**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow manufacturer's guidelines to ensure that blood glucose glucometers were sanitized/cleaned properly. On 03/25/25 at 12:10 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 03/25/25 at 12:15 PM, the Administrator was notified that the facility's failure to have systems in place to monitor for blood glucose glucometers constituted Immediate Jeopardy (IJ) at F880. On 03/26/25 at 3:00 PM, the facility provided an acceptable IJ Removal Plan. On 03/26/25 at 4:10 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F880 at a lower scope and severity of D. Findings include: Record review of facility policy titled Staff Education/Orientation Policies and Procedures Blood Glucose Monitoring last revised 01/12/24 revealed reference facility specific Blood Glucose Monitoring Device manufacturer's recommendations. Clean Glucometers utilizing two-step process with an approved Environmental Protective Agency (EPA) disinfectant wipe which is labeled effective against Tuberculosis (TB), or Hepatitis B Virus (HBV), Hepatitis C (HCV), or Human Immunodeficiency Virus (HIV) to remove any visible contaminants, soil, or other debris. Use a second EPA disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time. Record review of facility policy Infection Prevention and Control Policies and Procedures Transmission Based/Standard Precautions, and Enhanced Barrier Precautions (EBP), last revised 05/15/23 revealed EBP will be implemented for all residents with the following: infection or colonization with a Multidrug-resistant Organisms (MDRO) when contact precautions due not otherwise apply; wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. Record review of the Manufacturer's recommendation for the Evencare G2 Meter revealed Cleaning and disinfecting the meter is very important in the prevention of infectious disease. The following products are validated for disinfecting the EVENCARE G2 Meter ., .Medline Micro-Kill Bleach Germicidal Bleach Wipes. During a medication administration observation on 03/24/2025 at 5:20 PM with Registered Nurse (RN)1. She stated each resident has an individual glucometer. She pulled R86's pouch from the medication cart. The glucometer was not located in the pouch. She checked some of the other pouches and said R168's glucometer was not in his pouch either. She then looked in the drawers of the medication cart and found a glucometer and said this was R86's blood sugar check machine (finger stick blood sugar). She found an Even Care G2 glucometer. It did not have R86's name on it. RN1 said she checked her blood sugar this am. It was 153 at lunch. She wiped the machine with an alcohol prep pad and entered R86's room to perform the blood sugar checks check. She then returned to the medication cart afterward. She cleaned the glucometer with an alcohol prep pad. She returned the pouch back into the medication cart. Observation on 3/24/25 at 5:50 PM, Licensed Practical Nurse (LPN) 1 was observed placing an Evencare G2 glucometer into a pouch. LPN1 stated she had just finished checking a resident's blood sugar and had cleaned it with an alcohol wipe since all residents have their own glucometer. During an interview on 3/24/25 at 5:54 PM, LPN2 described how she cleans the Evencare G2 glucometers stating that she uses MicroKill Bleach Wipes even though each resident has their own glucometer. On 03/24/2025 at 5:55 PM RN1 opened the medication cart. She opened each pouch and pulled the machine from the pouch to verify who had a glucometer. R168 and R67 did not have a glucometer in their pouches. When asked if she performed a blood sugar check on either of these residents, she stated, I had to do a blood sugar checks check earlier on R168, around noon. I used R86's blood sugar checks machine for him. I always clean with an alcohol pad, with each person. His blood sugar was 279. Record review of R86's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to type 2 diabetes mellitus, binge eating disorder, and morbid obesity. Record review of R86's quarterly Minimum Data set (MDS) with an Assessment Reference Date (ARD) of 02/19/25 revealed a Brief Interview Mental Status (BIMS) score of 15, of 15, indicating she was cognitively intact. Record review of R168's Face Sheet revealed he was admitted on [DATE] with diagnoses including but not limited to: orthopedic aftercare following surgical amputation. Record review of R168's MDS admission MDS with an ARD date of 03/18/25 revealed a BIMS score of 15, of 15, indicating he was cognitively intact. Record review of R168's MAR dated 03/24/25 at 12:30 PM indicated that a blood sugar check was performed, with a result of 279 mg/dL. Record review of R67's Face Sheet revealed R67 was admitted to the facility on [DATE] with the diagnoses including but not limited to: type 2 diabetes mellitus with hyperglycemia, hypertension, pain, and schizophrenia. Record review of R67's quarterly MDS with an ARD of 03/14/25 revealed a BIMS score of 12 of 15 which indicates he is moderately impaired. Record review of R67's Medication Administration Record (MAR) dated 03/24/25 at 12:00 PM, indicated that a blood sugar check was performed, with a result of 106 mg/dL. During an interview 03/25/25 at 08:23 AM, the Director of Nursing (DON) said, for glucometer cleaning, wash hands, don gloves. Inspect the glucometer to see it is visibly soiled, wipe with an alcohol pad, then use Environment Protection Agency (EPA) approved germicidal wipes, wash hands, don gloves, place barrier down and place glucometer on it, wet it down, with blue top for 3 minutes. Each patient has their own glucometers, we have extras in the supply room. If they don't have one, we have replacements. She said it is not ok for a nurse to use another resident's glucometer; each resident has their own. In the room, they should transport the glucometer in a cup and or place a barrier down at bedside. Each resident has their own clear pouch. The Unit Manager audits the carts every Monday, making sure each resident has their own glucometer. I made sure we had at least 5 extras in the supply room. During an interview on 03/25/25 at 10:48 AM RN2 stated, R188 has a wound vac and is not on EBP. During an interview on 03/25/25 at 11:05 AM, LPN4 stated R86 should be on EBP and should have an order for it. She also confirmed R168 should have EBP signage on his door and an order for it as well. The facility's removal plan dated 03/26/25 noted the following: Residents who require blood glucose moitoring will be assessed for signs and symptoms of infection by the licensed nurses on 02/25/2025. R#188 without negative effects. Resident #168 had EBP implemented on 03/25/2025. EPA disinfectant wipes were placed in medication carts that store glucometers. An audit of glucometers was completed by the DON/Designees on 03/25/2025 to validate each resident that requiring blood glucose monitoring has a glucometer available. A review of current in house residents will be completed by the DON/Designee on 03/25/2025 to identify residents who require EBP which include; Resident with an infection or colonization with a multi-drug resistant organism not on transmission based precautions. Resident with wounds, including pressure, diabetic foot, unhealed surgical and venous wounds. Residents with an indwelling medical device such as a central line, urinary catheter, feeding tube, tracheostomy, and peripherally inserted central catheters. Residents identified as meeting the criteria for EBP will have a signage placed at the door, provider notified and order written, responsible party notified and care plan updated on 03/25/2025. Licensed nurses will be reeducated with competency validation by the DON on 03/25/2025 on blood glucose monitoring including; Validating the residents assigned glucometer is used. Location and availability of additional glucometers. Using a barrier to place the glucometer on if needed in residents room. Using a 2 step process with an approved EPA disinfectant wipe to remove any visible contaminants, soil or other debris and using a second EPA disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time. Validating EPA disinfectant is available on their medication cart at the beginning of their shift. Licensed nurses will be reeducated by the DON on 03/25/2025 on EBP including criteria that required EBP: Resident with an infection or colonization with a multi-drug resistant organism not on transmission based precautions. Resident with wounds, including pressure, diabetic foot, unhealed surgical and venous wounds. Residents with an indwelling medical device such as a central line, urinary catheter, feeding tube, tracheostomy, and peripherally inserted central catheters. Any licensed nurse not receiving this reeducation validation by 03/25/2025 will receive prior to their next scheduled shift. This will be presented in new hire orientation and in Agency orientation. The DON will randomly observe 2 licensed nurses for 5 days performing blood glucose monitoring to validate proper procedure including infection control technique and correct glucometer is being utilized. The DON/Designee will validate each morning for 5 days EPA disinfectant wipes and available on each med cart that stores glucometers. The DON/Designee will review the facility activity report and 24-hour report in the clinical morning meeting Monday-Friday to identify any resident who require EBP and validate orders are written, provider and responsible party are notified, signage on residents door, PPE is available and care plan updated. On 03/26/2025 at 4:00 PM the removal plan was accepted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy, the facility failed to provide appropriate supervision to prevent Resident (R)1's elopement from the facility. On 06/14/24 at 1:28 PM, the Administrator was notified that the failure to properly supervise a resident, resulting in a successful elopement from the facility, constituted Immediate Jeopardy (IJ) at F689. On 06/14/24 at 1:28 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 06/11/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 06/14/24 at approximately 2:18 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The survey team considers the IJ at Past Non-Compliance as of 06/12/24. 