**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, medical record review, observation, and interview, the facility failed to ensure a safe, secure environment for a vulnerable and high-risk resident with wandering behaviors for 1 of 5 sampled residents (Resident #1) reviewed for elopement/wandering. The facility's failure to ensure a safe, secure environment resulted in Immediate Jeopardy (IJ) when Resident #1 exited the facility through the window in his room. Resident #1's sister called the facility around 5:30 AM to notify the facility that Resident #1 was found sitting on her front porch which was approximately 3 miles from the facility, along highly trafficked city streets and in a heavily populated area. Facility staff were unaware Resident #1 had exited the facility for approximately 8 and a half hours. 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 was notified of the Immediate Jeopardy (IJ) on 11/7/2024 at 8:05 PM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ began 6/22/2024 through 6/26/2024. The Immediate Jeopardy was removed on 6/27/2024 when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyor on 9/9/2024 and 9/10/2024. The facility was cited as past non-compliance and is not required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Elopements and Wandering Patients, dated 2/5/2024, revealed, .To provide guidance on elopement and residents who exhibit wandering behaviors and/or are at risk for elopement .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so .The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, Evalution and analysis of hazards and risks, implementing interventions when necessary .Residents shall be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team .Adequate supervision shall be provided to help prevent accidents or elopements . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Acute Cystitis with Hematuria, Chronic Kidney Disease, Adult Failure to Thrive, Schizoaffective Disorder, Unspecified Convulsions, Dementia, Depression, Repeated Falls, Epileptic Seizures without Status Epilepticus, Muscle Weakness, and Other Lack of Coordination. Review of the Elopement Risk Assessment for Resident #1 dated 4/24/2024, revealed the resident experienced periods of cognitive impairment and/or poor decision-making skills, ambulated independently, and had a history of eloping from home or the facility. A wander guard bracelet was implemented, and Resident #1's care plan was initiated/updated to reflect his elopement risk and the interventions which were implemented. Review of the Psychiatric Evaluation dated 4/29/2024, for Resident #1 revealed .Reports from hospital suggest patient [Resident #1] is an elopement risk .When asked patient [Resident #1] why he was at the facility stated 'I do not know'. Impaired judgement and insight. Patient [Resident #1] showing deficits in his ability to process, abstraction, rationalize information . Review of the Elopement Risk Assessment for Resident #1 dated 5/15/2024, revealed Resident #1 experienced a change in status, cognitive impairment, poor decision-making skills, and ambulates independently. Further review revealed patient made comments about leaving the facility and experienced exit seeking behaviors. Interventions implemented were a wanderguard, diversional activities, care plan initiated and updated to reflect elopement risk and interventions. Resident #1 was given education on the risk of leaving the facility to seek out substance, discharge process including Against Medical Advice (AMA), and Leave of Absence (LOA) process. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated no cognitive impairment, and the resident sustained a fall within the last month. Resident #1's MDS revealed no wandering or behaviors. Review of the undated Comprehensive Care Plan for Resident #1 revealed, .Confusion, alteration, in thought process related to [Named Resident #1] had dementia .[Named Resident #1] has exhibited Wandering Behavior .Wander guard on Rt [right] ankle .Record behaviors on Behavior Tracking Form .Use wander guard/location monitor daily .6/23/24 [2024] Elopement: verified resident locate [location] and physical assessment and transferred [to] another facility .Observe for changes in behavior, altered mental status, sudden change in cognitive function, orientation, and/or communication .5/28/24 [2024] Resident prefer [prefers] to sleep on bathroom floor . Review of a Physician's Order for Resident #1 dated 5/15/2024, revealed .Wander guard. Notes: Montior [monitor] placement of wander guard (RLE) [right lower extremity] . Review of a Physician's Order for Resident #1 dated 5/15/2024, revealed .Wanderguard Function Test. Notes: Check function daily using 707 tester [system to check wander guards] . Review of a Progress Note for Resident #1 dated 5/15/2024, revealed .Updated elopement/wandering assessment completed. The resident [Resident #1] presents as an elopement risk due to wandering and exit seeking behaviors. Wander guard initiated, placed to RLE .RP [Responsible Party] made aware . Review of a Provider Progress Note for Resident #1 dated 5/24/2024, revealed .History of behavioral disturbances and elopement risk . Review of the June 2024 Treatment Administration Record (TAR) for Resident #1 revealed on 6/22/2024 Resident #1's wander guard was checked twice and tested on ce per orders. Review of the Investigation Summary dated 6/23/2024, revealed .Report Received: 6/23 [6/23/2024] reported by [Named Assistant Director of Nursing (ADON)] .Type of Allegation Elopement .Detailed Description of Allegation: Sometime during the night resident [Resident #1] left his room via [by way of] his window. Window was raised and he exited the building going to his sister's house. When his brother in law left the house at 5:40 AM, he saw [Named Resident #1] sitting on porch. He [Resident #1's brother in law] notified his wife that her brother was sitting on [the] porch. She [Resident #1's sister] notified nursing home and made arrangements to return him at 10:00 AM .The allegations were verified . Review of the Nurse's Event Note by the ADON dated 6/23/2024, revealed .Description: Elopement .No apparent injury .Received call from nurse stating [Resident #1] had exited the facility via window. The nurse was notified by the resident's sister . [Resident #1] was sitting on her front porch. The sister was laughing and said he had a history of doing this .[Resident #1] was transferred to secured facility . During an interview on 9/5/2024 at 11:02 AM, Family Member (FM) A stated, .[Named Resident #1] was a high elopement risk and had an ankle monitor. [Named Resident #1] climbed out the window sometime during the night. [Named Resident #1] didn't have his monitor on when he got to my house, and I don't know when he took it off. I found [Named Resident #1] at my house on the porch sometime after 5 [5:00] AM. The weather that morning was hot, and my brother was dressed appropriately for the weather. The facility didn't know he was at my house. [Resident #1] was missing from about 8 [8:00] PM to when I called the facility after 5 AM from what I was told. I was told by one of the nurses that [Named Resident #1] was last seen in the facility around 8:00 PM. The ADON came by my house and spoke with my brother. My brother said he wanted to leave which is why he left through the window. My brother has a history of wanting to leave and has left family member's houses before. Nobody knew [Named Resident #1] was gone until I called. I live about 3 miles from the facility. The facility did speak with me about transferring [Named Resident #1] to another facility that could provide him with a higher level of care. [Named Resident #1] was sent to another facility that had a lockdown unit . During an interview on 9/5/2024 at 4:12 PM, the Life Enrichment Director stated, .Usually I add resident names outside the room when they first come. If it's late at night, then I do it first thing in the next morning. If it is a weekend, then the name would be placed on the room the following Monday. [Named Resident #1]'s name was not outside his room. [Named Resident #1] was sent out for a period of time and when he came back, he was put in different room. [Named Resident #1]'s original room was [named room on the 500 hall] and his name was on that room but when he came back, he was put in room [named Resident #1's room also on the 500 hall]. Normally, the nurses would just switch the name tag to the new room. I'm not sure why his name didn't get switched. I guess it was just an oversight . During an interview on 9/6/2024 at 10:13 AM, Licensed Practical Nurse (LPN) I stated that Resident #1 normally slept in bathroom on the floor. LPN I explained she went in Resident #1's room during her first medication pass around 8:00 PM/9:00 PM and spoke with the [Resident #1]. He did not want to sleep in his bed. LPN I stated, .I didn't go back to his room after that because he didn't receive morning medications. LPN I was asked how often staff should do rounds on the residents. LPN I stated the CNA assigned to him [Resident #1] should have made rounds every 2 hours. LPN I stated, .I went back to [Resident #1]'s room after I received a phone call that he was not in the building, and the window was open .the CNA assigned to [Resident #1] did not go back in his room to check on him during her shift .the windows could open all the way, but now the windows only open about 6-8 inches . During an interview on 9/6/2024 at 10:58 AM, the Director of Nursing (DON) stated that she expects staff to do rounds on residents at least every 2 hours at a minimum. During an interview on 9/6/2024 at 11:04 AM, Certified Nursing Assistant (CNA) H stated, .I came to work at around 7:00 PM that night. I was assigned the 500 Hall minus room [Resident #1's room]. I am unsure if it said minus [bed A or bed B. I just remember it saying minus [Resident #1's room]. I did my first rounds from 7 [7:00] PM-11 [11:00] PM. I opened the door to room [Resident #1's room], and there was no name on the door, and the room was empty. I didn't go back to that room on my second round because no one was in there when I did my first rounds. I didn't know that someone was supposed to be in that room until I was told that morning that [Named Resident #1] had eloped . During an interview on 9/6/2024 at 2:58 PM, LPN L stated, .