**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to protect the Residents' right to be free from neglect when they failed to provide necessary care and services to meet the needs of the Residents for 2 of 5 (Resident #3 and #4) sampled residents reviewed for a change in mental status. Resident #3, a vulnerable Resident with severe cognitive impairment, experienced seizure activity on [DATE], and staff failed to perform neurological (neuro) assessments and monitor the Resident after a seizure. On [DATE], Resident #3 experienced a change in condition including vomiting, increased lethargy, changes in speech, gurgling respirations, and subsequently became unresponsive to verbal and tactile stimulation. Resident #3 was hospitalized on [DATE] with diagnosis of an intraparenchymal hemorrhage (a bleed on the brain) and subsequently expired on [DATE]. The facility's failure to perform neuro assessments and monitoring after a seizure on [DATE] and a change in condition on [DATE], resulted in Immediate Jeopardy for Resident #3. The facility failed to obtain a Urinalysis (UA) with culture and sensitivity (C&S) ordered on [DATE] for Resident #4, who was experiencing hematuria (bloody urine). Three days later, on [DATE], the UA with C & S was obtained. On [DATE], Resident #4 was unable to be aroused and unresponsive to verbal and tactile stimulation. Resident #4 was hospitalized with metabolic encephalopathy (a disorder that affects brain function) and Leukocytosis (elevated white blood cell count caused by infections). 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 use its resources effectively to attain and maintain the highest practicable well-being of vulnerable residents, to ensure systems and processes were implemented to provide supervision and assistance to ensure the resident environment was free of neglect. The Administrator was notified of the Immediate Jeopardy (IJ) at F-600 on [DATE] at 3:42 PM, in the Administrator's office. The facility was cited at F-600 at a scope and severity of J which is Substandard Quality of Care. The IJ began on [DATE] through [DATE], the IJ was removed on [DATE]. A partial extended survey was conducted on [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE] at 12:17 PM, with an alleged removal date of [DATE]. The Removal Plan was verified and validated onsite by the surveyor on [DATE] through review of the in-service training records and audits, review of the facility's policy, observations, and staff interviews. The last day of the IJ was [DATE]. The IJ was removed on [DATE]. The facility's non-compliance at F-600 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the undated facility policy titled, Abuse Prevention, revealed .Abuse .includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being .Neglect .A failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain .Employ trained, qualified, registered, licensed and certified staff on each shift to meet the needs of the resident . Review of the undated facility policy titled, Neurological Evaluations, revealed .It is the policy of this facility to perform a neuro vital sign evaluation when indicated by resident condition.Perform neurological checks.and document on the Neurological Evaluation Flow Sheet.Determine state of consciousness.Check all three spheres (person, place , time) and observe speech pattern.Take temperature, pulse, respirations and blood pressure.Check pupil reaction. Darken room. Open eyelid with your fingertips. Turn on flashlight and observe size and reaction of pupil. Repeat for the other eye. Determine motor ability.Determine sensation in extremities.Document additional findings in the Progress Notes. Review of the undated facility policy titled, Laboratory Tests, revealed .Lab tests are completed as ordered by the physician or physician extender .Responsibility .All licensed Nursing Personnel monitored by Director of Nursing .The Licensed Nurse .shall obtain the labs ordered by the physician or physician extended .Any newly ordered labs needing immediate attention will be added to the Lab Scheduling/Tracking form on each unit. The lab will be obtained as ordered . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Hypertension, Cerebrovascular Accident, Dementia, and Seizure Disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment was not performed due to Resident #3 was severely cognitively impaired. Resident #3 received an antiplatelet medication (a drug that prevents blood clots from forming). Review of the Care Plan for Resident #3 dated [DATE], revealed .After seizure, take vital signs and neuro checks. Document seizure activity in the clinical record.Monitor for change in level of consciousness. Review of the Medication Administration Record (MAR) dated 10/2025, revealed Resident #3 was administered the following medication on [DATE] at 11:40 PM, Lorazepam [used to treat anxiety and seizures] injection .2 MG/ML [2 milligrams per milliliter] .Inject 1 ml intramuscularly every 5 minutes as needed for seizure activity . Review of the Orders Administration Note dated [DATE] at 11:40 PM, revealed LORazepam Injection Solution 2 MG/ML Inject 1 ml intramuscularly every 5 minutes as needed for seizure activity or behaviors related to OTHER SEIZURES.May give up to 3 doses. Review of the Nurse's Notes revealed there was no documentation by Licensed Practical Nurse (LPN) C that Resident #3 experienced seizure activity, no documentation that a neurological assessment was completed, no documentation of the length and time of the seizure activity, and no documentation of the effectiveness of medication administered on [DATE] at 11:40 PM, for Resident #3, after seizure activity occurred. Review of the Nurse's Note for Resident #3 dated [DATE] at 2:26 AM, revealed, Resident observed in bed with vomit coming from both her mouth and nose along with twitching movements coinciding to seizure. Prn [as needed] im [intramuscularly] ativan [used to treat anxiety or seizures] administered. Resident's b/p [blood pressure] elevated 145/99 hr [heart rate] 62 rr [respiratory rate] 16 o2 [oxygen saturation] 96% [percent] on RA [room air] temp. [Temperature] 98 NP [Nurse Practitioner] notified . The facility failed to perform a neurological assessment and failed to document the length of time and description of seizure activity on [DATE] at 2:26 AM, for Resident #3 after seizure activity occurred. Review of the Nurse's Note for Resident #3 dated [DATE] at 3:08 AM, revealed .Unclear speech at times. Review of the Nurse's Note for Resident #3 dated [DATE] at 6:31 AM, revealed Resident noted with small amount of bleeding in oral cavity. Small cut noted to inside of [Resident #3's] lip. Per nurse report, resident appeared to bite inside of mouth during seizure activity. The facility failed to perform a neurological assessment and failed to document the length of time and description of seizure activity on [DATE] at 6:31 AM, for Resident #3 after seizure activity occurred. Review of the Nurse's Note for Resident #3 dated [DATE] at 6:32 PM, revealed .Patient follow-up post [after] seizure.Patient medication held due to lethargic status noted. RP, Unit manager and NP notified. No bleeding from patient mouth noted . The Medical Director was not notified of Resident #3's lethargy and there were no new orders documented. The facility failed to perform a neurological assessment for follow up after seizure activity to determine if Resident #3 had returned to her baseline (refers to a normal state of a person's health or condition). Review of the physician's orders dated 10/2024, revealed no documentation of an order to hold all of Resident #3's medications. Review of the [DATE] MAR for Resident #3 revealed no medications were documented as administered on [DATE]. Review of the Nurse's Note for Resident #3 dated [DATE] at 12:31 AM, revealed Resident remains lethargic at this time. Upon assessment resident does not respond to verbal or tactile stimuli. Deep Snoring and gurgling noted. Small amount of blood noted in mouth. Vitals are as follows: B/P [Blood Pressure]-199/96 P [Pulse]-78 R [Respirations]-17 T. 99.8 BS [Blood Sugar]-163 O2 [Oxygen saturation]-98% RA. Skin hot/clammy to touch.RR [Resident Representative] voiced concerns and request for resident to be sent to [named hospital] for evaluation. On [DATE] at 11:38 PM, Emergency Medical Services (EMS) was called for transport and arrived at the facility on [DATE] at 12:08 AM. Resident #3 was transferred by EMS to the hospital emergency room on [DATE] at 12:20 AM. Review of the hospital admission Note for Resident #3 dated [DATE], revealed .presents to ED [Emergency Department] from her nursing home. Staff report she had a seizure and vomited yesterday morning around 0700 [7:00 AM]. Last night around 1900 [7:00 PM] she was found unresponsive .CT [Computed Tomography - creates as detailed xray image of the body] head .describes a large intraparenchymal hemorrhage [brain bleed] .ED physician spoke with daughter updated this is a devastating bleed .Assessment/Plan Intracranial hemorrhage [bleeding within the skull], Hypertensive emergency, Acute Respiratory Failure, Acute toxic encephalopathy [acute global brain dysfunction manifested by altered consciousness, behavior changes and/or seizures]. Review of the hospital CT results for Resident #3 dated [DATE], revealed a large, extensive brain bleed. Review of the hospital Discharge Summary for Resident #3 dated [DATE], revealed .Patient never awoke from her coma .Family made her a DNR [Do Not Resuscitate] .Patient time of death was 1705 [5:05 PM] on [DATE] . Review of Certified Nursing Assistant (CNA) F's undated witness statement in the facility's investigation revealed On [DATE], I was making my last round on the 3-11 [3:00 PM to 11:00 PM] shift when I heard a noise. I went down the hall to find [Resident #3] throwing up. I notified [the] nurse. She came an [and] assessed the patient. I cleansed my patient up and continued to observe her for the remainder of the night. Review of LPN C's undated witness statement in the facility's investigation revealed On [DATE] I [LPN C] was called to room [named Resident #3's room] .Upon entering resident [Resident #3] observed [symbol for with] clear vomit coming from both her mouth and nose .HOB [head of bed] was elevated .also noted having tremor the seizure lasting approx. [approximately] 2 min [minutes]. Resident assessed. Mouth cleansed. Small cut noted to lower lip [symbol for with] small amount of bleeding .VS: [B/P] 145/99 .Resident lethargic .NP [Nurse Practitioner] notified .new orders given for STAT [immediately] labs [laboratory tests] and x1 [times 1] dose phenergan [medication given for nausea and vomiting] 12.5 mg [milligram] IM [intramuscular]. Resident also received PRN [as needed] Ativan [Lorazepam] .as ordered .Resident monitored throughout shift . Review of the physician's orders dated [DATE], revealed there was not an order for IM Phenergan to be administered. Review of the medical record revealed there was no documentation that neuro assessments were completed, no documentation of follow up monitoring of vital signs or assessment, no documentation on the MAR that Phenergan was administered, or that a second dose of Ativan was administered on [DATE] at 2:26 AM, and no documentation of follow up monitoring after medication administration. Review of Registered Nurse (RN) E's undated witness statement in the facility's investigation revealed, On [DATE] patient [Resident #3] assigned noted resting in bed. Patient noted with movement and opening of eyes while assessing vitals. Patient vitals within normal limits, afebrile noted. Patient noted with no signs and symptoms of pain or discomfort. No seizure like activity noted during shift. RP, Unit Manager, and MD notified of patient's status per previous shift report. Continued to monitor patient throughout shift. Call light within reach. Review of the medical record revealed RN E only charted on Resident #3 one time