**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, Director of Maintenance job description, facility investigation, manufacturer's manual recommendations, medical record review, observation, and interview, the facility failed to ensure the environment was free from accident hazards when dangerously elevated hot water temperatures were measured and when the facility failed to provide a safe environment and adequate supervision to prevent falls and injury for 2 of 5 (Resident #14 and #86) sampled residents reviewed for accidents. On 4/29/2024 and 5/7/2024, dangerous elevated hot water temperatures ranging from 121 degrees Fahrenheit (F) to 142 degrees Fahrenheit (F) were found in 32 of 169 (Resident Rooms #100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #115, #116, #203, #205, #212, #213, #215, #216, #306, #309, #316, #317, #318, #320, #325, #332, #400, #401, #406, #413, and #414) resident rooms checked for water temperatures. Hot water temperatures ranging from 121 degrees to 133 degrees F were found in 3 of the 4 (Resident Shower Rooms 100 hall, 200 hall and 400 hall) resident shower rooms. Three Residents who were physically and/or cognitively impaired (Residents #46, #85, and #114) resided in a room with elevated dangerous hot water temperatures and two residents were able to access the hot water in their rooms. Five residents were assessed for wandering (Resident #28, #41, #47, #117, and #479) and at risk of serious bodily injury, harm, burns, or death. Three cognitively intact (Residents #8, #115 and #280) stated the water would get too hot. The facility's failure to prevent the dangerously hot water temperatures placed all residents with the ability to access the hot water in Immediate Jeopardy. The facility's failure to properly use a mechanical lift during the transfer of Resident #86 resulted in Actual Harm when Resident #86 fell and sustained a Lumbar 1 (L1 - a fracture of the lumbar spine that causes moderate to severe pain) compression fracture, and when the facility's failure to implement one on one care for a resident resulted in Resident #14 sustaining a fall which resulted in an emergency room visit. The failure of the facility to maintain safe hot water temperatures placed all residents with access to these rooms in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance has caused, or has potential to cause serious injury, harm, impairment, or death to a resident). The facility's census was 131. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy (IJ) for F689 on 4/29/2024 at 6:19 PM, in the Conference Room. An acceptable allegation of removal was received on 5/3/2024. On 5/7/2024 beginning at 10:00 AM, while attempting to validate the allegation of removal, dangerously elevated hot water temperatures ranging from 121 degrees F to 124 degrees F were observed in resident rooms #115, #203, #212, #215, #400, #406, #413 and #414 and in the 200 and 400 hall resident shower rooms. The Interim Administrator, Facility Consultant and the DON were notified of the Immediate Jeopardy (IJ) for the amended F689 on 5/7/2024, at 5:19 PM, in the facility Conference Room. An extended survey was conducted 5/1/2024 through 5/8/2024. The Immediate Jeopardy for F-689 began on 4/29/2024. The Immediate Jeopardy is ongoing. The findings include: 1. Review of the facility policy titled, WATER TEMPERATURES, SAFETY OF, revision date 12/2009, revealed .Tap water in the facility shall be kept within a temperature range to prevent scalding of residents .Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures on no more than 100 .F or the maximum allowable temperature per state regulation .Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log .If any time water temperatures feel excessive to the touch .staff will report this finding to the immediate supervisor .exposure to warm or hot water .to certain temperatures will cause scalding or burns .Nursing staff will be educated about signs and symptoms of burns . Review of the State licensure regulations revealed at 720-18-.08, .Water distribution systems shall be arranged to provide hot water at each hot water outlet at all times. Hot water at shower, bathing and hand washing facilities shall be between 105°F and 115°F . Review of the undated and unsigned Director of Maintenance job description revealed .The Maintenance Director is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times .Maintaining the building in compliance with current federal, state .regulations, and guidelines .Maintaining the building in good repair and free from hazards .Export knowledge of general building maintenance duties .Knowledge of safe practices in Long Term Care environment .Knowledge of Federal and State Regulations . Review of the facility's policy Fall Prevention And Management, dated 10/2023, revealed .It is the policy . to ensure a safe environment .A Fall Prevention and Management Program is used to provide a safe environment for residents .designed to identify residents at risk for falls .define interventions for the prevention of falls and/or decrease the likelihood of injury .A fall is when a resident comes to rest unintentionally on the floor .Interventions appropriate to individual residents and their risk for falls will be implemented .All products and devices included as interventions .will be used according to manufacturer's recommendations . Review of the facility's policy titled, Accidents/Falls, dated 6/8/2022, revealed .The facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents .All employees must follow these guidelines and procedures for safe resident handling . Review of the facility's policy titled, Safe & Proper Resident Handling, dated 6/5/2023, revealed .To provide guidelines that will assist with the facility to select the safest technique and/or equipment for resident handling and movement tasks .Key Points for health care staff to consider .Identify any equipment required and know how to use it . Review of the facility's policy titled, Use of a Mechanical Lift, dated 10/2022, revealed .To define the guideline for use of a Mechanical lift .must be used by two (2) nursing assistants to perform the procedure . Review of the manufacturer's manual Invacare Reliant 450 .600 .Patient Lift, revealed .Operating the Lift WARNING .recommends that two assistants be used for all lifting . Using the Sling WARNING .Be sure to check the sling attachment each time .to ensure that it is properly attached before the patient is removed from a stationary object (bed, chair or commode) .Transferring the Patient WARNING When elevated a few inches off the surface of the stationary object .and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar. If any attachments are not properly in place, lower the patient back onto the stationary object .and correct this problem . 3. The surveyor's thermometers were calibrated (a procedure using ice water to ensure the thermometer is measuring correctly) before water temperature checks were obtained. The surveyor's hot water temperature checks in resident rooms on 4/29/2024 beginning at 1:22 PM, revealed the following: room [ROOM NUMBER] was 130 degrees F. room [ROOM NUMBER] was 122 degrees F. room [ROOM NUMBER] was 120 degrees F The Maintenance Team Lead and the surveyor's hot water temperature checks using a calibrated thermometer in resident rooms and showers on 4/29/2024 beginning at 2:40 PM, revealed the following: room [ROOM NUMBER] was 137 degrees F. room [ROOM NUMBER] was 135 degrees F. room [ROOM NUMBER] was 133 degrees F. room [ROOM NUMBER] was 134 degrees F. room [ROOM NUMBER] was 137 degrees F. room [ROOM NUMBER] was 134 degrees F. room [ROOM NUMBER] was 137 degrees F. room [ROOM NUMBER] was 135 degrees F. room [ROOM NUMBER] was 135 degrees F. room [ROOM NUMBER] was 135 degrees F. room [ROOM NUMBER] was 137 degrees F. room [ROOM NUMBER] was 141 degrees F. room [ROOM NUMBER] was 140 degrees F. room [ROOM NUMBER] was 135 degrees F. room [ROOM NUMBER] was 132 degrees F. room [ROOM NUMBER] was 127 degrees F. room [ROOM NUMBER] was 122 degrees F. room [ROOM NUMBER] was 120 degrees F. room [ROOM NUMBER] was 121 degrees F. room [ROOM NUMBER] was 137 degrees F. room [ROOM NUMBER] was 136 degrees F. room [ROOM NUMBER] was 129 degrees F. room [ROOM NUMBER] was 129 degrees F. room [ROOM NUMBER] was 137 degrees F. room [ROOM NUMBER] was 133 degrees F. room [ROOM NUMBER] was 142 degrees F. room [ROOM NUMBER] was 138 degrees F. room [ROOM NUMBER] was 137 degrees F. room [ROOM NUMBER] was 130 degrees F. room [ROOM NUMBER] was 133 degrees F. room [ROOM NUMBER] was 121 degrees F. The Residents' Shower room on the 100-hall in stall #1 was 133 degrees F and in stall #2 was 131 degrees F. The Residents' Shower room on the 200-hall in stall #1 was 122 degrees F. The Maintenance Technician and the surveyor's hot water temperature checks using a calibrated thermometer in residents rooms and showers on 5/7/2024 beginning at 10:00 AM, revealed the following: room [ROOM NUMBER] was 121 degrees F. room [ROOM NUMBER] was 123 degrees F. room [ROOM NUMBER] was 121 degrees F. room [ROOM NUMBER] was 122 degrees F. room [ROOM NUMBER] was 123 degrees F. room [ROOM NUMBER] was 123 degrees F. room [ROOM NUMBER] was 124 degrees F. room [ROOM NUMBER] was 122 degrees F. The Residents'Shower room on the 200-hall in stall #1 was 120 degrees F. The Residents'Shower room on the 400-hall in stall #1 was 121 degrees F. 3. Per Minimum Data Set (MDS) review revealed Residents #46, #85 and #114 were cognitively and/or physically impaired, and the Residents had access to the hot water with the dangerously elevated hot water temperatures. The facility provided a list of ambulatory residents and a list of residents who wander. The facility lists revealed Residents #28, #41, #47, #117 and #479 were cognitively impaired and had been identified by the facility as Residents with wandering behaviors (random, repetitive, or aimless locomotion/movement throughout an area) had the potential to be affected by the dangerously hot water temperatures. 4. Medical record review revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Hypertension, Dementia, Cognitive Communication Deficit, and Malignant Neoplasm of the Prostate. Review of the annual MDS dated [DATE], revealed a BIMS score of 9 which indicated the Resident was moderately cognitively impaired, and required moderate assistance with bed to chair transfer, required maximum assistance with toileting hygiene and was dependent on staff for bathing. Review of the Wander List dated 4/26/2024, revealed Resident #28 was moderate to high for wandering. Resident #28 resided in a room which measured the dangerously elevated hot water temperature of 137 degrees F in the resident's sink, and the Resident had the ability to access the hot water. 5. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE], with diagnoses including Diabetes, Hypertension, and Dementia. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #46 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the Resident was severely impaired cognitively. Resident #46 required partial to moderate assistance from staff to wash and dry their face and hands and to shower/bath self. Observation and interview on 4/29/2024 at 4:18 PM, revealed Resident #46 dressed, lying in the bed and was asked about the hot water in his bathroom. Resident #46 stated, The water be too hot. I tell them they have to change the water to make it be not so hot . Resident #46 resided in a room which measured the dangerously hot water temperatures of 121 degrees F. 6. Review of the medical record revealed Resident #85 was admitted to the facility on [DATE], with diagnoses including Traumatic Subdural Hemorrhage, Diabetes, Depression, and Hypertension. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 10 which indicated the Resident was moderately cognitively impaired. Resident #85 used a wheelchair and requires assistance for bathing. Observation on 4/29/2024 at 10:39 AM, revealed 2 staff members in Resident #85's room assisting the Resident to the wheelchair. Observation on 4/30/2024 at 4:15 PM, revealed Resident #85 dressed, and sitting in a wheelchair in the friendship area at the table with other residents playing bingo. Resident #85 resided in a room which measured the dangerously elevated hot water temperatures of 122 degrees F. and had the ability to access the hot water. 7. Review of the medical record revealed Resident #114 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction due to Embolism of Left Middle Cerebral Artery, Chronic Obstructive Pulmonary Disease, Hypothyroidism, and Left Leg Above the Knee Amputation. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 8 which indicated the Resident was moderately cognitively impaired. Observation on 4/30/2024 at 9:29 AM, revealed Resident #114 sitting in a wheelchair outside with other residents in the smoking area, wearing an apron and smoking a cigarette. Observation on 5/01/2024 at 11:15 AM, revealed Resident #114 self-propelling in a wheelchair down the hall, and stated she was looking for someone to get her some ice. During an interview on 4/29/2024 at 4:21 PM, Resident #114 was asked if the water was hot in her bathroom. Resident #114 stated, .the hot water is too hot . Resident #114 resided in a room which measured the dangerously elevated hot water temperature of 122 degrees F. and the Resident had the ability to access the hot water. 8. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Congenital Diaphragmatic Hernia, Aphasia, Dysphagia, Sleep Disorder, and Alcohol and Cocaine Abuse. The facility identified the resident as ambulatory and had a wanderguard. Review of the quarterly MDS dated [DATE], revealed Resident #41 BIMS score was not assessed. Resident #41 required set up to moderate assistance with Activities of daily living skills, and moderate assistance with toileting hygiene, bathing and mobility. Review of the Care Plan dated 1/23/2024, revealed Resident # 41 was identified for wandering and elopement. Resident #41 resided in a room which measured the dangerously elevated hot water temperature of 137.8 degrees F, and the Resident had the ability to access the hot water. 9. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnosis including Diabetes, Kidney Failure, Psychotic Disorder with Delusions, and Heart Failure. Review of the annual MDS dated [DATE], revealed Resident #47 has a BIMS score of 7 which indicated the Resident was severely cognitively impaired. Resident #47's upper/lower extremities were with no impairment, ambulated with a walker, used a wheelchair, and required maximum assistance with bathing. Review of the Care Plan dated 1/23/24, revealed, .I [Resident #47] am a wanderer . Observation on 4/30/2024 at 7:47 AM, revealed Resident #47 dressed, and sitting in a wheelchair across from nursing station with their eyes closed. Resident #47 resided in a room which measured the dangerously hot water temperature of 121 degrees F, and the Resident had the ability to access the hot water. 10. Review of the medical record revealed Resident #117 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Encephalopathy, Schizophrenia and Hypertension. Review of the quarterly MDS dated [DATE], revealed Resident #117 was rarely or never understood and had impaired long and short-term memory problems. Resident #117 was independent with toilet transfer and required supervision with toilet hygiene. The MDS did not have a BIMS score. Resident #117 resided in a room with the of the dangerously elevated hot water temperature that measured 138.7 degrees F, and the Resident had the ability to access the hot water. 11. Medical record review revealed Resident #479 was admitted on [DATE], with diagnoses including Cerebral Infarction, Hemiplegia, Dementia, Convulsions, Dysphagia and Hypertension. Review of the admission MDS dated [DATE], revealed a BIMS score of 1 which indicated the Resident was severely cognitively impaired. Resident #479 required maximum assistance with toileting hygiene, transfer and bathing. Review of the Wander List dated 4/26/2024, revealed Resident #479 was moderate to high risk for wandering. Resident #479 resided in a room which measured the dangerously elevated hot water temperature of 137 degrees F, and the resident had the ability to access the hot water. 12. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Cerebral Palsy, Repeated Falls, Legal Blindness and Anxiety. Review of the quarterly MDS dated [DATE], revealed Resident #8 with a BIMS score of 13 which indicated the Resident was cognitively intact and was dependent on staff for bathing, no impairment upper and lower extremities, requires moderate assist to transfer from bed to a chair and uses a wheelchair. During an interview on 4/29/2024 at 4:20 PM, Resident #8 stated that sometimes the water was too hot. 13. Review of the medical record revealed Resident #115 was admitted to the facility on [DATE] with diagnoses including Diabetes, Hypertension and Chronic Kidney Disease. Review of the quarterly MDS dated [DATE], revealed Resident #115 with a BIMS score of 15, which indicated the Resident was intact cognitively. Resident #115 used a wheelchair for mobility. During an interview on 4/29/2024 at 4:23 PM, Resident #115 was asked if the water was hot in the bathroom. Resident #115 stated, It gets too hot . 14. Review of the medical record revealed Resident #280 was admitted on [DATE], with diagnoses including Hypertension, Diabetes, Encephalopathy, and Acute Kidney Failure. Review of the admission MDS dated [DATE], revealed Resident #115 scored a 14 on the BIMS which indicated the Resident was cognitively intact. Resident #280 had no impairment on the upper and lower extremities, required set up for bathing and required supervision for transfers from bed to chair. During an interview on 4/29/2024 at 4:03 PM, Resident #280 stated the water temperature had been too hot when bathing and the washcloths were too hot at times. 15. During an interview on 4/29/2024 at 4:33 PM, CNA R was asked about any concerns with the water being too hot or too cold. Staff R stated, .some do get too hot .if you turn it up, it gets really hot .showers not too hot .[the hot water], it don't [doesn't] last long . During an interview on 5/1/2024 at 8:37 AM, Maintenance Team Lead was asked if he had any orientation on checking water temperatures. Maintenance Team Lead stated, No, ma'am .we just started watching them [water temperatures] a year or 2 after I got here. Maintenance Team Lead was asked when they had been notified the water was too hot. Maintenance Team Lead stated, When y'all found out . The Maintenance Team Lead was asked who had trained the Maintenance Technician. The Maintenance Team Lead stated, Nobody .we all didn't have any training .I have trained him [Named Maintenance Technician] this week on taking the water temps. The Maintenance Team Lead was asked how often water temperatures were being checked. The Maintenance Team Lead stated, .every hall gets checked once a week. I was not the one doing it .it was supposed to been done correctly .problems with water pipes in the winter .we had to turn the water up, and we never turned it back down .the water was cold .the hot water tank [heater] was turned up. The Maintenance Team Lead was asked was if the hot water heater was turned up to bring the water temperature up. The Maintenance Team Lead stated, Yes. The Maintenance Team Lead was asked when the hot water heaters were turned back down. The Maintenance Team Lead stated, We never got to it .until now .both water tanks [hot water heaters] were turned up . During an interview on 5/1/2024 at 9:21 AM, the Maintenance Technician was asked about the orientation when hired. The Maintenance Technician stated, .we went over few things I would be doing .I got hands on training .had to learn on my own . The Maintenance Technician was asked who the supervisor was. The Maintenance Technician stated, .