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's policy titled Elopement last revised 11/01/17, stated, To safely and timely redirect patients/residents to a safe environment. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: vascular dementia, abnormalities of gait and mobility, lack of coordination, difficulty in walking, unsteadiness on feet, reduced mobility, altered mental status, fall from bed, neurocognitive disorder with Lewy bodies, and depression. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 05/08/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating R1 was severely cognitively impaired. Further review of the MDS revealed that wandering behaviors occurred 1 to 3 days. Review of R1's Elopement Risk Tool dated 05/02/24, revealed R1 is not alert and oriented. R1 is confused and does not have safe decision-making capabilities. R1 has a history of wandering and has previously attempted to leave the health care center. Further review revealed, R1 has diagnoses that requires supervision. Review of R1's Physician Orders dated 08/01/23, revealed the following order, Wander guard to right ankle; check placement and function Q shift. Review of R1's Progress Note dated 06/11/24 at 7:21 PM, revealed, At 6:30 resident attempt to go out of building doors was opened, but I the nurse and staff re-direct her back into the building. Review of R1's Progress Note dated 06/11/24 at 9:32 PM revealed, At 7.18pm this nurse was in the med room. when i got out of the med room I saw other nurses running towards the back door. This nurse left the stuff she was carrying in the cart and rushed to where the other nurses where running to. Upon going out, this nurse saw that it was her resident who was on the ground. Assessment done on resident she reported she hit her head . During an interview on 06/14/24 at 11:59 AM, Licensed Practical Nurse (LPN)1 stated that on the night of 06/11/24 at approximately 7:15 PM, the door alarm/wander guard system alarm went off, LPN1 then went to check the panel to see which door it was, it was 2B, LPN1 then went down the hall, however it was the wrong hall. LPN1 then went down E hall and out the door and found R1 lying on the ground in the parking lot next to a light pole. LPN1 states that R1 reported to her that she fell and hit her head. 911 was then called for R1. During an interview on 06/14/24 at 12:09 PM, R1 stated that she wanted to go to the white house across the street, so just got up and walked out the door. R1 further stated that she fell in the parking lot on a curb and hit her head and was sent to the emergency room. During an interview on 06/14/24 at 12:45 PM, LPN2 stated that R1 was wearing a white top, pink pants and non-slip socks, when she was found in the parking lot. According to the Weather Channel, on 06/11/24, the high was 89 degrees Fahrenheit with a low of 63 degrees Fahrenheit. On 06/14/24 at approximately 2:18 PM, the facility provided a removal plan, which included the following: Resident R1 had fall, possibly hitting head. Sent to ED for evaluation as precaution. Elopement risk evaluation repeated. Resident had Wandergard in place and properly functioning at time of incident. MD/RP notified. Administrator and CSD notified of incident. Residents at risk of elopement have the potential to be affected. Elopement risk evaluations done in the past 90 days on current residents in facility reviewed by nursing managers for accuracy. Residents identified at risk will be reviewed for appropriate interventions. All doors check for auditory alarm; found to be in working order. Educate facility staff the expectation that if a door is noticed to be alarming, immediately report to door to verify no resident has eloped then do a facility wide head count of residents. If door is found to be malfunctioning, administrator to be notified immediately and an employee posted at the door until otherwise indicated and redirected by a member of management. Licensed nurses will be re-educated on the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. Staff will be reeducated on appropriate response to alarms. This re-education will be initiated on 06/11/2024 and completed by 06/12/2024. Any member of target audience not receiving this by this date will receive prior to next scheduled shift. New admissions will be reviewed in morning meeting daily Monday thru Friday as part of the clinical morning meeting process. Elopement risks assessments will be reviewed for accuracy and interventions validated if indicated. Quarterly assessments will be reviewed as part of the MDS/Care planning process. The Director of Nursing or designee will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks then monthly for 2 additional months to validate accuracy. The maintenance director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months. The Administrator or designee will make rounds weekly for 4 weeks then monthly for 2 additional months to validate that doors are functioning properly. The maintenance director or designee will activate a door alarm once a month on each shift to validate appropriate response for 3 months or until compliance. Ad hoc QAPI held on 06/12/2024. Medical Director was notified of the incident and plan for improvement on 06/12/2024. This process will be reviewed in QAPI for a minimum of 3 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility policy, record reviews, and interviews, the facility failed to protect 1 of 1 residents from sexual abuse. Resident (R)1 inappropriately touched R2 on 08/28/2023 at approximately 5:20 p.m. This was observed by staff members. On 09/01/2023 at 05:30 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 09/01/2023 at 05:30 pm, the survey team presented the Administrator with the Immediate Jeopardy (IJ) template, notifying her that the failure to protect R2 from sexual abuse by R1 constituted IJ at F600 with the start date of 08/28/2023. The facility presented an acceptable removal plan for F600 on 09/01/2023 via email. The SA returned to the facility on [DATE] to verify the removal of the IJ. Following a review of the facility's implementation plan, along with a review of audits, education, and interviews, the IJ was verified as removed as of 09/01/2023 and the facility remained out of compliance at a scope and severity level at D. An extended survey was conducted in conjunction with the complaint survey constituting substandard quality of care. Findings include: A review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment revised 10/01/2020, states Sexual abuse is non-consensual sexual contact of any type with a resident. C- Rape, Molestation, or other inappropriate sexual behavior against a resident such as Sexual harassment, Sexual assault, Sexual Coercion, or Inappropriate sexual behaviors displayed by and/or toward incapable resident. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular dementia with other behavioral disturbances and cognitive communication deficit. R1 scored a Brief Interview of Mental Status (BIMS) of 07 out of 15, indicating severe cognitive impairment, as of 07/26/2023 on quarterly Minimum Data Set (MDS). Review of R1's Physician orders revealed R1 had an order for 1:1 supervision with a start date of 07/13/2023. A policy was requested for 1:1 supervision, however, the facility Administrator stated there was no policy related to 1:1 supervision. R1 had been care-planned since 07/31/2023 for Unwanted touching of female and entering other resident's rooms without permission. Interventions included redirection, visits with psychiatric services, and Gradual Dose Reduction (GDR) attempts. R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, cognitive communication deficit and major depressive disorder. R2 scored a BIMS of 11 out of 15 indicating she was moderately, cognitively impaired as of 08/02/2023 on a quarterly MDS. An interview with the Facility Administrator and DON (Director of Nursing) on 09/01/2023 at 12:40 PM revealed that they were informed by the agency nurse who worked the floor that she had witnessed R1 in R2's room with his hand on her breast, outside of clothing, while R2 was resting, and was not aroused. There was no evidence of the resident making inappropriate comments. The DON stated that R1 did not attempt to remove any of her clothing and that R1 has a history of using physical touch to communicate. The DON stated that two (2) staff members were suspended for failure to provide R1 with 1:1 supervision. The scheduler pulled the 2nd shift sitter to work a group setting because R1 was going to have a decrease on 1:1 due to behaviors improving. The 7-3 sitter clocked out early due to her relief showing up. The DON also stated that a review of the Resident's Psych notes confirms that the resident is being seen for impulse control. The DON also stated that clarification of staff interviews related to inappropriate touching reveals resident will use