on [DATE], at 6:32 PM. There was no documentation that Resident #3 was monitored by RN E throughout the shift. Resident #3 exhibited seizure activity on [DATE] at approximately 11:40 PM and on [DATE] at 2:26 AM and 6:31 AM. Nurse progress notes dated [DATE] at 3:08 AM, revealed Resident #3 manifested unclear speech at times and on [DATE] at 6:32 PM, Resident #3 was lethargic, and the Resident's medications were not administered. Resident #3's MAR revealed no medications were documented as administered on [DATE]. Resident #3 was not transferred to the hospital until [DATE] at 12:20 AM, when her family requested that she be transferred, approximately 24 hours after the Resident first exhibited seizure activity and a decline in her medical condition. Resident #3 experienced a large, devastating brain bleed and expired on [DATE]. During a telephone interview on [DATE] at 11:58 AM, LPN C confirmed Resident #3 was having increased seizure activity with vomit out of nose and mouth during her shift from 11:00 PM on [DATE] until 7:00 AM on [DATE]. LPN C confirmed that a neuro assessment was not completed after Resident #3 experienced a seizure. LPN C was asked what medications were administered to Resident #3. LPN C stated she could not recall. LPN E Who worked the 7:00 AM to 7:00 PM on [DATE], failed to answer or return the surveyor's calls. During a telephone interview on [DATE] at 1:18 PM, RN A confirmed the day shift nurse (LPN E) informed her when arriving for her shift on [DATE] at 7:00 PM, that Resident #3 had been lethargic and difficult to arouse all day during the previous shift. RN A was asked if she had attempted to perform a neuro assessment or check the Resident's cognition prior to [DATE] at 12:30 AM. RN A stated, No, she [Resident #3] appeared to be sleeping. RN A confirmed that Resident #3 had snoring type respirations, was sweaty and unresponsive when she was assessed at midnight. During an interview on [DATE] at 2:14 PM, RN D Unit Manager confirmed Resident #3 was having increased seizure activity on [DATE] and does not recall if staff performed a neuro assessment on resident post seizure. RN D Unit Manager was asked what should be done if a resident has a seizure. RN D Unit Manager confirmed that staff should perform vital signs and monitor the resident at least hourly. There was no documentation in the medical record that Resident #3 was monitored hourly after she experienced seizure activity on [DATE] and [DATE]. During an interview on [DATE] at 2:27 PM, the Director of Nursing (DON) was asked what should staff do after a resident has a seizure. The DON confirmed that staff should notify the physician to report the Resident's seizure activity, administer as needed medications, and the next step would be to send the Resident to the emergency room for continued seizure activity. The DON confirmed that a neuro assessment should be completed after a seizure and documented. During an interview on [DATE] at 3:00 PM, the DON confirmed that neuro checks were not performed for Resident #3 from [DATE] through [DATE]. During a telephone interview on [DATE] at 12:34 PM, the Medical Director (MD) confirmed that staff should monitor Resident's post seizure activity and notify the NP or MD if resident has ongoing symptoms. The MD confirmed that it is unacceptable for the facility staff to document ongoing lethargy for Resident's condition post seizure without the Resident returning to her baseline. During a telephone Interview on [DATE] at 4:03 PM, the Nurse Practitioner (NP) confirmed that he takes call Monday through Friday from 7:00 PM to 7:00 AM and on weekends. The NP confirmed that he does not have access to the resident's electronic medical records and is not familiar with any of the residents in the facility due to taking call for multiple facilities at the same time. The NP confirmed that he does not keep a record of calls received from the facility staff, and only relays messages to the Medical Director when advice is needed. The NP was asked if the MD is informed regarding Residents who have a change in condition. The NP stated, No, I don't. The NP did not recall staff calling him regarding Resident #3's seizure activity and increased lethargy. NP stated, I typically send residents out if there is a poor controlled medical issue. During an interview on [DATE] at 10:31 AM, the Administrator confirmed that staff should implement the Resident's care plan for monitoring and assessing a Resident's neurological status post seizure, and that staff are expected to recognize when a significant change in condition has occurred with a resident and implement appropriate interventions. 3. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Quadriplegia, and Neuromuscular Dysfunction of Bladder. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #4 was moderately cognitive impaired. Resident had an indwelling urinary catheter. Review of the Care Plan dated [DATE], revealed .Suprapubic Catheter [a tube inserted through the abdomen to drain the bladder] related to Neuromuscular Dysfunction of the bladder and is at risk for complications, trauma and UTI [Urinary Tract Infection].Monitor/record/report to MD [Medical Director] for s/sx [signs and symptoms] UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of the Nurse's Note for Resident #4 dated [DATE] at 3:47 PM, revealed New order UA related to hematuria [blood in urine]. Review of the Nurse's Note for Resident #4 dated [DATE] at 10:30 AM, revealed New order for UA with culture r/t [related to] hematuria. Review of the Nurse's Note for Resident #4 dated [DATE] at 4:43 AM, revealed Resident has order for urine to be collected for UA/C-S [culture and sensitivity] c/o's [complaints of] of hematuria. Review of the Nurse's Note for Resident #4 dated [DATE] at 7:00 PM, revealed New order for UA with culture r/t hematuria. The facility failed to collect the UA with C&S, failed to notify the MD that Resident #4 was experiencing blood in his urine, and failed to document the reason for not collecting the UA with C&S for four days after the order was received. Review of the Nurse's Note for Resident #4 dated [DATE] at 6:54 AM, revealed UA/C&S: I collected a urine specimen from [Named Resident #4] for a urine analysis, and culture .His urine was thick foul odor, yellow w/ [with] large amounts of sediment [solid particles]. The facility failed to notify the MD that Resident #4's urine was thick with a foul odor. Review of the Nurse's Note for Resident #4 dated [DATE] at 8:14 AM, revealed CNA notified this writer that resident [Resident #4] was hard to arouse when attempting to offer breakfast tray. This writer went to resident's room to assess resident .unable to arouse resident with verbal or tactile stimuli. NP [Nurse Practitioner] .verbal order to transfer resident to ER [Emergency Room] for further evaluation . Review of the Nurse Practitioner's Note for Resident #4 dated [DATE], revealed resident [Resident #4] unresponsive .not responding to any commands .pupils sluggish .likely UTI .unable to arouse .send out 911 [universal emergency number] for evaluation . Review of the hospital admission report for Resident #4 dated [DATE], revealed .Assessment/Plan.Acute metabolic encephalopathy .UTI with sepsis. Review of the hospital Urinalysis collected on [DATE] at 12:02 PM revealed the following abnormal findings: Resident #4's urine was orange in color, cloudy, with sediment noted. The Urinalysis revealed white blood cells, red blood cells, and bacteria were present in the urine. Review of the hospital Physician Progress Note for Resident #4 dated [DATE], revealed .Assessment/Plan .Acute mental status change, Acute metabolic encephalopathy, Leukocytosis rule out sepsis .UTI .4/16 [2025] from nh [nursing home] with ams [altered mental status] .ua+ [urinalysis positive] . Review of the hospital Medication Administration Record (MAR) for Resident #4 revealed the following medications were administered from [DATE] through [DATE]. a. Ceftriaxone (used to treat bacterial infections) 1 gram (g) Intravenous (IV) on [DATE] in the emergency department. b. Zosyn (a powerful antibiotic used to treat bacterial infections) 3.375g IV every eight hours from [DATE] through [DATE]. c. Vancomycin (used to treat bacterial infections) 125 milligram (mg) 1 cap by mouth every six hours from [DATE] through [DATE]. Review of the medical record revealed Resident #4 returned to the facility on [DATE]. Review of the Physician's Order for resident #4 dated [DATE], revealed .levoFLOXacin [antibiotic medication used to treat infections] Oral Tablet 500 MG [milligram].Give 1 tablet by mouth one time a day for URINARY TRACT INFECTION until [DATE] 08:30 [8:30 AM]. During an interview on [DATE] at 10:01 AM, the DON confirmed that an order was obtained on [DATE] to collect a UA with C&S for Resident #4. The DON confirmed that staff did not collect the UA until three days later, on [DATE], and that staff failed to document in Resident #4's medical record why the UA was not obtained prior to [DATE]. The DON confirmed that labs should be obtained the same day as order is received and documentation should reflect if staff were unable to collect. During a telephone interview on [DATE] at 12:34 PM, the Medical Director (MD) confirmed that it was unacceptable for a Resident to have ongoing hematuria, and the staff failed to collect the UA with C&S until [DATE]. The Medical Director confirmed that a Resident should be sent to the emergency room if there's a decline in mental status and/or vital signs. During an interview on [DATE] at 2:12 PM, the DON was asked why Resident #4 was started on Levofloxacin 500mg for UTI once the resident returned from the hospitalization. The DON confirmed that Resident's medications are reconciled by the MD upon the Resident's return to the facility. During an interview on [DATE] at 10:31 AM, the Administrator confirmed that staff should collect all labs the same day as the order is received for residents who are having symptoms, and staff should notify the MD or Nurse Practitioner (NP) if unable to collect labs and document in the resident's medical record. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE] at 12:17 PM, with an alleged removal date of [DATE]. The Removal Plan was verified and validated onsite by the surveyor on [DATE] through review of the in-service training records and audits, review of the facility's policy, observations, and staff interviews. The last day of the IJ was [DATE]. The IJ was removed on [DATE]. Review of the facility's removal plan amended [DATE] and [DATE] revealed the following: The facility failed to provided neuro assessments and monitoring for Resident #3. As a result, the facility failed to monitor, assess, and document seizure activity [DATE] when Resident #3 experienced seizure activity. On [DATE] Resident #3 experienced a change in condition including vomiting, increased lethargy, changes in speech, gurgling respirations, and subsequently became unresponsive to verbal and tactile stimulation. AMENDED [DATE] AT 1:18 PM TO INCLUDE: The facility failed to obtain a UA with C&S on 4//11/25 for Resident #4, who was experiencing hematuria. Three days later, on [DATE] the UA with C&S was obtained. On 4 15/2025, Resident #4 was unable to be aroused and unresponsive to verbal and tactile stimulation. AMENDED [DATE] AT 3:42 pm to include Neglect. Education: I. Director of Nursing (DNS), Assistant Director of Nursing (ADNS), Unit Managers, will in-service all licensed staff on adding a statement to the electronic medication administration (EMAR) to initiate neuro-checks after any seizure activity, policy G.6 titled, Neurological Assessment, on [DATE] and G6 a. titled Neurological Evaluation Flow Sheet. This in­ service was started on 6/26 2025 and will be completed [DATE]. AMENDED Education: I. DNS, ADNS, Unit Managers, will in-service all licensed staff titled, Timely Collection of Laboratory Specimens. AMENDED #2 Education: 1. DNS (Director of