**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 ensure a resident had a safe and orderly discharge from the facility, for 1 of 1 resident. Specifically, Resident (R)60 was transported and discharged from the facility on 06/12/24 to the [NAME] Housing Authority, 62 miles from the facility. The [NAME] Housing Authority was not able to receive R60 due to financial issues. Furthermore, the facility failed to obtain a physician order for the discharge. On 06/13/24 at 7:19 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to ensure a resident had a safe and orderly discharge from the facility constituted Immediate Jeopardy (IJ) at F624. On 06/13/24 at 7:30 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 06/12/24. The IJ was related to 42 CFR 483.15 - Admission, Transfer, and Discharge. On 06/14/24 at 8:57 AM, the facility provided an acceptable IJ Removal Plan. On 06/14/24 at approximately 10:00 AM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F624 at a lower scope and severity of D. Findings include: Review of the facility policy titled Discharge/Transfer with a complete revision date of 11/01/2017 states, The patient/ resident will be discharged /transferred (home/another entity) by order of his/her attending physician. The facility will include the patient/resident and family in developing a safe discharge plan to address the patient's/ resident's individual needs. Procedures: 1. Obtain a discharge order from the physician. 2. Notify the patient/resident, his/her legal representative, if any, or an interested family member and document the discharge. Types of discharges: Planned discharge to the patient's/resident's home/private residence. Obtain an order for discharge/transfer from the patient's/resident's physician. Arrange community resources identified by the interdisciplinary team/patient/resident and/or family. Provide written Discharge Instructions for care to the patient/resident and/or family when discharging the patient home or to a community setting such as assisted living. Complete the Discharge Summary, documenting the patient's/resident's assessment at time of discharge and a summation of the patient's/resident's stay. Place a copy of the completed forms in the patient's/resident's medical record. Refer to Social Services Policy on Discharge Planning. Review of R60's Face Sheet revealed that R60 was admitted to the facility on [DATE], with diagnoses including but not limited to: Schizophrenia, chronic obstructive pulmonary disease, moderate persistent asthma, hyperlipidemia, Type 2 diabetes mellitus without complications, shortness of breath, and acute on chronic systolic (congestive) heart failure. Review of R60's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R60 was cognitively intact. Review of R60's Decisional Capacity Form dated 05/31/24, revealed R60 does not meet all the criteria for decisional capacity and therefore cannot make healthcare decisions for himself. Review of R60's Discharge summary dated [DATE] revealed, This resident is being seen today for discharge assessment and is set to discharge from this facility later today, this patient will be going home with family care later today. The Discharge Summary further revealed, R60 was discharged to Section Housing through [NAME] Housing Authority on 06/12/24 and R60 signed his own discharge. Review of R60's Physician Orders revealed an order dated 04/12/24 which stated, I certify that this resident requires continuing placement in a long term care facility. Further review of R60's Physician Orders revealed there was no order for R60's discharge. Review of R60's Care Plan dated 04/16/24 revealed the following: Problem: R60 has discharge potential to a less restrictive environment. A safe discharge plan will be developed to allow him/her to return to the community or less restrictive or alternate environment. R60's stated discharge goal is to return home to [NAME]. R60 is working with [NAME] Housing Authority on alternate residences. Problem: R60 has schizophrenia. Problem: R60 has the risk of respiratory issues related to congestive heart failure, asthma, COPD. He has trouble with SOB when lying flat at times. Problem: R60 appears to have a recall deficit as evidenced by: : [ ] Short-term recall, [ ] Long-term memory recall, [ ]inability to understand commands/communication [ ]Poor decision-making Related to the diagnosis of: [ ]Intellectual Disability, [ ]Dementia, [ ]Traumatic Brain Injury, [ ]Parkinson's Disease, [ ]Late effect of CVA, Others: schizophrenia with periods of inattentiveness and disorganized thinking. Review of R60's Progress Notes revealed the following: 06/12/2024 11:26 AM [Recorded as Late Entry on 06/13/2024 11:26 AM] Resident discharged from facility via Ambustar transport. All discharge paperwork, medications, Rx and belongings sent with resident. 