: 01/27 /22 Resident #206990 (R1) admitted to facility on the rehab unit. Her admitting diagnoses include: Metabolic Encephalopathy, CVA with left-sided hemiparesis/hemiplegia, and DM 03/04/22 Resident (R1) became long term care and moved to secured unit. 04/07/22 Family concerned of resident's (R1) decline being on the secured unit. She was then moved to Morning Star, a unit that is not secured. Elopement assessments indicated she was not an elopement risk. Resident thrived on Morning Star, moving freely around the unit, to the dayroom, to the dining room, etc. Never any issues. 08/15/23 New order for Trulicity to be administered every Tuesday. 08/30/23 Third dose of Trulicity administered at approx. 1600. 08/29/23 2300 Shift began. CNA 1 reports resident in her bed. 2300 Nurse (LPN 1) states resident sitting in dayroom. 08/30/23 0015 Nurse (Licensed Practical Nurse 1)states resident propelled herself to the nurse's station and c/o nausea, suspected cause was the Trulicity injection. She sat at the nurse's station for a period of time (unsure how long). 0030 CNA (Certified Nursing Assistant) 1 saw resident transfer herself out of bed. She then alternated between sitting in the dayroom/watching tv/propelling back and forth to her room. 0200 CNA 2 saw resident between nurse's station and dayroom. 0230 CNA 2 states she saw resident rolling herself into dayroom. Nurse (LPN 1) pushed resident back to her room. 0240 CNA 1 states resident noticed at the nurse's station when she was about to begin her last round of the shift. 0430 Nurse (LPN 1) making rounds and checking blood sugars. Noticed resident wasn't in her room . (Resident is a diabetic and needed blood sugar checked.) CNA 2 believes she saw resident propel herself to the dayroom at approximately this time. 0430 Search for resident began on Morning Star and Dayspring (these two units are near one another) 0500 Resident (R1) found sitting in w/c in parking lot. Registered Nurse (LPN 1) asked resident what she was doing and she stated she was looking for her medicine. Registered nurse (LPN 1) immediately returned resident to her unit. Body audit, pain assessment and incident report completed. Facility provider/ED (Executive Director)/DON/ADON (Assisteant Director of Nursing) notified. 0800 ED completed Reportable 0900 Facility provider assessed resident as soon as she arrived to facility. Provider states in her note resident has no recollection of the incident earlier in the morning. Vital signs within normal limits at time of evaluation. Resident (R1) states to provider that she feel nauseous. Provider suspects the Trulicity is causing this and order is discontinued. 0900 ED spoke with resident's RP (Resident Representative) and it was agreed resident should be on secured unit for her safety. Move not made immediately because waiting on other resident to discharge. 1300 Resident (R1) moved to room on secured unit. 08/31/23 Facility provider ordered CBC (complete blood count), CMP (comprehensive metabolic panel), U/A (urinalysis) C&S (culture and sensitivity) r/t (related to) resident with increased confusion.