Nursing), ADNS (Assistant Director of Nursing), Unit Managers will in-service all licensed staff on titled education Neglect, and Timely Reporting Resident's Change in Condition. System to be followed per policy, evaluation, and documentation in the resident's Medical Record: o Following seizure, the Licensed Nurse shall place the resident on the 24-Hour Report, document the seizure, and notify MD and resident's representative, neuro­ checks will be initiated. o Each resident with seizure diagnosis has a statement, {After each seizure activity, perform neuro-checks every 15 minutes times 4, every 30 minutes times 4, every l hour times 5, & every 4 hours times 4, until resident returns to baseline as needed. Notify MD of any abnormalities,} added to the electronic medication record to initiate neuro-checks after seizure activity. The QA Nurse/Director of Nursing/Unit Managers will monitor compliance of neuro-checks completion following seizure activity during the daily [NAME] (Health Assessment Review Team,) meeting. Results of seizure monitoring will be reviewed monthly in the Quality Assurance Performance Improvement (QAPI) meeting times 3 months for further recommendations as deemed necessary. AMENDED System to be followed per policy, evaluation, and documentation in the resident's Medical Record: AMENDED System to be followed per policy, evaluation, and documentation in the resident's Medical Record: o Timely collection of laboratory specimens. The laboratory provider only provides STAT lab collections for weekend specimens. If the provider (MD or FNP) orders labs on Friday, Saturday, or Sunday, the nurse must clarify that order to determine one of the following options: Can the lab be collected on the next lab day? If urgent, the lab must be ordered STAT, or the resident needs to be sent out to the emergency room for evaluation. o Amended [NAME] (Health Assessment Review Team) sheet. Once a lab order is received by the nurse, the information is placed on the 24-hour nursing report. The report is brought to the [NAME] review meeting. All new orders are reviewed for proper entry, documentation, notification, Kardex update (if needed), Care Plan update (if needed), and the addition of the update with laboratory specimen timely collection, results, and follow through. DNS, ADNS, and Unit Managers will monitor compliance of lab orders, and their timeliness/follow-up. AMENDED #2 System Change: o Education to be provided to all licensed staff. DNS, ADNS, Unit Managers or designee will in-service all licensed staff on titled education Neglect, and Timely Reporting Resident's Change in Condition. Action List: l. Emergency Quality Assurance committee meeting held on [DATE] to review and approve deficiency action plans: F684. 2. Medical Director Notified of IJ deficiency F684 on 6 26/2025 3. Facility completed 100% audit to identify all residents with seizure diagnosis. These residents have a statement added to the electronic medication administration (EMAR) to initiate neuro-checks after any seizure activity {After each seizure activity, perform 4. neuro-checks every 15 minutes times 4, every 30 minutes times 4, every lhour times 5, & every 4 hours times 4, until resident returns to baseline as needed. Notify MD of any abnormalities} on [DATE] 5. The nursing management will in-service I00% of licensed staff on adding a statement to the electronic medication administration (EMAR) to initiate neuro-checks after any seizure activity. Policy review of, G.6 titled, Neurological Assessment, and G6 a. titled Neurological Evaluation Flow Sheet on [DATE]. No licensed staff will be allowed to work in the facility until they have received the in-service. 6. Residents with diagnosis of seizure disorders have had their care plan reviewed and updated to reflect additional interventions on [DATE]. AMENDED Action list: I. Emergency Quality Assurance committee held on [DATE] to review and approve deficiency AMENDED action plans: F684 2. DNS, ADNS, Unit Managers, will in-service all licensed staff titled, Timely Collection of Laboratory Specimens. No licensed staff will be allowed to work in the facility until they have received the in-service. AMENDED #2 Action List: 1. Emergency QAPI AD HOC to identify tag replacement to F600 to identify Neglect, 2. DNS (Director of Nursing), ADNS (Assistant Director of Nursing), Unit Managers will in-service all licensed staff on titled education Neglect, and Timely Reporting Resident's Change in Condition. Refer to F726

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, video camera footage review, medical record review, observation, and interview, the facility neglected to supervise a resident with confusion and periods of hallucinations, and at risk for wandering and elopement for 1 of 6 sampled residents (Resident #338) reviewed for wandering and elopement. Resident #338 exited the facility without staff supervision and staff knowledge and was found off the facility property, sitting on a concrete block at the entrance of a housing community, across the street from a lake, approximately 459 feet and 6 inches from the front entrance of the facility, 0.2 miles from a busy intersection and 172 feet from a busy street that had a 45 miles per hour speed limit. Resident #338 was outside the facility without staff supervision and knowledge and off the facility property for approximately 39 minutes. The facility's failure resulted in Immediate Jeopardy for Resident #338. 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 Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/19/2021 at 2:45 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited an Immediate Jeopardy at F-600 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 9/30/2021 through 10/21/2021. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 10/20/2021 at 5:27 PM, and was validated onsite by the surveyors on 10/22/2021 through review of elopement books, policies and procedures, audit tools, documentation of elopement drills, Elopement Risk Assessments, medical records, in-service records, observations, and staff interviews. The findings include: Review of the facility's undated policy titled, ABUSE PREVENTION, revealed .The facility is committed to protecting the residents from abuse .Neglect .failure of the facility to provide .services necessary to avoid physical harm, mental anguish, emotional distress . Review of the facility's policy titled, MISSING RESIDENT/ELOPEMENTS, dated 7/2018, revealed .The Unit Nurse is responsible for knowing the location of their residents . Review of the facility's policy titled, Elopement Guidelines, dated 8/2017, revealed .The Elopement Risk Evaluation is to be done upon admission and quarterly & [and] as needed with exit seeking behaviors .Wander Guard alert bracelets [mechanical bracelet device to alert staff of wandering residents that make the door alarm when a resident is close to exit door] (if used) are in place .When exit seeking activity occurs consider 1:1 [one on one] supervision or 15 minute checks . Review of the medical record, revealed Resident #338 was admitted to the facility on [DATE] with diagnoses of Coronavirus, Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure, Polyarthritis, Convulsions, Pancytopenia, Cystitis, and Asthma. Review of the Base Line Care Plan dated 9/28/2021, revealed, .Mental health needs .Psych [psychiatric] .panic d/o [Disorder] .concerns with hallucinations & thought process .Hx [History of] substance abuse . Review of the Risk for Elopement Evaluation dated 9/28/2021, revealed .NO RESIDENT IS NOT AT RISK FOR ELOPEMENT . Review of the Departmental Notes dated 9/29/2021 at 6:30 AM, revealed .Resident is alert to self with confusion noted, also having hallucinations. Redirected several times without success. Her thought process is scattered . Review of the Departmental Notes dated 9/29/2021 at 6:42 AM, revealed .Resident very up set [upset] this am .Resident states she is going home .Resident noted to be speaking with people that were not there .Difficult to redirect, notable visual [seeing] and auditory [hearing] hallucination. Resident attempting to get out the door next to her room. Became upset when redirected and states that she will leave if she wants to . Review of the Departmental Notes dated 9/29/2021 at 9:52 AM, revealed .Resident is alert to self with confusion noted, continues to have hallucinations. Redirected several times w/o [without] success . Review of the facility's video camera footage of the East Entrance French doors dated 9/30/2021, revealed the following: a. At 3:32 PM, Resident #338 was ambulating down the East Hallway toward the East Entrance French doors dressed in a short sleeve purple shirt, light colored pants, open toe shoes with white socks, a purse on her left arm and a white cup in her right hand with Licensed Practical Nurse (LPN) #1 walking behind her from the East end of the building. Resident #338 and LPN #1 remained at the door having a conversation, LPN #1 pointed toward the East hallway and Resident #338 pointed toward the Front lobby. b. At 3:45 PM, LPN #1 walked down the East hallway and left Resident #338 at the East Entrance French doors, unsupervised and unattended. c. At 3:46 PM, Resident #338 stepped out of sight of the camera and then returned into sight and was standing at the East Entrance French Doors. Resident #338 walked through the East Entrance French doors into the Front Lobby walking toward the glass Front Entrance doors that exited the facility. Review of the facility's video camera footage of the Front Door Entrance dated 9/30/2021, revealed the following: a. At 3:47 PM, Resident #338 walked toward the Front Door Entrance. Resident #338 pushed on the right side of the door and the door appeared to be locked. Resident #338 then pushed on the left side of the door, the door opened with a 4 second delay, and Resident #338 exited the building through the front door. Resident #338 sat on a bench that is located to the right of the Front Door Entrance. b. At 3:53 PM, Resident #338 stood up and attempted to reenter the building without success. The door appeared to be locked. c. At 3:54 PM, Resident #338 ambulated away from the bench and appeared to ambulate towards the parking lot on the right side of the facility and was no longer seen on the video footage. d. At 3:57 PM, the Maintenance Director walked through the Front Lobby from the East Entrance French doors and exited the facility through the front door. e. At 3:58 PM, Maintenance Assistant #1 and #2 entered the Front Lobby through the East Entrance French doors and exited the facility through the front doors. f. At 3:59 PM, LPN #1 exited through the East Entrance French doors, went to the Receptionist window, and appeared to be speaking to the Receptionist. LPN #1 then looked around the lobby and looked through the glass door but did not open the door. g. At 4:00 PM, LPN #1 exited the Front Lobby and reentered the facility through the East Entrance French doors. h. At 4:03 PM, LPN #1 returned to the Front Lobby and exited the Front Lobby through the double glass front door. i. At 4:04 PM, the Social Services Director exited the facility through the double glass front doors. j. At 4:05 PM, Receptionist #2 came out of the office and stood at the edge of the Receptionist Window in the Front Lobby. k. At 4:07 PM, LPN #1 reentered the facility and went through the East Entrance French Doors. l. At 4:26 PM, 2 male staff members assisted Resident #338 back into the facility in a wheelchair. Review of the Risk for Elopement Evaluation dated 9/30/2021 at 4:00 PM, revealed Resident #338 was having hallucinations, had attempted to leave the facility prior to the elopement, wandered aimlessly, and pushed on exit door handles. Resident #338 has also stated, I am going home . Resident #338 was documented at risk for elopement. Review of the Incident Report dated 9/30/2021, revealed .Incident Type .Wande [Wandering] on Grounds .Type of Injury .None .Date/Time .9/30/2021 .03:47 PM [3:47 PM] .Activity at time .exiting facility .Witness 1 .