[Named Maintenance Team Lead] because we cannot keep a maintenance supervisor . The Maintenance Technician was asked to explain how he took the water temperatures before yesterday 4/30/2024. Maintenance Technician stated, .run the water for 1 to 2 minutes, let the water get hot, place the thermometer tip in between the water. I would have half of the tip out of the water, learned now I should have the tip in the water and before .once I saw the number I would record. The Maintenance Technician was asked how the water temperatures are checked, now that he is trained. Maintenance Technician stated, Now trained to check .turn water on let it run for a few minutes .5 minutes, make sure numbers are not jumping .it will take 2 to 3 minutes of running and tip of thermometer in center to make sure . The Maintenance Technician was presented documentation of the facilities previously documented water temps and asked if he thought the documented water temps were accurate. The Maintenance Technician stated, I would say not . I was doing the tip in the water the wrong way .they are not right, if I was doing them the wrong way . The Maintenance Technician was asked how often the water temps were checked. The Maintenance Technician stated, I used to do them every day but now since . 2 months ago .changed to every Wednesday, do a hall a week . The Maintenance Technician stated he was told yesterday (4/30/2024) that the water temps were too high. The Maintenance Technician was asked had he ever been shown the federal guidelines for water temperatures. Maintenance Technician stated, No. The Maintenance Technician was asked did he know anything about the water being cold. The Maintenance Technician stated, . CNAs complained about the water being cold .I did not think the water was cold, it was warm .the people who put it in came out here and turned it up [referring to the hot water heater] .October . The Maintenance Technician was asked if the water temperatures could be visualized on the hot water heater. The Maintenance Technician stated, Yes. The Maintenance Technician was asked who monitored the water temperatures on the hot water heaters. The Maintenance Technician stated, Nobody. The Maintenance Technician was asked what the temperatures were on the hot water heaters today. The Maintenance Technician stated, .it was at 175 degrees on the oldest hot water heater and [Named Regional Director of Maintenance (RDOM)] changed it this week .[now set at] 115 . The Maintenance Technician confirmed he was not checking the shower room water temperatures. The Maintenance Technician was asked should he check the shower room temps. The Maintenance Technician stated, I think so, now. During an interview on 5/1/2024 at 4:08 PM, the RDOM, who prior to this interview was employed at a sister facility as part of their Maintenance Staff, was asked who was responsible for the maintenance of the facility. The RDOM stated, .I guess right now that would be me. The RDOM was asked about the hot water temperatures at the facility. The RDOM stated, It was brought to my attention you all had seen a temperature reading of 140 or 143. I thought that's impossible and thought that it had to be a bad mixing valve .I went downstairs and lowered temperatures on the boilers [hot water heaters]. The RDOM was asked what the temperatures were at that time. The RDOM stated, I want to say 130, 131 and I reduced it to 115 degrees and opened up the hot water valve in the janitors closet to expel the additional hot water .to bring the temperatures down .brought down to below standards .I lowered it to get the danger to the residents gone, so that it wasn't going to cause harm . This is purely assumption on my part, but makes the most sense, the [previous] Maintenance .turned up the temp and didn't follow up on it .I think when he [Previous Maintenance Director] left nobody looked or checked. If they had been doing temps the correct way, they would have caught it. The RDOM was asked were the two current maintenance staff reeducated about water temperatures and how to take temperatures properly. The RDOM stated, Honestly no, but I will. The RDOM was asked with the seriousness of the situation and the possibility of residents being seriously burned, should they have reeducated staff when this was found. The RDOM stated, .temp reading is something definitely going to be addressed .plan to address tomorrow .been working on Life Safety issues . The RDOM was asked since the problem with the water temperatures has been discovered as being too hot have the maintenance staff checked the water temperatures been taken. The RDOM stated, [Named Maintenance Team Lead] and I have .came in yesterday [4/30/2024] and took temps . did not write them down. The RDOM was asked with the seriousness of harm or death should the water temperatures be written down, kept, and reported back to the Administrator. The RDOM stated, That would fall under the Maintenance Director, and I am currently in that position, that is why I got the temp confirmed, he did not write them down. The RDOM was asked if he knew the federal regulations for water temperatures. The RDOM stated, No, what are they? The RDOM was asked what education was going to be provided to the maintenance staff if he didn't know the federal guidelines for water temperatures. The RDOM stated, . I will know them today. During an interview on 5/01/2024 at 4:49 PM, the Director of Nursing (DON) was asked about the water temperatures. The DON stated, .my understanding 104-110 in resident rooms .I don ' t know shower rooms . The DON was asked has anyone educated them on the correct water temperature ranges this week. The DON stated, I wouldn't say they educated me about it .that was the range we agreed on. The DON confirmed the Maintenance staff should have been able to tell them what the correct temperature ranges should be and stated, .I have not been keeping up with the water . During an interview on 5/02/2024 10:20 AM, the DON stated to the RDOM, . going to have to get tight on the water .the water is too low . The RDOM stated, .I talked to [named Life Safety surveyor] .he told me what the range is . During an interview on 5/02/2024 at 2:09 PM, the Administrator was asked if she had been notified of the hot water temps. The Administrator stated, .Monday night . got a text from my housekeeping supervisor .said we got an IJ [immediate jeopardy] for the water temperature . The Administrator confirmed no one else had let her know about the IJ and stated, The one that should have notified me was the DON who was second in command . The Administrator was asked how the communication was within the facility. The Administrator stated, .it's been poor . The Administrator was asked if she felt the response to the IJ had been immediate. The Administrator stated, .there was a call to a vender .and the boilers [hot water heaters] were turned down immediately .showers were halted and bed baths .until we could determine the proper temperature. The Administrator confirmed everyone should have been aware of the water temperature and stated, .100 degrees for baths .120 degrees for 5 minutes burn . The Administrator confirmed it would be too cold to receive baths/shower under 100 degrees and stated, It would be too cold . The Administrator confirmed she had no idea what the water temperature acceptable ranges should be and was asked who was responsible for the hot water temperatures. The Administrator stated Maintenance .they are supposed to do water checks daily. The Administrator confirmed she was not aware that the maintenance didn't know how to correctly take the water temps. The Administrator was asked where the communication breakdown was. The Administrator stated, .I don't know .it's definitely .a good question .maybe failure to carry out assigned duties [referring to the hot water heater being to high and not being turned down] . The Administrator was asked who was responsible for the building. The Administrator stated, I am. During an interview on 5/08/2024 at 10:51 AM, the Medical Director confirmed he was notified about the IJ related to hot water temperatures and stated, I told them the water should be fixed quickly .I think when it comes to spending money the owners drag their feet .it should be the right temperature .shouldn't be too hot or too cold .the building is [AGE] years old .it's going to cost some money but it is worth it for the residents . During an interview on 5/08/2024 at 11:20 AM, the Superintendent of the Service Department of an outside vendor was asked why they were called out to facility. The Superintendent stated, .they [the facility] are having hot water in faucets .it was hotter than it was supposed to be .when we got here .originally it was a boiler and 2 water tanks .some time ago, in the 80's .90s boiler went out and replaced .with 2 water heaters .we replaced one [referring to the water heater] in the last couple years .it had flooded down there [in the facility basement], it's been years ago when they took the boiler out, they piped it up differently, cold water feeds with them having to circulate through builder boilers, they require a holding tank . when boilers were replaced . they had a boiler with a holding tank, boiler doesn't have a tank and can't circulate .they left the cold tied into the tank instead of the water heaters, they are mixing .the problem was going into the holding tank . we have already rerouted that, to maintain that, they [the facility] kicked the hot water up . the hot and cold was mixing .they have circulating pumps and aren't working . The Superintendent was asked was the water issued fixed at this time. The Superintendent stated, .not that I ' m aware of it shows 74 degrees .to get it right, they would have to re-pipe the whole building .they are so old, they don't have a system monitoring the valves . The Superintendent was asked if the water issues can recur. The Superintendent stated the only way to properly correct the problem was, tearing out walls and ceiling are going to be the only way .yes .&quo[TRUNCATED]

Based on facility policy review, job description review, and interview, Administration failed to provide oversight that ensured a safe environment and adequate supervision to prevent serious injuries, failed to ensure a Quality Assurance Performance Improvement (QAPI) process of data collection, analysis, interventions, monitoring and follow up, and failed to ensure the highest practicable wellbeing of residents with wheelchair dependency, dementia and wandering behaviors. The facility Administration failed to ensure the 200 hall elevator functioned in a safe manner, failed to conduct a thorough investigation related to accident/hazards involving the malfunction of the 200 hall elevator, failed to take immediate actions to protect all residents from the 200 hall elevator malfunction, and failed to ensure a safe environment to prevent injuries for 4 of 14 (Residents #1, #2, #6, and # 15) sampled residents for wheelchair/elevator and wandering/elopement accidents and incidents. Residents #1, #2, and #6 experienced falls from their wheelchairs when exiting the 200 hall elevator when the elevator floor was not level with the hallway floor. Resident #6 had a fall exiting the elevator in his wheelchair on 5/22/2023 but did not sustain injuries. Resident #2 sustained a rib fracture and right leg fracture on 6/2/2023. Resident #1 sustained bilateral leg fractures on 7/22/2023, and later died. The facility Administration failed to ensure oversee that services were implemented and evaluated to meet resident needs to maximize resident quality of life, failed to consult with department directors concerning the operation of their departments to assist in correcting problems and improving services, failed to ensure that a system for maintaining and improving building, grounds, and equipment is planned, implemented and evaluated, failed to oversee the planning, implementation and evaluation of an environmental safety program that will maintain the health, welfare and safety of residents, and failed to maintain responsibility for the facility being maintained in a safe manner for residents by assuring that necessary equipment was maintained to prevent elopement hazards for Resident #15, when a cognitively impaired resident who was at risk for wandering, eloped from the facility on 7/7/2023. The facility Administration's failure placed Residents #1, #2, #6, and #15 in Immediate, Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Nurse Consultant, the Administrator, and Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/16/2023 at 9:00 AM in the Conference Room. F-835 was cited at a scope and severity of J. The Immediate Jeopardy began on 5/22/2023 and ended on 8/22/2023. An acceptable Removal Plan, which removed the immediacy of jeopardy, was received on 8/21/2023 at 5:07 PM, and was validated onsite by the surveyors on 8/24/2023 through observations, medical record review, review of education records, and audit tools, meeting minutes, and staff interviews. F-835 remains at a scope and severity of D. The findings include: 1. Review of the facility's undated Safety and Supervision policy revealed .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Review of the facility's policy Elopement revised 3/2023, revealed .Staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing . Review of the facility's undated Wandering Policy revealed . Staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures [including searching] for any resident who is discovered to be missing from the unit or facility . 2. Review of the facility's undated Licensed Nursing Home Administrator job description, revealed .The primary purpose of the Nursing Home Administrator position is to oversee the day-to-day operation of the facility, to assure resident safety and to review organizational performance .Oversee that nursing services, social service programs, activity programs, food service programs and medical services are planned, implemented and evaluated to meet resident needs to maximize resident quality of life and quality of care .Identify, monitor, and ensure that quality indicators and quality improvement programs are utilized to maximize effectiveness in resident care and services .Consult with department directors concerning the operation of their departments to assist in correcting problems and improving services .Make routine inspections of the facility to assure that established policies and procedures are being followed .Ensure that a system for maintaining and improving building, grounds, and equipment is planned, implemented and evaluated .Oversee the planning, implementation and evaluation of an environmental safety program that will maintain the health, welfare and safety of residents, staff and visitors .Review accident/incident reports and establish an effective accident prevention program .Maintain responsibility for the facility being maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained . Review of the facility's undated Director of Nursing Services job description, revealed .The primary purpose of the Director of Nursing [DON] position is to plan, organize, develop, and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times .Develop, implement, and maintain an ongoing quality assurance performance improvement program for the nursing department .Assist the Quality Assurance Performance Improvement Committee in developing and implementing appropriate plans of action to correct identified deficiencies . Review and insure that charting documentation procedures for nursing are met according to state and federal guidelines .Chair, serve on, participate in, and/or attend various committee meetings of the facility [i.e. Quality Assurance Performance Improvement meetings] .provide written and/or oral reports of the nursing program, as required or directed by the above committees. Evaluate and implement recommendations from established committees as they may pertain to nursing services .Inform nursing personnel of new admissions and include all pertinent logistical information .Review nurses' notes to ensure that they are informative, descriptive of the nursing care and consistent .Assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident .Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan .Review nurses' notes to determine if the care plan is being followed .Communicates with the medical staff, nursing personnel, and other department supervisors . 3. Review of an emailed Transmittal Form dated 5/12/2023, revealed the facility received a packet of documents from [Named Elevator Company] to be completed for approval for updating the 100 hall and the 200 hall elevators. The documents were not completed and signed by the Administrator until 7/27/2023. The Administrator stated the cost of the recommended updating for the 200 hall elevator was not approved until 7/27/2023. During an interview on 8/1/2023 at 11:55 AM, the Administrator was asked what has been put in place since the 3 accidents (On 5/22/2023 Resident #6 fell from a wheelchair when exiting the unleveled floor from the 200 hall elevator. On 6/2/2023, Resident #2 fell to the floor in a wheelchair when exiting the 200 hall elevator and sustained a fractured rib and fractured leg. On 7/22/2023, Resident #1 exited the 200 hall elevator in a motorized wheelchair, the elevator floor was not level with the floor of the hallway when the elevator door opened and the resident sustained bilateral leg fractures, and later died) involving the 200 hall elevator that will keep it from happening again. He stated, .To my knowledge we have never had issues with leveling .I watched the video [for the incident with Resident #1 on 7/22/2023], and it appears the front wheels of the motorized chair got caught in the threshold. I did question the level when I first watched it .It's an old elevator from 1960's. They [Elevator Services] tell us it needs replacing or updating . During an interview on 8/8/2023 at 10:00 AM, when the Administrator was asked if the facility conducted a thorough investigation and questioned all staff concerning the elopement of Resident #15, he stated No, we didn't question all staff. When asked if the facility had a copy of the video footage of Resident #15's elopement, he stated No, I don't have a copy and it's gone from the video system. We don't have Cloud for backup storage . When asked if the facility has a summary of the video footage with times and locations or any notes, he stated No. When asked if the facility conducted a root cause analysis, the Administrator stated No. When asked did you or the DON come in when called by staff, he stated No. 4. During an interview on 8/9/2023 at 10:25 AM, when asked if the staff working on 7/22/2023, when the accident involving Resident #1 happened, had been interviewed and statements recorded in an investigation of the accident, the Director of Nursing (DON) stated Not sure. I talked to the nurse when she called me. I didn't write anything down. [Named Administrator] and the Social Worker were going to get statements . During an interview on 8/14/2023 at 4:39 PM, the DON was asked was a root cause analysis completed for the elopement of Resident #15 or the elevator accidents involving Residents #1, #2 and #6, he stated .No . During an interview on 8/15/2023, when asked if the incident involving Resident #6's fall from the elevator on 5/22/2023 was investigated, the DON stated, It was talked about. The DON confirmed the Quality Assurance Performance Improvement committee did not meet and discuss the incident, implement interventions, or determine a root cause. The DON would not give any details about what was discussed or when it was discussed related to the incident. During an interview on 8/15/2023 at 3:08 PM, the DON was asked if the facility put any interventions in place to keep the unsafe operation of the elevator and resident incident/accidents from happening again [since the 7/22/2023 incident], he stated .No . The DON confirmed there has been no process for tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underlying causes and developing and implementing corrective action or performance improvement activities and monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed for the 7/7/2023 elopement incident or the unsafe operations of the elevator which resulted in resident incidents/accidents 5/22/2023, 6/2/2023 and 7/22/2023. Refer to F689. The surveyors verified the Removal Plan by: 1. Facility Administration consists of the leadership team including: Administrator, Director of Nursing, Unit Managers, Director of Maintenance, Housekeeping Director, Therapy Director, Activities Director, Dietary Manager, and department heads. The surveyor reviewed the list and interviewed Administration. 