06/07/2024 11:11 AM SW called and left message with resident's sister, informing her of resident's dc plans and requesting a return call with any questions. SW will continue to observe and assist PRN. 06/07/2024 10:55 AM SW spoke with resident's CLTC caseworker via phone and informed her that resident will be discharging next week. She stated she did not need a new referral since resident's case was still open. [CLTC caseworker] stated she only needs resident's discharge date and new address. SW emailed this information to caseworker per her request. SW will continue to observe and assist PRN. During an interview on 06/13/24 at 1:42 PM, R60 stated, When I got to the house yesterday, they were requesting a deposit, which I didn't have. No one told me I needed a $900.00 deposit. Transport dropped me off and left. I slept in a motel last night. I'm talking to you on the phone and I'm walking, trying to find a place to stay. I'm hot. My sister lives in New Jersey, I don't think she knows I left. During an interview on 06/13/24 at 2:16 PM, Social Services (SS) confirmed she knew the resident and assisted him with his discharge. SS stated that R60 requested to be discharged because he was ready to go. SS stated that the resident's family members were contacted on April 2024 shortly after admission and they agreed and requested [NAME] SC. SS stated she spoke with a cousin, who contacted the housing authority on 05/06/24. No NOMNC was issued because the resident was only on Medicaid. SS stated Housing Authority set up water and electricity provided by [NAME] (Housing Authority Representative). SS stated she called the resident's sister related to the discharge and left a voicemail, no actual conversation. SS stated she was not aware that the resident did not have a decisional capacity to make his own decisions. SS stated that R60 is not his own responsible party. SS stated I was going off his BIMS and it's a 15. An attempt to interview the Ombudsman on 06/13/24 at 2:52 PM, was unsuccessful, a voicemail was left for a return call. An attempt to interview the Medical Doctor on 06/13/24 at 3:02 PM, was unsuccessful, a voicemail was left for a return phone call. During an interview on 06/13/24 at 3:27 PM, the Housing Authority Representative ([NAME]) confirmed housing plans were made with the facility social worker and the resident. The resident's appointment was not on 06/12/24, so he was not to report there. His appointment was today 06/13/24 at 2:00 PM. They are currently working on the resident's housing, but he will be staying in a motel until housing is available. The [NAME] stated she did not call the facility today to report that housing fell through. The [NAME] states she cannot provide any more information due to the Privacy Act. During an interview on 06/13/24 at 3:48 PM, the Ambustar Transport Driver (TD) stated, I took him [R60] to downtown [NAME] SC, it was an old building. I do not know the exact building. Once I came to the city limits, the resident took over with directions and said there it is. The facility did not give me a form with the address, they didn't give me anything, just his belongings. We have an app we use, with an address for him. He didn't have any equipment. He walked fine and carried a few bags. When we arrived, [R60] stated, This is it and he never opened the front door. He said, I got it, and everything is fine. I took everything out of the van and the resident requested me to put his belongings on the porch. He didn't knock on the door or ring the doorbell. He was just standing there, it looked like he was walking towards the diner across the street. He looked like he knew what he was doing, so I left. During an interview on 06/13/24 at 5:06 PM, the Administrator (FA) and Director of Nursing (DON) stated for a resident-initiated discharge, the resident's representative is to be notified. Social Services gets involved and get a doctor's order. We talk to family to discuss discharge and where the placement would be. The sister was difficult to get in touch with. The FA and DON confirmed they were not aware of R60's decision-making capacity form. The FA and DON stated common practice is to call the RP and verify his documents before discharge. The FA stated that she felt bad and that was not right. The FA confirmed no discharge order in the records at 5:11 PM. On 06/14/24 at 8:57 AM, the facility provided an acceptable IJ Removal Plan, which included: Residents who have been discharged in the past 30 days have been reviewed to validate safe, orderly discharge including living arrangements by the Director of Social Services or designee. The Administrator, Director of Nursing, and Interdisciplinary Team including the Social Worker will be reeducated by the Clinical Consultant on 6/13/24 on discharge planning including: Obtaining an order for discharge from the resident's physician. Validating community resources that are identified by the interdisciplinary team, resident, and/or family have been arranged. Providing written discharge instructions for care. Notifying the resident's legal representative, if any, or an interested family member regarding the upcoming discharge. Licensed Nurses will be reeducated on 6/13/24 by the Director of Nursing/Designee on the discharge process which includes Obtaining an order for discharge from the resident's physician. Providing written discharge instructions for care. Notifying the resident's legal representative, if any or an interested family member regarding the discharge. Licensed Nurses not receiving this reeducation by 6/13/24 will receive prior to their next scheduled shift. Anticipated discharges will be reviewed in the Clinical Morning Meeting Monday - Friday by the Interdisciplinary Team to validate