[Dietician] .Witness 2 [Director of Social Services] .Narrative of Incident and description of injuries .Resident was noted at the front doors stating she wanted to go home with the nurse. The nurse left to call the resident's son and brother to let them know the resident wanted to go home. While the nurse was doing this, the resident remained at the double doors and watched the comings and goings of the front lobby. At approximately 3:48 PM, the resident walked through the double doors into the front lobby went to the front door where she pushed the door until it opened and walked out in the parking lot .the resident was found in the parking lot .she was found by staff along the fence line .after much encouragement and re-direction staff was able to get resident back into the building .Family notified .FNP [Family Nurse Practitioner] notified . Review of the facility's investigation dated 9/30/2021, revealed a handwritten statement by LPN #1 dated 9/30/2021 that documented, .On September 30, 2021, [Named Resident #338] was down Central Hall ambulating onto another floor, this nurse attempted to redirect resident back on the Central Hall. Resident became aggressive and agitated. Therefore, this nurse proceeded to alert Social Services so we can place a call to the brother and son informing them she wanted to go home . During an interview on 10/13/2021 at 10:20 AM, the Executive Director stated, .she [Resident #338] exited the facility on 9/30/2021 at approximately 4:00 PM . The Executive Director confirmed staff failed to inform her of Resident #338's confusion and periods of hallucinations until she began her investigation into the elopement. The Executive Director stated, All my knowledge came post [after the incident] elopement. The Executive Director was asked if she should have been informed when the wandering and exit seeking behaviors started on 9/29/2021. The Executive Director stated, Yes . The Executive Director was asked where Resident #338 was found. The Executive Director stated, .they found her at the fence line that took her off the property . The Executive Director confirmed Resident #338 was not assisted back into the facility until 4:40 PM on 9/30/2021. During an interview on 10/13/2021 at 1:10 PM, LPN #1 confirmed she was the nurse on duty when Resident #338 exited the facility without staff supervision and knowledge. LPN #1 stated, .I was passing medications and I seen [saw] her walk past me going off the unit and I walked behind [her] to try to get her to come back and she became agitated and I left her alone for a minute and I was going to notify the Social Worker to see if they could put a bracelet [Wander Guard] on her and I went to call her family and let them know how agitated she was and by the time I finished she was not behind me and I went up front looking for her and I didn't see her and I went back on the floor and asked a few people and I asked the Receptionist and she hadn't seen her and I looked outside the door and I didn't see her and I walked out the building and I walked around and I informed someone to call a Dr. Wander [Missing Resident Alert] . During an interview on 10/13/2021 at 1:37 PM, the DON confirmed that she was off duty on 9/30/2021 and the Executive Director had informed her by telephone that Resident #338 had exited the facility without staff supervision and knowledge on 9/30/2021 at approximately 4:00 PM. The DON confirmed LPN #1 was the attending nurse for Resident #338 on 9/30/2021. The DON confirmed Resident ##338 was initially admitted to the facility on [DATE] on the 1000 Hall and was moved to the 400 Hall on 9/29/2021. The DON confirmed Resident #338 was relocated to another room in the building due to voicing her desire to leave the facility and attempting to push on an exit door on the 1000 Hall. During an interview on 10/13/2021 at 2:10 PM, the Maintenance Director confirmed he was working on 9/30/2021 when Resident #338 exited the facility without staff supervision and knowledge. The Maintenance Director confirmed he was in front of the facility cutting down a tree with 2 of his assistants when the Dr. Wander was called. The Maintenance Director confirmed he checks the facility doors daily for proper working condition. The Maintenance Director was asked if he checked the doors on 9/30/2021. The Maintenance Director confirmed he checked the doors early that day prior to the elopement. The Maintenance Director was asked if he checked the doors after Resident #338 exited the facility without staff supervision or knowledge. The Maintenance Director confirmed he only checked the Front Entrance doors on 9/30/2021 at 4:30 PM when Resident #338 was assisted back into the facility and no other doors were checked until 10/1/2021. During an interview on 10/13/2021 at 3:53 PM, the Social Service Director confirmed she was responsible for oversight of the Wander Guard administration. The Social Service Director confirmed a Wander Guard is used when a resident is actively exit seeking or talking about leaving the facility and had the capability to do so. The Social Service Director confirmed the Wander Guard makes the door alarm sound if a resident with a Wander Guard gets close to the door, alerting staff to respond. The Social Service Director confirmed she checks the Wander Guards and ensures they are available for staff to use when there is a need. The Social Service Director was asked if she was aware of Resident #338's attempt to exit a door on the 1000 Hall on 9/29/2021 at 6:30 AM and there was no Wander Guard available for staff to apply to the resident. The Social Service Director confirmed she was not informed of Resident #338's wandering and exit seeking behavior on 9/29/2021 or the need for a Wander Guard but should have been informed and was unaware the resident had exit seeking behaviors until 30 minutes prior to her exiting the building on 9/30/2021. The Social Service Director was asked if she responded to the Dr. Wander alert and she responded that the Maintenance Director, the Registered Dietician (RD) and herself responded to the Dr. Wander and arrived at the end of the facility's driveway at the same time with other staff members. She stated she saw Resident #338 sitting on a white brick wall located down a sidewalk off the facility property. Observation on 10/13/2021 at 4:30 PM of the area outside the facility where Resident #338 was located, the Maintenance Director used a measuring device to measure the distance from the Front Entrance doors to the location where the Social Service Director and the Registered Dietician indicated Resident #338 was found. The distance measured was a total of 459 feet and 6 inches. The speed limit for the two lane street was 45 miles per hour for both the East and [NAME] bound lanes of traffic. The Maintenance Director confirmed it was always a heavily traveled city street. During an interview on 10/15/2021 at 11:54 AM, the RD confirmed she was working the day that Resident #338 exited the facility. The RD confirmed the Dr. Wander was called at approximately 4:00 PM. The RD confirmed she responded to the Dr. Wander by exiting the facility on the East Side of the building and started walking toward the parking lot toward the driveway exit and a sidewalk. The RD was asked where Resident #338 was located. The RD stated, She was sitting along-side the fence facing the road but sitting down. When asked what Resident #338 was sitting on, the RD stated, I think it was [an] area of rocks or [a] rock wall . During an interview on 10/19/2021 at 8:25 AM, the Assistant Director of Nursing (ADON) confirmed she was working on 9/30/2021 at the time Resident #338 exited the facility. The ADON was asked what the facility procedure was when a resident exhibited wandering and exit seeking behaviors. The ADON confirmed the Social Service Director, DON, or herself if the DON is not available, the physician, and psychiatric services are notified. The ADON was asked if she was aware that Resident #338 had exhibited wandering and exit seeking behaviors on 9/29/2021 at 6:30 AM. The ADON confirmed she was not aware, and should have known. The ADON confirmed LPN #1 made her aware between 3:30 PM and 4:00 PM on 9/30/2021 that she could not locate Resident #338, and called a Dr. Wander alarm. During an interview on 10/19/2021 at 10:55 AM, LPN #3 confirmed she was the nurse on duty the morning of 9/29/2021 when Resident #338 attempted to exit the facility through a door on the 1000 Hall. LPN #3 stated, We heard the door alarm, and we were able to keep her from getting out the door. LPN #3 was asked if Resident #338 exited the building on 9/29/2021. LPN #3 stated, She had one foot in [the facility] and one foot out the door, she was standing in between the door and the outside. LPN #3 confirmed she called the Nurse Practitioner who gave an order to transfer her to a different room. LPN #3 confirmed she made the DON aware that Resident #3 had attempted to exit the door on the 1000 Hall. LPN #3 confirmed a Wander Guard was not placed on Resident #338 due to one not being available. Refer to F-689 The surveyors verified the Removal Plan by: 1. The Nurse Practitioner for Resident #338 was notified on 9/30/2021 at 4:55 PM that Resident #1 exited the facility, expressed a desire to go home, and was agitated. The surveyors interviewed the Nurse Practitioner and reviewed documentation in the medical record. 2. The Nurse Practitioner ordered a one-time dose of Lorazepam for severe agitation and the resident was placed on 1:1 until the resident was calm and allowed a Wander Guard bracelet to be placed. The surveyors interviewed the Nurse Practitioner and reviewed documentation in the medical record. 3. The Elopement Risk Assessment was updated on 9/30/2021 to indicate the resident was an elopement risk and wore a Wander Guard bracelet. The surveyors reviewed the Elopement Risk dated 9/30/2021. 4. The resident Care Plan was updated on 9/30/2021 for elopement risk, exit seeking and for actual elopement. The surveyors reviewed Resident #338's Care Plan. 5. Resident #338 had previously been moved from her room on the 1000 Hall to the 400 Hall at 6:42 AM secondary to the resident's restlessness and attempts to open the door next to her room. Resident #338 was agitated and stated she wanted to go home. Surveyors reviewed documentation in the medical record. 6. On 9/30/2021 at 5:30 PM, the brother of Resident #338 was notified Resident #338 exited the building and was demanding to go home. The brother informed staff that he would be at the facility the next morning to pick the resident up and take her home as she wished. The surveyors reviewed documentation in the medical record. 7. The facility initiated a successful elopement drill at 6:15 PM on 10/19/2021,one on the 11:00 PM-7:00 AM shift, and one on the 7:00 AM-3:00 PM shift on 10/20/2021. Elopement drills will be conducted on each shift weekly for 4 weeks, then monthly for 2 months then resume a quarterly schedule. The surveyors reviewed documentation of elopement drills and interviewed staff. 8. The facility staff completed a new Elopement Risk assessment for each of the 147 residents on 10/19/2021. The surveyors reviewed the Elopement Risk Assessments on all residents. 9. Resident #338 was discharged home with her brother on 10/1/2021 at 11:34 AM and a home health referral was requested. No durable medical equipment was required. Resident #338 and her brother were instructed they should follow up with their Primary Care Physician. The surveyors reviewed documentation in the medical record. 10. On 9/30/2021 and again on 10/1/2021, the facility initiated staff education regarding building security, missing residents, and preventing Resident Elopement rearview. The surveyors reviewed documentation of education and conducted staff interviews on all shifts. 