2. Regional Nurse educated Facility Administration regarding their individual and specific roles related to administration and oversight of the following corrective action plans. The surveyor reviewed the education material, sign in sheet and interviewed Administration. 3. Regional nurse will provide administrative oversight to ensure corrective actions are properly implemented and evaluate effectiveness by conducting routine facility visits and observations. The surveyor interviewed the Regional Nurse. 4. Director of Nursing and/or Unit Managers will complete a new Baseline Elopement assessment for current residents and reevaluate assessments upon admission/readmission, quarterly, annually and change in condition. Any discrepancies identified will be reevaluated by Interdisciplinary team and necessary corrections will be entered to resident's care plan and implemented. The surveyor reviewed the records, audit review and interviewed staff. 5. Director of Nursing/Unit Manager will ensure accuracy by reviewing wander risk assessments during clinical meetings by comparing entered data in residents' charts and actual residents' behaviors. The surveyor reviewed clinical meeting form, record review and interviewed staff. 6. Director of Nursing/Unit Manager will Implement interventions according to wander risk assessment score and elopement assessment. The surveyor reviewed records and interviewed staff. 7. Director of Nursing/Unit Manager/Administrator will ensure adequate staffing for oversight of dementia and wandering residents daily. The surveyor reviewed staffing matrix form for scheduling and interviewed staff. 8. Administration will evaluate referrals and review hospital records with high potential for elopement prior to admission to determine elopement risk. Preadmission evaluations for high-risk elopement referrals will be conducted by DON or Administrator. A determination on whether the resident is appropriate for admission or potential interventions will be made prior to admission. The surveyor reviewed referral admission criteria matrix and interviewed staff. 9. Nurses will check for wander guard placement daily with visual check and documentation on MAR. The surveyor reviewed medical record and interviewed staff. 10. Director of Nursing and/or Unit Managers will review new admits elopement assessments and exit-seeking behaviors to identify high risk residents and transfer to secure unit for monitoring if appropriate, as discussed by interdisciplinary team. The surveyor reviewed records and interviewed staff. 11. Director of Nursing and/or Unit Managers will place photos of residents identified as high risk for elopement at nurses' stations and front desk binder. The surveyor reviewed the books and interviewed staff. 12. Maintenance/Administrator will conduct Elopement Drill and monthly thereafter. The surveyor reviewed the sign in sheets, drill debriefing information and interviewed staff. 13. Maintenance will perform baseline audit of all exit doors to ensure functionality and security. The surveyor reviewed audit sheets and interviewed staff. 14. 200 Hall back elevator will remain off and prohibited from use until replaced and cleared by elevator company. The surveyor observed the elevator, reviewed the audit forms, and interviewed staff. 15. Out of order sign placed on elevator door. The surveyor observed the sign, reviewed the audit form, /and interviewed staff. 16. Sign placed to direct residents/staff/visitors to use front elevators. The surveyor observed the sign and interviewed staff. 17. Director of Nursing and/or Unit Managers will identify residents that use the elevators via standard or electric wheelchairs. The surveyor reviewed the records and interviewed staff. 18. Therapy will evaluate residents that use elevators via standard or electric wheelchairs for safe entering and exiting. The surveyor reviewed the records and interviewed staff. 19. Maintenance will check elevator functionality daily and maintain log. The surveyor reviewed the log and audit and interviewed staff. 20. Facility will initiate and implement QAPI for F835. The surveyor reviewed the forms and interviewed staff. 21. Regional Nurse will in-service Facility Administration regarding F835 and proper facility oversight. The surveyor reviewed the education material, sign in sheet and interviewed staff. 22. Director of Nursing will in-service nurses including agency on accurate completion of elopement assessments. The surveyor reviewed the education material, sign in sheet and interviewed staff. The surveyor reviewed the education material, sign in sheet and interviewed staff. 23. Director of Nursing will in-service nurses including agency regarding implementation of proper interventions based on wander and elopement assessments. The surveyor reviewed the education material, sign in sheet and interviewed staff. 24. Director of Nursing will in-service nurses including agency regarding Dementia, wandering residents and behavior management. The surveyor reviewed the education material, sign in sheet and interviewed staff. 25. Director of Nursing will in-service staff including agency personnel on elopement policy and protocols. The surveyor reviewed the education material, sign in sheet and interviewed staff. 26. Director of Nursing will in-service staff including agency personnel on abuse/abuse reporting. The surveyor reviewed the education material, sign in sheet and interviewed staff. 27. Director of Nursing will in-service staff including agency personnel to ensure that residents with active exit-seeking behaviors are immediately addressed and placed on 1:1 or transferred to the secured unit. The surveyor reviewed the education material, sign in sheet and interviewed staff. 28. Director of Nursing will in-service staff including agency personnel on providing vulnerable residents (moderate/high risk wanderers, active exit-seekers, cognitively impaired with confusion, high fall risks, wheelchair/power chair users) with adequate supervision and safe environment to prevent accidents and elopements. The surveyor reviewed the education material, sign in sheet and interviewed staff. 29. Director of Nursing/Maintenance will in-service staff including agency personnel to ensure exit doors are properly closed and secure, and not propped open to ensure security of residents. The surveyor reviewed the education material, sign in sheet and interviewed staff. 30. Director of Nursing will in-service staff including agency personnel on immediately reporting to Maintenance and/or facility administration when they observe/notice a faulty or improperly functioning elevator. The surveyor reviewed the education material, sign in sheet and interviewed staff. 31. Director of Nursing/Maintenance will in-service staff including agency on proper use of elevator and ensure carts are carefully placed to prevent potential damage to elevator mechanism. The surveyor reviewed the education material, sign in sheet and interviewed staff. 32. Director of Nursing will in-service staff including agency personnel on F835. The surveyor reviewed the education material, sign in sheet and interviewed staff. 33. Education will be ongoing for all new staff including agency. The surveyor reviewed the education material, sign in sheet and interviewed staff. 34. Staff who have not completed education will not be allowed to work the floor until all education is completed and verified. The surveyor reviewed the employee list and interviewed staff. 35. QAPI meeting minutes will be submitted to Regional Nurse for review and verification of completed performance improvement plans. The surveyor reviewed the minutes and interviewed staff. 36. Maintenance will audit and maintain log binder of all exit doors being checked for proper closure daily at minimum, and random times throughout the day. The surveyor reviewed the audits, log binder and interviewed staff. 37. Maintenance will complete audits daily to ensure facility doors are locking appropriately and wander guard system is working. The surveyor reviewed the audits and interviewed staff. 38. Director of Nursing and/or Unit Managers Audits will complete audits 3 times a week to ensure elopement assessments are completed upon admission, quarterly, annually and change of condition; and ensure appropriate interventions are implemented. The surveyor reviewed the audits and interviewed staff. 39. Facility administration will conduct environmental audits 3 times a week to ensure residents have a safe environment to prevent accidents and elopement incidents. The surveyor reviewed the audits and interviewed staff. 40. Audit results will be submitted to QAPI committee to be reviewed and addressed as needed. The surveyor reviewed audit reports and interviewed staff. Noncompliance of F-835 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, review of Quality Assurance Performance Improvement (QAPI) minutes, and interview, the QAPI committee failed to ensure systems and processes were in place and consistently followed by staff that address quality issues related to a safe environment and adequate supervision to prevent serious injuries. The QAPI Committee failed to identify quality safety deficiencies and failed to implement and monitor effective safety interventions for 4 of 14 (Residents #1, #2, #6, and # 15) sampled residents for wheelchair/elevator and wandering/elopement accidents and incidents. On 5/22/2023, Resident #6 fell from a wheelchair when exiting the unlevel floor from the 200 hall elevator. On 6/2/2023, Resident #2 fell to the floor in a wheelchair when exiting the 200 hall elevator and sustained a fractured rib and fractured leg. On 7/22/2023, Resident #1 exited the 200 hall elevator in a motorized wheelchair, the elevator floor was not level with the floor of the hallway when the elevator door opened and the resident sustained bilateral leg fractures, and later died. Additionally, the QAPI committee failed to conduct thorough investigations to determine the root cause of resident accidents related to an unsafe operating elevator and a resident elopement. The QAPI Committee failed to identify quality safety deficiencies, failed to monitor and maintain secure exit doors, identify residents with exit seeking behaviors and implement safety measures, and monitor the effectiveness of any measures implemented related to a cognitively impaired resident with wandering and exit seeking behaviors. Resident #15 exited the facility on 7/7/2023 at approximately 12:00 AM, without staff knowledge, and was found by the police making rounds at 3:45 AM. The facility's QAPI Committee failures placed Residents #1, #2, #6, and #15 in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Nurse Consultant, the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/15/2023 at 4:47 PM in the Conference Room. The facility was cited IJ at F-867 at a scope and severity of J. The IJ began on 5/22/2023 and ended on 8/22/2023. The facility was previously cited Immediate Jeopardy at F-689 for elopement on a complaint survey on 3/15/2023. An acceptable Removal Plan, which removed the immediacy of jeopardy, was received on 8/21/2023 at 5:07 PM, and was validated onsite by the surveyors on 8/24/2023 through observations, medical record and record reviews, review of education records and audit tools, and staff interviews. F-867 remains at a scope and severity of D. The findings include: 1. Review of the facility's undated policy titled Quality Assurance and Performance Improvement (QAPI) Program - Design and Scope revealed .The QAPI program is designed to address all systems and practices in this facility that affect residents, including clinical care, quality of life, resident choice and safety . Review of the facility's undated policy titled Quality Assurance and Performance Improvement (QAPI) Program revealed .This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents .The objectives of the QAPI program are to: provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators .establish systems through which to monitor and evaluate corrective actions .The administrator is responsible for assuring that this facility's QAPI program complies with federal, state, and local regulatory agency requirements. The QAPI committee reports directly to the administrator .The QAPI committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee. The QAPI plan describes the process for identifying and correcting quality deficiencies. The components of this process include tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. The committee meets monthly to review reports, evaluate data, and monitor QAPI related activities and make adjustments to the plan . Review of the facility's undated policy titled Quality Assurance and Performance Improvement (QAPI) Program Governance and Leadership revealed .The quality assurance and performance improvement program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body .The responsibilities of the QAPI committee are to: collect and analyze performance indicator data and other information; identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services; identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process; utilize root cause analysis to help identify where identified problems point to underlying systematic problems; help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care; establish benchmarks and goals by which to measure performance improvement; coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals; and communicate all phases of the QAPI process to the administrator and governing body through sharing meeting minutes, committee activities and results of QAPI activities .Special meetings may be called by the administrator as needed to present issues that need to be addressed before the next regularly scheduled meeting . Review of the facility's undated policy titled Quality Assurance and Performance Improvement (QAPI) Program Analysis and Action revealed .The QAPI program overseen by the QAPI committee is designed to identify and address quality deficiencies through the analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level .The QAPI committee is responsible for analyzing, identified problems, establishing corrective actions, measuring progress against the established goals and benchmarks, communicating information to staff and residents, and reporting findings to the administrator and governing board . Review of the facility's undated policy titled Quality Assurance and Performance Improvement (QAPI) Program Feedback, Data and Monitoring revealed .Information is collected, evaluated and monitored by the QAPI committee .The QAPI process focuses on identifying systems and processes that may be problematic and could be contributing to avoidable negative outcomes related to resident care, quality of life, resident safety, resident choice or resident autonomy, and on making a good faith effort to correct or mitigate these outcomes .Root cause analysis is conducted to identify problematic processes and systems that need to be addressed. Corrective actions and performance improvement activities are initiated and monitored. The committee tracks and documents the progress of existing initiatives as well as newly identified ones, as part of the ongoing QAPI process . Review of the facility's undated policy titled Safety and Supervision of Residents revealed .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide a commitment to safety at all levels of the organization. When accident hazards are identified, the QAPI/safety committee shall evaluate and analyze the cause[s] of the hazards and develop strategies to mitigate or remove the hazards to the extent possible .The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary .The interdisciplinary care team shall analyze information obtained from assessments and observations to identify and specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards .monitoring the effectiveness of interventions .Resident supervision is a core component of the systems approach to safety . Review of the facility's undated policy titled Accidents/Incidents-Medical Director Review of revealed .The medical director shall review accident and incident reports. The medical director shall consult with the administrator and director of nursing regarding accidents and incidents and make recommendations about preventive approaches and corrective actions. As part of the QA process, the medical director will work with the director of nursing services, administrator, and other department to evaluate trends, patterns, and interventions .QA documentation will include the medical director's input on these issues . 2. Review of the facility's undated Licensed Nursing Home Administrator job description, revealed .The primary purpose of the Nursing Home Administrator position is to oversee the day-to-day operation of the facility, to assure resident safety and to review organizational performance .Oversee that nursing services, social service programs, activity programs, food service programs and medical services are planned, implemented and evaluated to meet resident needs to maximize resident quality of life and quality of care .Identify, monitor, and ensure that quality indicators and quality improvement programs are utilized to maximize effectiveness in resident care and services .Consult with department directors concerning the operation of their departments to assist in correcting problems and improving services .Make routine inspections of the facility to assure that established policies and procedures are being followed .Review accident/incident reports and establish an effective accident prevention program .Ensure the integration of resident rights with all aspects of the facility environment . Review of the facility's undated Director of Nursing Services job description, revealed .The primary purpose of the Director of nursing position is to plan, organize, develop, and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times .Develop, implement, and maintain an ongoing quality assurance performance improvement program for the nursing department .Assist the Quality Assurance Performance Improvement Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Review and insure that charting documentation procedures for nursing are met according to state and federal guidelines .Chair, serve on, participate in, and/or attend various committee meetings of the facility [i.e. Quality Assurance Performance Improvement meetings] .provide written and/or oral reports of the nursing program, as required or directed by the above committees. Evaluate and implement recommendations from established committees as they may pertain to nursing services .Inform nursing personnel of new admissions and include all pertinent logistical information .Review nurses' notes to ensure that they are informative, descriptive of the nursing care and consistent .Assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident. Ensures a written plan of care for each resident is developed that identifies the problems/needs of the resident indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care .Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Review nurses' notes to determine if the care plan is being followed . Review of the QAPI minutes dated 7/7/2023, revealed team members names in attendance RN #1 Unit Manager, RN #2 Unit Manager, Maintenance Director, Medical Director. During an interview on 8/1/2023 at 11:55 AM, the Administrator was asked about the accidents involving the 200 hall elevator. He stated, .To my knowledge we have never had issues with leveling [the elevator door would open and the elevator floor was not level with the hallway floor] .I watched the video [for the accident with Resident #1 on 7/22/2023], and it appears the front wheels of the motorized chair got caught in the threshold. I did question the level when I first watched it .It's an old elevator from 1960's. They [Elevator Services] tell us it needs replacing or updating . During an interview on 8/8/2023 at 10:00 AM, the Administrator was asked if the facility did a thorough investigation concerning the elopement of Resident #15, he stated No, we didn't question all staff. When asked if the facility had a copy of the video footage of Resident #15's elopement, The Administrator stated No, I don't have a copy and it's gone from the video system. We don't have Cloud for backup storage . When asked if the facility had a summary of the video footage with times and locations or if there were any notes [related to the elopement], he stated No. When asked if the facility did a root cause analysis [related to Resident #15's elopement], he stated No. When asked if the Administrator or DON came to the facility to begin the investigation to determine the root cause the Administrator said No. During an interview on 8/14/2023 at 4:39 PM, the Director of Nursing (DON) was asked what his role was in QAPI. He stated . [Named Administrator] took control .I did not attend any QAPI meeting .The elopement occurred on a Friday and I was on vacation all the next week .When I came back from vacation, I didn't do anything else related to the elopement . When asked if a root cause analysis was completed for Resident #15's elopement or the elevator accidents involving Resident #1, Resident #2, and Resident #6, he stated .No . During an interview on 8/14/2023 at 4:52 PM, the Director of Social Services was asked what role she had in the investigation of Resident #15's elopement. She stated .My only role was to facilitate a psych [psychiatric] evaluation . When asked about her involvement in meetings, including QAPI, the Director of Social Services stated .no, I had no involvement in any meetings .just notify psych .no QAPI or meeting about it . During a phone interview on 8/14/2023 at 5:05 PM, the RN #2 Unit Manager was asked if a head count was completed after Resident #15's elopement to ensure all residents were accounted, she stated .no . just the room change nothing else . When asked if she participated in meetings about Resident #15's elopement, RN #2 stated .no, no meeting, no monitoring, nothing else comes to mind . During an interview on 8/14/2023 at 5:10 PM, the RN #1 Unit Manager was asked if she participated in meetings about Resident #15's elopement or was asked to monitor anything (resident wandering/elopement screen if completed and accurate, review nurse's notes per shift for resident's behaviors, resident's care plans if completed and accurate), she stated .no meetings .no request to do anything from management .I just know what to do for my patients .no meetings to discuss or investigate what happened .nothing . When asked if she participated in a QAPI meeting, RN #1 stated .no, definitely not . During an interview on 8/15/2023 at 4:04 PM, the Maintenance Director was asked if he was informed of Resident #15's elopement. He stated .No, no one informed me of the elopement until a week later .If [named Administrator] don't want me to know he don't tell me. We close [the Maintenance Director was very close with the previous Administrator], I can't say things if I don't know. We close like that. If you don't know then can't give out information .don't know [the maintenance director stating he doesn't know]. He [previous Administrator] didn't report it to you [State Agency], and he didn't report it to me. A week or so after the elopement happened, he just asked me to copy the video . When asked if he participated in QAPI the Maintenance Director stated .no I don't . When asked if he attended a QAPI meeting about the elopement, he stated .no . When shown the attendance list [for the QAPI minutes dated 7/7/2023] he stated .no didn't know anything about it and no I did not attend . During the interview the Maintenance Director looked at his phone and said I got a text from him on 7/14/2023 and it said he [Administrator] needed a door audit from me and it needed to be dated 7/7/2023 .Another text was sent to me from him dated 7/19/2023 and it said he [Administrator] needed a weekly wander guard test for last 2 weeks and one needs to be on the 7th . The previous Administrator presented a typed list of attendees to the 7/7/2023 QAPI meeting concerning Resident #15's elopement with the Maintenance Director, Unit Manager #1 and #2 and Medical Director listed as being present. In accordance with the listed attendees interviews, they were not present for a QAPI meeting regarding the elopement nor had any part in an investigation related to the elopement. Review of the May 2023 through July 2023 incident/accident reports revealed no documentation the Medical Director reviewed of the reports. During an interview on 8/15/2023 at 3:08 PM, the DON confirmed there was no electronic signature or hard copy print of the incident/accident reports where the medical director had reviewed and signed. He stated .no signature on the electronic record and we do not print a hard copy everything we do is electronic .The medical director would have signed it electronic if reviewed . During a phone interview on 8/16/2023 at 1:00 PM, the Medical Director stated .I was notified of the elopement. I don't recall the date or time .I do not recall any meeting to discuss the investigation or outcomes. I just heard about it .Same about the elevator and the resident [Resident #1] with two fractured femurs that died. I was notified of it but no meeting to discuss any investigation, plans or outcomes. I just heard about it .When asked if she was notified of Resident #2 and Resident #6's accident involving the 200 hall elevator and/or if she attended a meeting to discuss the accidents, the Medical Director stated .no . During an interview on 8/15/2023 at 3:08 PM, the DON stated, No the facility did not perform a root cause analysis on any incidents from May 2 023 - 8/15/2023. The DON confirmed the facility did not identify problems or potential problem areas, did not track and monitor, set goals and threshold, analyze, or develop action plans and assess if those actions were effective for the 7/7/2023 elopement incident or the unsafe operations of the elevator which resulted in resident incidents and accidents on 5/22/2023, 6/2/2023 and 7/22/2023. The DON stated .I went on vacation on 7/10/2023 and did not return until 7/14/2023 and did not participate in anything .no I did not have any system in place to analyze the interventions, monitor and assess the effectiveness of those interventions for the elopement .no, we had no QAPI meeting or discussion of the resident's incidents concerning the elevator floor not being level with the hallway floor when the door opened . When asked if the facility put any interventions in place to keep the unsafe operation of the elevator and resident incident/accident from happening again, the DON stated .No . There was no documentation of an effective QAPI program was in place. Refer to F-689 and F-835. The Surveyor verified the Removal Plan by: 1. QAPI committee will meet weekly to discuss corrective actions to ensure compliance and determine effectiveness of improvement plans. The surveyor reviewed the meeting minutes and interviewed Administration. 2. The QAPI process will serve as formal oversight of completed corrective action plans and identify any trends resulting from audits conducted. The surveyor interviewed Administration. 3. QAPI meeting minutes will be submitted to Regional Nurse for review and verification of completed performance improvement plans and audits. The surveyor interviewed Administration. 4. Director of Nursing will update Wandering Risk Assessment to include guidelines to implement appropriate interventions based on total assessment score. The surveyor reviewed records and interviewed staff. 5. Director of Nursing/Unit Manager will Implement interventions according to wander risk assessment score and elopement assessment. The surveyor reviewed records and interviewed staff. 6. Director of Nursing and/or Unit Managers will complete a new Baseline Elopement assessment for current residents and reevaluate assessments upon admission/readmission, quarterly, annually and change in condition. Any discrepancies identified will be reevaluated by Interdisciplinary team and necessary corrections will be entered to resident's care plan and implemented. The surveyor reviewed records and interviewed staff. 7. Director of Nursing/Unit Manager will ensure accuracy and appropriate interventions by reviewing wander risk assessments during clinical meetings and comparing entered data in residents' charts and actual residents' behaviors. The surveyor reviewed records and interviewed staff. 8. Director of Nursing/Unit Manager/Administrator will ensure adequate staffing for oversight of dementia and wandering residents daily. The surveyor reviewed staffing chart and interviewed staff. 9. Administration will evaluate referrals and review hospital records with high potential for elopement prior to admission to determine elopement risk. Preadmission evaluations for high-risk elopement referrals will be conducted by DON or Administrator. A determination on whether the resident is appropriate for admission or potential interventions will be made prior to admission. The surveyor reviewed admission criteria and interviewed Administration. 10. Nurses will check for wander guard placement daily with visual check and documentation on MAR. The surveyor reviewed medical record and interview of staff. 11. Director of Nursing and/or Unit Managers will review new admits elopement assessments and exit-seeking behaviors to identify high risk residents and transfer to secure unit for monitoring if appropriate, as discussed by interdisciplinary team. The surveyor reviewed audit records and interviewed staff. 12. Director of Nursing and/or Unit Managers will place photos of residents identified as high risk for elopement at nurses' stations and front desk binder. The surveyor reviewed all binders and interviewed staff. 13. Maintenance/Administrator will conduct Elopement Drill and monthly thereafter. The surveyor reviewed the elopement drill documentation and interviewed staff. 14. Maintenance will perform baseline audit of all exit doors to ensure functionality and security. The surveyor reviewed audit results and interviewed staff. 15. 200 Hall back elevator will remain off and prohibited from use until replaced and cleared by elevator company. The surveyor verified by observation and interviewed staff. 16. Out of order sign placed on elevator door. The surveyor verified by observation and interviewed staff. 17. Sign placed to direct residents/staff/visitors to use front elevators. The surveyor verified by observation and interviewed staff. 18. Director of Nursing and/or Unit Managers will identify residents that use the elevators via standard or electric wheelchairs. The surveyor reviewed records and interviewed staff. 19. Therapy will evaluate residents that use elevators via standard or electric wheelchairs for safe entering and exiting. The surveyor reviewed records and interviewed staff. 20. Maintenance will check elevator functionality daily and maintain log. The surveyor reviewed log and interviewed staff. 21. Facility will initiate and implement QAPI for F867. The surveyor reviewed records and interviewed Administration. 22. Regional Nurse will in-service Facility Administration (Administrator, Director of Nursing, Unit Managers, Department heads) regarding F867 and QAPI policy. The surveyor reviewed education material, sign in sheets and interview of staff. 23. Director of Nursing will in-service nurses including agency staff regarding QAPI policy, Root Cause Analysis and Completion of Performance Improvement Plans. The surveyors reviewed education material, sign in sheets and interviewed staff. 24. Director of Nursing will in-service nurses including agency on accurate completion of elopement assessments. The surveyors reviewed education material, sign in sheets and interviewed staff. 25. Director of Nursing will in-service nurses including agency regarding implementation of proper interventions based on wander and elopement assessments. The surveyors reviewed education material, sign in sheets and interviewed staff. 26. Director of Nursing will in-service nurses including agency regarding Dementia, wandering residents and behavior management. The surveyors reviewed education material, sign in sheets and interviewed staff. 27. Director of Nursing will in-service staff including agency personnel on elopement policy and protocols. The surveyors reviewed education material, sign in sheets and interviewed staff. 28. Director of Nursing will in-service staff including agency personnel on abuse/abuse reporting. The surveyors reviewed education material, sign in sheets and interviewed staff. 29. Director of Nursing will in-service staff including agency personnel to ensure that residents with active exit-seeking behaviors are immediately addressed and placed on 1:1 or transferred to the secured unit. The surveyors reviewed education material, sign in sheets and interviewed staff. 30. Director of Nursing will in-service staff including agency personnel on providing vulnerable residents (moderate/high risk wanderers, active exit-seekers, cognitively impaired with confusion, high fall risks, wheelchair/power chair users) with adequate supervision and safe environment to prevent accidents and elopements. The surveyors reviewed education material, sign in sheets and interviewed staff. 31. Director of Nursing/Maintenance will in-service staff including agency personnel to ensure exit doors are properly closed and secure, and not propped open to ensure security of residents. The surveyors reviewed education material, sign in sheets and interviewed staff. 32. Director of Nursing will in-service staff including agency personnel on immediately reporting to Maintenance and/or facility administration when they observe/notice a faulty or improperly functioning elevator. The surveyors reviewed education material, sign in sheets and interviewed staff. 33. Director of Nursing/Maintenance will in-service staff including agency on proper use of elevator and ensure carts are carefully placed to prevent potential damage to elevator mechanism. The surveyors reviewed education material, sign in sheets and interviewed staff. 34. Director of Nursing will in-service staff including agency personnel on F835. The surveyors reviewed education material, sign in sheets and interviewed staff. 35. Education will be ongoing for all new staff including agency. The surveyor reviewed material and interviewed staff. 36. Staff who have not completed education will not be allowed to work the floor until all education is completed and verified. The surveyor reviewed list of employees and interviewed staff. 37. Maintenance will audit and maintain log binder of all exit doors being checked for proper closure daily at minimum, and random times throughout the day. The surveyor reviewed audit tools, results and binders and interviewed staff. 38. Maintenance will complete audits daily to ensure facility doors are locking appropriately and wander guard system is working. The surveyor reviewed audits and interviewed staff. 39. Director of Nursing and/or Unit Managers will complete audits 3 times a week to ensure elopement assessments are completed upon admission, quarterly, annually and change of condition; and ensure appropriate interventions are implemented. The surveyor reviewed audit tools and results and interviewed staff. 40. Facility administration will conduct environmental audits 3 times a week to ensure residents have a safe environment to prevent accidents and elopement incidents. The surveyor reviewed audit tools, results and interviewed staff. 41. Audit results will be submitted to QAPI committee to be reviewed and addressed as needed. The surveyor reviewed audit results and interviewed staff. Noncompliance of F-867 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, video footage, hospital record review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a safe environment to prevent serious injury and elopement 4 of 14 (Residents #1, #2, #6, and # 15) sampled residents for wheelchair/elevator and wandering/elopement accidents and incidents. On [DATE] Resident #1 exited the 200 hall elevator in a motorized wheelchair, the elevator floor was not level with the floor of the hallway when the elevator door opened, the resident fell out of the wheelchair sustaining bilateral leg fractures, and later died. Resident #2 fell to the floor in a wheelchair when exiting the unlevel elevator floor on [DATE], resulting in fractured leg, and Resident #6 fell from a wheelchair when exiting the unlevel elevator floor on [DATE], resulting in no injuries. Resident #15, a cognitively impaired resident with Dementia and a history of wandering and exit seeking behaviors, eloped from the facility for an undetermined length of time and was found by the police when making routine rounds on [DATE] at 3:45 AM. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to provide a safe environment to prevent serious injuries which resulted in fractures and potential serious injury for Resident #1, #2, and #6, and failed to supervise a cognitively impaired resident with Dementia and a history of wandering behaviors, which resulted in Resident #15's elopement. The facility's failure placed Resident #1, #2, #6, and # 15 in Immediate Jeopardy. The Regional Nurse Consultant, the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 4:47 PM, in the Conference Room. F-689 was cited at a scope and severity of J which is Substandard Quality of Care. The IJ began on [DATE] and ended on [DATE]. Noncompliance remains for F-689 at a scope and severity of D The facility was previously cited Immediate Jeopardy at F-689 for elopement on a complaint survey/investigation on [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 3:56 PM, and the Removal Plan was validated onsite by the surveyors on [DATE] through observation, medical record review, record review, review of education records and audit tools, and staff interviews on various shifts. The last day the facility was in Immediate jeopardy was [DATE]. The findings include: 1. Review of the facility's undated Safety and Supervision policy revealed .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .The individualized care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents .The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly .Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment .The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment .Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. Thes risk factors and environment factors include the following .Falls .Unsafe wandering . Review of the facility's undated Resident Accident/Incident policy revealed .DEFINITION: An accident is an unexpected, unintended event that can cause a resident bodily injury .PROCEDURE/RESPONSIBILITY/ACTION: 1. All residents will be assessed for fall risk during the initial assessment period. 2. The fall assessment tool will be used as a guide in assessing those residents at risk. 3. If a resident is found to be at risk for an accident or incident a plan of care will be initiated by the IDCP [Interdisciplinary Care Plan] team to prevent such incidents .4. Each resident will be reviewed by the DON/Designee, Unit Manager, and the resident's record, care plan and incident report will be brought to the morning meeting for further review and evaluation .5. The fall assessment will be done initially on admission and readmission, annually and with each significant change in status .DOCUMENTATION .Any resident who sustains an accident or an incident, including Injuries of unknown cause will be assessed and an accident and Incident report will be filled out .A description of the incident is to be noted on the incident report and in the nurse's note .The resident will be questioned (unless resident is not appropriate to interview) as to the cause of the incident and possible corrective action .If the cause is unknown an immediate investigation is to begin and the DON/Designee and administrator are to be notified . Review of the facility's policy titled Unusual Occurrence Reporting revised [DATE], revealed As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors .Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident .The administration will keep a copy of written reports on file . Review of the facility's policy Elopement dated 6/2017 and revised 3/2023, revealed .Staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing . Review of the facility's undated Wandering Policy revealed .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who area at risk for harm because of unsafe wandering [including elopement]. The staff will assess at-risk individuals for potentially correctible risk factors related to unsafe wandering .Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures [including searching] for any resident who is discovered to be missing from the unit or facility . 2. Review of the medical record revealed Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of Diastolic Heart Failure, Atrial Fibrillation, Type 2 Diabetes Mellitus, Sacral Decubitus, Pain in Unspecified Hip, Essential Hypertension, and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment for daily decision making. Resident #1 was dependent on staff for transfers and used a motorized wheelchair independently for mobility. Review of a nurse's note dated [DATE], revealed .this nurse was called to the elevator by another resident [Resident #3], where he had witnessed the pt [patient- Resident #1] fall from the elevator .pt c/o [complained of] back and knee pain. Resident was transported to [Named hospital] via 911 . Review of the facility's video camera footage for [DATE], revealed the 200 hall elevator doors opened at 4:32:05 PM Resident #1 attempted to exit the elevator in a motorized wheelchair at 4:32:10 PM. The camera footage revealed the front of the motorized wheelchair immediately tilted forward and Resident #1 fell to the floor and was lying on her right side. The wheelchair remained in the doorway of the elevator with the back of the chair raised. Resident #1 was transferred from the scene of the accident by Emergency Medical Services (EMS) at 4:53:30 PM. Continued review of the video footage revealed Certified Nursing Assistant (CNA) #1 and an EMS personnel pushed the motorized wheelchair slightly backwards and then lifted the back of the chair down to the hallway floor. Review of the facility investigation for Resident #1's fall on [DATE], showed no indication the video camera footage was reviewed. Review of the Resident #1's hospital record revealed Resident #1 presented to the hospital Emergency Department (ED) on [DATE], via EMS. Review of the ED Triage assessment dated [DATE] at 6:42 PM, revealed the Chief Complaint was related to a fall out of the scooter (motorized wheelchair) with complaints of pain to bilateral legs at a scale of 10 out of 10 (a scale with 0 being no pain and 10 being the worst pain). Review of the hospital's Computerized Tomography (CT) results of Resident #1's right leg dated [DATE] at 8:04 PM, revealed .IMPRESSION: Comminuted [broken in more than 3 separate pieces, typically caused from severe trauma] and angulated [the two ends of the broken bone are at an angle to each other] distal right femur fracture . Further review of the hospital CT of Resident #1's left leg dated [DATE] at 8:11 PM, revealed .Distal left femur fracture . Review of Resident #1's hospital ED History and Physical Examination dated [DATE] at 12:30 AM, revealed . She [Resident #1] presents to ED today following a fall from 4 feet. She says she was in her wheelchair and was thrown from a faulty elevator 4 feet to the floor below .Was at [Name of nursing facility] where this occurred . In ED she received pain medications . Review of Resident #1's hospital physician consult dated [DATE] at 11:58 PM, revealed .EVALUATE FOR ICU [Intensive Care Unit] TRANSFER .admitted to medicine service and plans per ortho [orthopedic] to take her to surgery for repair. She became hypotensive [low blood pressure] tonight with a blood pressure of 70/56 [normal 120/80]. We were consulted to evaluate her for ICU transfer. She has Albumin [used to treat low albumin levels and low blood volume] ordered that has not yet infused. Her hbg [hemoglobin- protein in blood that carries oxygen] had a marked decrease from the night she presented to the ED to early the next morning .Because of the earlier decrease in her hgb she is going to get one unit PRBCs [packed red blood cells]. She does have a history of chronic Atrial fibrillation . Review of Resident #1's hospital's physician consult dated [DATE] 6:07 PM, revealed .On admission patient was found hypotensive with decreasing hematocrit from initial of 34.7 to 21.2 .Assessment/Plan .Femur fracture .Fall from height of greater than 3 feet .Acute pain due to trauma .Lactic acidosis .IMPRESSION .Acute kidney injury stage 3 in the setting of hypotension due to hemorrhagic shock--most likely etiology is postischemic acute tubular necrosis. --We will rule out post traumatic rhabdomyolysis .Lactic acidosis on presentation [to the ED] . Review of the hospital's physician progress note dated [DATE] at 11:15 AM, revealed .Presents for fall from scooter. Has bilateral femur fractures. Hospital course complicated by hemorrhagic shock [a form in which severe blood loss leads to inadequate oxygen at the cellular level] likely secondary to rhabdomyolysis [occurs when damaged muscle tissue releases proteins and electrolytes into the blood and can be the result of a crush injury]. Nephrology following. Hemorrhagic shock improved, plans to transfer out of ICU today . Review of the hospital's physician progress note dated [DATE] at 5:00 PM, revealed .Went into afib RVR [Atrial Fibrillation with Rapid Ventricular Response-rapid contractions of the atria makes the ventricles beat fast too] and became hypotensive .OR [surgery] cancelled, transfer to ICU . Review of the hospital's Procedure note dated [DATE] at 7:15 PM, revealed .Central line insertion procedure .Indication: medication delivery, need for venous access, resuscitation . Review of the hospital's Discharge Summary for Resident #1 dated [DATE], revealed .DEATH SUMMARY .CAUSE OF DEATH: Multifactorial shock [Shock after traumatic injury] is likely to be hypovolemic [liquid portion of the blood (plasma) is too low], but different types of shock can occur in combination]. SECONDARY DIAGNOSES .Acute on chronic renal failure with refusal to undergo renal replacement therapy .Hyperkalemia [elevated potassium levels] .Severe lactic acidosis [when the body produces too much lactic acid and cannot metabolize it quickly enough-can occur with severe trauma] .Atrial fibrillation with rapid ventricular response .History of fall with bilateral distal femur fractures . HOSPITAL COURSE .In short, the patient came from her care home after a fall. She was found to have bilateral femur fractures. She had multiple comorbid issues that were treated while she was here. She did have severe renal disease with worsening renal function and hyperkalemia .She was stable for a period and went for attempted operative revision of her femur fractures but developed severe hypotension preoperatively with atrial fibrillation with rapid ventricular response. She was intubated for stabilization and transferred to the intensive care unit where she continued to decline .She was made Do Not Resuscitate and unfortunately passed away shortly after. May she rest in peace . 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses, Cardiac Arrhythmias, Muscle Weakness, and Vitamin D Deficiency. The quarterly MDS assessment dated [DATE], documented the resident scored a 9 on the BIMS assessment which indicated moderate cognitive impairment for daily decision making. The Functional Status section of the MDS dated [DATE], documented the resident needed supervision for transfers and dressing. Further review revealed Resident #2 used a wheelchair independently for mobility. Review of an incident report dated [DATE], revealed .Fall .Incident Location Hallway/Corridor .Problem Statement [Resident #2's] Foot caught on opening of the elevator . Review of a nurse's note dated [DATE], revealed .Summoned to first floor per staff member. Informed that resident [Resident #2] was on floor near elevator. Wheelchair was overturned with resident still in it. States he was getting out of elevator when his foot got caught in elevator door. Resident observed lying on right side. Complains of right side, right hip, and head pain. Unable to extend right leg without pain . The resident was transferred to the hospital for evaluation. Review of the hospital records revealed Resident #2 was admitted to the hospital on [DATE], for surgical interventions. Review of the hospital's History and Physical examination dated [DATE], revealed .Chief Complaint pt [Resident #2] fell out of wheelchair, pt c/o right hip and shoulder pain .The patient sustained a fall from his wheelchair at the skilled nursing facility and complained of right hip and right rib pain .IMPRESSION: 1. Acute appearing nondisplaced right lateral 8th rib fracture .2. Acute impacted subcapital right femoral neck fracture [usually caused by a fall of an elderly patient to the side] . Resident #2 was unable to tolerate a surgical intervention and was discharged back to the nursing home on [DATE], with orders for physical therapy. Review of the quarterly MDS assessment dated [DATE], documented Resident #2 scored a 9 on the BIMS assessment which indicated moderate cognitive impairment for daily decision making. The MDS assessment further documented the resident currently required extensive assist for transfers and dressing. Resident #2 used a wheelchair independently for mobility. Observations of Resident #2 on [DATE] at 3:50 PM at Friendship Corner (activities area), revealed Resident #2 seated in a wheelchair. He was alert and oriented and was able to propel himself in the wheelchair throughout the hallways. During an interview on [DATE] at 9:30 PM, when asked if resident had a fall while at the facility, Resident #2 nodded his head to signify yes and stated, That's how I broke my leg .It was the floor. It was raised up and I didn't know it. I went to get out and my foot got caught on the floor somehow. My wheelchair fell over . [Elevator] still messes up sometimes. One woman fell last week and broke her leg. I heard she died . 4. Review of the medical record revealed Resident #6 admitted to the facility on [DATE], with diagnoses of Hemiplegia and Hemiparesis Left Non-Dominant Side, Aphasia, Heart Failure, Atrial Fibrillation, and Vitamin D Deficiency. Review of the quarterly MDS assessment dated [DATE] documented the resident scored a 3 on the BIMS assessment which indicated severe cognitive impairment for daily decision making. Resident #6 was dependent upon staff for transfers and used a wheelchair independently for mobility. Review of a nurse's note dated [DATE], revealed .Pt [Resident #6] lying in front of w/c [wheelchair at the elevator] alert and verbal. Pt is oriented to staff though unable to verbalize our names. When asked what happened pt answered with one word 'fell' .send to ER for eval [evaluation] . Review of the annual MDS assessment dated [DATE] documented the resident scored a 3 on the BIMS assessment which indicated severe cognitive impairment for daily decision making. Resident #6 was dependent upon staff for transfers and used a wheelchair independently for mobility. Observation and interview on [DATE] at 1:15 PM, in the resident's room, revealed Resident #6 lying supine in bed. The resident was alert and oriented, but unable to speak in full sentences. He used hand gestures to attempt to express his thoughts. When asked if he had a fall, Resident #6 stated, Yes, On/off came down Boom! When asked if he was referring to the elevator, Resident #6 stated, Yes, open then Boom! The resident used hand gestures in an up/down motion then stated, Boom! Resident #6 confirmed he fell from his wheelchair on [DATE] when exiting the elevator. 5. Review of facility requests for the Elevator Services Technician for the rear/200 hall elevator revealed the following: a. [DATE] (Requested after the 3rd resident incident) - the rear elevator (rear/200 hall) is not leveling down properly. b. [DATE] (during the survey) - last night the inner/outer doors on the #2/rear (200 hall) elevator were separated, he (Maintenance Director) used key to reset. During a telephone interview with the elevator Service Technician on [DATE] at 12:16 PM, when asked for a summary of the service call made on [DATE], the Service Technician stated, I came out when the call came in to check the elevator because it was not leveling properly. I was not able to duplicate that [unlevel] .With this being an elevator from 1962, the elevator does not store history for me to be reviewed. We don't have the ability to review the previous activity . 6. Observations on [DATE] at 11:01 AM, at the 200 hall elevator, revealed the elevator did not operate when the up/down button was pressed. There was no Out of Order signage on the elevator. 7. During an interview with Resident #3 on [DATE] at 1:10 PM, when asked if he witnessed Resident #1 have a fall, he stated, I heard Help me! Help me! about four times. I saw her on the floor and her wheelchair turned over. I told the nurse .Her wheelchair was up on the elevator floor. I didn't see her fall. During an interview on [DATE] at 1:32 PM, when asked if aware of any facility elevator malfunctioning, CNA #4 stated (regarding the 200 hall elevator), .Elevator is up higher when door opens at times .A few months ago the elevator was higher than the floor when the door opened; I'd estimate 4 to 5 inches. It was a whole step down .They [Maintenance] knew it wasn't working the way it was supposed to . During a telephone interview on [DATE] at 2:30 PM, when asked if Nurse #1 was aware of any problem with the elevator doors opening and closing properly, Nurse #1 stated, I was working on 200 hall when [Named Resident #1] had the fall. Her wheelchair fell forward, and she was on the floor .In the past the elevator would not be even with the floor when the door opened . When asked if the malfunctioning elevator had been reported, Nurse #1 stated, I had not reported it, but everyone knew it was a problem. It had been reported in the past . During a telephone interview on [DATE] at 3:20 PM, when asked if aware of any problems with the 200 hall elevator functioning properly, CNA #5 stated, .It has not been leveling all the way. If going from up here [2nd floor] to 1st floor when the doors open the elevator floor is up about 12 inches. If you are not paying attention, you would fall off. The last time I saw it doing that was on [DATE]th [2023] Maintenance knew it was messing up. Other residents each had a fall because of that elevator. Maintenance would turn it off a couple days and then it would work again. Sometimes it would be shaky and jerky when riding it. When asked if training or inservices had been given since the accident involving Resident #1, CNA #5 stated, We haven't had anything about that. It's hush hush. During an interview on [DATE] at 3:41 PM, when asked if aware of any problems with the 200 hall elevator functioning properly, Resident #5 stated, Sometimes the elevator won't go all the way down. I can't get out and I push the button in the elevator again and the floor [elevator floor] goes down . During an interview on [DATE] at 11:55 AM, the Administrator was asked if he interviewed staff that were working when the [DATE] accident occurred, the Administrator stated, Not at the time. [Named DON] should have. The Administrator stated he was not aware of a malfunction in the elevator when the other 2 falls [ resident #2 and #6] occurred. During an interview on [DATE] at 1:54 PM, with Resident #8, the Resident Council President, when asked if there had been any discussion in Resident Council meetings related to the elevator problems, Resident #8 stated, No, don't think we talked about it. The elevator on 200 hall sometimes doesn't go all the way down when the door opens .There needs to be some way to remind a person to look and make sure the elevator is all the way down to the floor .If it's not even you could fall. Happened to me, but I didn't fall out of my chair .It was a few inches drop off that time. Sometimes it's more. You never know when it might happen. I looked down at the floor, not everyone looks. Resident #8 was asked when the elevator floor was not level with the hallway floor when the door opened occurred. Resident #8 stated, About 3 weeks ago .The nurses knew about it. They said it had been reported. During an interview on [DATE] at 3:18 PM, when asked if he recalled the details of the accident involving a recent fall at the 200 hall elevator. CNA #6 stated he had not witnessed the floors being unlevel prior to the accident on [DATE] but had heard about it being unlevel from other staff. CNA #6 stated on [DATE], . [Named Resident #1] was on the floor. The wheelchair was in the doorway of the elevator kind of tilted .The front of the wheelchair was tilted. When asked if the elevator floor was level with the hallway floor, CNA #6 stated, No, it was kind of cocked about 12 inches. You could tell the wheelchair back was resting on the floor of the elevator. When questioned when he was asked for a statement about the accident CNA #6 stated, Today [[DATE]]. During an interview on [DATE] at 4:05 PM, the Maintenance Director stated, No one had reported to me that the floor was not level [elevator floor not leveling with the hallway floor] .The elevator company always says to update it. It's from the 1960s and needs replaced. That's what they have told us . During a telephone interview on [DATE] at 9:18 AM, when asked if CNA #2 was working on [DATE] when Resident #1 had a fall from the elevator, CNA #2 stated, .I was working on the 200 hall .The wheelchair was stuck on the elevator. The back wheels were hung on the elevator floor. The front wheels were on the actual hall floor. There was a gap between the elevator floor and the hall floor, maybe 8 inches or more. The wheelchair was at a slant. I heard there had been other issues with the