preparation for a safe discharge is in place including living arrangements, family and/or responsible party notification, and physician order for discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observations, and interviews, the facility failed to provide an accessible call system with functioning devices while residents are in bed, toilet, bath and/or shower for 17 out of 43 residents; 2 out of 3 shower rooms reviewed for resident call systems. On 03/21/2023 at 6:43 PM, the Administrator and the Director of Nursing were notified that the nonoperational call lights constituted Immediate Jeopardy (IJ) at F919, with a start date of 11/01/2022. The facility presented an acceptable plan of removal of the IJ on 03/22/2023 at 10:40 AM. The survey team validated that the IJ was removed on 03/22/2023 at 12:20 PM following the facility's implementation of the plan of removal of the immediate jeopardy. The facility remained out of compliance at F919 at a lower scope and severity of E (pattern with potential for minimal harm) following removal of the IJ. Findings include: Review of the facility's undated policy titled Call Lights - Answering Of revised on 07/01/2023 revealed that staff were meant to leave the call light in the resident's reach prior to exiting the room. The policy did not outline a system of ensuring the call lights were operational. Interview with Resident (R)1 on 03/21/2023 at approximately 1:47 PM revealed the resident remembered the incident, R1 stated she was in pain that day and she wanted some pain medicine, she didn't feel safe because her call lights do not work. R1 further stated the call light has not been working for some time and she must holler for assistance until she is hoarse. R1 concluded her roommate cannot talk because she has a trach, and she must holler for her also. A test of R1's call light revealed, the call light was activated at 1:50 PM on 03/21/2023 and revealed no response or light up feature was present on the appliance outside of the door. The call light button for R1's roommate was located on the floor behind the bed. At approximately 3:22 PM on 03/21/2023, a tour was conducted with the Maintenance Director (MD) to complete a room-to-room assessment for verification and confirmation of inoperable call lights. The tour revealed the following rooms did not to have operable call lights/signal systems: RM102 RM103 RM104 RM106 RM108 RM109 RM110 RM111 RM112 RM113 RM119 RM124 Shower room [ROOM NUMBER]st Floor Observation of the second-floor call system revealed that rooms 201, 203, 209, 212, and 213 and the shower room had no functional call light and no alternative system for requesting assistance from nursing staff. This also affected the residents' bathrooms. The call lights failed to illuminate either above the doorway or at the nursing station. The tour with the MD from 3:34 PM - 3:45 PM on 03/21/2023 confirmed the call lights were not operational. Interview with the MD on 03/21/2023 at approximately 3:44 PM revealed this was his first day at work. The MD stated that the normal procedures if the call light system isn't working would be the use of bells for each resident. Interview on 03/22/2023 at approximately 9:58 AM with the previous Administrator revealed, I was aware of the call light system malfunction on November 1, 2022. The problem with the call light system was it would not make noise or sounds. I needed three quotes before the system could be repaired. But an invoice was requested from Wanderguard, and they informed me at that time, the system was an antiquated (outdated) system. The alternatives that she offered at that time were hand bells. I did not relay this information to the oncoming Administrator because they were not hired before she left the facility. There should be documentation of an invoice from Wanderguard for the purpose of verifying the date. Complaints were received by residents that their call buttons were not working. Problems were noted mostly on the Rehab Hall which is located directly in front of the main entrance. Staff were in-serviced and trained in reference to responding to call lights in a timely manner. R6 resided in room [ROOM NUMBER], admitted on [DATE] with diagnoses including, but not limited to, generalized anxiety disorder (GAD), major depressive disorder (MDD), heart failure, and unspecified intellectual disabilities. R6's 02/02/2023 Brief Interview for Mental Status (BIMS) score was 99, indicating they were unable to complete the interview. She requires extensive assistance with two person assist for Activities of Daily Living (ADLs). R7 and R8 resided in room [ROOM NUMBER]. R7 was admitted on [DATE] with diagnoses including, but not limited to, congestive heart failure, muscle wasting and atrophy, type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD). R7's 01/09/2023 BIMS score was 15/15, indicating R7 was cognitively intact. The resident was independent with ADLs. R8 was admitted to the facility on [DATE] with diagnoses including, but not limited to, anxiety, depression, and type 2 diabetes mellitus (DM2). R8's 02/28/2023 scored 13/15 indicating R8 was cognitively intact. She required 1-person limited assistance with ADLs. R9 and R10 resided in room [ROOM NUMBER]. R9 was admitted on [DATE] with diagnoses including, but