terms such as dear, baby, honey when addressing staff and places his hand on the female hip and/or lower back. The DON stated that R1 has a tendency to become irate and agitated when questioned because he believes that his behaviors are appropriate, and gestures are his normal way of communicating. The DON stated that psych services continue to reinforce accountability and work on impulsive behaviors. The DON stated that R2, who was the victim has a BIMS of 9 and was startled upon the male resident being in the room. R2 was easily calmed down by staff when staff saw and immediately removed R1 from the room. DON stated that Social Services Director did refer R2 to psych services due to initial trauma from waking up and being startled. DON stated that R1 was discharged home the next day, 08/29/2023 into the custody of his brother and R2 remains at baseline and followed by psych services as a preventative measure. In an interview with R2 on 09/01/2023 at 1:55 PM she revealed, I was sleeping, and he was kissing me in my mouth, he touched me (pointing at both breasts), I woke up scared and said, You got to go, and he did not leave. R2 stated that two staff members saw R1 and pulled R1 out of the room and started checking me. R2 stated that she fears for her life, she can't sleep, and every time she closes her eyes, she sees him. R2 stated that staff comes in to visit and try to cheer her up, however, she just wants to go home. The Social Services Director was unavailable for interview. A phone interview with Licensed Practical Nurse (LPN)1 on 09/01/2023 at 02:38 PM revealed that R1 was on 1:1 supervision when the incident occurred. LPN1 stated that she was walking with R1 at the nurse's station and turned around to talk to another staff member for less than 30 seconds and when she (LPN1) turned around to check on R1, he was gone. LPN1 stated that she started searching for him due to wandering behaviors and she (LPN1) located R1 in R2's room in his wheelchair, on the right side of R2's bed, with his hand on R2's right breast, over her clothing. LPN1 stated that R2 stated Get off of me, and immediately removed R1 from the room and notified another nurse to report it to the DON. The facility's removal plan included: Staff and resident interviews did not reveal any other concerns, completed on 08/28/2023. Re-Education on Abuse, Neglect, and Misappropriation and Abuse policy to staff. This re-education will be completed by 09/01/2023. Any staff member not receiving this education by this date will receive it prior to the next scheduled shift. DON or Social Services will review the resident's reported inappropriate behaviors in the clinical morning meeting Monday-Friday to validate that safety interventions are appropriate and in place to maintain a safe environment. The administrator will review monitored information and the clinical morning meeting agenda with identified changes of condition/signs and symptoms of trauma, including grief weekly for 4 weeks then monthly for two months. Ad-hoc QAPI held on 08/29/2023. The Medical Director was notified of the incident and plan for improvement on 08/29/2023 (via phone call). The results of the monitoring will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations for a period of 3 months. Concerns identified will be addressed at the time of discovery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy, the facility failed to provide and document sufficient preparation and orientation to a resident to ensure safe and orderly discharge from the facility for 1 of 1 residents reviewed for discharge. Specifically, Resident (R)1, nor his representative was adequately prepared or informed of R1's discharge from the facility. On 09/01/23 at 5:30 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 09/01/23 at 5:30 PM, the survey team presented the Administrator with the Immediate Jeopardy (IJ) template, notifying her that the failure to ensure a proper and safe discharge for R1 constituted IJ at F624 with a start date of 08/29/23. The facility presented an acceptable removal plan for F624 on 09/01/23 via email. The survey team returned to the facility on [DATE] to verify the removal of the IJ. Following a review of the facility's implementation plan, along with a review of audits, education, and interviews, the IJ was verified as removed as of 09/01/23 and the facility remained out of compliance at a lower scope and severity level of D. Finding Include: Review of the facility policy titled Discharge Notification, with a complete revision date of 10/01/20, documented, All patients/residents will be discharged /transferred from the Facility by order of his/her attending physician, in a safe, secure and correct manner. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular dementia with other behavioral disturbances, morbid obesity, diabetes mellitus, and cognitive communication deficit. Review of R1's Physician Orders revealed R1 received, Levemir FlexTouch U-100 Insulin (insulin determir u-100) 100 unit/mL (3 m/L) insulin pen twice a day 45 units, subcutaneous, twice a day, Depokote (divalproex) 250 mg tablet, delayed release (DR/EC), Enema (sodium phosphates) 19-7 gram/118 mL enema once a day - PRN (as needed), 19-7 gram/118ml, rectal, once a day - PRN, may have enema if no bowel movement x7 days, and nitroglycerin 0.4 mg tablet, sublingual, 1 tablet, sublingual, every shift - PRN, place 1 tablet under the tongue every 5 minutes as needed for chest pain. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/23 revealed R1's Brief Interview of Mental Status (BIMS) score of 7 out of 15, indicating R1 was severely cognitively impaired. Review of R1's functional status revealed R1 required limited assistance with one person physical assist with Activities of Daily Living (ADL). Further review of the MDS revealed R1 utilizes an indwelling catheter and is occasionally incontinent of bowel. Documented under Medications revealed R1 received insulin injections during the last 7 days. The MDS also indicated that R1 has no guardian or legally authorized representative. Review of R1's discharge MDS with an ARD of 08/29/23 revealed R1 was discharged on 08/29/23 and indicated the type of discharge was Planned. The MDS indicated R1 was discharged to the community. Further review of the MDS revealed R1 required physical help in part of bathing activity. R1 was not rated for urinary continence due to R1 having a catheter, urinary ostomy, or no urine output. The MDS documented that R1 was occasionally incontinent of bowel. Review of R1's Care Plan dated problem start date 07/31/23, revealed the following, [R1] has not had a fall but he is at risk due to psychoactive medication use and unsteadiness in transitions. He has dx [diagnosis] of dementia. ADL/Dental/Vision; [R1] has teeth with some in poor appearance. He has not c/o [complaints of] mouth or teeth pain. He has impaired hearing and vision. [R1] scored 7 on his BIMS, has impaired cognitive skills with impaired memory recall and he requires supervision. He has unclear speech but is able to make concrete requests and he responds adequately to simple direct communication and he has dx of Dementia AND bilateral conductive hearing loss. [R1] is at risk for infection r/t [related to] use of foley catheter. He has dx of urinary retention/obstructive uropathy. [R1] is at risk for medication side effects r/t psychotropic drug use. he has dx of dementia and depression. [R1] has potential for fluctuating of blood pressure, headaches, lightheadedness/dizziness r/t dx of hypertension/hypotention. Review of R1's Social Service Review dated 07/27/23 revealed R1 has severe impairment with behaviors of wandering and removing catheter from privacy bag. The Social Service Review also indicated under Discharge Planning, Remain in facility. Review of R1's Discharge summary dated [DATE] revealed R1 is Discharge per facility. He is being discharged per facility order due to behavioral issues, he is to be picked up by his son today. The Discharge Summary further documented, Follow up with PCP in 30 day. and Needs to follow up with urology regarding long term foley catheter or alternatives for treatment of urinary retention. Review of R1's Progress Note dated 08/29/23 at 11:21 AM documented, Resident discharged and left facility via transport to brothers house. Transport driver called and notified facility that resident was dropped off at brothers home. In an interview on 09/01/23 at 12:11 PM, R1's representative (RR1) revealed the facility called him the day of and stated that the resident went into another resident's room and touched her inappropriately. RR1 stated that the resident likes to talk with his hands. The facility told him They needed to pick the resident up right now or they are kicking him out. RR1 stated he couldn't pick him up, which he was not in agreement with because the resident was supposed to stay long-term. RR1 stated, The only thing the facility was concerned about was where to send him because they were kicking him out. RR1 further stated that he is active in his brother's care and participated in his care plan meeting and a discharge was not discussed. An attempted interview with the Social Services Director was unsuccessful. An attempted interview with R1's Physician was unsuccessful. In a follow up interview on 09/01/23 at 4:08 PM, RR1 stated, That night they called me and told me I needed to come get him right now. I told them I have no means to take care of him or pick him up. They said they could put him in an Uber the next day. I called them back the next morning and they said they