elevator with the doors and the floor. During a telephone interview on [DATE] at 9:46 AM, when asked if Registered Nurse (RN)/Unit Manager #1 was working when Resident #1 had a fall from the elevator on [DATE], RN/Unit Manager #1 stated, .I came to the scene .The elevator would jam sometimes. There have been times when you get on the elevator, and it malfunctions. It would be jerking while it was moving . When asked if she had reported the malfunctions, she stated, No, but they all knew about it. RN #1 stated she was aware of the incident on [DATE] with resident #2 falling when exiting the elevator. During a telephone interview on [DATE] at 9:31 AM, when asked if CNA #1 was aware of anyone having a fall when exiting the 200 hall elevator, CNA #1 stated, .A lady fell at the elevator, [Named Resident #1] .I saw the elevator floor was a foot or so gap higher. It wasn't flush with the floor. Her chair [wheelchair] was at an angle. The rear tires were on the elevator floor . When asked when Resident #1's wheelchair was moved away from the elevator, CNA #1 stated, One of the ambulance personnel assisted me to move the chair out of the elevator door once [Named Resident #1] was taken to the ambulance. We lifted the back [back of wheelchair] that was hung on the floor and set it down to the hallway floor . When asked if he had given a statement about the accident to the Administrator, CNA#1 stated, No ma'am. A couple days ago [[DATE]] was the first time I had spoken to anyone about it in an interview for a statement. During an interview on [DATE] at 12:38 PM, when asked if aware of any problems with any facility elevator not functioning properly, CNA #3 stated, Yes ma'am. I've seen the elevator not level. You never know when it's going to happen. I told the Maintenance people before. I've been on it and the door opened and it was not level .I told Maintenance workers .They would walk around in the morning, and I made sure to tell them. You never knew when it would open and there be a drop down . When asked which elevator, CNA #3 stated, The one on 200 hall. During an interview on [DATE] at 1:36 PM, Resident #9 stated, I've seen the elevator [200 hall elevator] door open and not go all the way down. Something needs to be done. I know to always look, but some people don't know or might forget. I've told my nurse about it. When asked when he had seen the 200 hall elevator floor unlevel with the hall floor, Resident #9 stated, About 2 or 3 weeks ago. During an interview on [DATE] at 3:30 PM, when asked if she had noted any malfunctioning of the 200 hall elevator, the Director of Marketing stated, I don't take that elevator [200 hall elevator] if I can help it after the incident with [Named Resident #2]. He had a fracture after that fall. I was on it one time when it [unlevel floors] happened. I took the stairs after that . During an interview on [DATE] at 11:40 AM, when asked if LPN #2 had known of a resident having a fall at the 200 hall elevator, LPN #2 stated, I remember a while back there was a resident that fell getting off the elevator. The elevators have trouble all the time. When asked if she had reported the elevators malfunctioning, LPN # 2 stated, No, but everyone knew. It happened often, just never knew when it would. During an interview on [DATE] at 3:12 PM, when asked if she had witnessed Resident #6's fall on [DATE], CNA #7 stated, .I heard him hit the floor. The elevator wasn't working, half up and half down [the floor of the elevator was not level with the hallway floor]. He went to go out of it and the wheelchair tilted down .The elevator door was open because the wheelchair was stuck [in the doorway of elevator] .The Supervisor saw the elevator . When asked if the malfunctioning elevator was reported, CNA #7 confirmed she reported to the Nurse Supervisor. During an interview [DATE] at 10:13 AM, when asked if she was notified when Resident #1 had a fall, Nurse Practitioner (NP) #1 stated Yes, I was called .That surprised me because Resident #1 was very knowledgeable of the use of her wheelchair. When asked if she had been told the elevator malfunctioned, she stated .I've been told the floors are not level at times . NP #1 stated she could not remember being told the other falls were caused by the unlevel floors of the elevator and hallway. During an interview on [DATE] at 10:25 AM, when asked if the staff working on [DATE], when the accident involving Resident #1 happened, had been interviewed and statements recorded in an investigation of the accident, the Director of Nursing (DON) stated Not sure. I talked to the nurse when she called me. I didn't write anything down. [Named Administrator] and the Social Worker were going to get statements . The DON stated he was not aware of any other falls related to unlevel floors of the elevator and hallway. During an interview on [DATE] at 11:15 AM, when asked if the 200 hall elevator was out of service, the Maintenance Director stated the elevator was taken out of service because It's a safety concern. The techs [Elevator Technicians] always clear it and we always have issues after it's cleared .I just don't feel comfortable. I don't want anyone else to get hurt. When asked if signage was placed on the elevator doors to alert residents and staff the elevator was out of service, the Maintenance Director stated, My fault. I didn't have any caution tape. When asked about an Out of Order sign, the Maintenance Director stated, Yeah, I could put one up; My fault. The Maintenance Director stated the 200 hall elevator was working when he took it out of order, but because of the random malfunctioning he decided not to allow the elevator to be used. When asked how the residents and staff would know it was out of order, the Maintenance Director stated, It's turned off. When they push the button, nothing will happen. It's completely off. During an interview on [DATE] when asked if the incident involving Resident #6's fall on [DATE] was investigated, the DON stated, It was talked about [in the morning meetings] with the DON and Unit Managers. The DON previously[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a safe environment, provide adequate supervision, and accurately assess a severely cognitively impaired resident with Dementia, confusion and a history of wandering to prevent elopement for 1 of 14 sampled residents (Resident #1) reviewed with wandering behaviors and elopement. Resident #1 eloped from the facility on 1/2/2023 at approximately 1:15 PM, walked across the employee back parking lot and was found near the street. The Weather History web site revealed the recorded temperature for Memphis, TN on 1/2/2023 at 4:00 PM, was 65 degrees Fahrenheit and raining. Resident #1 was unsupervised outside the building without staff knowledge, which resulted in Immediate Jeopardy (IJ) for Resident #1. The facility failed to conduct accurate assessments that ensured a safe environment, provide adequate supervision, and accurately assess 14 of 14 (Residents #1, #4, #6, #7, #8, #10, #12, #18, #19, #20, #21, 23, 24, and #25) residents reviewed with wandering and/or elopement behaviors. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to supervise a severely cognitively impaired resident with Dementia, confusion, and a history of wandering behaviors, which resulted in Resident #1's elopement. The facility's failure placed Resident #1 in Immediate Jeopardy. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/15/2023 at 2:16 PM in the Conference Room. F-689 was cited at a scope and severity of J which is Substandard Quality of Care. The IJ was effective 1/2/2023 and is ongoing. The findings include: 1. Review of the facility's Wandering, Unsafe Resident policy initiated 6/2017 and reviewed 1/2023, revealed, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm because of unsafe wandering. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Staff will notify the Administrator and Director of Nursing immediately and will institute appropriate measures [including searching] for any resident who is discovered to be missing from the unit or facility. Review of the Wandering Risk Screen system revealed a computerized assessment system (Point Click Care) that listed applicable sections titled, Orientation, Behavior/Mood, Recent Experiences, Mobility, Diagnosis, Medications, and History of Wandering. Based on the accuracy of the data entered by the nurse, the system would designate the resident's level for unsafe wandering risk. Review of the facility's Wander Guard Policy policy initiated 6/2017 and reviewed 1/2023 revealed, Wander Guards are put in place to detect when a resident is near a protected exit and alert staff. The exit can then be secured, or the resident can be assisted by a member of staff. Placement of wander guards are determined through nursing assessment and can be added once exit seeking behavior is observed at any time after admission. All wander guards require a physician order for implementation. Weekly monitoring of wander guards and doors equipped with wander guard system. Residents at risk of wandering wear a wrist or ankle transmitter or tag which allows them free movement within the facility but prevents them from exiting monitored doors. Current system is configured to create an audible alert at the door where resident is attempting to exit that has a wander guard on their person. Wander guard is also integrated with Access Control so that the door will lock as the resident approaches and unlock again as they move away from the area. Review of the facility's Admission/Assessment Policy policy dated 4/1/2020 and reviewed 1/5/2023 revealed, Facility shall complete resident assessment upon admission. Residents shall be assessed by nurse and complete a head to toe evaluation including all systems upon admission. Nurse shall complete following assessments: Wandering .Baseline Care plan shall be created within 48 hours of admission based on admission assessments. Appropriate interventions shall be provided to ensure resident safety and maintain functional independence .Nursing shall document admission assessment findings in EMR [electronic medical record] .Wander Guard Orders/Elopement Risk and Documented on Medical Record [if applicable] . 2. Review of the hospital's History and Physical (which was dated 12/19/2022) and received by the facility upon the Resident #1's admission on [DATE] revealed Resident #1, .lived with [his] nephew .fell at home few times .more confused with periods of sundowning and wandering at night . Resident #1 had diagnoses that included Dementia with Behaviors, Diabetes Mellitus Type 2, Syncope and Collapse. Review of Resident #1's Admit/Readmit Information that included the Wandering Risk assessment dated [DATE], revealed there was no documentation the resident's known history of wandering was included. Review of the Instant Care Plan dated 12/30/2022, revealed no documentation Resident #1 had Dementia or wandering behaviors. Review of the Nurse Practitioner note dated 12/30/2022, revealed Resident #1 was had previously been a patient at, .[named hospital] after fall at home .Dementia with increased confusion and sundowning . Review of the physician's order dated 12/31/2022, revealed, .Trazadone HCL [Hydrochloride] [an antidepressant/sedative medication] oral tablet 50 mg [milligrams] give 1 tablet by mouth at bedtime for depression . Review of the Wandering Risk Screen assessment dated [DATE], revealed Resident #1's scored was an 8, which indicated a moderate risk for wandering. There was no documentation in the screen assessment of the resident having the diagnosis of Dementia or the antidepressant medication of Trazadone. Review of the Nurse's notes dated 1/2/2023 at 4:43 PM, revealed, .1322 [1:22 PM] noted pt [Resident #1] not in his room on nurse rounds. last visual on pt was at 1315 [1:15 PM] by nurses in report. Staff sent to check the therapy gym, 100 hall sunroom therapy gym, pt not found. Code Purple [Alert for a missing resident] initiated [at approximately 4:30 PM per Certified Nursing Assistant (CNA) #3's interview] .Pt located by staff approx 1,000 ft [feet] from the building, he was noted alert and w/o [without] s/s [signs and symptoms] of distress and no visual injuries noted. Pt escorted back to the building and was placed on the 400 hall in room [ROOM NUMBER] . Based on the Memphis, TN Weather History web site, the recorded temperature for Memphis, TN on 1/2/2023 at 4:00 PM was 65 degrees Fahrenheit and raining. Review of the Nurse's notes dated 1/2/2023 at 7:39 PM, revealed, Pt wandering in the halls. Wander guard [a sensor alarm system worn by residents to alert staff if a resident attempts to exit through monitored exit doors] placed to the R [right] ankle for safety . During an interview on 3/15/2023 at 8:36 AM, Registered Nurse (RN) #2 was asked when the wander guard was placed on Resident #1. RN #2 stated, .After the elopement I put the wander guard on, not before . Review of the facility's investigation dated 1/3/2023 of Resident #1's elopement on 1/2/2023, revealed the facility reviewed a video (Camera #1) showing the resident exiting the building through the 100 hall unit door out to a courtyard area and rounded the corner. Camera #1 lost view after the resident rounded the corner. Another camera (Camera #2) positioned at the ambulance door aimed at the back parking lot revealed Resident #1 walking toward the street. The ambulance door camera (Camera #2) then lost sight of Resident #1. The facility's investigation documentation revealed he was found outside on the sidewalk beside the street, a 1,000 feet from the building. The facility documented Resident #1 exited the courtyard either thru a gap between a chain link fence and gate (that was loosely locked with a bike type rope lock) or through a gap that was between the chain link fence and the building wall. The facility failed to save the video as part of the investigation and did not include a summary of the video with times and locations in the investigation. The surveyor was unable to view the video and the Administrator did not keep notes from review of the video. During an interview on 3/6/2023 at 12:53 PM, RN #2 stated, .[Resident #1] would walk around a lot, walk to the Friendship corner, sit in the lobby, anywhere there was a TV .[Resident #1] would look at .[Resident #1] would ask why was he here, where is the food, who paid for him to be here, what were we going to do for him .When we couldn't find him [Resident #1] we called a Code Purple and looked everywhere inside the building then looked outside .I can't remember what time I found him on the far side of the back employee parking lot located near the street and the apartments .Resident #1 was walking and looking left and right like didn't know where to go, not sure .Just me and him I don't remember any other staff around when I found him. Resident #1 had on pants and a shirt .It was a little rainy, wet but not cold .I called his name and he said 'Hey baby I'm glad to see you'. I told [Resident #1] let's go back inside and he went with me with no problems . During an interview on 3/6/2023 at 3:04 PM, CNA #1 stated, .I came to work on 200 hall about 3:12 PM to 3:25 PM and was in room [ROOM NUMBER] and looked out the window facing [name of the street, a two lane neighborhood street entering to a busy 6 lane major street] and saw a tall male standing on the sidewalk wearing blue sweatshirt and match blue pants with yellow socks, dark shoes like brown/black house slippers and had a Reacher [a reaching device to maintain independence] hanging on his left arm .[Resident #1] was facing the employee parking lot looking around. He had a clear plastic bag [trash bag] with eyes poked out over his head .the fire department truck was across the street at those [NAME] apartments .An aide told me a person was missing. I said on [Name of the street] .Me [CNA #1] and another employee then got in my truck and started driving slow around to try and find him .I was driving slow and looking everywhere as we drove .It was misting rain and you needed long sleeves .We turned right from the parking lot and drove up to [Name of a busy street] and over to [Name of another street] .when we got a call all clear patient [Resident #1] located outside . During an interview on 3/7/2023 at 3:20 PM, CNA #3 stated, .[On 1/2/2023] I work three to eleven and I was here at 3:00 PM. I saw him [Resident #1] standing at the double door in the lobby between 100 hall and the lobby. He [Resident #1] said I am trying to go to [name of a street] street. I said ok well, let me go down here and see what is going on. I came back up front and he [Resident #1] was gone .It was about 4:30 PM when Code Purple was paged .It was around 6:00 PM before tray pass when someone said he was found in the basement .I never saw him [Resident #1] again that day . The admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1's Brief Interview of Mental Status (BIMS) score was 4, which indicated Resident #1 had severely impaired cognition for daily decision making. Continued review revealed Resident #1 had an unsteady gait and could stabilize without staff assistance. Review of the Wander Guard Bracelet Weekly Inspection form dated January 2023 through March 2023, revealed no documentation Resident #1's wander guard functionality had been inspected in accordance with the facility's wander guard policy. During an interview on 3/7/2023 at 1:40 PM, DON stated, .Maintenance does the resident's wander guard functionality inspection weekly .No, I don't see any documentation where [Named Resident #1] wander guard was inspected for functionality . During an interview on 3/7/2023 at 1:46 PM, the Administrator was asked if there was any documentation of [Resident #1's] wander guard functionality being checked January, February, and March 2023. He stated, .I don't see it .that's all I have, do what you got to do . Observations on 3/8/2023 at 1:30 PM, revealed the 2nd floor activity room/office was unlocked and unattended, and there were residents in the hallway near the entrance. In the activity room/office was another door that led to the roof top of the facility. The door that led onto the facility roof top was not locked and had no alarms to signal when opened. Observations of exit door #9 located between resident dining room and Therapy gym on 3/15/2023 at 11:34 AM, revealed the door opened with employee badge and would remain unlocked until someone could activate the door lock button located on the left top frame of the door. Continued observations revealed the Administrator stated to the employee, .Be sure you press the red button to lock once you go through . Observations of exit door #11, with an indicating exit sign above, located on the 200 hall near the nurse's station on 3/15/2023 at 11:40 AM, revealed the door was not latched and ajar (slightly open) no alarm sounding. This exit door leads to a stair well and to an outside exit door that is not locked and does not alarm when opened. Observations on 3/15/2023 at 11:55 AM revealed exit door #19, with an indicating exit sign above, located on the 2nd floor Memory Care Unit the revealed door was opened by an employee with an employee badge, did not latch, and stayed unlocked with green light on. This exit door leads to a stair well and to an outside exit door that is not locked and does not alarm when opened. During an interview on 3/14/2023 at 1:55 PM, the Maintenance Director stated, .We have two doors that have the wander guard system. The front door and the ambulance entry door .they are the only doors that can detect the wander guard . During an interview on 3/15/2023 at 1:00 PM, the Administrator stated, .That's [doors] definitely got to be fixed .this old building when the weather changes sometimes have to shave the door, things like this . 4. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with a diagnosis of Dementia with Psychosis. Review of Resident #4's care plan dated 1/18/2023 revealed there was no documentation of the resident's wandering behaviors. Review of the physician's order dated 1/18/2023 revealed, .Oxycodone Acetaminophen 5-325 mg [a narcotic medication to treat pain] 1 by mouth every 4 hours prn [as needed] for pain . Review of the admission Wander Risk Assessment dated 1/19/2023, revealed Resident #4 scored a 10 indicating moderate risk for wandering. There was no documentation the assessment included the resident's diagnosis of Dementia, and narcotic medication prescribed. Review of the Resident #4's admission MDS assessment dated [DATE], revealed Resident #4 scored a 11 on the BIMS assessment which indicated moderately impaired cognition. The assessment documented Resident #4 had the behaviors of wandering 1 to 3 days of the assessment period. Review of the maintenance record Wander Guard Bracelet Weekly Inspection dated 3/10/2023, revealed there was no documentation that Resident #4's wander guard functionality had been tested. Observations in Resident #4's room on 3/8/2023 at 1:45 PM, revealed Resident #4 to be sitting in a chair, alert and oriented to self, wander guard device on left ankle. 5. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses Dementia with Behaviors, Anxiety and Alcohol Dementia. Review of the Nurse's note dated 1/18/2023 at 7:55 PM, revealed .Resident [#6] arrived by stretcher with 3 EMT [Emergency Medical Technician] at side upon enter building resident unfasten belt to stretcher and jumped off stretcher. Staff and EMTs caught resident. Resident became violent started swinging and trying to hit staff and EMTs. They assisted resident to room [Resident #4's room number] he started stripping all clothing off, refused to allow staff to place gown on, continued to try and ambulate out of the room, gait very unsteady. Resident AAO x1 [alert, oriented] name only .limited assist with ambulation. Independent with bed mobility and transfer .resident continued to try and ambulate throwing bed sheets and pillows on floor . The admission Minimum Data Set (MDS) 1/25/2023, documented the resident scored a 0 on the BIMS indicating the resident had severely impaired cognition for daily decision making. The assessment documented the resident had the behaviors of wandering 1 to 3 days during the assessment period. Review of the Care Plan dated 1/18/2023, revealed there was no documentation of a wandering/elopement risk. Review of the admission Wander Risk Assessment dated 1/19/2023, revealed Resident #6 scored a 13 which indicated a high risk for wandering. There was no documentation the assessment included the resident's diagnosis of Dementia. 6. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Dementia Without Behavioral Disturbance, End Stage Renal Disease, Dependence on Renal Dialysis, and Essential Hypertension. Review of the hospital History and Physical dated 10/31/2022, received by the facility upon admission, revealed .the patient [Resident #7] has wandered off. Family with concerns regarding the patient's confusion, anxiousness and wandering off . Review of the Instant Care Plan dated 11/16/2022 revealed there was no documentation the care plan included the resident had Dementia or wandering behaviors. Review of the Wandering Risk Screen dated 11/17/2022, revealed Resident #7 scored a 3 which indicated a low risk for wandering. There was no documentation the screen/assessment included the resident having the diagnosis of Dementia and known history of wandering. Review of the Wandering Risk Screen dated 1/4/2023 revealed there was no documentation the screen was completed. Review of a Plan of Care Note dated 1/8/2023, revealed .[Named Resident #7] has packed his clothes and shoes this morning. He stated that he is going to leave the facility. He began walking toward the exit door with his belongings .[Resident #7] has a wander-guard placed on lower extremity . Record review revealed there was no order for a wander guard for Resident #7 and there was no documentation the facility had determined the wander guard functionality. Review of the Care Plan dated 2/7/2023, revealed .Resident was seen by this nurse and a CNA walking towards the side door to outside with a bag in his hand and his cane . Review of the comprehensive care plan with a target date of 5/13/2023, revealed there was no documentation Resident #7 had behaviors of wandering or the use of a wander guard device. Review of the quarterly MDS assessment dated [DATE], revealed Resident #7 scored a 10 on the BIMS assessment which indicated moderately impaired cognition. The resident required limited assistance for ambulation. Resident #7 had an unsteady gait and could stabilize without staff assistance. Observations in the resident's room on 3/8/2023 at 9:59 AM, revealed Resident #7 was seated on the side of the bed and transferred himself to a standing position. A wander guard was in place on the resident's right ankle. He ambulated independently in his room using a cane. The resident stated, I like to walk to the door every morning and would go out, but they put this thing [wander guard] on my leg . During an interview on 3/7/2023 at 2:38 PM, when asked if Resident #7 had a wander guard placed due to wandering/exit seeking behaviors, The DON stated, No one has ever told me he was a wanderer .He doesn't have a wander guard. During an interview on 3/14/2023 at 8:55 AM, when asked if there were any residents on the 100 hall with a wander guard in place, LPN #1 stated, I don't have any resident with a wander guard that I'm aware of . Resident #7 resided on the 100 hall. 7. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Depression, End Stage Renal Disease, Dependence on Renal Dialysis, Aphasia, Essential Hypertension, and Lack of Coordination. Review of the admission Summary dated 2/14/2023, revealed .Pt [patient, (Resident #8)] is ambulatory and has some confusion, wander guard to R [right] ankle placed . Review of the Admit/Readmit Information assessment dated [DATE], revealed there was no documentation of the resident's cognitive status and taking antidepressants was included in the assessment. Resident #8 had a physician's order dated 2/15/2023 for Zoloft 50 mg daily (an antidepressant medication). The wandering risk assessment was not revised to reflect the Zoloft medication. Review of the Wandering Risk Screen dated 2/15/2023, revealed Resident #8 scored a 4 which indicated a low risk for wandering. The screen/assessment revealed the resident's history of wandering was not included in the screen. Review of the physician's orders dated 2/18/2023, revealed .Check Placement of Wander Guard to right ankle every shift for wandering . Continued review revealed there was no documentation the facility had determined the wander guard was functioning properly. Review of the Plan of Care Note dated 2/18/2023, revealed .Resident is displaying exit seeking behavior. Packing up his belongings and continuing to walk up to exit doors with belongings in his hand . Review of the admission MDS assessment dated [DATE] revealed Resident #8 scored a 6 on the BIMS assessment which indicated severely impaired cognition. The resident required supervision with ambulation and had an unsteady gait and needed staff assistance to stabilize. Review of the Plan of Care Note dated 2/22/2023, revealed Resident #8 was .pacing facility with his belongings in his arms trying to exit facility. Attempted to reorient patient [Resident #8], was unsuccessful . Review of the Wandering Risk Screen dated 2/27/2023, revealed an inaccurate assessment. The screen/assessment did not include the resident's history of wandering. Review of the Plan of Care Note dated 2/27/2023, revealed .resident in the front lobby telling the receptionist that he needed to get out of this place . Observations in the resident's room on 3/13/2023 at 3:25 PM, revealed Resident #8 walking in his room. There was a wander guard on his left ankle. During an interview on 3/13/2023 at 3:29 PM, when asked if Resident #8 had behaviors of wandering and a wander guard placed, RN #4 stated, I don't know. He came to this floor [300 Hall] yesterday. 8. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Cerebrovascular Disease, Delirium, Hypertension and Encephalopathy. Review of physician's orders with a start date 10/18/2022 revealed, .Wander guard monitoring: wander guard on at all times check placement every shift . Review of physician's orders with a start date 10/19/2022 revealed, .Quetiapine Fumarate 50 mg [an antipsychotic medication] 1 by mouth twice daily for psychotic disorder with delusions . The quarterly MDS dated [DATE] documented the resident scored an 8 on the BIMS assessment which indicated moderately impaired cognition for daily decision making. Review of the Wandering Risk Screen dated 1/3/2022 revealed a score of NA (not applicable) low risk, there was no documentation the screen was completed. Review of the maintenance record Wander Guard Bracelet Weekly Inspection dated February and March 2023 revealed there was no documentation of Resident #10's wander guard functionality tested. Observations in room [ROOM NUMBER] B on 3/8/2023 at 1:26 PM revealed Resident #10 lying in bed, alert and oriented to self, wander guard on left ankle. During an interview on 3/13/2023 at 1:19 PM, the Director of Nursing (DON) confirmed Resident #10's wandering risk screen dated 1/3/2023 was not completed. He stated, .all the areas are blank .It is not completed .This was when we were to review all residents on 1/3 [1/3/2023] and 1/4 [1/4/2023] as part of our performance improvement plan .It should have been completed . 9. Review of the medical record revealed Resident #12 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia Without Behavioral Disturbance, Bipolar Disorder, Schizoaffective Disorder, Personality Disorder, and Type 2 Diabetes Mellitus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #12 scored a 10 on the BIMS assessment which indicated moderately impaired cognition. The resident required limited assistance with ambulation. Resident #12 had an unsteady gait and was able to steady self without staff assistance. Review of the Admit/Readmit Information assessment dated [DATE] revealed an inaccurate assessment. The wandering risk assessment section had no documentation of the resident's diagnosis of Dementia. Review of the Admit/Readmit Information assessment dated [DATE] revealed a score of 2 which indicated low risk for wandering. The assessment revealed there was no documentation of the resident's diagnosis of Dementia. Review of the Wandering Risk Screen dated 1/3/2023 revealed no documentation the screen/assessment was completed. Observation in the resident's room on 3/7/2023 at 2:21 PM revealed Resident #12 was not in her room or in the hallway near her room. During an interview on 3/7/2023 at 2:23 PM, when asked where Resident #12 was, LPN #3 stated, I don't know where she is. She is somewhere. She goes around the halls all the time. When asked if the resident had any exit seeking behaviors, the LPN stated, Leave? She might try. She is very confused and has random thoughts . 10. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses Alzheimer's Disease and Dementia without Behaviors. Review of Resident #18's Wandering Risk Screen dated 1/13/2023 revealed the resident had a known history of wandering. Review of physician's orders with a start date 1/25/2023 revealed, .Wander guard in place every shift for wandering . The admission MDS 1/26/2023 documented the Resident #18 scored a 2 on the BIMS assessment which indicated severely impaired cognition for daily decision making. Review of the care plan dated January 2023 revealed Resident #18 had wandering behaviors with wander guard. Review of Resident #18's MARs dated February through March 2023 revealed the wander guard in was place every shift for wandering was checked as completed on all shifts every day. Review of the maintenance record Wander Guard Bracelet Weekly Inspection revealed on 2/3/2023, 2/17/2023, 3/3/2023 and 3/10/2023 no tag was marked as resident not having a wander guard. Continued review revealed on 2/24/2023 the pass/fail was marked related to Resident #18's wander guard. During an interview on 3/14/2023 at 1:45 PM the Maintenance Assistant was asked about the wander guard bracelet weekly inspection report. The Maintenance Assistant stated . ' no tag ' means not on him .I told nurse [named person] he didn't have one [wander guard] on . Observations on 3/14/2023 at 9:30 AM, revealed Resident #18 had no wander guard on. During an interview on 3/14/2023 at 9:30 AM, CNA #2 confirmed Resident #18 had no wander guard. She stated, .no, he doesn't have one [wander guard] on . 11. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of Dementia without Behaviors, Diabetes Mellitus Type 2, Anxiety, and Major Depression. The quarterly MDS 2/4/2023 for resident #19 documented the resident scored a 5 on the BIMS which indicated severely impaired cognition for daily decision making. Review of the physician's orders with a start date 7/29/2022 revealed .Buspirone HCL 10 mg [medication for anxiety] 1 by mouth twice daily anxiety .Escitalopram Oxalate 10 mg [a medication to treat depression and anxiety] 1 by mouth every am .Trazodone HCL 50 mg [antidepressant] give 25 mg by mouth at hs [bedtime] depression . Review of the physician's orders with a start date 11/30/2022 revealed .Wander guard in place every shift for Wandering . Review of the Wandering Risk Screen dated 1/3/2023 revealed Resident #19 scored a 2 which indicated a low risk for wandering. There was no documentation in the screen/assessment that included the resident's diagnosis of Dementia, no documentation the medications for depression or anxiety were included, and no documentation of the resident's history of wandering included in the screen assessment. Review of Resident #19's MARs dated February and March 2023, revealed Wander guard in place every shift for wandering was checked as completed on all shifts every day. Review of the maintenance record Wander Guard Bracelet Weekly Inspection dated 3/10/23, revealed .pass . During an interview on 3/14/2023 at 1:45 PM, the Maintenance assistant revealed, .pass means they had a wander guard on, and it passed the test . Observations on 3/14/2023 at 9:35 AM, revealed Resident #19 with had no wander guard on. During an interview on 3/13/2023 at 1:19 PM, the DON confirmed Resident #19's wandering risk screen dated 1/3/2023 was not accurate. He stated, .some areas are blank .It is not accurate .This was when we were to review all residents on 1/3 and 1/4 as part of our performance improvement plan .It should have been completed correctly . During an interview on 3/14/2023 at 9:35 AM, CNA #2 confirmed Resident #19 did not have a wander guard. She stated, .No, he doesn't have one [wander guard] on . 12. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses Dementia with Agitation and Psychotic Disorder with Delusions. The quarterly MDS 2/9/2023 documented the resident scored a 3 on the BIMS which indicated severely impaired cognition for daily decision making. Review of the physician's orders dated 8/29/2022 [TRUNCATED]

Based on job description review, interview, and document review, the facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable wellbeing of residents with Dementia and wandering behaviors. Administration failed to provide appropriate oversight to ensure residents with Dementia and wandering behaviors received care in a safe and supervised environment, failed to ensure the facility conducted accurate resident assessments. The facility Administration failed to be accountable for to the Quality Assurance and Performance Improvement (QAPI) developed by the facility to ensure appropriate actions were implemented after a resident eloped from the facility without staff knowledge and supervision. The Administration's failure to ensure a safe environment placed 1 of 14 sampled residents (Resident #1) in Immediate Jeopardy (IJ) when Resident #1, a severely cognitively impaired, vulnerable resident with Dementia, confusion, and wandering behaviors, eloped from the facility on 1/2/2023 at approximately 1:15 PM, walked across the employee back parking lot and was found near the street. Resident #1 was unsupervised outside the building which resulted in Immediate Jeopardy (IJ) for Resident #1. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to supervise a severely cognitively impaired resident with Dementia, confusion, and a history of wandering behaviors, which resulted in Resident #1's elopement. The facility's failure placed Resident #1 in Immediate Jeopardy. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/15/2023 at 2:16 PM in the Conference Room. F-835 was cited at a scope and severity of J. The IJ was effective 1/2/2023 and is ongoing. The findings include: 1. Review of the facility's undated Licensed Nursing Home Administrator job description revealed, .The primary purpose of the Nursing Home Administrator position is to oversee the day-to-day operation of the facility, to assure resident safety and to review organizational performance .Oversee that nursing services, social service programs, activity programs, food service programs and medical services are planned, implemented and evaluated to meet resident needs to maximize resident quality of life and quality of care .Identify, monitor, and ensure that quality indicators and quality improvement programs are utilized to maximize effectiveness in resident care and services .Make routine inspections of the facility to assure that established policies and procedures are being followed .establish an effective accident prevention program .Ensure the integration of resident rights with all aspects of the facility environment . Review of the facility's undated Director of Nursing Services (DON) job description revealed, .The primary purpose of the Director of Nursing position is to plan, organize, develop, and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times .Develop, implement, and maintain an ongoing quality assurance performance improvement program for the nursing department .Assist the Quality Assurance Performance Improvement Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Review and insure that charting documentation procedures for nursing are met .Assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident. Ensures a written plan of care for each resident is developed that identifies the problems/needs of the resident indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care .Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Review nurses' notes to determine if the care plan is being followed . 2. The facility Administration failed to provide oversight that established and implemented policies and procedures to ensure a safe environment for all residents. On 1/2/2023 Resident #1, a cognitively impaired resident, eloped from the facility without staff knowledge or supervision and was found approximately 1000 feet from the facility on a street sidewalk. The facility Administration failed to ensure all wander/elopement assessments were accurate for 14 of 14 (Residents #1, #4, #6, #7, #8, #10, #12, #18, #19, #20, #21, 23, 24, and #25) sampled residents with wandering behaviors. 