not limited to, paroxysmal atrial fibrillation, muscle weakness, epilepsy, scoliosis, and spinal stenosis. R9's 01/23/2023 BIMS score was 10/15, indicating R9 had moderately impaired cognition. He required extensive 1-person assistance for ADLs. R10 was admitted on [DATE] with diagnoses including, but not limited to, chronic kidney disease (CKD), dementia, and muscle weakness. R10's 02/06/2023 BIMS score was 10/15, indicating R10 had moderately impaired cognition and he required 1-person extensive assistance with his ADLs. R4 resided in room [ROOM NUMBER]. R4 was admitted on [DATE] with diagnoses including, but not limited to, cerebral infarction, DM2, muscle wasting, and lack of coordination. R4's quarterly 02/04/2023 BIMS score was 11/15, indicating R4 had moderately impaired cognition. He required 1-person limited assistance with his ADLs. R11 and R5 resided in room [ROOM NUMBER]. R11 was admitted on [DATE] with diagnoses including, but not limited to COPD, end stage renal disease (ESRD), and muscle weakness. R11's 02/28/2023 admission BIMS score was 14/15, indicating R11 was cognitively intact. She required limited 1-person assistance with ADLs. R5 was admitted on [DATE] with diagnoses including, but not limited to, anxiety and DM2. R5's admission 2/15/2023 BIMS score was 15/15, indicating R5 was cognitively intact. She was totally dependent for her ADLs. R12 and R1 resided in room [ROOM NUMBER]. R12 was admitted on [DATE] with diagnoses including, but not limited to, depression, open wound of neck, and gastrostomy. R12's 03/21/2023 BIMS score was 12/15, indicating she was moderately cognitively intact. R1 was admitted on [DATE] with diagnoses including, but not limited to, anxiety, acute osteomyelitis of right ankle and foot, and need for assistance with personal care. R1's 02/15/2023 BIMS score was 15/15, indicating she was cognitively intact. She is a 1-person physical assist for ADLs. R13 and R14 resided in room [ROOM NUMBER]. R13 was admitted on [DATE] with diagnoses including, but not limited to, CKD, depression, dementia, and unspecified displaced fracture of surgical neck of right humerus. R13's 03/20/2023 admission BIMS score was 3/15, indicating R13 had severely impaired cognition. R14 was admitted on [DATE] with diagnoses including, but not limited to DM2, pressure ulcer of sacral region, and CHF. R14's 02/09/2023 BIMS score was 7/15, indicating R14 was mildly cognitively intact. She required extensive 2-person assistance for ADLs. R15 resided in room [ROOM NUMBER]. R15 was admitted to the facility on [DATE] with diagnoses including, but not limited to CHF, CKD, and muscle weakness, and cognitive communication deficit. R15's quarterly 03/09/2023 BIMS score was 9/15, indicating R5 was mildly cognitively intact. She required 1-person limited assistance for ADLs. R16 and R17 resided in room [ROOM NUMBER]. R16 was admitted on [DATE] with diagnoses including, but not limited to, muscle weakness, need for assistance with personal care, and cognitive communication deficit. R16's quarterly 01/02/2023 BIMS scored 13/15, indicating R16 was cognitively intact. He required 1-person extensive assistance with ADLs. R17 was admitted on [DATE] with diagnoses including, but not limited to, heart failure, CKD, cognitive communication deficit, legal blindness, and muscle wasting and atrophy. R17's quarterly 02/14/2023 BIMS scored 15/15, indicating R17 was cognitively intact and he was independent with ADLs. R18 resided in room [ROOM NUMBER]. R18 was admitted on [DATE] with diagnoses including, but not limited to, bipolar disorder, unspecified convulsions, history of falling, and blindness in right and left eye. R18's 02/16/2023 admission BIMS scored 11/15, indicating R18 was moderately cognitively intact and he required limited 1-person assistance for ADLs. R19 and R20 resided in room [ROOM NUMBER]. R19 was admitted on [DATE] with diagnoses including, but not limited to, cerebral infarction, difficulty walking, muscle wasting and atrophy, CHF, DM2 and chronic pain. R19's quarterly 01/02/2023 BIMS score was 14/15, indicating she was cognitively intact. She required 2-person assistance for ADLs. R20 was admitted on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis affecting unspecified side, delirium due to known physiological condition, and pain. R20's quarterly 01/02/2023 BIMS score was 15/15, indicating she was cognitively intact and she required 2-person assistance for ADLs. R21, R22, and R23 resided in room [ROOM NUMBER]. R21 was admitted on [DATE] with diagnoses including, but not limited to, Alzheimer's disease, delusional disorders, pain, and need for assistance with personal care. R21's quarterly 01/30/2023 BIMS score was 13/15 indicating she was cognitively intact, and she was totally dependent for ADLs. R22 was admitted on [DATE] with diagnoses including, but not limited to, unsteadiness on feet, cognitive communication deficit, COPD, spinal stenosis, schizophrenia, and bipolar disorder with psychotic features. R22's 01/02/2023 BIMS score was 99, indicating the assessment could not be completed. She required supervision only for ADLs. R23 was admitted on [DATE] with diagnoses including, but not limited to, COPD, need for assistance with personal care, reduced mobility, and unsteadiness on feet. R23's 02/20/2023 