sent him about 15 mins ago. He arrived in a transport van, he had a Walmart bag full of medicine. He can't take his own medication. They (the facility) didn't provide me with any education or anything. He arrived in a broken wheelchair, and I called 911 to pick him up. Because I couldn't take care of him. He is currently in room L502 at the local hospital. I had a couple phone meetings with the facility about updates, we never discussed any discharge plans for him. They literally kicked him out and I didn't know he left until I called and they said he was 15 minutes out. In an interview on 09/01/23 at 5:00 PM, R1's Nurse Practitioner (NP) stated, I was told by the facility that they were getting him out of the facility. I was told that he was going home with his son. I was not informed that the resident was not able to be cared for upon discharge. This is the first time I have dealt with a situation like this. Normally people are set up with home health and physical therapy and have a plan for discharge. I was not aware of the full situation, I was told that they were going home and it was a quick discharge given the situation. I was under the impression that family was going to be caring for him. On 09/01/23 the facility provided a removal plan which included the following: Notification to resident responsible party on 08/28/2023 RP agreed to accept custody of resident and requested facility arrange transportation. Primary Care Physician notified of event on 08/28/2023 and order received to discharge resident to RP brothers care On 8/28/23 via phone with RP DON offered to set up home health care and RP declined, stated he would use family PCP. Transportation arranged on 8/29/23 [R1] discharged on 08-29-2023 to care of POA with additional catheter kit, medications, personal belongs. Social services attempted to set up additional home health services with RP on 8/31/23 via phone, no answer- message left. Residents who have been discharged in past 48 hours have been reviewed to validate safe, orderly transfer/discharge. 1 resident identified and has transferred back to facility no concerns. Re-education facility staff responsible for discharge planning (Administrator, Social Services, DON, Therapy Director, Medical Supply) will be completed by 9/1/23. Any staff member not receiving this education by this date will receive prior to next scheduled shift. DON, Social Services and Administrator will review anticipated discharges in morning meeting Monday-Friday times 3 months to identify preparation for safe, orderly transfer/discharge. The Administrator will review monitored information with identified changes of for 4 weeks then monthly for 2 months. Ad-hoc QAPI held on 09/01/23. Medical Director was notified of the incident and plan for improvement on 9/1/23 (via phone call). Results of the monitoring will be presented to the Quality Assurance Performance Improvement committee for review and recommendations for a period of 3 months. Concerns identified will be addressed at time of discovery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and the review of the facility's policy titled Abuse, Neglect, Exploitation and Mistreatment, the facility failed to prevent a successful elopement for 1 of 3 residents reviewed for Neglect. Resident (R)1 had a successful elopement from the facility on 05/09/23 at an unspecified time and was without supervision for an extended period of time. R1 was found by the police at the baseball field, across the street from the facility on 05/09/23 around 08:50 PM and at 9:00 PM Licensed Practical Nurse (LPN)2 went to the baseball field and returned R1 back to the facility. On 5/16/23 at approximately 10:00 AM, 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 5/16/23 at 10:50 AM, the Administrator was notified that the allegation of elopement for R1 constituted Immediate Jeopardy (IJ) at F600 and the IJ template was presented. On 5/16/23 at 3:31 PM, the facility provided an acceptable plan of removal for the IJ. The IJ was lowered to a scope and severity of D for no actual harm with potential for more than minimal harm, that is not immediate jeopardy. An extended survey was conducted on 5/16/23 due to the failure constituting substandard quality of care. The facility's implemented removal plan included required facility wide training, along with in-services to be conducted, beginning 5/16/23 related to elopement/neglect. Findings include: Review of the facility's policy Abuse, Neglect,, Exploitation, or Mistreatment, with a revision date of 11/1/17 revealed The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. R1 was admitted to the facility on [DATE] from an acute care hospital. Review of R1's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he is cognitively intact. R1 has diagnoses including but not limited to; age-related physical debility, acquired absence of left leg, and muscle weakness. R1 requires assistance with activities of daily living (ADL)s. Review of R1's care plan revealed no evidence related to R1's ability to sign himself out of the facility, unsupervised. Review of R1's Physician Orders did not indicate an order allowing R1 to sign himself out. An observation of R1 on 5/15/23 at 06:42 PM revealed R1 was appropriately dressed without odors noted. Review of R1's elopement assessment dated [DATE] revealed R1 was not at risk for elopement/wandering at this time. There was no other elopement assessment made available at the time of the survey. During an interview on 5/15/23 at 6:15 PM, LPN1 reported that R1 did not elope from the facility. She stated he is alert and oriented and is capable of signing himself in and out of the facility. On this day, he signed himself out and went to the ball game. LPN1 reported that R1 is not an elopement risk. During an interview on 5/15/23 at 6:42 PM, R1 revealed he left the facility and failed to sign himself out when he left. He stated he wanted to watch the baseball game and the police was called and this was the first time something like this has occurred. R1 reported he was fussed at by staff for not signing himself out to attend the ball game. During an interview on 5/15/23 at 6:50 PM, the Administrator stated that R1 did not elope from the facility. She stated, R1 signed himself out of the facility and has a BIMS of 13 or 15. She reported that she received a phone call from the on-call nurse reporting that R1 was across the street at the ball game and saw a former nurse of the facility, who called the police and R1 did not understand why this occurred since he had previously watched the games. During an interview on 5/15/23 at 8:43 PM, LPN2 reported to be R1's nurse on the night of the elopement and she was not aware that R1 was not in the facility. She reported passing medications on D hall and was going to pass some of the meds on C hall, as she and another nurse split that hall and she reported hearing staff say R1 was at the baseball game on 5/9/23. She reported working the 7:00 PM -7:00 AM shift and learned at 8:50 PM that R1 was not in the facility and walked over to the ball game get him at 9:00 PM. She reported she pushed him back in his wheelchair. During an interview on 5/16/23 at 09:45 AM the DON reported R1 had 2 elopement assessments in the system. The DON reported getting a call at 9:30 PM on 5/9/23 from the Administrator informing her that a resident had left the facility. She was unsure at this time what resident had left the facility. The DON reported she called the facility and asked who was out of the building and a nurse reported that R1 was not in facility and had signed himself out and at this time this was all over Facebook. The DON stated, The receptionist at the front desk put the code in to allow R1 to leave and this would have occurred before 8:00 PM. The DON reported that when residents leave the facility, they ring the doorbell to come back into the facility. The DON said the facility interprets R1's leaving the facility as a leave of absences and not an elopement. During an interview on 5/16/23 at 11:15 AM, the Receptionist revealed that R1 went to the front door and told her he had signed himself out of the facility at the nurse' station. The Receptionist could not confirm the time R1 left and estimated it to be between 6:00 and 6:30 PM on 5/9/23. The Receptionist was asked what time R1 returned to the facility, and she reported prior to her leaving for the day, which is between 8:00 PM and 8:05 PM. The Receptionist confirmed she does not verify with the nurses' station if a resident signs out, she takes their word. She also confirmed she did not notify anyone of R1 being out of the building. Review of the Leave of Absence (LOA) sign in/out log revealed a signature, however, it indicated a time of 8:02, with no indication of AM/PM. The Receptionist confirmed R1 was supposed to be back in the facility prior to her leaving, so she was unsure how he got back out of the facility. During an interview on 5/16/23 at 1:06 PM, the Social Worker (SW) reported being advised about R1 leaving the facility on 5/10/23 when she reported to work. She said R1 went to a baseball game. She said I do not get any information about him signing himself out, just that he was found at the baseball field and no time given. The SW reported not being aware of R1 going to the games. The facility's removal plan included: 1. R1 has a BIMS level 15 reviewed on 05/09/23 and was reviewed by Nurse Practitioner on 05/16/23, no concerns with LOA privileges. 2. Review of Sign in/Sign out LOA log revealed R1 signed out 8:02 on 05/09/23. 