3. The facility Administration failed to maintain oversight, establish, and implement policies and procedures to ensure an effective QAPI was established to oversee the facility, failed to identify the root cause of concerns identified, and failed to ensure systems and processes were developed and consistently followed by facility staff related to a safe environment. The facility Administration developed an improvement plan dated 1/2/2023 to address Resident #1 ' s elopement incident. The facility Administration failed to ensure all interventions in the plan were implemented and were accurate as follows: The Improvement plan to review new admits' elopement assessments for appropriate interventions was not accurate as evidenced by the inaccurate wander/elopement assessments. The Improvement plan to audit all elopement assessments was not implemented as the facility was unable to provide the audits, audit results and the assessments that were conducted were not accurate. The Improvement plan to submit all audit results to the QAPI committee to be reviewed and address as needed was not completed. The facility was unable to provide evidence that the QAPI committee received and reviewed the plan and had not had a meeting. During an interview on 3/7/2023 at 2:30 PM, the DON revealed, .As part of our Performance Improvement [PIP] we audited all residents for wandering risk screen/assessments on 1/3 and 1/4 [2023] to see if anyone was at risk for wandering or elopement or if anyone new . When the DON was asked what they learned and about the outcome, he stated .Well I don't know .We did the audit .No, I don't have any quantitative data to show . When asked how you would know your outcome and if you needed to work on something, he stated, .We wouldn't know .We didn't evaluate it or look at the results . 4. During an interview on 3/7/2023 at 9:09 AM, the DON was asked what he did and his role concerning Resident #1's elopement. The DON stated the staff called and told him that Resident #1 was missing from the facility. The DON stated, .I told them to check the parking lot and the basement. I texted the Administrator .I did not come in until the next day .Once he was found I told them to put a wander guard on him and take him upstairs to the secure unit . The DON stated he was not aware of the resident's wandering history based on the information sent from the hospital. The DON stated he did not participate in a Root Cause Analysis (RCA) related to the elopement incident of Resident #1. The DON stated he did not interview all staff involved related to the elopement incident, only Certified Nursing Assistant (CNA) #1 that saw the resident outside and Registered Nurse (RN) #2 that was the Unit Manager for the hall that Resident #1 resided on. During an interview on 3/7/2023 at 2:50 PM the DON was asked about the Performance Improvement Plan (PIP) interventions that included the Audit Elopement Assessments data related to Resident #1's elopement. The DON stated Review new admits elopement assessment and transfer to secure unit for 7-day monitoring if triggered . The DON stated, .I don't have a tool .I don't have results . When asked if there was documentation of an audit with quantitative results, analysis, interventions, evaluation and follow up, The DON stated, .No . The DON was asked did nursing implement anything because of this elopement to keep it from happening again to residents with wandering behaviors. He stated, .No . During an interview on 3/7/2023 at 3:20 PM, CNA #3 revealed, .I work three to eleven and I was here at 3:00 PM. I saw him [Resident #1] standing at the double door in the lobby between 100 hall and the lobby. He said I am trying to go to [Name of a street]. I said OK well, let me go down here and see what is going on. I came back up front and he was gone . During an interview on 3/15/2023 at 1:00 PM the Administrator was asked what had been put in place since the elopement that will prevent it from happening again. The Administrator stated, .We fixed the gate and the courtyard fence . When the surveyor reviewed the inaccurate wander risk screen assessments with the Administrator, the Administrator stated, .That has definitely got to be fixed . The Administrator was asked about discrepancies with the wander guard system, the ineffective the interventions of checking the functionality of the wander guards, not following or obtaining a physician's order for the wander guards, staff being unaware of the policies/interventions for wander guards, and the non-secure exit doors on the 3/15/2023 tour, The Administrator stated .Yeah .Yes .that has to be fixed . Refer to F689 and F867.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on job description review, policy review, document review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to provide oversight that established and implemented policies and procedures to assure the facility was administered in a manner to use its resources effectively and efficiently. The QAPI committee failed to ensure a QAPI program that identified opportunities for improvement related to accurate wandering/elopement assessments and failed to implement performance improvement activities to provide a safe environment for residents, identify, report, investigate and prevent incidents of elopement and failed to ensure systemic processes were in place and consistently followed by staff and administration. The QAPI committee failed to implement a systematic approach to accurately identify and assess, implement interventions, monitor the implementation of and the effectiveness of its performance improvement activities to ensure improvements are sustained in identifying processes to identify deviations and adverse events when a resident exited the facility without staff knowledge, failed to provide adequate supervision to prevent elopement and failed to ensure a safe environment for 1 of 14 sampled residents (Resident #1) in Immediate Jeopardy when Resident #1, a severely cognitively impaired, vulnerable resident with Dementia, confusion, and wandering behaviors, eloped from the on 1/2/2023 at an unknown time after 1:15 PM, walked across the employee back parking lot and was found near the street. Resident #1 was unsupervised outside the building which resulted in Immediate Jeopardy (IJ) for Resident #1. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to supervise a severely cognitively impaired resident with Dementia, confusion, and a history of wandering behaviors, which resulted in Resident #1's elopement. The facility's failure placed Resident #1 in Immediate Jeopardy. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/15/2023 at 2:16 PM in the Conference Room. F-867 was cited at a scope and severity of J. The IJ was effective 1/2/2023 and is ongoing. The findings include: 1. Review of the facility's undated Quality Assurance and Performance Improvement [QAPI] Policy and Procedure, revealed .To ensure that [Name of the facility] implements a comprehensive QAPI program which addresses all the care and unique services that the Facility provides. To ensure continuous evaluation of the Facility's systems .It is the policy of the Facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life .The facility will maintain a QAPI program that will ensure that the Facility obtains feedback, uses data, and takes action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting Facility-wide processes that impacts quality of care, quality of life, and resident safety .The facility shall develop and implement policies and procedures .These approaches may include root cause analysis, reverse tracker methodology, or healthcare failure and effects analysis .The Facility shall collect and monitor data reflecting its performance, including adverse events. Data collection can be done by audit tools, direct observations, interview, or testing .The Facility will take actions aimed at performance improvement, which includes implementation of corrective actions, measuring success, and tracking performance, to ensure improvements are achieved and sustained .The performance improvement activities will track medical errors and adverse resident events, analyze their causes, implement preventive actions and mechanisms to prevent future events .Responsibilities of QAA [Quality Assurance] Committee .is responsible for .Regularly reviewing and analyzing data .acting on available data to make improvements; identifying and responding to quality deficiencies throughout the facility; .developing and implementing corrective action, and monitoring to ensure performance goals or targets are achieved; revising corrective action when necessary . Review of the facility's policy Quality Assurance Performance Improvement dated 12/15/2020 and reviewed 12/15/2022, revealed .The facility shall implement a QAPI program that addresses all the care and unique services the facility provides .The Administration of this facility will develop and lead the QAPI program .This facility will implement and maintain systems to monitor care and services, drawing data from multiple sources .It also includes tracking, investigating, and monitoring Adverse Events that will be investigated every time they occur, and action plans implemented to prevent recurrences .This facility will conduct Performance Improvements Projects [PIPs] to examine and improve care or services in areas that are identified as needing attention .This facility will use a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its root causes, and implications of a change .This facility has policies and procedures to demonstrate proficiency in the use of Root Cause Analysis . 2. Review of the facility's undated Licensed Nursing Home Administrator job description revealed, .The primary purpose of the Nursing Home Administrator position is to oversee the day-to-day operation of the facility, to assure resident safety and to review organizational performance .Oversee that nursing services, social service programs, activity programs, food service programs and medical services are planned, implemented and evaluated to meet resident needs to maximize resident quality of life and quality of care .Identify, monitor, and ensure that quality indicators and quality improvement programs are utilized to maximize effectiveness in resident care and services .Make routine inspections of the facility to assure that established policies and procedures are being followed .establish an effective accident prevention program .Ensure the integration of resident rights with all aspects of the facility environment . Review of the facility's undated Director of Nursing Services (DON) job description revealed, .The primary purpose of the Director of Nursing position is to plan, organize, develop, and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times .Develop, implement, and maintain an ongoing quality assurance performance improvement program for the nursing department .Assist the Quality Assurance Performance Improvement Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Review and insure that charting documentation procedures for nursing are met .Assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident. Ensures a written plan of care for each resident is developed that identifies the problems/needs of the resident indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care .Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Review nurses' notes to determine if the care plan is being followed . 3. Resident #1 was admitted to the facility from the hospital on [DATE]. The hospital's History and physical was sent to the facility upon the resident's admission and revealed Resident #1 had lived with his nephew, had falls at home, and was having more confusion with periods of sundowning and wandering at night. A staff interview revealed that cognitively impaired Resident #1 exhibited exit seeking behaviors prior to exiting/eloping from the facility. On 1/2/2023 on the 3:00 PM -11:00 PM shift, Certified Nursing Assistant (CNA) #3 stated, .I saw him [Resident #1] standing at the double door in the lobby between 100 hall and the lobby. He said I am trying to go to [Name of a street]. I said ok well, let me go down here and see what is going on. I came back up front and he was gone . There were no interventions implemented for Resident #1's exit seeking behaviors at that time. Resident #1 exited/eloped on 1/2/2023 at an unknown time and was out of the facility unknown to staff and unsupervised by staff for an unknown period of time. The resident was later found by Registered Nurse (RN) #2. RN #2 stated, . I can't remember what time I found him on the far side of the back employee parking lot located near the street [Name of the street] and the apartments .He was walking and looking left and right like didn't know where to go, not sure .Just me and him I don't remember any other staff around when I found him. He had on pants and a shirt .It was a little rainy, wet but not cold .I called his name and he said Hey baby I'm glad to see you . The facility's investigation dated 1/3/2023 of Resident #1's elopement on 1/2/2023 revealed he was found outside on the sidewalk beside the street, a 1,000 feet from the building. The facility documented Resident #1 exited the courtyard either thru a gap between a chain link fence and gate (that was loosely locked with a bike type rope lock) or through a gap that was between the chain link fence and the building wall. The facility failed to save the video as part of the investigation and did not include a summary of the video with times and locations in the investigation. The surveyor was unable to view the video and the Administrator did not keep notes from review of the video. 4. The facility Administration failed to maintain oversight, establish, and implement policies and procedures to ensure an effective QAPI was established to oversee the facility, failed to identify the root cause of concerns identified, and failed to ensure systems and processes were developed and consistently followed by facility staff related to a safe environment. Review of facility data and information obtained during the survey revealed the QAPI committee members consist of at the Administrator, DON, Minimum Data Set (MDS) Nurse, Social Services, Medical Director, Medical Director designee, and Consultant. The facility developed an improvement plan dated 1/2/2023 to address Resident #1's elopement incident. The facility failed to ensure the following interventions were implemented: The Improvement plan to review new admits' elopement assessments for appropriate interventions failed to be implemented as evidenced by the wander/elopement assessments not containing all data. The Improvement plan to audit all elopement assessments was not implemented as the facility was unable to provide the audits, audit results and the assessments that were conducted were not accurate. The Improvement plan to submit all audit results to the QAPI committee to be reviewed and address as needed was not completed as the facility could not provide evidence. The facility's QAPI committee failed to ensure the facility developed, implemented, monitored and sustained appropriate actions to prevent resident elopements and failed to ensure policies and procedures were followed in accordance with the facility QAPI policy. 5. During an interview on 3/7/2023 at 2:30 PM, the DON revealed, .As part of our Performance Improvement [PIP] we audited all residents for wandering risk screen/assessments on 1/3 and 1/4 [2023] to see if anyone was at risk for wandering or elopement or if anyone new . When the DON was asked what was learned and what the outcome was, he stated .Well I don't know .We did the audit .No, I don't have any quantitative data to show . When asked how you would know your outcome and if you needed to work on something, he stated, .We wouldn't know .We didn't evaluate it or look at the results . When asked did you do 100% of the residents, he stated .Yes . When asked about QAPI and the elopement discussion he stated, .I just get into the clinical side how everyone was .didn't get involved in investigation or how he got out. That was administrator and maintenance director . The Surveyor requested every day during the survey for the DON to provide the Performance Improvement Project (PIP) results of an audit of all new admits elopement assessment after 1/4/2023. The DON did not provide documentation of the audit or results during the survey. Review of the facility's census on 1/3/2023, revealed 131 residents. Review of the list of residents with a wander risk screen provided by the DON revealed 48 out of 131 were not completed for a 36.6%. When the DON was asked did you do quantitative results he stated .No .we didn't do that . When asked why were only 63.4% completed, He stated, .I didn't know all [resident screens] were not done .two of my unit managers were to do them . When asked what the analysis and interventions put into place, and were the interventions monitored and evaluated, he stated .We didn't do any of that . During an interview on 3/6/2023 at 12:53 PM, RN #2 was asked what interventions were implemented after the elopement. She stated, .everything stayed the same .I [RN #2] have no knowledge of anything implemented since . When she was asked were you part of a QAPI meeting to discuss the elopement and part of a root cause analysis, she stated, .I was not part of a root cause analysis or QAPI meeting .yes that is my signature on the QAPI paper, but I was not part of a meeting .nothing was implemented that I am aware of . During an interview on 3/15/2023 at 1:00 PM, RN #2 was asked did you participate in the wander risk screen audit for all residents, she stated .I just did what I was told .I did 100 hall .I don't recall anything we did in response to the audit .my process is the same I don't do anything different .it's the same . When she was asked did you audit all residents on 100 hall, she stated .I guess I missed some . During an interview on 3/6/2023 at 2:32 PM, the Director of Maintenance revealed .I don't go to QAPI .I am not part of the QAPI meeting . During an interview on 3/7/2023 at 7:50 AM, RN #1 was asked about her role in QAPI, she stated .Yes that is my signature [QAPI signature sheet] but I can't remember anything about it [meeting about elopement 1/2/2023] .No, don't know how he got out or what interventions put in place after that .I don't know anything about any root cause analysis or analysis . During an interview on 3/8/2023 at 12:30 PM, the Nurse Practitioner revealed, .I got a call when he [Resident #1] got out .I came in the next day examined [named person Resident #1] and met with administrator and I can't remember who else was in there in [named DON] office .I was told he got out through the basement door .I don't know who said that . When asked if she received any follow up from the 1/3/2023 meeting, she stated, .No, I have received no follow up .No discussion .He got out through the basement as far as I know . During an interview on 3/14/2023 at 3:16 PM, the Administrator was asked if a root cause analysis was performed. He stated, .I thought my PIP was a root cause analysis .No, I didn't include in the analysis people involved .If something is nursing, I let [named person DON] speak to that .I watched the video and concluded how he got out . When the Administrator was asked did you ask the staff about any behaviors or triggers the resident may have experienced prior to the incident, the Administrator stated, .I didn't think about that .No, I didn't include direct care staff . When the Administrator was asked did you follow up, what did you do with the audit results or learn from the audit, he stated .No, I see what you are saying . During an interview on 3/15/2023 at 1:00 PM, the Administrator was asked about the Quality Assessment & Performance Improvement (QAPI) PIP dated 1/2/2023, the audit results of all residents wander risk screen/assessments dated 1/3/2023 and 1/4/2023 and the audit results of all new admits after 1/4/2023 wandering risk screen/elopement assessments. He stated, .If it's not there, it is not there .No proof it [audit, analysis, interventions, follow up] was done .I understand not done . Refer to F 689 and F835.