[Named Resident #1] didn't have a roommate. I didn't work with him that night. He [Resident #1] liked to sleep in the bathroom. He [Resident #1] did have a wander guard. The windows in the facility are usually closed at night, but [Named Resident #1] did have the mental and physical capacity to unlock and open the window if he wanted to . During an interview on 9/6/2024 at 3:15 PM, CNA K stated the last time she saw Resident #1 was around 7:30 PM or 8:00 PM. CNA K stated Resident #1 was in the hallway. CNA K was asked how often are CNAs expected to do their rounds. CNA K stated staff are expected to do their rounds every 2 hours. During an interview on 9/9/2024 at 10:44 AM, the Maintenance Director stated, .New locks were ordered for the windows after the elopement. The windows were going to be secured to open no more than 8 inches. In morning meeting, it was brought up that all the windows could open all the way so that's when we were told to put the blocks in the windows. The window blocks were ordered on 6/23/2024 and arrived the next day which was Monday 6/24/2024. The window blocks were installed into each residents' room window and require a specialty tool called an[named] key to install and remove if needed. Until the window blocks arrived, we were required to do 2 hour checks on the windows . Observations on 9/9/2024 by surveyor a nd administrator for window checks for the window blocks are as follows: 4:15PM 200 Hall all windows secured to 8inches when opened 4:27PM 700 Hall all windows secured to 8inches when opened 4:42PM 600 Hall all windows secured to 8inches when opened 4:53 PM 500 Hall all windows secured to 8inches when opened 5:07 PM 400 Hall all windows secured to 8inches when opened 5:19 PM 300 Hall all windows secured to 8inches when opened During an interview on 9/9/2024 at 12:56 PM, the ADON stated, .I went to the sister's home to see [Named Resident #1] make sure he was okay. I received a call at home that a patient [Resident #1] left the facility. [Resident #1] had no reported exit seeking behavior that day because I would have been made aware of it. [Named Resident #1] had a habit of sleeping in the bathroom on the floor with the door closed . The ADON was asked how often is staff supposed to do rounds on residents. The ADON stated, .Staff are supposed to round Q [every] 2 hours or as much as possible. We don't require documentation of CNA doing rounds unless they report an issue to the nurse on duty . The ADON was asked if the CNA that was assigned to Resident #1 conducted her rounds that night. The ADON stated, I would think that she would have. The ADON was asked if rounds were being conducted should someone have noticed that Resident #1 was not in the facility. The ADON stated, .Sometimes [Named Resident #1] would sleep in the bathroom with the door closed so you may not see him in there . The ADON was then asked would that need to be something that was on Resident #1's care plan so that new staff would know to check the bathroom if resident needed to be located. The ADON stated, .Yes, that would need to be something that was on the care plan The ADON confirmed this was not addressed on Resident #1's care plan. During an interview on 9/9/2024 at 2:37 PM, the Maintenance Assistant stated, .The administration had me put new window blocks in the very next day in every room. We had to check the windows every 2 hours until the block came in the next day (6/24/ 2024) . During an interview on 9/10/2024 at 2:47 PM, CNA P stated, .I did provide care to [Named Resident #1] on 6/22/2024. [Named Resident #1] was in the building during my 7 [7:00] AM-7 PM shift. [Named Resident #1] didn't have any exit seeking behaviors that day and didn't mention anything about leaving. [Named Resident #1] liked to sleep in his bathroom on the floor but would come out for meals. I did give a verbal report to the oncoming CNA, but I don't remember the CNA's name. I did let the oncoming CNA know that [Named Resident #1] was in the bathroom . The facility's corrective action plan included the following: 1. 6/23/2024 facility conducted a check to make sure all residents in the building were accounted for. 2. 6/23/2024-6/24/2024 100% (percent) elopement assessments conducted for all residents. 3. 6/23/2024 window checks conducted every 2 hours. 4. 6/23/2024 100% wander guard placement and checks completed. 5. 6/26/2024 100% audit for name tag outside door. 6. 6/23/2024 residents with a BIMS 12 or higher were interviewed regarding their care. 7. 6/26/2024 Body Audits were conducted on resident with a BIMS under 12. 8. 6/23/2024 Governing Body call was held to discuss elopement. 9. 6/24/2024 ADHOC (meeting conducted for a particular purpose) QAPI (Quality Assurance Performance Improvement) Meeting was held to address elopement. 10. 6/24/2024 Behavior Meeting was held to go through behavior log to ensure all behaviors have been documented and care planned. 11. Elopement Drills occurred on 6/24/2024, 6/26/2024, 7/3/2024, 7/4/2024, 7/10/2024, 7/18/2024, 7/25/2024, and 7/29/2024. 12. Elopement/Wandering, Rounding, and Abuse Trainings were conducted on 6/23/2024 and is ongoing. 13. Weekly Audits for Staff Education Weekly and Maintenance logs from June 2024-September 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to timely report allegations of abuse and neglect for 5 of 21 (Resident #2, #3, #19, #4, and #5) sampled residents reviewed for abuse. The facility failed to report an allegation of sexual abuse to the State Survey Agency within 2 hours when Resident #2 reported/alleged to staff on 5/8/2024 at approximately 11:00 PM that Resident #3 assaulted her through anal penetration. The facility failed to report Resident #19 ' s cocaine overdose in the facility on 11/8/2023 at approximately 8:30 PM, within 2 hours to the State Survey Agency. The facility ' s failure to ensure all allegations of abuse and neglect were reported immediately resulted in an Immediate Jeopardy (IJ) for Resident #2, #3, and #19. An Immediate Jeopardy 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 facility failed to report an allegation of sexual abuse to the State Survey Agency after staff witnessed alleged sexual abuse for Resident #4 and Resident #5 which did not rise to an IJ level. The Administrator was notified of the Immediate Jeopardy for F-609 on 10/21/2024 at 5:44 PM in the Conference Room. The facility was cited at F-609 at a scope and severity of K, which constitutes Substandard Quality of Care. The Immediate Jeopardy began on 11/8/2023 and is on-going. A partial extended survey was conducted on 10/21/2024 to 11/7/2024. The facility is required to submit a Plan of Correction (POC). The findings include: 1. Review of the facility ' s policy titled, Abuse Prohibition Plan, dated 11/2/2023, revealed, .External Reporting .Reports to the State agency shall be made electronically by use of the state electronic reporting system or alternatively by fax. 2 HOUR TIME LIMIT .All alleged violations are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . 2. Review of the medical record revealed Resident #2 was admitted on [DATE] and discharged on 5/11/2024 with diagnoses which included Gastroenteritis, Chronic Kidney Disease, End Stage Renal Disease, and Essential Hypertension. Review of the 5-day MDS assessment dated [DATE] revealed Resident #2 scored an 11 on the BIMS assessment which indicated moderately impaired cognition. Continued review revealed Resident #2 had no indicators for Psychosis or behavior symptoms. Review of the medical record revealed Resident #3 admitted to the facility on [DATE] and discharged [DATE] with diagnoses which included Enterocolitis due to Clostridium Difficile, Unspecified Abdominal Pain, and Dementia. Review of the admission MDS with assessment reference date 5/9/2024 revealed Resident #3 scored a 7 on the BIMS assessment which indicated severely impaired cognition. Continued review revealed Resident #3 wandered daily, placed the resident at risk of getting in a dangerous place, and significantly intruded on the privacy of others. Review of Police Department #1 ' s Incident Report dated 5/9/2024 at 9:54 PM, reveal .Incident Date Time From .5/8/2024 21:30 [9:30 PM] To .5/9/2024 21:54 [9:54 PM] Offense Code .Forcible Fondling .Offense Description SEXUAL BATTERY, WOMAN .Weapon Code .PERSONAL (HANDS, ECT. [Et Cetera]) . Victim [Resident #2] .Victim to Suspect .[Resident #3] .WITNESS .