3. Facility staff completed an audit of all the remaining residents. All residents were accounted for on 05/09/23. 4. Phone interview completed with evening receptionist. Statement obtained. Resident did not elope independently, signed LOA. Receptionist allowed him to leave. 5. Exit doors locked and secure. Audit revealed exits secure, environment safe. 6. Residents at risk for elopement accounted for with wanderguard in place. 7. R1 re-educated on LOA process, verbalized understanding. 8. Staff re-educated on LOA process with focus on checking sign in/out binder to validate in house census. 9. Re-education on F600/F689. Staff not present will received prior to next scheduled shift after 05/16/23. -Residents at risk for elopement have the potential to be affected. Residents at risk for elopement accounted for with wanderguard in place. -Capable residents with a BIMS of 15 or higher with privileges will be re-educated on LOA process. -The DON will randomly interview a minimum of 2 staff and 2 capable residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with LOA sign in/out process. -The Maintenance Director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months. -The Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with Maintenance Director to validate that doors are functioning properly. -Adhoc QAPI held on 05/16/23. This process will be reviewed in QAPI for a minimum of 3 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and the review of the facility's policy, the facility failed to provide adequate supervision to prevent a successful elopement for 1 of 3 residents reviewed for accidents. Resident (R)1 had a successful elopement from the facility on 05/09/23 at an unspecified time and was without supervision for an extended period of time. R1 was found by the police at the baseball field, across the street from the facility on 05/09/23 around 08:50 PM and at 9:00 PM Licensed Practical Nurse (LPN)2 went to the baseball field and returned R1 back to the facility. On 5/16/23 at approximately 10:00 AM, 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 5/16/23 at 10:50 AM, the Administrator was notified that the allegation of elopement for R1 constituted Immediate Jeopardy (IJ) at F689 and the IJ template was presented. On 5/16/23 at 3:31 PM, the facility provided an acceptable plan of removal for the IJ. The IJ was lowered to a scope and severity of D for no actual harm with potential for more than minimal harm, that is not immediate jeopardy. An extended survey was conducted on 5/16/23 due to the failure constituting substandard quality of care. Findings include: Review of the facility's policy titled, Leadership Policies and Procedure subject Elopement, last revised November 1, 2017, revealed, To safely and timely redirect patients/residents to a safe enviroment. R1 was admitted to the facility on [DATE] from an acute care hospital. Review of R1's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he is cognitively intact. R1 has diagnoses including but not limited to; age-related physical debility, acquired absence of left leg, and muscle weakness. R1 requires assistance with activities of daily living (ADL)s. Review of R1's care plan revealed no evidence related to R1's ability to sign himself out of the facility, unsupervised. Review of R1's Physician Orders did not indicate an order allowing R1 to sign himself out. An observation of R1 on 5/15/23 at 06:42 PM revealed R1 was appropriately dressed without odors noted. During an interview on 5/15/23 at 6:15 PM, LPN1 reported that R1 did not elope from the facility. She stated he is alert and oriented and is capable of signing himself in and out of the facility. On this day, he signed himself out and went to the ball game. LPN1 reported that R1 is not an elopement risk. During an interview on 5/15/23 at 6:42 PM, R1 revealed he left the facility and failed to sign himself out when he left. He stated he wanted to watch the baseball game and the police was called and this was the first time something like this has occurred. R1 reported he was fussed at by staff for not signing himself out to attend the ball game. During an interview on 5/15/23 at 6:50 PM, the Administrator stated that R1 did not elope from the facility. She stated, R1 signed himself out of the facility and has a BIMS of 13 or 15. She reported that she received a phone call from the on-call nurse reporting that R1 was across the street at the ball game and saw a former nurse of the facility, who called the police and R1 did not understand why this occurred since he had previously watched the games. During an interview on 5/15/23 at 8:43 PM, LPN2 reported to be R1's nurse on the night of the elopement and she was not aware that R1 was not in the facility. She reported passing medications on D hall and was going to pass some of the meds on C hall, as she and another nurse split that hall and she reported hearing staff say R1 was at the baseball game on 5/9/23. She reported working the 7:00 PM -7:00 AM shift and learned at 8:50 PM that R1 was not in the facility and walked over to the ball game get him at 9:00 PM. She reported she pushed him back in his wheelchair. During an interview on 5/16/23 at 09:45 AM the DON reported R1 had 2 elopement assessments in the system. The DON reported getting a call at 9:30 PM on 5/9/23 from the Administrator informing her that a resident had left the facility. She was unsure at this time what resident had left the facility. The DON reported she called the facility and asked who was out of the building and a nurse reported that R1 was not in facility and had signed himself out and at this time this was all over Facebook. The DON stated, The receptionist at the front desk put the code in to allow R1 to leave and this would have occurred before 8:00 PM. The DON reported that when residents leave the facility, they ring the doorbell to come back into the facility. The DON said the facility interprets R1's leaving the facility as a leave of absences and not an elopement. During an interview on 5/16/23 at 11:15 AM, the Receptionist revealed that R1 went to the front door and told her he had signed himself out of the facility at the nurse' station. The Receptionist could not confirm the time R1 left and estimated it to be between 6:00 and 6:30 PM on 5/9/23. The Receptionist was asked what time R1 returned to the facility, and she reported prior to her leaving for the day, which is between 8:00 PM and 8:05 PM. The Receptionist confirmed she does not verify with the nurses' station if a resident signs out, she takes their word. She also confirmed she did not notify anyone of R1 being out of the building. Review of the Leave of Absence (LOA) sign in/out log revealed a signature, however, it indicated a time of 8:02, with no indication of AM/PM. The Receptionist confirmed R1 was supposed to be back in the facility prior to her leaving, so she was unsure how he got back out of the facility. During an interview on 5/16/23 at 1:06 PM, the Social Worker (SW) reported being advised about R1 leaving the facility on 5/10/23 when she reported to work. She said R1 went to a baseball game. She said I do not get any information about him signing himself out, just that he was found at the baseball field and no time given. The SW reported not being aware of R1 going to the games. The facility's removal plan included: 1. R1 has a BIMS level 15 reviewed on 05/09/23 and was reviewed by Nurse Practitioner on 05/16/23, no concerns with LOA privileges. 2. Review of Sign in/Sign out LOA log revealed R1 signed out 8:02 on 05/09/23. 3. Facility staff completed an audit of all the remaining residents. All residents were accounted for on 05/09/23. 4. Phone interview completed with evening receptionist. Statement obtained. Resident did not elope independently, signed LOA. Receptionist allowed him to leave. 5. Exit doors locked and secure. Audit revealed exits secure, environment safe. 6. Residents at risk for elopement accounted for with wanderguard in place. 7. R1 re-educated on LOA process, verbalized understanding. 8. Staff re-educated on LOA process with focus on checking sign in/out binder to validate in house census. 9. Re-education on F600/F689. Staff not present will received prior to next scheduled shift after 05/16/23. -Residents at risk for elopement have the potential to be affected. Residents at risk for elopement accounted for with wanderguard in place. -Capable residents with a BIMS of 15 or higher with privileges will be re-educated on LOA process. -The DON will randomly interview a minimum of 2 staff and 2 capable residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with LOA sign in/out process. -The Maintenance Director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months. -The Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with Maintenance Director to validate that doors are functioning properly. -Adhoc QAPI held on 05/16/23. This process will be reviewed in QAPI for a minimum of 3 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy titled, Abuse, Neglect and Exploitation, record review, and interviews, the facility failed to ensure Resident (R)1 was free from neglect related to elopement. R1 had a successful elopement from the facility on 04/07/23 at 7:15 AM. On 04/07/23 at 7:15 AM R1 was found by Certified Nursing Assistant (CNA)1, walking on a local street, near a local BBQ restaurant and Hardees. R1 was found approximately 0.7 miles from the facility, which was a 7 minute brisk walk according to Apple Maps. R1 was observed wearing a white t-shirt, pajama bottoms, and construction like boots. R1 was not wearing a jacket or hat. The