11. On 10/19/2021, the facility initiated re-education regarding building security, missing residents, preventing resident elopement, and neglect for all staff. Any employee who has not completed this education as of 10/20/2021 will not be allowed to work until the education is completed. The surveyors reviewed documentation of the education and conducted staff interviews on all shifts. 12. The Maintenance Director completed a check of all exit doors to ensure they alarmed when the panic bar is pressed on 10/19/2021 at 4:30 PM and found all doors to be in working order. The Maintenance Director will check exit doors weekly for 4 weeks then monthly thereafter. The surveyors reviewed documentation of door checks and interviewed the Maintenance Director. 13. The facility Elopement Risk Books were reviewed and updated on 9/30/2021 by Social Services to ensure all residents at risk were identified and the Care Plan was updated if needed. The surveyors reviewed the Elopement Books on all halls. 14. On 10/19/2021, photos of elopement risk residents were placed in easy view of the Receptionist desk to aid in identification and monitoring of at-risk residents. The surveyors confirmed the photos were in place in the Receptionist office. 15. The Evening Receptionist received 1:1 elopement in-service from the Business Office Manager on 9/30/2021 to stress improving vigilance of monitoring residents in the Front Lobby. The other Receptionist will complete in-service education on 10/20/2021. The surveyors reviewed the in-service training and interviewed the Receptionists. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring the effectiveness of the 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, facility investigation review, video camera footage review, medical record review, observation, and interview, the facility failed to thoroughly investigate incidents of elopement for 1 of 6 sampled residents (Resident #338) reviewed for wandering and exit-seeking behaviors. The facility's failure to thoroughly investigate incidents of elopement resulted in Immediate Jeopardy for Resident #338, a resident with episodes of confusion and hallucinations. Resident #338 exited the facility through the front door without staff supervision or knowledge and was found in front of a town house complex entrance, approximately 459 feet and 6 inches away from the facility. Resident #338 was outside the facility unsupervised for approximately 39 minutes. The facility is located on a congested 2 lane street with a lake across the street from the location where Resident #338 was found sitting on a brick landing. 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 Executive Director and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/21/2021 at 2:02 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 9/30/2021 through 10/21/2021. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 10/22/2021 at 3:46 PM, and was validated onsite by the surveyors on 10/22/2021 through review of incident reports, assessments, Care Plans, elopement book, policies and procedures, in-service education, observations, and staff interviews. The findings include: Review of the facility's undated policy titled, ABUSE PREVENTION, revealed .The facility is committed to protecting the residents from abuse .Neglect .failure of the facility to provide .services necessary to avoid physical harm, mental anguish, emotional distress .will appoint an Abuse Coordinator and inform all staff, residents and family of who holds that position .Identify events such as .occurrences .that may constitute abuse .determine the direction of the investigation .facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect .substantiated cases of resident abuse or neglect .shall be thoroughly investigated, documented .in addition .is to be reported to at least one law enforcement agency .It is the responsibility of all staff to provide a safe environment for the residents . Review of the facility's policy titled, MISSING RESIDENT/ELOPEMENTS, revised 7/2018, revealed .The Unit Nurse is responsible for knowing the location of their residents .It is the responsibility of all personnel to report any resident attempting to leave the premises .facility personnel should discuss and document the facts . Review of the facility's policy titled, RESIDENT BILL OF RIGHTS, revised 11/2017, revealed .Each resident has a right to a dignified existence .the right to be free of abuse, neglect . Review of the medical record, revealed Resident #338 was admitted to the facility on [DATE] with diagnoses of Coronavirus, Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure, Polyarthritis, Convulsions, Pancytopenia, Cystitis, and Asthma. Review of the Risk for Elopement Evaluation dated 9/28/2021, revealed .NO RESIDENT IS NOT AT RISK FOR ELOPEMENT . Review of the Risk for Elopement Evaluation dated 9/30/2021 at 4:00 PM, revealed Resident #338 was having hallucinations, had attempted to leave the facility prior to the elopement, wandered aimlessly, and pushed on exit door handles. Resident #338 had also stated, I am going home . Resident #338 was documented at risk for elopement. Review of the witness statement written by Licensed Practical Nurse (LPN) #1 dated 9/30/2021, revealed .[Named Resident #338] was down Central Hall ambulating .this nurse attempted to redirect .Resident became aggressive and agitated .nurse proceeded to alert social services .she [Resident #338] wanted to go home . Review of the facility's investigation, revealed LPN #1's witness statement was the only statement in the investigation. Review of the Incident Report dated 9/30/2021 at 5:00 PM, revealed Resident #338 was found in the parking lot on the kitchen side of the facility and was then found by staff along the fence line. Review of the facility's video camera footage of the East Entrance French doors dated 9/30/2021, revealed the following: At 3:32 PM, Resident #338 was ambulating down the East Hallway toward the East Entrance French doors with LPN #1 walking behind her. Resident #338 and LPN #1 remained at the door having a conversation, LPN #1 pointed toward the East hallway and Resident #338 pointed toward the Front lobby. At 3:45 PM, LPN #1 walked back down the East hallway and left Resident #338 at the East Entrance French doors, unsupervised and unattended. At 3:46 PM, Resident #338 stepped out of sight of the camera and then returned into view of the camera and was standing at the East Entrance French Doors. Resident #338 walked through the East Entrance French doors into the Front Lobby, walking toward the glass Front Entrance doors that leads outside the facility. Review of the facility's video camera footage of the Front Door Entrance dated 9/30/2021, revealed the following: At 3:47 PM, Resident #338 walked toward the Front Door Entrance. Resident #338 pushed on the right side of the door. The door appeared to be locked. Resident #338 then pushed on the left side of the door. The door opened with a 4 second delay and Resident #338 exited the building through the front door. Resident #338 sat on a bench located to the right of the Front Door Entrance and remained there until 3:53 PM. At 3:53 PM, Resident #338 stood up and attempted to reenter the building without success. The door appeared to be locked. At 3:54 PM, Resident #338 ambulated away from the bench and appeared to ambulate toward the parking lot to the right of the facility and was no longer visible on the video footage. At 3:57 PM, the Maintenance Director walked from the East Entrance French doors through the front lobby and exited the front door. At 3:58 PM, Maintenance Assistant #1 and #2 entered the Front Lobby through the East Entrance French doors and exited the facility through the front doors. At 3:59 PM, LPN #1 came through the East Entrance French doors, went to the Receptionist window, and appeared to be speaking to the Receptionist. LPN #1 then looked around the lobby and looked through the glass door but did not open the door. At 4:00 PM, LPN #1 exited the Front Lobby and went back through the East Entrance French doors. At 4:03 PM, LPN #1 returned to the Front Lobby and exited the Front Lobby through the double glass front door. At 4:04 PM, the Social Services Director exited the facility through the double glass front doors. At 4:05 PM, Receptionist #2 came out of the office and stood at the edge of the Receptionist Window in the Front Lobby. At 4:07 PM, LPN #1 came back into the facility and went through the East Entrance French Doors. At 4:26 PM, 2 male staff members assisted Resident #338 back into the facility in a wheelchair. The following forms were provided by the facility that are to be used in their investigation process: Supervisor Investigation Summary Form and Elopement Checklist. These forms were not included in the investigation packet provided by the facility for Resident #338. Observation on 10/13/2021 at 4:30 PM of the area outside the facility where Resident #338 was located, the Maintenance Director used a measuring device to measure from the Front Entrance doors to the location where the Social Service Director and the Registered Dietician indicated Resident #338 was found. The distance measured was a total of 459 feet and 6 inches. The speed limit on the two-lane street in front of the facility was 45 miles per hour for both the East and [NAME] bound traffic. The Maintenance Director confirmed it is always a heavy traveled city street. During an interview on 10/13/2021 at 5:26 PM, the Executive Director was asked if elopement drills and in-services were conducted on all shifts. The Executive Director stated, .no we did not do on 11-7 [11:00 PM-7:00 AM] shift, I feel like we should have . The Executive Director was asked if all the doors were checked in the facility after the elopement. The Executive Director stated, I think they checked the front door and then the other doors I am not sure about . During an interview on 10/19/2021 at 2:15 PM, the Executive Director confirmed she did not know if the front door alarm had sounded. The Executive Director confirmed she did not know how Resident #338 exited the building. The Executive Director confirmed she verbally spoke to employees instead of asking for individual written statements. The Executive Director confirmed she did not have a list of staff that she had spoken to about the incident and was unsure where Resident #338 was found. During an interview on 10/20/2021 at 3:29 PM, the [NAME] President confirmed the Executive Director should have received more individual statements from staff working the day of the elopement and confirmed there was not a list of staff that found Resident #338 when she eloped from the facility. The facility failed to accurately document Resident #338's elopement, obtain written witness statements from staff working the day of the elopement, failed to thoroughly investigate, failed to conduct maintenance door checks, and the Executive Director was uncertain of the details of the elopement. Refer to F-600, F-689, and F-835. The surveyors verified the Removal Plan by: 1. In-service education was completed on 10/21/2021 with the Executive Director, the DON, and the Assistant Director of Nursing (ADON) on completing a thorough investigation utilizing the Investigation Elopement Checklist and Supervisory Investigation Summary tool provided by the [NAME] President. Surveyors interviewed the [NAME] President, the DON, and the ADON, and reviewed the Investigative Elopement Checklist and Supervisory Investigation Summary tools. 2. A root cause of the event will be obtained by utilizing the Elopement Checklist and the Supervisory Investigation Summary Tool as a guide. The surveyors reviewed the Supervisory Investigation Summary tool forms for elopement. 3. All facility elopement investigations will be reviewed and approved by a member of the Administrative Support staff (Vice President or Clinical Operations Nurse) to ensure a thorough investigation has been completed prior to the final 5-day submission to the Unusual Incident Reporting System. The surveyors interviewed the [NAME] President. 