[Resident #7] .Injured VICTIM 1 [Resident #2] .Administration provided video footage with a time stamp 05/09/2024 at 0303 [3:03 AM] hours showing [Resident #3] at the end of the hallway completely naked. Officers observed at 0307 [3:07 AM] hours [Resident #3] then entered a room and at 0313 [3:13 AM] hours exit a room and was then assisted by staff at the facility . The police report revealed Resident #3 continued to wander the hall naked after the allegation of sexual abuse occurred on 5/8/2024 at 11:00 PM which placed other vulnerable residents in the facility at risk for sexual abuse. Review of the IRS dated 5/9/2024 completed by Facility #1 revealed, .Abuse specify .Sexual .Date/Time Administrator was notified of the incident .5/9/2024 8:30 AM . Allegation of sexual assault reported .Date and time when the alleged incident occurred .5/8/2024 11:00 PM . The IRS revealed the allegation of sexual abuse was reported on 5/9/2024 a day after the alleged sexual incident occurred on 5/8/2024. Review of a Coaching and Counseling Session form dated 5/9/2024 with Registered Nurse (RN) CC revealed .Allegation of abuse made by Resident [Resident #4] during this Nurse ' s shift on 5/8/24 [2024]. Nurse failed to Immediately Report to Supervisor .Unit manager, ADON [Assistant Director of Nursing], DON, or Administrator .Report All Allegations Immediately as a Mandatory Reporter .Separation of employment .Employee Comments I am very sorry for any harm to the resident. I take full responsibility for my lack of action. I knew better .Investigation Complete Termination Do Not Re-Hire . RN CC failed to report the allegation of sexual abuse to the Abuse Coordinator. During a telephone interview on 9/12/2024 at 1:32 PM, Former Interim DON(DON) stated, I was in the car on the way to the facility around 8:30 AM got a call from the ADON (Assistant Director of Nursing). Resident #2 alleged that someone came in her room and put their penis in her butt and the other Resident was Resident #3. At shift change on the morning of 5/9/204, RN KKK reported to the ADON about the incident. Resident #2 alleged sexual abuse. I conducted an investigation and determined that the entire night shift knew about the sexual abuse allegation but did not report it. I spoke to the assigned tech Certified Nursing Assistant (CNA J) for Resident #2 and she stated Resident #2 told her what happened to her, and she reported it to the nurse (RN CC) and that the nurse told her (CNA J) that it was a busy night and that Resident #2 makes up stories all the time and don ' t tell anyone else that. No one on that night shift reported the sexual abuse allegations. I suspended RN CC then terminated her upon completion of the investigation. During a telephone interview on 10/3/2024 at 10:56 AM, RN CC stated, .I failed to report the allegation of sexual abuse .I was sitting at nurses' station .[CNA J] and [Licensed Practical Nurse LPN MMM] were whispering .basically I heard a little .I asked the CNA what was going on and she said [Resident #2] alleged this man [Resident #3] raped her .I heard the nurse tell her oh she is crazy .[LPN MMM] was an agency nurse .I told [LPN MMM] the resident maybe crazy but you still have to report it .the nurse just brushed it off .I had dealt with [Resident #3] earlier he was walking hall naked and a CNA had to go get a gown and put a brief on him .he had went into another female residents room and sat on her bed .that was hours earlier . RN CC was asked at any point during the night shift was Resident #3 placed on 1 on 1 supervision. RN CC stated, .No, mostly just trying to redirect him .I wish I would have done better .I hate that resident went through that . During a telephone interview on 10/8/2024 at 121:27 AM, the Former Interim DON stated, .I don ' t recall talking to [LPN MMM] .but [RN CC] said everybody knew about it and they were told to keep their mouth shut . 3. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region, Pressure Ulcer of Sacral Region-Stage 4, Fracture of Unspecified Neck of Right Femur, Diabetes Mellitus, Hypertension, Protein-Calorie Malnutrition, and Depression. Review of the 5-day MDS dated [DATE], revealed Resident #19 scored a 15 on the BIMS assessment, which indicated he was cognitively intact, and was dependent on staff for all activities of daily living (ADLs). Review of the Incident Reporting System (IRS) report for Resident #19 dated 11/9/2023 at 4:45 PM, revealed the Administrator was notified of the incident on 11/8/2023 at 9:30 PM. Continued review of the IRS report revealed, On 11/8/23 [2023] resident [#19] was seen by facility staff alert and oriented X3 [to person, place, and time] at approximately 8PM [8:00 PM]. Resident had an unidentified visitor that entered his room at approximately 8:20PM. After visit, resident was found unresponsive at approximately 8:40PM. Resident was treated immediately until EMS [Emergency Medical Services] arrived. On 11/9/2023 DON [Director of Nursing LL] contacted hospital for update and was made aware that resident was being treated for cocaine overdose. Date and time when the alleged incident occurred .11/08/2023 8:30 PM .Resident was immediately assessed and treated with Narcan [medication to reverse opioid overdose] prior to EMS arrival. Immediately after resident departure to hospital, staff removed a paper bag from residents [resident ' s] room. The bag was secured until police could examine what appeared to be an illicit substance inside . Review of Discharge Summary from Hospital #2 dated 11/13/2023, revealed Resident #19 admitted to the hospital on [DATE]. Resident #19 reported to staff that he overdosed on what he thought was heroin that a family member brought him, however, Resident #19 ' s drug screen revealed cocaine with metabolites (the presence of cocaine or one of the chemicals your body makes to process cocaine] was found in his urine. Resident #19 was admitted to the Intensive Care Unit and required an intravenous drip of Narcan. Resident #19 discharged home with home health on 11/13/2023. During a telephone interview on 10/2/2024 at 8:36 AM, Administrator #3 confirmed he was the Administrator at Facility #1 from September 2023 until February 2024. Administrator #3 stated he was responsible for reporting reportable incidents to the appropriate agencies. Administrator #3 was asked what the process was for reporting abuse allegations. Administrator #3 stated, The process is we report abuse within 2 hours, any allegation of abuse we report. Administrator #3 was asked what about neglect. Administrator #3 stated, The same .We didn ' t feel like necessarily it was an abuse situation. The guy [Resident #19] had potentially gotten some drugs in the building . Administrator #3 was asked when he was notified of the incident. Administrator #3 stated, I would have to look back to get you a definite answer I ' m pretty sure it was that night .pretty certain . The facility reported Resident #19 ' s overdose on 11/9/2023 at 2:00 PM, the day following the incident. During an interview on 10/15/2024 at 11:11 AM, the DON reviewed the investigation the facility provided for Resident #19 ' s overdose in the facility on 11/8/2023. The DON was asked how soon that (Resident #19 ' s overdose) should be reported to the State. The DON stated, Within 2 hours. The DON acknowledged the overdose occurred on 11/8/2023 and was not reported to the State Survey Agency until 11/9/2023. The DON was asked did the facility submit the incident to the State timely. The DON stated, No. The facility failed to report Resident #19 ' s cocaine overdose in the facility to the State Survey Agency within 2 hours. 4. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Traumatic Subarachnoid hemorrhage, Essential Hypertension, and Dementia. Review of the Quarterly MDS dated [DATE] revealed Resident #4 scored a 5 on the BIMS assessment which indicated severely impaired cognition. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Altered Mental Status, Depression, and Diabetes Mellitus. Review of the admission MDS dated [DATE] revealed Resident #5 scored an 11 on the BIMS assessment which indicated moderately impaired cognition. Review of the IRS report dated 7/7/2024, completed by Facility #1 revealed .Abuse specify .Sexual .Date/Time .staff became aware of the incident .07/07/2024 7:00 PM .Date/Time administrator was notified of the incident .07/07/2024 7:30 PM .Alleged Perpetrator [Resident #5] .What was reported and to whom or which agency/entity .Sexual assault to police, APS [Adult Protective Services], Ombudsman and state health department .Submission Report .Date/time .report was submitted .07/07/2024 10:15 PM . The IRS revealed the allegation of sexual abuse was reported to the State Agency on 7/7/2024 at 10:15 PM, 3 hours and 15 minutes after the alleged sexual assault occurred. During an interview on 9/10/2024 at 10:31 AM, the Administrator stated he was the abuse coordinator. The DON was his backup abuse coordinator. He stated he was responsible to report abuse allegations to the state agency within 2 hours. The Administrator acknowledged that the abuse [7/7/2024] was reported past the 2-hour timeframe. Refer to F-600 and F-610.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility investigation review, medical record review, and interview, the facility failed to conduct a thorough investigation and take appropriate corrective actions for 6 of 21 (Resident #4, #5, #2, #3, #7 and #19) sampled residents reviewed for abuse. The facility failed to conduct a thorough investigation into an allegation of sexual abuse between Resident #4, a vulnerable, cognitively impaired resident with a diagnosis of dementia, and Resident #5 on 7/7/2024. The facility failed to conduct a thorough investigation into Resident #2's allegation that Resident #3 sexually assaulted her through anal penetration on 5/8/2024, which resulted in psychosocial harm and delayed incontinence care for the victim. The facility failed to conduct a thorough investigation into Resident #19's cocaine overdose in the facility on 11/8/2023. The facility's failure to perform a thorough investigation resulted in an Immediate Jeopardy for Resident #4, #5, #2, #3, #7, and #19. 