temperature outside on 04/07/23 at 6:53 AM was 66 degrees Fahrenheit and a 3 mile per hour wind speed. CNA1 stated, It was chilly that morning and I had a coat on when I was on the way to work that morning. On 04/10/23 at 4:23 PM, an Immediate Jeopardy (IJ) template was presented to the Administrator and Director of Nursing (DON), notifying them that an IJ existed at F600 with an effective date of 04/07/23. On 04/11/23 at 4:00 PM , the facility presented an acceptable IJ Removal Plan. The immediacy of the IJ was removed on 04/11/23. The IJ was lowered to a scope and severity of D (no actual harm with potential for more than minimal harm). The facility's failure constituted substandard quality of care at F600 and an extended survey was conducted on 04/11/23. Findings include: Review of the undated facility policy titled Abuse, Neglect, Exploitation, or Mistreatment revealed The facilities leadership prohibits neglect, mental, physical, and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient's/resident's property and/or funds ensure and all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately. R1 was admitted to the facility on [DATE] with the diagnosis including but not limited to; type 2 diabetes, acute osteomyelitis (right ankle and foot), anxiety disorder, dementia with behavioral disturbances, and chronic kidney disease. According to the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/23, R1 has a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicates R1 has severe cognitive impairment. Review of R1's Care Plan dated 01/24/23 revealed, history of wandering through out the facility. Resident is a risk for elopement; entering into others private space; increased fall risk; rejection of care; and moving furniture in the hallway related to diagnosis of dementia and stroke. Review of R1's Progress Note dated 04/07/23 at 7:45 AM revealed, resident sitting on bed in his room, resident alert and confused. No acute distress noted, resident does not recall leaving the facility nor returning with staff member. When asked where his electronic monitoring system was at, resident lifted his right leg and said 'I don't know'. Electronic monitoring system already replaced on left ankle. Review of R1's Progress Note dated 04/07/23 at 5:45 PM revealed This writer was receiving report from oncoming nurse when C.N.A. brought resident to desk and stated he was off premises, and she brought the resident back to the facility. Resident has asked staff in the past to remove the electronic monitoring device from ankle and has history of exit seeking. This writer assessed resident and he was not in any distress, no visible signs of injury but the electronic monitoring device was not in place. This writer replaced the electronic monitoring system to left ankle and order was updated in electronic medical record. Resident stated 'I was going to work', this writer made sure his Resident Representative was aware of the elopement and Nurse Practitioner. An interview on 04/10/23 at 11:07 AM with the Director of Nursing (DON) revealed, the resident was found by CNA1 on 04/07/23 around 7:15 AM, away from the premises of the facility. CNA1 was on the way to work and recognized the resident and brought him back to the facility. R1 was accounted for at approximately 7:00 AM by Licensed Practical Nurse (LPN)2 and other staff. LPN2 and the Wound Nurse assessed the resident, and he had no signs of distress or injury. R1 had an electronic monitoring system due to his high risk of elopement however, during the time of elopement the device was not on the resident. R1 must have taken it off but unsure of when or how long it's been off. An interview on 04/10/23 at 11:18 AM with the Wound Nurse/ Licensed Practical Nurse (LPN)1 revealed, they received a call on the way to work that R1 had eloped from the facility. When they arrived to work the resident was back at the facility in his room agitated and looking for his work boots (believing that he had to go to work). They were able to redirect the resident and did a body audit, the resident had no injuries and showed no sign of distress. LPN1 stated, I work with the resident several times a week (Monday - Thursday) because he has a surgical wound on his right great toe, I think I saw his electronic monitoring system on his left leg on Monday and Tuesday, but I can't remember if I saw it during the later days of the week. An interview on 04/10/23 at 11:32 AM with CNA1 revealed, CNA1 observed R1 attempting go across a very busy street in town. R1 had recognized CNA1 and was willing to return to the facility with CNA1. R1 has issues with his feet and has difficulty walking, R1 walks slow but can ambulate without assistance. A phone Interview on 04/10/23 at 1:05 PM with LPN2 revealed, I was receiving a report from another (LPN3) when CNA1 had come into work with R1 and said that she found him close to Hardees and brought him back to the facility. The LPN that was giving me the report about the night before (LPN3) was unaware that R1 was outside and not at the facility. I assessed R1 and noticed that he no longer had an electronic monitoring system on. I put it on him in December of 2022. I put another electronic monitoring system on the resident and did a body audit and the resident had no signs of injury or distress. I spoke with the resident's niece and made her aware of the situation. A phone interview with R1's Resident Representative (RR) on 04/10/23 at 2:02 PM revealed, LPN2 had notified them that the resident had eloped from the facility on 04/07/23 around 11:00 AM. Staff told her that a CNA had saw the resident walking nearby on a side street and brought him back to the facility. The LPN explained to her that R1 was able to exit the building because it was in the middle of a shift change with night shift and day shift leaving the facility. R1 must have walked out of the front door because at that time the front door is unlocked for staff and visitors. The LPN also explained that R1 was supposed to have on an electronic monitoring system but must have taken it off. R1's RR stated, I've been at the facility and have noticed R1 wearing an electronic monitoring system but can't remember if I saw it during my last visit about a month ago, but I also wasn't looking of it specifically. I have seen him have one in previous visits. A phone interview on 04/10/23 at an unspecified time, with CNA2 revealed, CNA2 worked the night into the day shift of 04/7/23. R1 was one of my residents and when the other CNA and I were completing our last set of rounds around 4:30 or 4:45 AM that morning, R1 was in his bed. R1's room is located on the C unit and we started our rounds on that side of the building with his room first and finished on the A unit. It is possible that he was able to leave while we were rounding on other residents because I think the front doors unlock at 5:30 AM. I never heard an alarm go off that night so he must have not had on his electronic monitoring system. I got a call when I was off and already left the facility that R1 was found walking down a side-street near the facility. Multiple attempts were made to contact LPN 3 on 04/10/23 and 04/11/23 with no success. The facility's removal plan for F600 included the following: 1. R1 has a Brief Interview of Mental Status (BIMS) score of 3 and was assessed upon arrival at the facility with no injuries noted. A complete body audit was done by the Wound Care Nurse and R1 with no abnormalities noted. 2. Facility staff completed an audit of all the remaining residents; all residents were accounted for. 3. Maintenance checked all exit doors to ensure they were secure. The windows in residents' rooms were checked to ensure that they would not open fully. Nurses performed checks on all residents with an electronic monitoring device to ensure proper functioning. 4. Residents at risk for elopement had an elopement evaluation repeated, clinical manager evaluated all residents for elopement risk. 5. R1's electronic monitoring device had been removed, the new device was placed, and the order was updated to reflect the new placement of the device. 6. Staff re-educated on monitoring the electronic monitoring device for R #1 and all residents who are at elopement risk. 7. The Medical Director (MD) and Resident Representative were notified of R #1 elopement and the ongoing need for an electronic monitoring device. 8. R1 was evaluated, no emotional distress was noted. 9. R1 Care Plan was reviewed for accuracy and updated as appropriate. 10. Elopement risk evaluations done in the past 60 days on current residents in the facility were reviewed by nursing managers for accuracy. Residents identified as at risk will be reviewed for appropriate interventions. 11. New admissions will be reviewed in the morning meeting daily Monday - Friday as part of the clinical morning meeting process. Elopement risk assessments will be reviewed for accuracy and interventions validated if indicated. Quarterly assessments will be reviewed as part of the Minimum Data Set/ Care planning process. 12. The DON will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks then monthly for 2 additional months to validate accuracy. 13. The Maintenance Director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months. 