quarterly BIMS score was 14/15, indicating she is cognitively intact and she was totally dependent for ADLs. R24 and R25 resided in room [ROOM NUMBER]. R24 was admitted on [DATE] with diagnoses including, but not limited to, anxiety, Guillain-Barre syndrome, and heart failure. R24's 01/16/2023 BIMS score was 15/15, indicating he was cognitively intact. He requires extensive 1-person assistance for ADLs. R25 was admitted on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis affecting right dominant side, cognitive communication deficit, and need for assistance with personal care. R25 quarterly 03/07/2023 BIMS score was 6/15, indicating cognitive impairment. Resident required extensive 1-person assistance for ADLs. R26 resided in room [ROOM NUMBER]. R26 was admitted on [DATE] with diagnoses including, but not limited to, need for assistance with personal care, muscle weakness, and chronic pain. R26's quarterly 03/09/2023 BIMS score was 15/15, indicating he was cognitively intact. He required extensive 1-person assistance for ADLs. R27 and R28 resided in room [ROOM NUMBER]. R27 was admitted on [DATE] with diagnoses including, but not limited to, muscle weakness, multiple sclerosis, intellectual disabilities, and COPD. R27's quarterly 02/24/2023 BIMS score was 99 indicating the assessment could not be completed and he was totally dependent for ADLs. R28 was admitted on [DATE] with diagnoses including, but not limited to, DM2, muscle weakness, multiple sclerosis, and MDD. R28's quarterly 02/20/2023 BIMS score was 11/15, indicating mild cognitive impairment, and he was totally dependent for ADLs. R2 and R29 resided in room [ROOM NUMBER]. R2 was admitted on [DATE] with diagnoses including, but not limited to, COPD, CHF, unsteadiness on feet, need for assistance with personal care, pain, and muscle weakness. R2's quarterly 01/09/2023 BIMS score was 7/15, indicating cognitive impairment. She required extensive 1-person assistance for ADLs. R29 was admitted on [DATE] with diagnoses including, but not limited to, history of falling, schizophrenia, and DM2. R29's annual 02/07/2023 BIMS score was 7/15, indicating cognitive impairment. She required supervision only for ADLs. R30 and R3 resided in room [ROOM NUMBER]. R30 was admitted on unspecified psychosis, CHF, COPD, cognitive communication deficit, and unsteadiness on feet. R30's quarterly 01/30/2023 BIMS score was 99 indicating the assessment could not be completed. She required 1-person limited assistance for ADLs. R3 was admitted on [DATE] with diagnoses including, but not limited to, schizophrenia, muscle wasting and atrophy, need for assistance with personal care, reduced mobility, and pain. R3's 02/06/2023 BIMS score was 14/15, indicating she was cognitively intact. She required 1-person assistance for ADLs. Interview with Certified Nursing Assistant (CNA)2 at 1:58 PM on 03/21/2023 revealed she was not aware of when the call light system stopped working. Interview with CNA1 at 2:05 PM on 03/21/2023 revealed she gave her residents hand bells to ring for assistance. Interview on 03/21/2023 at 2:10 PM with Licensed Practical Nurse (LPN)1, revealed when she started working in the facility in early January 2023, all residents in the facility were already using call bells. LPN1 stated that she and other staff assigned to the unit will do rounds every 2 hours if not more depending on resident needs. LPN stated that residents who do not have a functioning call light have access to bells to make needs known. LPN stated that mostly all residents located on the 2nd floor are verbal and can make their needs known. Interview at approximately 2:20 PM on 03/21/2023 with R2 revealed she stated the call bell system has not worked in 3 months. R2 stated she contacts the staff on her personal cell phone. Interview at approximately 2:22 PM on 03/21/2023 with R3 revealed she doesn't know how long the call lights have been inoperable, but stated probably a month ago. R3 stated her light is not working. Interview at approximately 3:13 PM on 03/21/2023 with R5 revealed she does not even have a call bell system on her wall. R5 stated it has been probably about a month ago when she no longer had a light. Review of facility grievance logs revealed that R5 complained about call light response times on 02/13/2023. The facility found that her call light was not working properly. Review of facility grievance logs revealed that R35 complained of call lights not being answered on 02/13/2023. Review of facility grievance logs revealed that R36 complained of using the call light for over an hour on second shift on 01/09/2023. Review of facility grievance logs revealed that R37 complained of using the call light for over an hour before it was answered on 12/14/2022. This incident occurred on 3rd shift. Interview with MD on 03/21/2023 at an unspecified time revealed he planned to test call lights weekly, but it was his first day that day and he had not been able to check call lights. It was unknown what the previous MD did to assess call light function The facility's removal plan included: Residents identified in rooms 102, 103, 104, 106, 108, 109, 110, 111, 112, 113, 119, 124, 201, 202, 209, 212, and 213 were provided hand bells on 03/21/2023 to alert nursing staff. Residents receiving showers on Units 1 and 2 will receive 2-person assists. 