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 was notified of the IJ for F-610 on 10/21/2024 at 5:55 PM in the Conference room. The facility was cited at F-610 at a scope and severity of K., which constitutes Substandard Quality of Care. The Immediate Jeopardy began on 11/8/2023 and is ongoing. A partial extended survey was conducted on 9/19/2024 through 11/7/2024. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled, Abuse Prohibition Plan, with effective date of 11/2/2023, revealed .The facility has a zero-tolerance policy for abuse. Verbal, mental, sexual, or physical abuse .is prohibited. The resident shall not be subjected to mistreatment, neglect .The facility shall attempt to identify and shall investigate any reported violation or allegation of abuse. The Abuse Policy applies to anyone involved with the residents of this facility, including, but not limited to, all facility staff, other residents, consultants .staff or other agencies serving the resident .Alleged Violation .is a situation or occurrence that is observed or reported by staff, resident .another healthcare provider, or others but has not yet been investigated .The Administrator shall investigate or assign the investigation to designated facility personnel such as the Director of Nursing (DON). The investigation shall begin immediately. The information gathered, and the findings/conclusion shall be provided to the Administrator .The individual conducting the investigation shall, at a minimum .Review the completed allegation/incident documentation .Review the Resident's medical record to determine events leading up to the incident .Interview the person(s) reporting the incident .Interview any witnesses to the incident .Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Review all events leading up to the alleged incident .Each interview shall be conducted separately and in a private location .Witness reports shall be reduced to writing. Witnesses shall be required to write a statement and be interviewed by the Abuse Coordinator/designee. They shall review the interview, then sign and date it, attesting to its accuracy. (Note: A copy of such reports must be attached to the investigation report) .All staff are required to cooperate during the investigation to assure the resident is fully protected .There may be some situations in which the psychosocial outcome to the resident may be difficult to determine or incongruent with what would be expected. In these situations it is appropriate to consider how a reasonable person in the resident's circumstances would be impacted by the incident .Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident .If sexual abuse is suspected, the Resident SHALL NOT be bathed, and clothing or linen shall not be washed. No items shall be removed from the area in which the incident occurred. The police shall be called immediately .For the protection of all individuals involved, copies of any internal reports, interviews, witness statements, photographs or video surveillance gathered during the investigation shall be released only with permission of the Administrator or the Facility Attorney . Review of the facility policy titled, Video Surveillance, with effective date of 5/28/2024, revealed .To establish guidelines related to the use of video monitoring of resident and staff in order to evaluate and maintain a safe and therapeutic treatment environment. Use of video surveillance system may also .Assist the Administrator or designee with incident investigation .Assist the treatment team in defining or updating patient therapeutic interventions, including but not limited to, confronting issues of denial, aggressive behaviors, maladaptive coping skills, drug diversion .The facility shall utilize monitoring as deemed appropriate to promote resident care and the overall safety of residents .If a recording is used in connection with an incident under investigation by Administrator or designee, at the discretion of the Administrator or designee, it may be retained indefinitely or until the case investigation has closed. The Administrator shall keep such recordings archived with date, time and location in a designated area . 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Traumatic Subarachnoid hemorrhage, Essential Hypertension, and Dementia. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 scored a 5 on Brief Interview for [NAME] Status (BIMS) assessment which indicated severely impaired cognition. Review of the Nurse ' s Event Note for Resident #4 dated 7/7/2024, revealed at approximately 6:45 PM a Certified Nursing Assistant (CNA) requested the assistance of a nurse in Resident #5's room. The CNA reported to the nurse she had walked in on Resident #4 performing oral sex on Resident #5. The nurse entered Resident #5's room to find him lying flat on his back, with the head of the bed down and Resident #4 sitting on the right side of the bed positioned over Resident #5's right groin area. The nurse noted the privacy curtain had been pulled to obscure Resident #5's roommate's (Resident #23) view. The CNA reported when she opened the door Resident #4's arms were resting along side both of Resident #5's hips and Resident #5 quickly pulled his pants up. Review of the facility investigation dated 7/12/2024 revealed on 7/7/2024 at 7:00 PM, CNA O found Resident #4 sitting on Resident #5's bed. Resident #5 was lying in the bed with his pants pulled down. Licensed Practical Nurse (LPN) M was notified and upon entering the room she saw Resident #5 pulling up his pants. Staff was interviewed and statements were taken. Resident #5 stated there was no sexual contact and insist they were watching TV. Resident #5's roommate (Resident #23) stated Residents #4 and #5 were about to engage in sexual activities when CNA O came into the room. The facility concluded there was no evidence of sexual abuse. Review of the police report dated 7/8/2024 revealed, .Victim [Resident #4] Suspect [Resident #5] .I spoke to nurse .[nurse] stated that the CNA informed her that she walked into [Resident #5]'s room and witnessed [Resident #4] performing oral sex on [Resident #5] .I spoke to [Resident #4] about the incident and her recollection of the events. She stated [Resident #5] grabbed her by the hand .he put it in his open pants fly and he made her touch his penis .she stated shortly after he grabbed her by the head and tried to force her to perform oral sex .[Resident #5] .stated .[Resident #4 and Resident #5] had sexual relations in a closet last Friday [7/5/2024] . Resident #4 reported allegations of sexual abuse occurred to Police Department #1 this was not included in the facility investigation. Resident #5 reported to the Police Department #1 that on Friday 7/5/2024 sexual relations occurred between the two in a closet. This was not included in the facility investigation. 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Altered Mental Status, Depression, and Diabetes Mellitus. Review of the admission MDS for Resident #5 dated 5/13/2024 revealed a BIMS score of 11, which indicated moderate cognitive impairment. Review of the Clinical Notes Report for Resident #5 dated 7/8/2024, revealed .1300 [1:00 PM] .Interviewed resident with admin [Administrator] about allegation of inappropriate sexual behavior. At the beginning of the interview resident was resistant to speaking of what occurred between resident and female resident. After speaking with resident and asking him to be truthful, resident stated that he believed that resident was A&O [Alert and oriented] and not confused. he stated that he had pulled privacy curtain down between him and roommate and pulled his pants down with the anticipation of a sexual encounter between him and female resident .resident stated several times that nothing occurred sexual between them and female resident but then stated that inappropriate contact between him and resident had occurred. [Resident #5] stated he was not aware that resident was confused and not able to give consent . Review of Nurse Practitioner (NP) MM's Progress Note dated 7/8/2024 for Resident #5 revealed, .On 7/7 [2024] it was alleged that patient sexually abused [Resident #4] .Roommate [Resident #23] was interviewed to this alleged event and he stated that the female has come to the room on multiple occasions and that on Friday [7/5/2024] night he and the woman were in the bathroom for an hour together where he could hear the woman giving the patient oral sex. Roomate [Roommate-Resident #23] stated that yesterday his roommate was planning it all day. Patient stated that he was looking for her and then when she came to his room he closed the curtains around his bed, [Resident #5] turned the television on and he could hear him speaking softly to the woman .[Resident #23] stated it was the same woman several times and you could here [hear] sexual acts going on between them. Nurse documented in the woman's chart that she walked into this patient's room and opened the curtain and found the female propped up on her elbows with her face in the area of [Resident #5]'s hips. [Resident #5] jerked up his pants .Nurse reported that [Resident #5] and .