4. The completed elopement investigation will be reviewed by the Quality Assurance Performance Improvement (QAPI) committee during quarterly meetings. The completed elopement investigation will be reviewed by the QAPI committee quarterly. The surveyors interviewed the [NAME] President and the Administrator. The facility's noncompliance at F-610 continues at a scope and severity of D for monitoring the effectiveness of the 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 camera footage review, medical record review, observation, and interview, the facility failed to provide adequate supervision for a resident with confusion and periods of hallucinations and failed to place and monitor a Wander Guard (mechanical bracelet device to alert staff of wandering residents that causes the door to alarm when a resident is close to exit door) for function for 2 of 6 sampled residents (Resident #96 and Resident #338) reviewed for wandering behaviors and elopement. Resident #338 exited the facility without staff supervision and knowledge and was found off the facility property, sitting on a concrete block at the entrance into a townhouse community, with a lake across the street. The resident was located approximately 459 feet and 6 inches from the front entrance of the facility, 0.2 of a mile from a busy intersection, and 172 feet from a two-lane busy street that had a 45 miles per hour speed limit. Resident #338 was outside the facility, unsupervised for approximately 39 minutes. The facility's failure resulted in Immediate Jeopardy for Resident #338. 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 Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/19/2021 at 2:45 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited an Immediate Jeopardy at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 9/30/2021 through 10/21/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 10/20/2021 at 5:27 PM, and was validated onsite by the surveyors on 10/22/2021 through policy review, observation, medical record review, review of education records, auditing tools, and staff interviews. The findings include: Review of the facility's policy titled, MISSING RESIDENT/ELOPEMENTS, dated 7/2018, revealed .The Unit Nurse is responsible for knowing the location of their residents . Review of the facility's policy titled, Elopement Guidelines, dated 8/2017, revealed .The Elopement Risk Evaluation is to be done upon admission and quarterly & [and] as needed with exit seeking behaviors .Wander Guard alert bracelets [mechanical bracelet device to alert staff of wandering residents that make the door alarm when a resident is close to exit door] (if used) are in place. Bracelets are to be checked each shift by nursing .When exit seeking activity occurs consider 1:1 [one on one] supervision or 15 minute checks . Review of the medical record revealed, Resident #338 was admitted to the facility on [DATE] with diagnoses of Coronavirus, Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure, Polyarthritis, Convulsions, Pancytopenia, Cystitis, and Asthma. Review of the Risk for Elopement Evaluation dated 9/28/2021, revealed .NO RESIDENT IS NOT AT RISK FOR ELOPEMENT . Review of Resident #338's Base Line Care Plan dated 9/28/2021, revealed .Mental health needs .Psych [psychiatric] .panic d/o [Disorder] .concerns with hallucinations & thought process .Hx [History of] substance abuse . Review of the Departmental Notes dated 9/29/2021 at 6:30 AM, revealed .Resident is alert to self with confusion noted, also having hallucinations. Redirected several times without success. Her thought process is scattered . Review of the Departmental Notes for Resident #338 dated 9/29/2021 at 6:42 AM, revealed .Resident [Resident #338] very up set [upset] this am .Resident states she is going home .Resident noted to be speaking with people that were not there .Difficult to redirect, notable visual [seeing] and auditory [hearing] hallucination. Resident attempting to get out the door next to her room. Became upset when redirected and states that she will leave if she wants to . Review of the Departmental Notes dated 9/29/2021 at 9:52 AM, revealed. Resident is alert to self with confusion noted, continues to have hallucinations. Redirected several times w/o [without] success . Review of the Risk for Elopement Evaluation dated 9/30/2021 at 4:00 PM, revealed Resident #338 was having hallucinations and had attempted to leave the facility prior to the elopement. Resident #338 .wandered aimlessly and pushed on exit door handles . Resident #338 also stated, I am going home . and was at risk for elopement. Review of the facility's video camera footage of the East Entrance French doors dated 9/30/2021, revealed the following: a. At 3:32 PM, Resident #338 was ambulating down the East Hallway toward the East Entrance French doors, dressed in a short sleeve purple shirt, light colored pants, open toed shoes with white socks, a purse on her left arm and a white cup in her right hand, Licensed Practical Nurse (LPN) #1 was walking behind her. Resident #338 and LPN #1 remained at the door involved in a conversation. LPN #1 pointed toward the East hallway and Resident #338 pointed toward the Front lobby. b. At 3:45 PM, LPN #1 walked down the East hallway and left Resident #338 at the East Entrance French doors, unsupervised and unattended. c. At 3:46 PM, Resident #338 stepped out of sight of the camera and then returned into sight and was standing at the East Entrance French doors. Resident #338 walked through the East Entrance French doors into the Front Lobby towards the Front Entrance doors that leads outside the facility. Review of the facility's video camera footage of the Front Entrance doors dated 9/30/2021, revealed the following: a. At 3:47 PM, Resident #338 walked toward the double glass Front Door Entrance. Resident #338 pushed on the right side of the door, the door appeared to be locked, Resident #338 then pushed on the left side of the door. The door opened with a 4-second delay and Resident #338 exited the building. Resident #338 sat on a bench that was located to the right of the Front Door Entrance and remained there until 3:53 PM. b. At 3:53 PM, Resident #338 stood up from the bench and attempted to reenter the building through the Front Door Entrance without success. c. At 3:54 PM, Resident #338 ambulated away from the bench, appeared to ambulate towards the parking lot to the right of the facility, and was no longer seen on the video footage. d. At 3:57 PM, the Maintenance Director walked through the Front Lobby from the East Entrance French doors and exited the double glass front door. e. At 3:58 PM, Maintenance Assistant #1 and #2 entered the Front Lobby from the East Entrance French doors and exited the facility through the double glass front doors. f. At 3:59 PM, LPN #1 came through the East Entrance French doors, went to the Receptionist window, and appeared to be speaking to the Receptionist. LPN #1 looked around the Front Lobby, looked through the glass door, but did not open the door. g. At 4:00 PM, LPN #1 exited the Front Lobby and went through the East Entrance French doors. h. At 4:03 PM, LPN #1 returned to the Front Lobby and exited the Front Lobby through the Front door. i. At 4:04 PM, the Social Services Director exited the facility through the Front doors. j. At 4:05 PM, Receptionist #2 came out of the office and stood at the edge of the Receptionist Window in the Front Lobby. k. At 4:07 PM, LPN #1 entered the facility and went through the East Entrance French Doors. l. At 4:26 PM, 2 male staff members assisted Resident #338 into the facility in a wheelchair. Review of the Incident Report dated 9/30/2021, revealed, .Incident Type .Wande [Wandering] on Grounds .Type of Injury .None .Date/Time .9/30/2021 .03:47 PM .Activity at time .exiting facility .Witness 1 .[Dietician] .Witness 2 [Director of Social Services] .Narrative of Incident and description of injuries .Resident was noted at the front doors stating she wanted to go home with the nurse. The nurse left to call the resident's son and brother to let them know the resident wanted to go home. While the nurse was doing this, the resident remained at the double doors and watched the comings and goings of the front lobby. At approximately 3:48 PM, the resident walked through the double doors into the front lobby went to the front door where she pushed the door until it opened and walked out in the parking lot .the resident was found in the parking lot .she was found by staff along the fence line .after much encouragement and re-direction staff was able to get resident back into the building .Family notified .FNP [Family Nurse Practitioner] notified . Review of the facility's Investigation dated 9/30/2021, revealed a handwritten statement by LPN #1 that documented, .On September 30, 2021, [Named Resident #338] was down Central Hall ambulating onto another floor, this nurse attempted to redirect resident back on the Central Hall. Resident became aggressive and agitated. Therefore, this nurse proceeded to alert Social Services so we can place a call to the brother and son informing them she wanted to go home . During an interview on 10/13/2021 at 10:20 AM, the Executive Director confirmed Resident #338 exited the facility on 9/30/2021 at approximately 4:00 PM without staff supervision or knowledge. The Executive Director confirmed staff failed to inform her of Resident #338's confusion and periods of hallucinations until she began her investigation into the elopement. The Executive Director stated, All my knowledge came post [after the incident] elopement. The Executive Director was asked if she should have been informed when Resident #338 began exhibiting the wandering and exit seeking behaviors on 9/29/2021. The Executive Director stated, Yes . The Executive Director was asked where was Resident #338 found. The Executive Director stated, .they found her at the fence line that took her off the property . The Administrator confirmed Resident #338 was not assisted back into the facility until 4:40 PM on 9/30/2021. During an interview on 10/13/2021 at 1:10 PM, LPN #1 confirmed she was the nurse on duty when Resident #338 exited the facility. LPN #1 stated, .I was passing medications and I seen [saw] her walk past me going off the unit and I walked behind [her] to try to get her to come back and she became agitated and I left her alone for a minute and I was going to notify the Social Worker to see if they could put a bracelet [Wander guard] on her and I went to call her family and let them know how agitated she was and by the time I finished she was not behind me and I went up front looking for her and I didn't see her and I went back on the floor and asked a few people and I asked the Receptionist and she hadn't seen her and I looked outside the door and I didn't see her and I walked out the building and I walked around and I informed someone to call a Dr. Wander [Missing Resident Alert] . During an interview on 10/13/2021 at 1:37 PM, the DON confirmed she was off the day of the elopement and the Administrator had informed her by telephone that Resident #338 had exited the facility on 9/30/2021 at approximately 4:00 PM. The DON confirmed LPN #1 was the attending nurse for Resident #338 on 9/30/2021. The DON confirmed Resident ##338 was initially admitted to the facility on [DATE] on the 1000 Hall and was moved to another room on the 400 Hall on 9/29/2021 due to voicing her desire to leave the facility and attempting to push on an exit door on the 1000 Hall. During an interview on 10/13/2021 at 2:10 PM, the Maintenance Director confirmed he was working when Resident #338 exited the facility. The Maintenance Director confirmed he was in the front of the facility cutting down a tree with 2 of his assistants when the Dr. Wander was called. The Maintenance Director confirmed he checks the facility doors daily for proper working