15-min checks were initiated on 03/21/2023 to monitor residents for needs and will continue until the call light system is repaired. A monitoring tool will be used to document 15-minute checks and will be used until the call light system is repaired. The remaining residents will be provided hand bells on 03/22/23. Resident council meeting will be held on 03/22/2023 to inform residents of plan for alerting staff for assistance and the plan for the repair of the call light system. The administrator will contact companies to obtain quotes for repairs of the call light system on 03/22/2023. Facility employees will be educated on the plan that was initiated. Any employee not receiving this education by 03/22/2023 will receive it before their next scheduled shift. This will include any agency personnel and new hire orientation. The Director of Nursing and Administrator will make rounds throughout the day to validate that resident needs are being met by responsiveness to the hand-held call bell or the 15-minute checks. Any concerns will be addressed at the time of discovery. The medical director was informed of the immediate jeopardy and the contents of this plan on 03/21/2023. An ad hoc Quality Assurance Performance Improvement meeting will be held on 03/22/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy titled Abuse, Neglect, Exploitation and Mistreatment, record review, and interviews, the facility failed to provide adequate supervision for 1 of 3 residents reviewed for Neglect related to elopement. Resident (R)1 had a successful elopement from the facility on 11/04/22 and was without supervision for an extended period. Certified Nursing Assistant (CNA)1 was making rounds at 3:45 AM on 11/04/22 and noticed that R1 was not in his room. He was last noted to be asleep in his room during the 2 AM rounds. R1 was found by the police at a local Krispy Kreme, drinking coffee, at 9:30 AM, approximately 0.7 miles away from facility. On 11/15/22 at 2:55 PM, an Immediate Jeopardy (IJ) template was provided to the facility's Administrator, notifying her that an IJ existed at F600 with an effective date of 11/04/22. On 11/15/22 at 6:10 PM, the facility provided an acceptable IJ Removal Plan. The immediacy of the IJ was removed as of 11/15/22. 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 11/15/22 due to the failure constituting substandard quality of care. The facility's removal plan implemented required facility wide training, in services to be conducted beginning 11/15/22 related to elopement/abuse. All staff will be re-educated by the Assistant Director of Nursing or staff development coordinator by 11/15/22. Implementation of the removal plan for F600 includes elopement risks assessments to be completed on current residents, the residents identified as being at risk care plans will be updated to reflect with interventions in place. Licensed nurses will be re-educated on the elopement risk assessment/process for accuracy and putting interventions in place based on risks identified. All staff will be re-educated on Abuse Policy. The Director of Nursing will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks and all new admissions, re-admissions and quarterly assessments will be reviewed in the morning meetings for 4 weeks beginning November 15, 2022. Implementation of the Removal Plan was verified through observations, staff interviews and record review. Findings include: Review of the facility's undated policy, titled, Abuse, Neglect, Exploitation and Mistreatment, revealed, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of the facility's face sheet revealed R1 has diagnoses including, but not limited to; anxiety, hypertension, and chronic obstructive pulmonary disorder. R1 was admitted to the facility for rehabilitation services following a hospital stay for a hip fracture. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/11/22 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15, which indicates that R1 was cognitively intact. Review of R1's Morse Fall assessment dated [DATE] revealed a score of 0 indicating R1 is at low risk for falls. Review of R1's Elopement Risk assessment dated [DATE] revealed resident is at risk for elopement. Review of R1's care plan revealed a problem area of, R1 has the potential for alteration in mood, behavior r/t placement. Goal is for R1 to accept placement as evidenced by; voicing satisfaction with room, staff, and facility related to placement. Approaches added as of 11/04/22 are for R1 to notify the nurse when leaving the floor and R1 to sign self out when leaving the facility. Record review of the nurse's progress notes dated 11/04/22 at 3:45 AM revealed CNA1 notified the nurse that resident in room [ROOM NUMBER] (R1), was not in his room. The nurse and CNA started a search of the Skyview Hall, going from room to room. R1 was not located, so the nurse then notified Unit 2 and Unit 3 of a Code [NAME] (Missing Person). An extended search was done in the basement, back stairwell and outer perimeter of the building. Record review of the nurse's progress notes dated 11/4/22 at 4:30 AM revealed the facility's Director of Nursing (DON) and Administrator were notified by phone that R1 was missing. 