[Resident #4] looked very surprised .I saw this patient this morning .I explained to patient that I would be interviewing him due to activities that took place over the weekend and he stated 'I did not do anything to her.' Patient knew exactly what incident I was speaking of .there were eyewitnesses to him and the female engaging in sexual acts together . Review of a typed interview statement performed by Regional Nurse Manager (RNM) and RNM #2 revealed an interview with Resident #23 on 7/8/2024. Resident #23 reported to the ADON that Resident #4 and Resident #5 were in the bathroom together Friday (7/5/2024). The ADON interviewed Resident #4 regarding the allegation of being in the bathroom with Resident #5 and she stated, no Resident #5 was interviewed, and he denied being in the bathroom with Resident #4. The RNM and RNM #2 interviewed Resident #23 for the second time and he again stated that he saw them enter the bathroom together. Resident #23 reported he saw Resident #4 come into his room and that she was on Resident #5's side of the room on 7/8/2024. Resident #23 stated he couldn't see what they were doing because the privacy curtain was pulled at the time. Resident #23 stated, he couldn ' t hear what they were saying to each other, but he assumed that something was going to go down but the staff member came in and caught them before they had a chance to do anything. The interview revealed the roommate (Resident #23) alleged Resident #4 and Resident #5 were in the bathroom together on 7/5/2024. The facility interviewed Resident #4 who had a BIMS score of 5 with a diagnosis of Dementia who was unable to give a clear statement related to the incident on 7/5/2024. 4. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses which included Pressure Ulcer of Sacral Region, Stage 4, Chronic Kidney Disease, Type 2 Diabetes Mellitus, and Obstructive and Reflux Uropathy. Review of the Quarterly MDS dated [DATE] revealed Resident #23 had a BIMS score of 15 which indicated no cognitive impairment. During an interview on 10/1/2024 at 2:10 PM, the ADON stated, .I was told to come out to the building they caught [Resident #4] in the room with [Resident #5] .the staff had taken her out of his room .the SSD [Social Service Director] and I talked with [Resident #4] .she was telling me he was trying to make her do something but she couldn ' t really explain it .she had dementia really bad .she would lose her train of thought .[Resident #23] did say they were in the room together .he could hear them at one point in the night and said they had been in the bathroom together one other time to . The facility investigation revealed no documentation or statements from employees related to Resident #4 and Resident #5 being in the bathroom together. During a telephone interview on 10/3/2024 at 9:40 AM, Psychiatric NP MM stated, .[Resident #4] apparently was the aggressor coming in frequently to visit [Resident #5] .He [Resident #5] had a child like mentality but I think he knew it was wrong .he allowed it to happen .she was confused going around to men .the roommate heard everything, he saw it and told all the stories .the facility sent her out .She couldn't give me any details about the incident .[Resident #5] denied and denied they done anything in the bathroom and then she [Resident #4] was in the room with him and [Resident #5] closed the curtain . During an interview on 10/3/2024 at 4:00 PM, Resident #23 stated, .they [Resident #4 and Resident #5] was in the bathroom for an hour on Friday night before from 11:30 PM to 12:30 PM .I know I looked at that clock on the wall .the woman came in here all the time . During an interview on 11/4/2024 at 9:48 AM, CNA O stated, .I was picking up trays, [Resident #5]'s door was shut I opened it and he had his pants down and [Resident #4] had her head down at the crotch area. [Resident #5] was able to walk and had pulled the curtain. He [Resident #5] quickly started pulling up his pants and [Resident #4] just looked at me. I shouldn't have left but I was shocked when I seen it. [Resident #23] was upset because [Resident #5] had pulled the curtain and shut the door . The facility investigation did not include information related to CNA O leaving Resident #4 and #5 alone after she witnessed the two residents in the male resident's room with door shut, curtain pulled, with Resident #5 with his pants down. During an interview on 11/6/2024 at 4:54 PM, the Regional Nurse was asked if Resident #4 with a BIMS score of 5 could give clear accounts to what happened between her and Resident #5. The Regional Nurse stated, .I don't know if she could clearly, but she said nothing happened either time .that is why we sent her out for sexual exam . The Regional Nurse was asked if the facility investigated Resident #23's report of Resident #4 and Resident #5 being in the bathroom together. The Regional Nurse stated, .it was reported at the same time .we interviewed the roommate [Resident #23] .I went over to his bed and from that side you couldn't see in the bathroom .I asked him about the bathroom incident . Review of the 26 employee statements provided in the investigation revealed all 26 employees denied witnessing any abuse, at any time while employed in the facility. The Regional Nurse was asked if staff interviews were conducted with staff that worked on the night Resident #23 reported the two residents were in the bathroom together. The Regional Nurse stated, I asked the staff about abuse. The Regional Nurse was asked to review the 26 employee statements provided in the investigation. The Regional Nurse was asked if she could determine what specific questions were asked in the interview by reading the statements. The Regional Nurse responded, .I know what was being investigated, I assume the questions were related to the incident [allegation of sexual conduct between Resident #4 and Resident #5]. Review of the facility investigation revealed the facility did not conduct a thorough inquiry into Resident #4 and #5 being in the bathroom together or any past physical or psychological relationship while in the facility. _____________________________________________________ 5. Review of the medical record revealed Resident #2 was admitted on [DATE] and discharged on 5/11/2024 with diagnoses which included Gastroenteritis, Chronic Kidney Disease, and End Stage Renal Disease. Review of the 5-day MDS assessment dated [DATE] revealed Resident #2 scored an 11 on the BIMS assessment which indicated moderately impaired cognition. Review of the facility Incident Reporting System (IRS) report dated 5/9/2024 revealed Resident #2 alleged Resident #3 sexually assaulted her on 5/8/2024. The alleged perpetrator was Resident #3. Resident #3 had recently become combative and resistant to redirection. The facility reported an allegation of sexual assault with no visible bruising, scratches, lacerations, or bleeding for Resident #2. Resident #2 became withdrawn and was showing expressions of fear. Resident #7 witnessed the alleged abuse. The 5-day follow up report submitted to the State Agency on 5/14/2024 revealed Resident #2 appeared somewhat withdrawn after the incident took place. The alleged victim stated that a male, without any clothes on entered her room and laid on the bed with her and attempted to penetrate her from behind with his penis. All staff were interviewed; however, no one witnessed the actual abuse of the alleged victim. The victim's roommate (Resident #7) was in her own bed at the time the incident took place. The privacy curtain between the two beds partially obstructed her view, but she did say that a naked man came into the room and laid down next to the victim on her bed. The charge nurse was unaware of anything taking place until she was directed to the alleged victim's room by other staff. The staff responsible for oversight of the alleged perpetrator were not aware of anything out of the ordinary taking place until they heard the alleged victim scream for help. No clinical or physical abnormalities were discovered after the alleged incident took place. Conclusion of the facility's investigation revealed, The allegation could not be verified because the resident changed her story from one day to the next. 6. Review of the medical record revealed Resident #7 was admitted on [DATE] and discharged on 8/9/2024 with diagnoses which included Epileptic Seizure, History of Transient Ischemic Attack and Cerebral Infarction. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #7 scored a 15 on the BIMS assessment which indicated intact cognition. Review of the Clinical Notes Report for Resident #2 with effective date 5/9/2024, revealed Registered Nurse (RN) KKK was notified by Resident #7 (Resident #2)'s roommate that she and her roommate needed to be cleaned up. RN KKK noticed Resident #2 was covered in her own feces and did not have a top sheet or a blanket on her. Resident #2 reported a male resident (Resident #3) came into her room naked, ripped everything off, and threw all of her covers in the floor. Resident #2 stated, I don't know why that naked man keeps coming in my room at night. He even tried to stick his penis inside my butt last night and got this shit all over his penis! Resident #2 and Resident #7 confirmed the incident happened last night (5/8/2024) and this was reported to the nurses last night. Resident #7 stated, Yes, I saw it happen: We both were screaming for him to get out! RN KKK immediately reported the allegation to the ADON. The ADON and RN KKK then went to report the allegation of sexual assault to the Administrator. Review of the Clinical Notes Report dated 5/9/2024, revealed Resident #2 alleged another resident (Resident #3) came into her room and got in the bed with her and attempted to place his penis in her rectum. The Former Interim DON and NP/Advance Practice Registered Nurse (APRN) performed a head-to-toe assessment and noted no abnormal findings of bruising, abrasions, or bleeding. Review of the Social Service Director note dated 5/9/2024, revealed Resident #2 reported Resident #3 came into her room and put his penis in her anus. Resident stated that she yelled for her tech to come and get him out because he wouldn ' t leave when she and her roommate asked him to leave. Resident #2 stated (Resident #3) pulled her blanket down and got into bed with her. Resident #2 stated this occurred around 11:00 PM and he (Resident #3) was naked from the waist down when he entered. Review of the Nurse's Event Note dated 5/9/2024 for Resident #2 revealed, .Resident stated that male resident entered her room during the night .was half clothes [clothed] with penis exposed, climbed into her bed with her .tried to have anal sex with her. She said he hit her on the hip . 