condition. The Maintenance Director was asked when the doors were checked on 9/30/2021. The Maintenance Director confirmed he checked the doors early that day prior to the elopement. The Maintenance Director was asked if he checked the doors on 9/30/2021 after Resident #338 exited the facility and stated he checked the Front Entrance doors on 9/30/2021 at 4:30 PM when Resident #338 was assisted back into the facility and none of the other doors were checked until 10/1/2021. During an interview on 10/13/2021 at 3:53 PM, the Social Service Director confirmed she was responsible for oversight of the Wander Guard administration. The Social Service Director confirmed a Wander Guard is used when a resident is actively exit seeking or making comments about leaving the facility and had the capability to do so. The Social Service Director confirmed the Wander Guard makes the door alarm sound if a resident with a Wander Guard gets close to the door and the alarm alerts staff to respond. The Social Service Director confirmed she checks the Wander Guards and ensures they are available for staff to use when there is a need. The Social Service Director was asked if she was aware Resident #338 attempted to exit a door on the 1000 Hall on 9/29/2021 at 6:30 AM and there was no Wander Guard available for staff to apply. The Social Service Director confirmed she was not informed of Resident #338's wandering and exit seeking behavior on 9/29/2021 or the need for a Wander Guard. She stated she should have been informed of that situation but was not informed Resident #338 had exhibited any exit seeking behaviors until 30 minutes prior to her exiting the facility. The Social Service Director was asked if she responded to the Dr. Wander and confirmed she did respond to the Dr. Wander and went out the Front Exit door looking for Resident #338. The Social Service Director confirmed that she and the Maintenance Director and the Registered Dietician went to the end of the facility's driveway at the same time along with other staff members and saw Resident #338 sitting on a white brick wall, located down a sidewalk off the facility property. Observation on 10/13/2021 at 4:30 PM of the area outside the facility where Resident #338 was located, the Maintenance Director used a measuring device to measure the distance from the Front Entrance doors to the location where the Social Service Director and the Registered Dietician indicated Resident #338 was found. The distance measured was a total of 459 feet and 6 inches. The speed limit for the two lane street was 45 miles per hour for both the East and [NAME] bound lanes of traffic. The Maintenance Director confirmed it was always a heavily traveled city street. During an interview on 10/15/2021 at 11:54 AM, the Registered Dietician (RD) confirmed she was working the day that Resident #338 exited the facility. The RD confirmed the Dr. Wander was called at approximately 4:00 PM. The RD stated she responded to the Dr. Wander and exited the facility on the East Side of the building into the parking lot near the fence. The RD was asked where Resident #338 was located and stated, She was sitting along-side the fence facing the road but sitting down. The RD was asked what Resident #338 was sitting on and stated, I think it was [an] area of rocks or [a] rock wall . The RD confirmed other staff were with the resident when she arrived. During an interview on 10/19/2021 at 8:25 AM, the Assistant Director of Nursing (ADON) confirmed she was on duty when Resident #338 exited the facility. The ADON was asked what procedure the facility followed when a resident exhibited wandering and exit seeking behaviors. The ADON stated the Social Service Director, DON, herself if the DON is not available, the physician, and psychiatric services are notified. The ADON was asked if she was aware that Resident #338 had exhibited wandering and exit seeking behaviors on 9/29/2021 at 6:30 AM and the ADON stated she was not made aware and should have been informed. The ADON was asked when she became aware that Resident #338 had exited the facility and confirmed LPN #1 made her aware between 3:30 PM and 4:00 PM on 9/30/2021 that she could not locate Resident #338, and she then called a Dr. Wander. The ADON confirmed Resident #338 was found toward the East end of the building at the end of the parking lot by the edge of the fence. During an interview on 10/19/2021 at 10:55 AM, LPN #3 confirmed she was the nurse on duty the morning of 9/29/2021 when Resident #338 attempted to exit the facility through a door on the 1000 Hall. LPN #3 stated, We heard the door alarm, and we were able to keep her from getting out the door .She had one foot in [the facility] and one foot out the door, she was standing in between the door and the outside. LPN #3 confirmed she called the Nurse Practitioner who gave an order to transfer her to a different room. LPN #3 confirmed she made the DON aware that Resident #3 had attempted to exit the door on the 1000 Hall. LPN #3 confirmed a Wander Guard was not placed on Resident #338 because there was not a Wander Guard available. During an interview on 10/19/2021 at 1:54 PM, the Executive Director confirmed Wander Guards should be made easily accessible for staff when the need arises. The Executive Director stated she was made aware of Resident #338 attempting to exit the door on the 1000 Hall on 9/29/2021 at 6:30 AM by LPN #3. The Executive Director stated, .she [LPN #3] told me that she [Resident #338] wanted to go home and went to the door and I told her to initiate the Wander Guard and move her to the 400 Hall to get her away from the exit door. The Executive Director confirmed staff failed to inform her that a Wander Guard was unavailable. The Executive Director was asked if she should have been informed there was not a Wander Guard available and replied Yes. Review of the medical record, revealed Resident #96 was admitted to the facility on [DATE] with diagnoses of Dementia, Psychosis, Depression, Post Traumatic Stress Disorder, and Violent Behavior. Review of the 5-day admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #96 was moderately cognitively impaired with daily decision making, wandering that intruded on the privacy of others, and a wander/elopement alarm was used. Review of the facility's admission Elopement Risk Evaluation dated 7/21/2021, revealed .dementia .Yes, resident is at risk for elopement . Review of the Care Plan revised 7/26/2021, revealed, .Wanders .place monitoring device on resident that sounds alarms when resident leaves building .PROBLEM ONSET .7/26/2021 . Review of a Physician's Order dated 8/12/2021, revealed .check function and placement of Wander Guard every shift right wrist . Review of the Nurses' Notes and MAR, revealed the Wander Guard was not placed on Resident #96 until 7/26/2021, and the placement and function of Wander Guard was not monitored until 8/12/2021. During an interview on 10/22/2021 at 9:52 AM, the Social Service Director confirmed Resident #96 was an elopement risk upon his admission into the facility on 7/21/2021. The Social Service Director confirmed the facility failed to apply a Wander Guard for the prevention of elopement until 7/26/2021, 5 days after admission. The Social Service Director confirmed the facility failed to monitor the Wander Guard for placement and function after the application of the Wander Guard on 7/26/2021, until 8/12/2021. Refer to F-600 and F-610. The surveyors verified the Removal Plan by: 1. The Nurse Practitioner for Resident #338 was notified on 9/30/2021 at 4:55 PM that Resident #338 exited the facility, expressed a desire to go home, and was agitated. The surveyors interviewed the Nurse Practitioner and reviewed documentation in the medical record. 2. The Nurse Practitioner ordered a one-time dose of Lorazepam for severe agitation for Resident #338. The Lorazepam was administered at 5:00 PM on 9/30/21 and Resident #338 was placed on 1:1 monitoring until she was calm and allowed a Wander Guard bracelet to be placed on her. The surveyors interviewed the Nurse Practitioner and reviewed documentation in the medical record. 3. The Elopement Risk Assessment was updated on 9/30/2021 to indicate Resident #338 was an elopement risk with a Wander Guard in place. The surveyors reviewed the Elopement Risk Assessment. 4. Resident #338's Care Plan was updated on 9/30/2021 for elopement risk and exit seeking, and for actual elopement. The surveyors reviewed Resident #338's Care Plan. 5. At 5:30 PM on 9/30/2021, the brother of Resident #338 was notified that Resident #1 exited the building and was demanding to go home. The brother informed staff that he would be at the facility the next morning to take the resident home as she wished. The surveyors reviewed documentation in the medical record and interviewed the brother. 6. The facility initiated a successful elopement drill on the 11:00 PM-7:00 AM shift on 10/19/2021 and the 7:00 AM-3:00 PM shift on 10/20/2021. Elopement drills will be conducted on each shift weekly for 4 weeks, then monthly for 2 months, then resume the quarterly schedule. The surveyors reviewed documentation of the elopement drills and interviewed staff. 7. The facility staff completed a new Elopement Risk Assessment for each of the 147 residents on 10/19/2021. The surveyors reviewed the Elopement Risk Assessments conducted on all the residents. 8. Resident #338 was discharged home with her brother on 10/1/2021 and a Home Health referral was made. No durable medical equipment was required. The surveyors reviewed the documentation in the medical record. 9. The facility initiated staff education on 9/30/2021 and again on 10/1/2021 regarding building security, missing residents, and preventing Resident Elopement. The surveyors reviewed documentation of the education and conducted staff interviews. 10. The facility initiated re-education regarding building security, missing residents, and preventing resident elopement, and neglect on 10/19/2021. Any employee who has not completed this education as of 10/20/2021 will not be allowed to work until education completed. The surveyors reviewed the documentation of the education and conducted staff interviews. 11. The Maintenance Director completed a check of all exit doors to ensure they alarmed when the panic bar is pressed on 10/19/2021 and found all doors to be in correct working order. The Maintenance Director will check exit doors weekly for 4 weeks and then monthly thereafter. The surveyors reviewed documentation of the door checks and interviewed the Maintenance Director. 12. The facility elopement risk books were reviewed and updated on 9/30/2021 by Social Services to ensure all residents at risk for elopement were identified and the Care Plans were updated if needed. The surveyors reviewed the elopement books on all halls and the Care Plans. 13. The facility placed photos of elopement risk residents in easy view of the Receptionist desk to aid in identification and monitoring of at-risk residents on 10/19/2021. The surveyors confirmed photos were in place in the Receptionist office. 14. The Evening Receptionist received a 1 on 1 elopement in-service from the Business Office Manager on 9/30/2021 to stress improving vigilance of monitoring residents in the Front Lobby. The other Receptionist will complete in-service education on 10/20/2021. The surveyors reviewed in-service training and interviewed the Receptionists. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring the effectiveness of the correction 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, job description review, medical record review, and interview, the facility Administration failed to administer the facility in a manner that protected residents that wandered and exhibited exit seeking behavior from eloping from the facility. Administration failed to provide oversight to monitor and provide a safe resident environment for a confused resident with periods of hallucinations from exiting the facility without staff knowledge or supervision, failed to thoroughly investigate an incident of elopement, failed to ensure policies related to wandering and elopement were followed, and failed to ensure Wander Guards (mechanical bracelet device to alert staff of wandering residents that would cause the door to alarm when a resident is close to an exit door) were available to use on residents with wandering behaviors. The facility's failure resulted in Immediate Jeopardy when Resident #338 exited the front door of the facility and was found on a brick landing of a housing complex that was approximately 459 feet and 6 inches from the facility, with a lake across the street, was 0.2 miles from a busy intersection, and 172 feet from a two-lane busy street in front of the facility which had a 45 miles per hour speed limit. Resident #338 was outside the facility unsupervised for approximately 39 minutes. 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 Executive Director and Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/21/2021 at 2:02 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600, F-610, F-689, and F-835. The facility was cited F-600, F-610, and F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 9/30/2020 through 10/21/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 10/22/2021 at 3:46 PM and was validated onsite by the surveyors 10/22/2021 through review of in-service records, policies and procedures, and staff interviews. The findings include: Review of the facility's undated policy titled, ABUSE PREVENTION, revealed .The facility is committed to protecting the residents from abuse .Neglect .failure of the facility to provide .services necessary to avoid physical harm, mental anguish, emotional distress .Identify events such as .occurrences .that may constitute abuse .determine the direction of the investigation .facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect .substantiated cases of resident abuse or neglect .shall be thoroughly investigated, documented .It is the responsibility of all staff to provide a safe environment for the residents . Review of the facility's policy titled, MISSING RESIDENT/ELOPEMENTS, revised 7/2018, revealed .It is the responsibility off all personnel to report any resident attempting to leave the premises .facility personnel should discuss and document the facts . Review of the facility's policy titled Elopement Guidelines, dated 8/2017, revealed .The Elopement Risk Evaluation is to be done upon admission and quarterly & as needed with exit seeking behaviors .When exit seeking activity occurs consider 1:1 [one on one] supervision or 15 minute checks . Review of the Executive Director's Job Description, revealed .The Executive Director leads and directs the overall operation of the facility in accordance with resident needs, government regulations and facility policies so as to maintain Quality Care for residents while achieving the facility' business objectives .Works with facility management staff in planning all aspects of facility's operations .Monitors each department's activities, communicates policies, evaluates performance .Is knowledgeable of resident rights and supports an atmosphere which allows for the privacy, dignity and well-being of all residents in a safe, secure environment . Review of the Director of Nursing Services Job Description, revealed .Responsible for the overall management of resident care .Participates in coordination of resident services through departmental and appropriate staff committee meetings .Reviews Accidents and Incidents (A/I) and develops an appropriate plan to prevent future accidents and incidents . Review of the medical record, revealed Resident #338 was admitted to the facility on [DATE] with diagnoses of Coronavirus, Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure, Polyarthritis, Convulsions, Pancytopenia, Cystitis, and Asthma. Review of the Departmental Notes dated 9/29/2021 at 6:30 AM, revealed, .Resident is alert to self with confusion noted, also having hallucinations. Redirected several times without success. Her thought process is scattered . Review of the Departmental Notes dated 9/29/2021 at 9:52 AM, revealed.Resident is alert to self with confusion noted, continues to have hallucinations. Redirected several times w/o [without] success . Review of the Risk for Elopement Evaluation dated 9/30/2021 at 4:00 PM, revealed Resident #338 was having hallucinations and had attempted to leave the facility prior to the elopement. Resident #338 .wandered aimlessly and pushed on exit door handles . Resident #338 also stated, I am going home . and was at risk for elopement. Review of the facility's investigation dated 9/30/2021 for the elopement of Resident #338 revealed the investigation only included a statement from 1 staff member regarding the incident of elopement. The facility was unable to provide any other witness statements (other than Licensed Practical Nurse (LPN) #1) regarding the incident or Resident #338's behavior prior to the incident from staff working with the resident. The following forms were provided by the facility that are to be used in their investigation process: Supervisor Investigation Summary Form and Elopement Checklist. These forms were not included in the investigation packet provided by the facility for Resident #338. During an interview on 10/19/2021 at 10:55 AM, LPN #3 confirmed she was the nurse on duty the morning of 9/29/2021 when Resident #338 attempted to exit the facility through a door on the 1000 Hall and called the Nurse Practitioner who gave an order to transfer Resident #338 to a different room. LPN #3 stated she notified the DON of the incident and a Wander Guard was not placed on the resident due to the facility not having one available. During an interview on 10/19/2021 at 11:14 AM, the Social Services Director confirmed she is responsible for making certain Wander Guards are available on each unit, and for checking them quarterly to ensure they are within date and functional. The Social Services Director confirmed that on 10/1/2021 the Wander Guard at the East Station was out of date and the [NAME] Station did not have a Wander Guard available to use on a resident with wandering behaviors. The Social Services Director was asked if the management team discussed residents with behaviors in the Morning Management Meeting. The Social Services Director stated, .No, they probably do that in clinical (morning clinical meeting) . The Social Services Director was asked if she attends the clinical meeting. The Social Services Director stated, No. The Social Services Director was asked if she should have been made aware of Resident #338's wandering behaviors and stated Yes The facility failed to ensure Wander Guard devices were available for staff to place on residents when new behaviors of wandering and exit seeking were identified. During an interview on 10/19/2021 at 1:55 PM, the DON confirmed Social Services is responsible for ensuring Wander Guards are available to staff. The DON confirmed residents behaviors are discussed in the morning clinical meeting. The DON was asked who attends the meeting and stated Social Services, the DON, ADON [Assistant Director of Nursing], Unit Managers and MDS [Minimum Data Set Coordinator]. The DON was asked if she was made aware of Resident #338's wandering behaviors on 9/29/2021 and stated, Yes. I told her [LPN #3] to initiate the Wander Guard and move her [Resident #338] to a hall away from the doors. The DON was asked if a Wander Guard was implemented at that time. The DON stated, No, staff reported that she refused. During an interview on 10/19/2021 at 2:15 PM, the Executive Director was asked who received education on elopement following the incident. The Executive Director stated, Whoever was here that day, the next day, through the weekend. The Executive Director was asked if elopement drills were conducted following the incident. The Executive Director stated, We failed to do it on 11-7 [11:00 PM-7:00 AM shift] because the actual elopement happened on 3-11 [3:00 PM-11:00 PM shift]. The Executive Director was asked if she attends the morning clinical meeting. The Executive Director stated, Not all the time. The Executive Director was asked if she was made aware of wandering residents' behaviors. The Executive Director stated, I'm not made aware of all behaviors .It would depend on the severity of the behavior. The Executive Director was asked if written statements were obtained from staff about the incident. The Executive Director stated, I got statements from the original nurse but that's all .Everything else was on the video .I did a notebook piece of paper and wrote down what was seen on the camera. The Executive Director was asked if there a Receptionist at the desk. The Executive Director stated, .We have a 2-10 [2:00 PM -10:00 PM] .I spoke to her. She said she had stepped out of the area to let someone know they had a phone call .In all likely hood the Receptionist may have let her [Resident #338] out, but she is claiming verbally she didn't. The Executive Director confirmed the Receptionist did not write a statement following the event. During an interview on 10/20/2021 at 3:29 PM, the [NAME] President of Operations confirmed the facility should have obtained statements from staff as part of the investigation. Refer to F-600, F-610, and F-689. The surveyors verified the Removal Plan by: 1. In-service education by the [NAME] President was completed on 10/21/2021 at 3:15 PM, with the Executive Director, the DON, and the ADON on completing a thorough investigation utilizing the provided investigation checklist for elopements and the Supervisory Investigation Summary tool. The surveyors reviewed the in-service documentation and interviewed the Executive Director, DON, and ADON. 2. A root cause of the event will be obtained by utilizing the Elopement Checklist and the Supervisory Investigation tool as a guide. The surveyors reviewed the Elopement Checklist and Supervisory Investigation tool and interviewed staff regarding use of the forms. 3. All facility elopement investigations will be reviewed and approved by a member of the Administrative Support staff (Vice President or Clinical Operations Nurse) to ensure a thorough investigation has been completed prior to the final 5-day submission to the Unusual Incident Reporting System. The surveyors interviewed the Executive Director and the [NAME] President of Operations. 4. The [NAME] President and or designee will make on site visits to provide over site monthly for 3 months and at a minimum of quarterly thereafter to ensure Administration administers the facility in a manner that enables its resources to efficiently and effectively attain and maintain the highest practical well-being of the residents. The surveyors interviewed the [NAME] President. 5. The facility initiated a successful elopement drill on 10/19/2021 on the 11:00 PM-7:00 AM shift, and 7:00 AM-3:00 PM shift on 10/20/2021. Elopement drills will be done on each shift weekly for 4 weeks, then monthly for 2 months, then resume a quarterly schedule. The surveyors reviewed documentation of elopement drills and interviewed the Maintenance Director. 6. The facility initiated re-education regarding building security, missing residents and preventing resident elopement, and neglect on 10/19/2021. Any employee who has not completed this education by 10/20/2021 will not be allowed to work until the education is completed. The surveyors interviewed staff on all shifts regarding education. 7. On 10/19/2021 at 4:30 PM the Maintenance Director completed a check of all exit doors to ensure they alarm when the panic bar is pressed and found all doors to be in correct working order. The Maintenance Director will check exit doors weekly for 4 weeks then monthly thereafter. The surveyors reviewed documentation of the door checks and interviewed the Maintenance Director. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.