911 was also called. A record review of the progress note dated 11/04/22 at 4:55 AM revealed, the nurse spoke with a local police officer. Staff searched the entire building with the Police Officer. R1 was not located. The Officer advised the nurse that he could not file a missing person's report because R1 has decisional capacity, but he will continue to ride around and look for him. Record review of the progress notes dated 11/4/22 at 5:09 AM revealed, staff continues to search for R1 without locating him. R1 was located by police on 11/4/22 at 9:30 AM at Krispy Kreme about 0.7 miles from the facility. R1 was transported to Spartanburg Regional Medical Center by ambulance for evaluation, no injuries were noted. During an interview with the Administrator on 11/15/22 at 11:45 a.m. who states she received a telephone call around 4:30 a.m. Along with police, they conducted a search of the entire facility. During an interview with R1 on 11/15/22 at 11:30 AM, R1 stated that he left because he needed to get things done. R1 stated he told 2 employees that he was leaving, but they did not believe him. R1 stated he got on the elevator and walked out the front door. R1 stated he walked to Krispy Kreme to get him a cup of coffee until he decided how he was going to get to Pacolet (a town neighboring Spartanburg). R1 stated that he does not need to be in a nursing home. During an interview on 11/15/22 at 2:05 PM with CNA1 revealed she made rounds around 2:00 AM on 11/4/22 emptying R1's urinal and he was in his room, in the bed asleep, at this time. CNA1 stated that when she went back down the hall, she noticed R1 was not in his bed. She looked in the bathroom and he was not there. CNA1 stated she then went to the Nurse Supervisor and told her that R1 was not in his room, so they both looked in every room on the floor and when he could not be found, LPN called Unit 1 and Unit 2 to alert them of a Code White and we all started to look for R1 inside and outside the building. CNA1 stated that she knows that R1 has told others that he was leaving, but he never told her that. If he did, she would have reported that to the charge nurse. CNA1 also revealed R1 has tried to leave the facility before. During an interview with Social Services Director (SSD) on 11/15/22 at 2:15 PM, she stated that she spoke with R1 about the elopement and states that he informed the CNA that he was leaving, but he did not know the name of the person he told. SSD stated that R1 told her that he was going to Pacolet to see a friend. He went downstairs using the elevator and exited the building using the door, which leads to the loading docks. R1 stated that he held down the handle for 15 seconds until it unlocked and allowed him to exit. SSD stated that R1 told her he knew where he was going and never felt unsafe because he used to be homeless. R1 told SSD that he was unhappy at this facility and needed to get out for a little bit. During an interview with CNA2 on 11/15/22 at 3:35 PM, she revealed this is not the first-time resident has tried to leave therefore they put him on the 3rd floor. CNA2 stated that she checked on R1 throughout the night,however, he left in between rounds because he knew when we were busy. Several attempts were made on 11/15/22 via telephone to contact LPN1 with no success.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy titled Elopement, record review, and interviews, the facility failed to provide adequate supervision for 1 of 3 residents reviewed for accidents related to elopement. Resident (R)1 had a successful elopement from the facility on 11/4/22 and was without supervision for an extended period. Certified Nursing Assistant (CNA)1 was making rounds at 3:45 AM on 11/4/22 and noticed that R1 was not in his room. He was last noted to be asleep in his room during the 2 AM rounds. R1 was found by the police at a local Krispy Kreme, drinking coffee, at 9:30 AM, approximately 0.7 miles away from facility. On 11/15/22 at 2:55 PM, an Immediate Jeopardy (IJ) template was provided to the facility's Administrator, notifying her that an IJ existed at F689 with an effective date of 11/04/22. On 11/15/22 at 6:10 PM, the facility provided an acceptable IJ Removal Plan. The immediacy of the IJ was removed as of 11/15/22. 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 11/15/22 due to the failure constituting substandard quality of care. The facility's removal plan implemented required facility wide training, in services to be conducted beginning 11/15/22 related to elopement/abuse. All staff will be re-educated by the Assistant Director of Nursing or staff development coordinator by 11/15/22. Implementation of the removal plan for F689 includes elopement risks assessments to be completed on current residents, the residents identified as being at risk care plans will be updated to reflect with interventions in place. Licensed nurses will be re-educated on the elopement risk assessment/process for accuracy and putting interventions in place based on risks identified. All staff will be re-educated on Abuse Policy. The Director of Nursing will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks and all new admissions, re-admissions and quarterly assessments will be reviewed in the morning meetings for 4 weeks beginning November 15, 2022. Implementation of the Removal Plan was verified through observations, staff interviews and record review. Findings include: Review of the facility's undated policy, titled, Elopement, revealed the purpose is to safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if patient/resident is considering missing. The facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/resident. A review of the facility's face sheet revealed R1 has diagnoses including, but not limited to; anxiety, hypertension, and chronic obstructive pulmonary disorder. R1 was admitted to the facility for rehabilitation services following a hospital stay for a hip fracture. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/11/22 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15, which indicates that R1 was cognitively intact. Review of R1's Morse Fall assessment dated [DATE] revealed a score of 0 indicating R1 is at low risk for falls. Review of R1's Elopement Risk assessment dated [DATE] revealed resident is at risk for elopement. Review of R1's care plan revealed a problem area of, R1 has the potential for alteration in mood, behavior r/t placement. Goal is for R1 to accept placement as evidenced by; voicing satisfaction with room, staff, and facility related to placement. Approaches added as of 11/04/22 are for R1 to notify the nurse when leaving the floor and R1 to sign self out when leaving the facility. Record review of the nurse's progress notes dated 11/04/22 at 3:45 AM revealed CNA1 notified the nurse that resident in room [ROOM NUMBER] (R1), was not in his room. The nurse and CNA started a search of the Skyview Hall, going from room to room. R1 was not located, so the nurse then notified Unit 2 and Unit 3 of a Code [NAME] (Missing Person). An extended search was done in the basement, back stairwell and outer perimeter of the building. Record review of the nurse's progress notes dated 11/04/22 at 4:30 AM revealed the facility's Director of Nursing (DON) and Administrator were notified by phone that R1 was missing. 911 was also called. A record review of the progress note dated 11/04/22 at 4:55 AM revealed, the nurse spoke with a local police officer. Staff searched the entire building with the Police Officer. R1 was not located. The Officer advised the nurse that he could not file a missing person's report because R1 has decisional capacity, but he will continue to ride around and look for him. Record review of the progress notes dated 11/04/22 at 5:09 AM revealed, staff continues to search for R1 without locating him. R1 was located by police on 11/04/22 at 9:30 AM at Krispy Kreme about 0.7 miles from the facility. R1 was transported to Spartanburg Regional Medical Center by ambulance for evaluation, no injuries were noted. During an interview with the Administrator on 11/15/22 at 11:45 a.m. who states she received a telephone call around 4:30 a.m. Along with police, they conducted a search of the entire facility. During an interview with R1 on 11/15/22 at 11:30 AM, R1 stated that he left because he needed to get things done. R1 stated he told 2 employees that he was leaving, but they did not believe him. R1 stated he got on the elevator and walked out the front door. R1 stated he walked to Krispy Kreme to get him a cup of coffee until he decided how he was going to get to Pacolet (a town neighboring Spartanburg). R1 stated that he does not need to be in a nursing home. During an interview on 11/15/22 at 2:05 PM with CNA1 revealed she made rounds around 2:00 AM on 11/4/22 emptying R1's urinal and he was in his room, in the bed asleep, at this time. CNA1 stated that when she went back down the hall, she noticed R1 was not in his bed. She looked in the bathroom and he was not there. CNA1 stated she then went to the Nurse Supervisor and told her that R1 was not in his room, so they both looked in every room on the floor and when he could not be found, LPN called Unit 1 and Unit 2 to alert them of a Code White and we all started to look for R1 inside and outside the building. CNA1 stated that she knows that R1 has told others that he was leaving, but he never told her that. If he did, she would have reported that to the charge nurse. CNA1 also revealed R1 has tried to leave the facility before. During an interview with Social Services Director (SSD) on 11/15/22 at 2:15 PM, she stated that she spoke with R1 about the elopement and states that he informed the CNA that he was leaving, but he did not know the name of the person he told. SSD stated that R1 told her that he was going to Pacolet to see a friend. He went downstairs using the elevator and exited the building using the door, which leads to the loading docks. R1 stated that he held down the handle for 15 seconds until it unlocked and allowed him to exit. SSD stated that R1 told her he knew where he was going and never felt unsafe because he used to be homeless. R1 told SSD that he was unhappy at this facility and needed to get out for a little bit. During an interview with CNA2 on 11/15/22 at 3:35 PM, she revealed this is not the first-time resident has tried to leave therefore they put him on the 3rd floor. CNA2 stated that she checked on R1 throughout the night,however, he left in between rounds because he knew when we were busy. Several attempts were made on 11/15/22 via telephone to contact LPN1 with no success.