7. Review of the medical record revealed Resident #3 admitted to the facility on [DATE] and discharged [DATE] with diagnoses which included Enterocolitis due to Clostridium Difficile, Unspecified Abdominal Pain, and Dementia. Review of the admission MDS with assessment reference date 5/9/2024, revealed Resident #3 scored a 7 on BIMS assessment which indicated severely impaired cognition. Review of Police Department #1's Incident Report dated 5/9/2024 at 9:54 PM revealed Resident #2 stated that Resident #3 entered her room completely naked. Resident #3 entered her bed and reached his hand beneath her diaper and touched her rectum with his penis. Resident #2 stated she was shouting at him to get off and to leave and Resident #3 told her to shut up. Resident #2 stated she had been having stool issues and that her diaper contained her feces and as a result she observed Resident #3 had feces on his penis. Resident #3 then left her bedroom and sent back into the hallway. Administration provided video footage with a time stamp 5/09/2024 at 3:03 AM showing [Resident #3] at the end of the hallway completely naked. The officers observed at 3:07 AM [Resident #3] then entered a room and at 3:13 AM, he exited a room and was then assisted by staff at the facility. Due to camera footage the officers were unable to confirm what room Resident #3 entered. Review of Police Department #1's incident report did not contain information related to evidence of the sheet Resident #3 used to clean feces from his penis. The report does not reflect the video surveillance was reviewed for the correct date or time of the reported incident 5/8/2024. The Police Department #1's report revealed Resident #3 continued to wander naked in the facility placing other residents at risk for abuse. During a telephone interview on 9/12/2024 at 11:18 AM, RN KKK stated, when he came into work that morning, a couple of employees were talking about how they found a man in the hallway half naked on the previous night before. RN KKK noticed a resident (Resident #2) was in a fetal position and had dried stool all over her and didn't have covers over her. I asked the resident why she was laying there with no covers and she stated that a man took them from her. The resident stated that a man came in her room and tried to stick his penis in her butt last night, and he got mad when she defecated on herself then took her covers to clean himself off then threw the covers in the corner. RN KKK stated he seen the covers in the corner, so the story did make sense. Resident #7 stated that they (Resident #2 and Resident #3) screamed for him to get out and cut on the call light, but no one came. RN KKK stated he reported it to the ADON as soon as he was told about it from the two residents. The incident should have been reported during the night shift. The facility investigation did not include information related to the sheet used by Resident #3 to clean feces from his penis. The investigation did not include information related to the disposition of the soiled sheet evidence. This evidence was not reported or given to the police as per the facility policy. During a telephone interview on 9/12/2024 at 1:32 PM, the Former Interim DON stated Resident #2 alleged that someone came in her room and put their penis in her butt and the other Resident was Resident #3. I spoke with [Resident #3] who said no to every question I asked him. Then [Resident #3] said if I did it, I don't remember I did it. At shift change on the morning of 5/9/2024 [RN KKK] reported to the ADON about the incident. [Resident #2] alleged sexual abuse. I conducted an investigation and determined that the entire night shift knew about the sexual abuse allegation but did not report it. I spoke to the assigned tech [CNA J] for [Resident #2] and she stated [Resident #2] told her what happened to her, and she reported it to the nurse [RN CC] and that the nurse told her that it was a busy night and that ]Resident #2] makes up stories all the time and don ' t tell anyone else that. No one on that night shift reported the sexual abuse allegations. I suspended [RN CC] then terminated her upon completion of the investigation. There should be statements in the investigation from [RN CC], [LPN MMM], and [CNA J] [staff assigned to care for Resident #2 on 5/8/2024] regarding that night shift. Review of the facility reported investigation revealed no signed statement from RN CC, LPN MMM, or CNA J. During a telephone interview on 9/17/2024 at 12:09 PM, LPN AA stated the only thing she remembers is around 1:00 AM, Resident #3 was found in the hallway naked, and he was taken back to his room to get clothes on . The interview revealed Resident #3 continued to wander the facility naked after the allegation of sexual assault occurred. The facility investigation did not contain a written statement from LPN AA. During a telephone interview on 9/26/2024 at 11:23 AM, Resident #7 (Resident #2's roommate) stated, .[Resident #3] came in showing his penis .he tried to get in the bed with her [Resident #2] .I started screaming .she had a gown on .I heard her [Resident #2] say 'what are you doing' .he is trying to have sex with me .I heard him say 'it will be over in a minute' .she started screaming .she was so sick she couldn't defend herself .we had our call light on .he finally left . Resident #7 was asked how the incident made her feel. Resident #7 stated, .It was scary .I felt like I wasn't safe .[Resident #2] cried for a little while after it happened and on the next day .[Family Member FM V] was at the facility the next day when the NP came in to see her [Resident #2] .FM V told the NP you didn't even do anything for her from 10:00 PM until the next morning . Resident #7 stated, .she laid with no covers and boo boo [bowel movement] on her until the next morning . The facility investigation did not reveal a statement from Resident #7. During a telephone interview on 9/30/2024 at 2:30 PM, Administrator #2 stated, .I do recall that incident .[Resident #2]'s story changed and in the end that didn't really happen .typically the Maintenance Director was the one that would look at the surveillance camera when we had an incident . The Administrator #2 was asked did the facility investigate as to why Resident #2 laid dirty without covers until the next morning. Administrator #2 stated, .maybe the DON did that at the time, I don ' t recall if it was investigated about why she laid in her feces .I think the DON done the investigation .I believe the DON got a statement from Resident #2 .some of the staff reported she was withdrawn .seems like we sent her to the hospital . The facility investigation did not include information related to Resident #2 being left soiled in feces for approximately 9 hours after the alleged sexual assault. During a telephone interview on 10/1/2024 at 8:46 AM, CNA UU stated, .I was working the next morning 5/9/2024 .she [Resident #2] was laying on her side covered in dried bowel movement [BM] .she told us [Resident #3] got in bed with her and tried to penetrate her bottom .she was shocked and upset .all the night shift was gone at that point .her brief was gone .I don ' t remember if we found the brief or where it was .she had no covers on her .her roommate [Resident #7] told me he got in the bed with her .[Resident #3] would wander around naked looking for a bathroom . During an interview on 10/1/2024 at 2:00 PM, the ADON stated, .I worked on that investigation involving [Resident #2 and Resident #3] .I was told about the incident the next morning by (RN KKK) .She (Resident #2) said he [Resident #3] got in the bed with her and tried to penetrate her anally but I didn't feel she was coherent enough to know what happened .by the time I got here she was already cleaned up .I just thought surely the nurse just miss understood the CNA on night shift when she reported the incident but the nurse said she was told on night shift about the allegation of sexual abuse and failed to report it .we let the nurse go .She [Resident #2] didn't seem upset to me .I didn't review the camera's to see if he went into the room .nothing stood out to me about any changes in her . During a telephone interview on 10/2/2024 at 2:18 PM the Nurse Practitioner/Advanced Practice Registered Nurse (NP/APRN) stated, .I went to see her [Resident #2] that morning [5/9/2024]. She was still in the bed. She told me that he [Resident #3] crawled in bed with her removed her brief .she said there was no penetration .her story was different at one point she said she had on a brief and then she said she removed it to have a bowel movement (BM) . The APRN stated, .she was alert and oriented .the family was involved they came to see her that day .I didn't see any tears or redness . The NP/APRN was asked if she assessed Resident #2 prior to her being cleaned up. The APRN stated, .no she was already cleaned up .I am not qualified to do a rape exam .[Resident #3] did wander .[Resident #7] said it scared her, she heard [Resident #2] scream and she saw the naked man in the room .