14. The Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with the Maintenance Director to validate that doors are functioning properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, and interviews, the facility failed to ensure adequate supervision was provided to prevent accidents/hazards for 1 of 3 Residents (R)1, reviewed. On 04/07/23, R1 had a successful elopement from the facility. On 04/07/23 at 7:15 AM R1 was found by Certified Nursing Assistant (CNA)1, walking on a local street, near a local BBQ restaurant and Hardees. R1 was found approximately 0.7 miles from the facility, which was a 7 minute brisk walk according to Apple Maps. R1 was observed wearing a white t-shirt, pajama bottoms, and construction like boots. R1 was not wearing a jacket or hat. The temperature outside on 04/07/23 at 6:53 AM was 66 degrees Fahrenheit and a 3 mile per hour wind speed. CNA1 stated, It was chilly that morning and I had a coat on when I was on the way to work that morning. On 04/10/23 at 4:23 PM, an Immediate Jeopardy (IJ) template was presented to the Administrator and Director of Nursing (DON), notifying them that an IJ existed at F689 with an effective date of 04/07/23. On 04/11/23 at 4:00 PM , the facility presented an acceptable IJ Removal Plan. The immediacy of the IJ was removed on 04/11/23. The IJ was lowered to a scope and severity of D (no actual harm with potential for more than minimal harm). The facility's failure constituted substandard quality of care at F689 and an extended survey was conducted on 04/11/23. Findings include: Record review of facility policy titled Leadership Policies and Procedures: Elopement last revised 11/01/17 revealed, To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. The facility will determine a signal code 'Code White' to designate a missing patient/resident. R1 was admitted to the facility on [DATE] with the diagnosis including but not limited to; type 2 diabetes, acute osteomyelitis (right ankle and foot), anxiety disorder, dementia with behavioral disturbances, and chronic kidney disease. According to the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/23, R1 has a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicates R1 has severe cognitive impairment. Review of R1's Care Plan dated 01/24/23 revealed, history of wandering through out the facility. Resident is a risk for elopement; entering into others private space; increased fall risk; rejection of care; and moving furniture in the hallway related to diagnosis of dementia and stroke. Review of R1's Progress Note dated 04/07/23 at 7:45 AM revealed, resident sitting on bed in his room, resident alert and confused. No acute distress noted, resident does not recall leaving the facility nor returning with staff member. When asked where his electronic monitoring system was at, resident lifted his right leg and said 'I don't know'. Electronic monitoring system already replaced on left ankle. Review of R1's Progress Note dated 04/07/23 at 5:45 PM revealed This writer was receiving report from oncoming nurse when C.N.A. brought resident to desk and stated he was off premises, and she brought the resident back to the facility. Resident has asked staff in the past to remove the electronic monitoring device from ankle and has history of exit seeking. This writer assessed resident and he was not in any distress, no visible signs of injury but the electronic monitoring device was not in place. This writer replaced the electronic monitoring system to left ankle and order was updated in electronic medical record. Resident stated 'I was going to work', this writer made sure his Resident Representative was aware of the elopement and Nurse Practitioner. An interview on 04/10/23 at 11:07 AM with the Director of Nursing (DON) revealed, the resident was found by CNA1 on 04/07/23 around 7:15 AM, away from the premises of the facility. CNA1 was on the way to work and recognized the resident and brought him back to the facility. R1 was accounted for at approximately 7:00 AM by Licensed Practical Nurse (LPN)2 and other staff. LPN2 and the Wound Nurse assessed the resident, and he had no signs of distress or injury. R1 had an electronic monitoring system due to his high risk of elopement however, during the time of elopement the device was not on the resident. R1 must have taken it off but unsure of when or how long it's been off. An interview on 04/10/23 at 11:18 AM with the Wound Nurse/ Licensed Practical Nurse (LPN)1 revealed, they received a call on the way to work that R1 had eloped from the facility. When they arrived to work the resident was back at the facility in his room agitated and looking for his work boots (believing that he had to go to work). They were able to redirect the resident and did a body audit, the resident had no injuries and showed no sign of distress. LPN1 stated, I work with the resident several times a week (Monday - Thursday) because he has a surgical wound on his right great toe, I think I saw his electronic monitoring system on his left leg on Monday and Tuesday, but I can't remember if I saw it during the later days of the week. An interview on 04/10/23 at 11:32 AM with CNA1 revealed, CNA1 observed R1 attempting go across a very busy street in town. R1 had recognized CNA1 and was willing to return to the facility with CNA1. R1 has issues with his feet and has difficulty walking, R1 walks slow but can ambulate without assistance. A phone Interview on 04/10/23 at 1:05 PM with LPN2 revealed, I was receiving a report from another (LPN3) when CNA1 had come into work with R1 and said that she found him close to Hardees and brought him back to the facility. The LPN that was giving me the report about the night before (LPN3) was unaware that R1 was outside and not at the facility. I assessed R1 and noticed that he no longer had an electronic monitoring system on. I put it on him in December of 2022. I put another electronic monitoring system on the resident and did a body audit and the resident had no signs of injury or distress. I spoke with the resident's niece and made her aware of the situation. A phone interview with R1's Resident Representative (RR) on 04/10/23 at 2:02 PM revealed, LPN2 had notified them that the resident had eloped from the facility on 04/07/23 around 11:00 AM. Staff told her that a CNA had saw the resident walking nearby on a side street and brought him back to the facility. The LPN explained to her that R1 was able to exit the building because it was in the middle of a shift change with night shift and day shift leaving the facility. R1 must have walked out of the front door because at that time the front door is unlocked for staff and visitors. The LPN also explained that R1 was supposed to have on an electronic monitoring system but must have taken it off. R1's RR stated, I've been at the facility and have noticed R1 wearing an electronic monitoring system but can't remember if I saw it during my last visit about a month ago, but I also wasn't looking of it specifically. I have seen him have one in previous visits. A phone interview on 04/10/23 at an unspecified time, with CNA2 revealed, CNA2 worked the night into the day shift of 04/7/23. R1 was one of my residents and when the other CNA and I were completing our last set of rounds around 4:30 or 4:45 AM that morning, R1 was in his bed. R1's room is located on the C unit and we started our rounds on that side of the building with his room first and finished on the A unit. It is possible that he was able to leave while we were rounding on other residents because I think the front doors unlock at 5:30 AM. I never heard an alarm go off that night so he must have not had on his electronic monitoring system. I got a call when I was off and already left the facility that R1 was found walking down a side-street near the facility. Multiple attempts were made to contact LPN 3 on 04/10/23 and 04/11/23 with no success. The facility's removal plan for F689 included the following: 1. R1 has a Brief Interview of Mental Status (BIMS) score of 3 and was assessed upon arrival at the facility with no injuries noted. A complete body audit was done by the Wound Care Nurse and R1 with no abnormalities noted. 2. Facility staff completed an audit of all the remaining residents; all residents were accounted for. 3. Maintenance checked all exit doors to ensure they were secure. The windows in residents' rooms were checked to ensure that they would not open fully. Nurses performed checks on all residents with an electronic monitoring device to ensure proper functioning. 4. Residents at risk for elopement had an elopement evaluation repeated, clinical manager evaluated all residents for elopement risk. 5. R1's electronic monitoring device had been removed, the new device was placed, and the order was updated to reflect the new placement of the device. 6. Staff re-educated on monitoring the electronic monitoring device for R #1 and all residents who are at elopement risk. 7. The Medical Director (MD) and Resident Representative were notified of R #1 elopement and the ongoing need for an electronic monitoring device. 8. R1 was evaluated, no emotional distress was noted. 9. R1's Care Plan was reviewed for accuracy and updated as appropriate. 10. Elopement risk evaluations done in the past 60 days on current residents in the facility were reviewed by nursing managers for accuracy. Residents identified as at risk will be reviewed for appropriate interventions. 11. New admissions will be reviewed in the morning meeting daily Monday - Friday as part of the clinical morning meeting process. Elopement risk assessments will be reviewed for accuracy and interventions validated if indicated. Quarterly assessments will be reviewed as part of the Minimum Data Set/ Care planning process. 12. The DON will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks then monthly for 2 additional months to validate accuracy. 13. The Maintenance Director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months. 14. The Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with the Maintenance Director to validate that doors are functioning properly.

Based on observations, record review, interviews, and review of the facility's policy titled, Abuse, Neglect, Exploitation and Mistreatment, the facility failed to protect 1 Resident (R) of 3 residents reviewed for sexual abuse. R2 was observed sitting next to R1 with his hands on R1's breast. On 2/22/23 at approximately 4:02 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 2/22/23 at 4:15 PM, the Administrator and the Director of Nursing (DON) were notified that the allegation of sexual abuse for R1 by R2 constituted Immediate Jeopardy (IJ) at F600. The facility presented an acceptable plan of removal of the IJ on 2/22/23 at 6:20 PM. The survey team validated that the IJ was removed on 2/22/23 at 6:20 PM following the facility's implementation of the plan of removal of the immediate jeopardy. An extended survey was conducted on 2/22/23 due to the failure constituting substandard quality of care. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Mistreatment, last revised 11/1/17, revealed: Sexual abuse is non-consensual sexual contact of any type with a resident. Review of the electronic medical record (EMR) revealed R1 has diagnoses including but not limited to; cardiovascular disease, hypertension, type 2 diabetes, hyperlipidemia, chronic kidney disease and muscle weakness. Review of R1's Minimum Data Set (MDS) with an unspecified date revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating R1 is not cognitively intact. Review of R1's care plan revealed R1 had an incident with another resident with inappropriate sexual behavior. Listed goals were for staff to provide emotional support to minimize mood, behavior, or ADL (activities of daily living) care. Approaches were to ensure R1 has no contact with male residents, observe for signs and symptoms of decline in mood, behavior or ADLs, observe for changes in sleep patterns, mood, affect, eating or vital signs and provide 1:1 interaction PRN (as needed). Staff will utilize non-pharmacological interventions i.e., redirect, offer comfort and reassurance to R1. Review of R1's progress notes revealed a note timed and dated 2/19/23 at 5:59 PM, which read, At 3:20 pm staff stated they saw R1 being touched inappropriately. Body assessment done by Nurse. Nothing observed. Administrator and DON and Unit Manager aware. Responsible party is aware and in route to facility. Dr. is aware and no new orders. R2 was admitted to the facility with diagnoses including but not limited to; end stage renal disease, muscle weakness, type 2 diabetes, vascular dementia with behavioral disturbance, age-related nuclear cataract, right eye, and hypotension. Review of R2's care plan revealed a problem: Resident allegedly had an incident of inappropriate sexual behavior. The listed goal is R2 will not touch any resident inappropriately and will be monitored by staff thru next review date. Listed approaches were R2 will have 1:1 staff member, continue Psychotherapist services with Life Source Behavioral Health, encourage and praise appropriate behavior and acceptable comments and will have no contact with R1. Additional approaches are to observe for episodes of inappropriate behavior and redirect, provide for safety of resident involved and other female residents at facility and seek alternative placement for R2. Review of R2's MDS with an unspecified date revealed a BIMS score of 15, indicating R2 is cognitively intact. Review of R2's Progress Notes revealed a note dated 02/20/2023 03:32 AM, which read, R2 returned to CCC via ambulance x2 attendants. R2 is A&Ox4 and able to make needs known. R2 has been moved from D-8-2 to A-8-1. Since R2 returned to the facility, he has been disturbing other residents, yelling out in the hallways, and demanding for his needs to be met. I've explained to R2 that this move is temporary till the morning. R2 insists he goes back to his room d/t his dialysis in the morning. R2 is on a 1:1 supervision. R2 returned with no new orders at this time, VS WNL. Will continue current plan of care. On 02/22/23 at 11:42 AM, during an interview with the Administrator, she reported the facility has conducted an in-service about abuse to the nurses and others and the incident was reported to the state and the facility is currently working on completing the investigation. She reported, A staff member, identified as Certified Nursing Assistant (CNA)1 went to staff at 3:20 PM and advised she saw R1 and R2 sitting next to each other in the day room with R2's hands on R1's breast. The Administrator stated review of the incident revealed R1 with a BIMS of 99 and R2 with a BIMS of 15, whom have been separated and R1 remains in her room on the East wing and R2 was moved to the North wing. MD and family were notified of the incident and R2 was placed on 1:1 observation until he was sent to the ER and will remain on 1:1 until he leaves the facility. The Administrator also revealed, According to R2, the incident was consensual and R1 placed R2's hand on her breast. R1 can understand some English and is able to communicate in broken English. R1 does not recall the incident. The facility has had two (2) interpreters in on yesterday (2/21/23) and another one this morning (2/22/23) and R1 is responding no to all questions regarding being hurt and reported nothing happened and reported she feels safe in the facility. During an interview on 2/22/23 at 12:08 PM, CNA1 reported she was walking down the hall just past the day room and observed R1 and R2 sitting next to each other. R2 was sitting very close to R1. CNA1 stated she then asked him why he was bothering R2 and at this time, CNA1 observed R2 remove his hands from inside her (R1)'s blouse and said, I am not doing anything. R1 had tears in her eyes. R2 was sitting on R1's right side and R1 was sitting in her Geri chair with a blouse with no bra on. R1 was immediately taken to her room. R1 was saying Man, Man, and she held her shirt up and stroked her breast. She looked like she was about to cry. CNA1 stated she reported the incident to the Nurse. R2 was placed on 1:1 and currently remains on 1:1. During an interview on 2/22/23 at 12:20 PM, R1 reported she did not want R2 to touch her. She reported this was the first time he touched her, and it is ok to be his friend, but not to touch her. During an interview on 2/22/23 at 12:52 PM with R1's son, he revealed, I got a call from the facility on Sunday 2/19/23, about my mother being touched. R1's son stated, I know my mother did not consent, she has Dementia and the entire time I was talking with her about the other resident touching her, she kept on asking me to go to the temple to ask for forgiveness for her. R1's son reported staff was trying to get her calm and it was hard. After speaking with facility staff on yesterday, I am a bit better, but I feel this whole thing could have been handled better. I wanted management here to tell me what occurred in person, not over the phone. After a meeting with the Social Worker (SW) and the current DON, I feel better, and the SW is keeping me updated daily with calls on how mom is doing. I would prefer if R2 was no longer here, but I know this takes time and with him being on 1:1 observation, I can handle this. During an interview on 2/22/23 at 1:29 PM, the SW revealed she was not present during the incident but was informed that R1 and R2 were in the day room and staff saw R2's hands on R1's breast. Per her knowledge, these two residents are not friends and are not involved in an ongoing relationship. The SW stated, R2 is currently on 1:1 observation and waiting on placement to another facility. During an interview on 2/22/23 at 1:41 PM, R2 reported that he attended dialysis today. R2 stated this was not the first time R1 had put his hands on her breast as she always does this, and this has been going on for weeks. R2 reported he told R1 to stop and R1 told him, This is my body, I can do what I want. R2 was asked if he had his hands inside R1's blouse and he responded, I have cataracts, I cannot see, so I do not know. R2 stated he is in an ongoing relationship with R1. During an interview on 2/22/23 at 2:55 PM, Registered Nurse (RN)1 revealed CNA1 alerted her to the situation, and she took steps to prevent R2 to getting near R1. R1 was wearing a v neck shirt and R2 had his hands inside R1's shirt. R1 looked distraught and she called the Administrator to report the incident. The residents were immediately separated and R1 looked very upset and had tears in her eyes. RN1 reported this was the first occurrence for something like this for R1 and R2 and R2 had been placed on 1 to 1 observation. During an interview on 2/22/23 at 3:22 PM, the Unit Manager revealed, R2 was sent out and was not sure of the time the incident took place, as she was not here. However, she was present when R2 returned to the facility at 1:15 AM, Monday morning. He was placed on 1:1 observation. R1 did not have any visits from R2 and to her knowledge, R2 did not have his hands on R1 in the past and R1 would not have given R2 consent to touch her. Implementation of the removal plan for F600 includes required facility wide re-education on Abuse, facility to review residents that trigger on behavioral monitoring forms, review 1:1 documentation for change in behavior for alleged perpetrator, transfer to alternative care setting as available for alleged perpetrator, and ongoing psyc consults for residents.