[Resident #2] was fine . The interview revealed Resident #2 was physically assessed after she had been cleaned up. The facility policy revealed a resident involved in a sexual assault should not be bathed prior to the examination. During a telephone interview on 10/1/2024 at 2:28 PM, Maintenance GGG (Past Maintenance Director) stated, .I did review the surveillance cameras at times when the facility needed me to .I was unable to save the videos to a drive I could only record the videos with my phone. I still have some videos on my phone .I will have to look and call you back . During a t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility job description, facility policy review, ADL (Activities of Daily Living) Verification Worksheet, Patient Weight Reports, Weight (wt) Loss Documentation Report, medical record review, observation and interview, the facility failed to recognize repeated, systemic failures to assess and address a resident ' s nutritional status and to implement pertinent interventions that resulted in continued significant weight loss for 5 of 9 (Residents #67, #65, #63, #45 and #46) sampled residents reviewed for nutritional needs. Resident #45 experienced a significant weight loss of 10% (percent) in 6 months. Resident #67 suffered a significant and severe weight loss of approximately 9.0% over 2 months from 8/15/2024 to 10/14/2024. Resident #65 suffered a significant and severe weight loss of approximately 8.5% over 1 month from 8/9/2024 to 9/13/2024. Resident #63 suffered a significant and severe weight loss of approximately 10.19% over 3.5 months from 2/5/2024 to 5/20/2024. Resident #45 suffered a significant weight loss of approximately 5.0% over 1.6 months from 2/5/2024 to 3/25/2024. Resident #46 suffered a significant and severe weight loss of approximately 13.5% over 1.5 months from 12/9/2023 to 1/23/2024. Repeated failure to assist vulnerable residents with meals and fluid intake and failure to document meal intake contributed to the continuation of a severe decline in the nutritional status. The facility failed to assist Residents #67, #65, #63, #45 and #46 with meals and/or record food intake percentages with each meal. The facility ' s failure to assess nutritional status, assist residents with meals, and monitor meal intakes resulted in significant and severe weight loss for Resident #67, #65, #63, #45 and #46 which resulted in 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. The Administrator was notified of the Immediate Jeopardy on 11/6/2024 at 1:15 PM in the Administrator's office. The facility was cited at F-692 with a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy began on 1/9/2024 and is ongoing. A partial extended survey was conducted on 10/21/2024 to 11/7/2024. The facility is required to submit a Plan of Correction (POC). The findings include: 1. Review of the Job Description for Certified Nurse Aide (CNA) dated 8/20/2021, revealed .ESSENTIAL JOB DUTIES .Recognize and respond to the needs of residents .Report and record resident ' s intake on meal percentage sheets and report to charge nurse intake of less than 25% . Review of the Job Description for the Regional Registered Dietician (RD) dated 8/20/2021, revealed .The Regional Registered Dietician is to provide clinical expertise through assessment of patients utilizing Medical Nutrition Therapy .ESSENTIAL JOB DUTIES .Assess individual patients regarding appropriate nutritional care in compliance with state and federal regulations .Conduct rounds, audit medical records to determine facility compliance with state and federal guidelines .Review quality initiative data . 2. Review of the facility policy titled, Dietary: Weight Monitoring, dated 11/9/2023, revealed .Based on the resident ' s comprehensive assessment, the facility shall ensure that all residents maintain acceptable parameters of nutritional status .If nutritional goals are not achieved, care planned interventions shall be reevaluated for effectiveness and modified as appropriate .Weight Analysis .5% change in weight in 1 month (30 days) .7.5% change in weight in 3 months (90 days) .10% change in weight in 6 months (180 days) . Review of the facility policy titled, Activities of Daily Living, dated 4/17/2024, revealed .Eating to include meals and snacks .A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition . 3. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses which included Unspecified Systolic (Congestive) Heat Failure, Dysphagia (difficulty swallowing), Oral Phase, and Anorexia Nervosa. Review of the Annual Minimum Data Set (MDS) assessment for Resident #67 dated 1/25/2024, revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated severe cognitive impairment. Continued review revealed setup or clean-up assistance with eating. Review of the care plan for Resident #67 dated 1/30/2024, revealed .2/13/2024 .At risk for malnutrition related weight loss .Monitor meal intake and offer substitute if resident eats less than {*} [no specific percentage indicated] % of meal .8/29/2024 .At risk for weight loss and malnutrition/related to receiving mechanically altered diet, diagnosis of adult failure to thrive .At risk for malnutrition/hydration deficit .Monitor meal intake and offer substitute if resident eats less than 50% of meal .Self care deficit R/T [related to] .eating .Eating-Encourage .to eat all meals in Dining Room as tolerated .Assist with eating as needed .Alteration in nutrition/hydration R/T Receives daily Diuretic and Ages related cognitive decline .Monitor food intake at each meal .Document % [percent] eaten .Offer water with each medication pass . Review of Resident (Res) #67 ' s Patient Weight Report dated 8/15/2024 through 10/14/2024, revealed: 8/15/2024: 142.0 lbs (pounds). 8/20/2024: 139.2 lbs; 9/16/2024: 138.0 lbs; 10/14/2024: 129.2 lbs. Resident #67 suffered a significant and severe wt loss of approximately 9.0% over 2 months from 8/15/2024 to 10/14/2024. Resident #67 lost a total of 12.8 lbs in 2 months. Review of the ADL verification worksheet for Resident #67 dated 8/15/2024 through 10/14/2024, revealed of the 180 meals delivered, 101 meals had no documentation of the percentage of total meal consumption. (56.11% of meal percentages were not documented) Review of the facility ' s Clinical Notes Entry for Resident #67 dated 9/23/2024, the RD documented, .inconsistent intake noted . Review of the facility ' s Progress Note for Resident #67 dated 10/23/2024 at 11:48 AM, the RD documented, .Res with sig [significant] wt loss x [times] 1 month .Wt down-10# [pound] in 1 month noted .Poor meal intake . Review of the facility ' s Weight Change Assessment for Resident #67 dated 10/24/2024, revealed the Director of Nursing (DON) documented .Previous Weight .138 .Current weight .129.2 .Weight change Percentage .6.3 .Weight Change in Pounds .8.8 .Timeframe for WT change .30 Days . 4. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy, Failure to Thrive, Unspecified Dementia, Dysphagia, Oropharyngeal Phase, and Failure to Thrive. Review of Resident #65 ' s Patient Weight Report dated 8/9/2024 through 9/13/2024, revealed: 8/9/2024: 114.6 lbs. 8/23/2024:112.8 lbs. 8/28/2024: 110.0 lbs. 9/13/2024: 104.8 lbs. Resident #65 suffered a significant and severe weight loss of approximately 8.55% over 1 month (35 days) from 8/9/2024 to 9/13/2024. Resident #65 lost a total of 9.8 lbs. in 1 month. Review of the ADL verification worksheet for Resident #65 dated 8/9/2024 through 9/13/2024, revealed of the 105 meals delivered, 78 meals had no documentation of the percentage of total meal consumption. (74.29 % of meal percentages were not documented) Review of the Annual MDS assessment for Resident #65 dated 8/13/2024, revealed a BIMS score of 11 which indicated moderate cognitive impairment. Continued review revealed Resident #65 required setup or clean-up assistance for eating. Review of the care plan for Resident #65 dated 8/29/2024, revealed .8/12/24 [2024] slow decline of wt .8/29/2024 .At risk for weight loss and malnutrition/related to receiving mechanically altered diet, diagnosis of adult failure to thrive .Dietary supplements as ordered .Monitor meal intake and offer substitute if resident eats less than 50% of meal .Offer between meal snacks .10/14 [2024] supplement order .receiving mechanically altered diet .Record food intake at each meal; offer appropriate substitutes for uneaten food . Review of the laboratory (lab) report for Resident #65 from Lab #1 dated 8/23/2024, revealed .ALBUMIN .3.4(L) . Review of the facility ' s Weight Change Assessment for Resident #65 dated 9/23/2024, revealed LPN FFFFFF documented .Previous Weight .117 .Current Weight .104 .Weight Change Percentage .11.0 .Weight Change in Pounds .13 .Timeframe for WT change .30 Days 90 Days 180 Days . Review of the facility ' s Clinical Note Entry for Resident #65 dated 10/14/2024, revealed .Double portions added to meals . Observation in Resident #65 ' s room beginning on 10/24/2024 at 11:50 AM, revealed the following: Resident #65 ' s lunch tray was delivered to the resident ' s room by CNA GGGGGG. Resident #65 was seated in a wheelchair with the bedside table over her lap. CNA GGGGGG prepared the tray (opened the drink, dessert and silverware packet) for Resident #65 and left the room. Resident #65 attempted to pick up her drink unsuccessfully. Resident #65 leaned over her tray and placed her mouth over the straw. After two attempts, Resident #65 was unable to scoop lasagna onto the fork and reach her mouth. Resident #65 ate two bites of a roll and one serving of ice cream. At 12:05 PM, CNA GGGGGG returned to Resident #65 ' s room to collect the lunch tray. CNA GGGGGG was asked how much of the meal Resident #65 ate. CNA GGGGGG stated, . I would say about 25% . CNA was asked how the meal intake would be documented. CNA GGGGGG stated, .I write the intake down on a piece of paper and pulled the paper from her pocket to show this surveyor. CNA GGGGGG was asked if the meal intake was documented in Resident #65 ' s medical record. CNA GGGGGG stated, .No, I ' m not able to document in the record, I don ' t have access . CNA GGGGGG was asked if Resident #65 ' s meal intakes were reported to the nursing staff. CNA GGGGGG stated, .If the nurse asks me how much a resident eats [residents eat], I ' ll tell them. CNA GGGGGG was asked if Resident #65 required assistance with eating. CNA GGGGGG stated, .[Resident #65] only needs her tray set up, she can feed herself . CNA was asked how to identify if a resident needs assistance with eating. CNA GGGGGG stated, .I just ask somebody, a nurse or another CNA . Resident #65 was not offered an alternative meal or encouraged to eat by CNA GGGGGG. The surveyor ' s assessment of Resident #65 ' s lunch tray revealed approx. 10 % of the meal was eaten by Resident #65. No meal ticket was observed on the lunch tray. Observation in Resident #65 ' s room on 10/29/2024 at 6:18 PM, revealed a dinner tray with < (less than) 10% of the food consumed by Resident #65. There was no evidence Resident #65 was assisted with dining. No double portions were on the tray as observed on the meal ticket. Observation in the hallway by the kitchen on 10/31/2024 at 8:20 AM, revealed Resident #65 ' s breakfast tray was delivered back to the kitchen with < 10% of meal consumed. During an interview on 11/1/2024 at 10:05 AM, the MDS Coordinator confirmed Resident #65 had not been care planned for a significant weight loss nor did the facility follow the care plan to record food intake at each meal. During an interview on 11/1/2024 at 10:10 AM, the DON acknowledged there was no care plan related to Resident #65 ' s significant weight loss. The DON also acknowledged food intake was not recorded at each meal per the care plan. When asked what the expectations were for a significant weight loss, the DON stated, It should have been care planned. Observation in the hallway by the kitchen on 11/5/2024 at 8:40 AM, revealed Resident #65 ' s tray was returned to the kitchen with less than 25% of breakfast eaten. Observation in Resident #65 ' s room on 11/6/2024 beginning at 12:03 PM, revealed Resident #65 was noted sitting up in her wheelchair in the room. Her tray had just been set up. The drink, dessert and silverware packet were opened. Surveyor watched Resident #65 pick up her fork, put a small bite of casserole in her mouth, and eat it. A few minutes later, Resident #65 used her fork to eat her dessert. Resident #65 took a small sip of her drink by leaning over her bedside table. No one came back to help assist Resident #65 with her food or offer her a substitute. Staff did nothing to help Resident #65 in any way. As lunch trays were picked up from the 200 Hall, none of the CNA ' s offered an alternative or encouraged Resident #65 to eat more of her food. Resident #65 consumed less than 10% of lunch. No meal ticket was observed on the lunch tray. 5. Review of the medical record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Dysphagia (difficulty swallowing), oral phase. Review of Resident #63 ' s Patient Weight Report dated 2/5/2024 through 5/20/2024, revealed: 2/5/2024: 157.0 lbs. 3/4/2024: 157.5 lbs. 4/30/2024:143.8 lbs. 5/6/2024: 145.0 lbs. 5/13/2024: 143.0 lbs. 5/20/2024: 141.0 lbs. Resident #63 suffered a significant and severe weight loss of approximately 10.19% over 3.5 months from 2/5/2024 to 5/20/2024. Resident #63 lost a total of 16 lbs in 3.5 months. Review of the ADL verification worksheet for Resident #63 dated 2/5/2024 through 5/20/2024, revealed of the 315 meals delivered, 249 meals had no documentation of the percentage of total meal consumption. (79.05% of meal percentages were not documented) Review of the facility ' s Weight Loss Assessment for Resident #63 dated 5/5/2023, revealed the ADON documented .Previous weight .155.6 .Current Weight .144.5 .Weight change Percentage .7.1 .Weight Change in Pounds .-11.1 .Timeframe for WT change .30 Days . Review of the Quarterly MDS assessment for Resident #63 dated 10/20/2023, revealed a BIMS score of 9 which indicated moderate cognitive impairment. Continued review revealed Resident #63 required setup or clean-up assistance. Further review of the MDS revealed Resident #63 was changed to partial/moderate assistance for eating on 7/14/2024 with a BIMS score of 7, which indicated severe cognitive impairment on the Quarterly MDS. Review of the lab results for Resident #63 from Lab #1 dated 4/11/2024, revealed .ALBUMIN .3.2 (L) [low] . Review of Resident #63 ' s Patient Weight Report dated 4/30/2024, revealed a weight of 143.80 lbs. Review of the facility Clinical Note Entry for Resident #63 dated 5/3/2024 at 8:37 AM, revealed the RD documented, .Res with sig wt loss at 3 months .CBW [Calculated Body Weight] 143.8# .intake ranges from 25-100% .Partial/moderate assistance with meals noted . Review of the care plan for Resident #63 dated 10/29/2024, revealed .10/13/2023 .At risk for weight loss and malnutrition due to receiving dysphagia level 1 diet .Monitor meal intake and offer substitute if resident eats less than {*}% [no percent present] of meal .Encourage .to eat all meals in Dining Room as tolerated .9/1/2024 .receiving mechanically altered diet .Monitor and document weight .Record food intake at each meal; offer appropriate substitutes for uneaten food .Requires assistance with meals . During an interview on 11/1/2024 at 10:05 AM, the MDS Coordinator confirmed Resident #63 had not been care planned for a significant weight loss nor did the facility follow the care plan to record food intake at each meal. During an interview on 11/1/2024 at 10:10 AM, the DON acknowledged there was no care plan related to Resident #63 ' s significant weight loss. The DON also acknowledged food intake was not recorded at each meal per the care plan. When asked what the expectations were for a significant weight loss, the DON stated, It should have been care planned. During an interview on 11/1/2024 at 11:11 AM, the RD was asked about weight loss on Resident #63. The RD stated, .He [Resident #63] had a significant weight loss at 3 and 6 months of about 11% .he had a weight loss in May 2024 of 10 lbs . During a telephone interview on 11/6/2024 at 10:20 AM, the RD was asked to elaborate on Resident #63 ' s severe weight loss at 3 and 6 months. The RD stated Resident #63 had experienced severe weight loss of 11.6% on 3/4/2024 at 3 months and another severe weight loss of 11.6% on 12/6/2023. When asked if labs should have been taken with a severe weight loss, the RD stated, .Yes .at 3 and 6 months . Continued interview revealed Resident #63 ' s last lab was taken on 1/23/2024. 6. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, Nutritional Deficiency, and Gastro-Esophageal Reflux Disease (GERD) without Esophagitis. Review of Resident #45 ' s Patient Weight Report dated 2/5/2024 through 3/25/2024, revealed: 2/5/2024: 201.2 lbs; 3/12/2024: 194.0 lbs; 3/19/2024: 194.0 lbs; 3/25/2024: 189.8 lbs. Resident #45 suffered a significant weight loss of approximately 5.0% over 1.6 months from 2/5/2024 to 3/25/2024. Resident #45 lost a total of 11.4 lbs in 1.6 months. Review of the ADL verification worksheet for Resident #45 dated 2/5/2024 through 3/25/2024, revealed of the 147 meals delivered, 113 meals had no documentation of the percentage of total meal consumption. (76.87% of meal percentages were not documented) Review of Hospital #2 records for Resident #45 dated 3/23/2024, revealed .Critically ill .admitted to the ICU [Intensive Care Unit] due to obtundation [a stated of reduced alertness or consciousness] and hypotension [decreased blood pressure] .received 2 L [liters] of fluid .had admission in January where she presented with decreased mental status and hypotension .felt to be secondary to dehydration .presented similarly during her last admission with altered mental status that seemed to improve with hydration .admission in November 2022 .very similar presentation . Review of the Annual MDS assessment for Resident #45 dated 8/31/2024, revealed a BIMS score of 00 which indicated the resident was unable to complete the interview. Continued review revealed Resident #45 was dependent for eating. Review of the Care Plan for Resident #45 revealed, .Weight loss; 5% or more in last 30 days or 10% or more in last 180 days .4/12/23 [2023]- 5% SWL [Significant Weight Loss] x 30 days .9/11/2024 .Self care deficit R/T [related to] .eating .At risk for malnutrition R/T Vascular Dementia, Alzheimer's, GERD [Gastroesophageal Reflux Disease] .Alteration in nutrition/hydration R/T dx [diagnosis] of Nutritional deficiency .At risk for behaviors r/t Cognitive loss, alteration in thought process related to [Resident #45] demonstrates modified impaired in cognitive skills for daily decision making related to Alzheimer's, depression, and vascular dementia with behavioral disturbance . Review of (named Facility #1) ' s Lunch ticket for Resident #45 dated 10/25/2024, revealed .Assist W [with]/Meals . During a telephone interview on 10/17/2024 at 12:15 PM, the RD was asked about weight loss for Resident #45. The RD stated on 11/10/2023, Resident #45 was 213 lbs, 12/23/2023 at 207.2 lbs, 2/5/2024 at 201.2 lbs, and 3/25/2024 at 189.8 lbs. Resident #45 had a significant weight loss of 10.6% at 6 months. When asked about meal percentages, the RD stated Resident #45 ate 50-75% of meals per documentation. During a telephone interview on 10/19/2024 at 9:33 AM, Family Member (FM) AAAAA stated Resident #45 required total assistance with eating. She stated Resident #45 had been hospitalized three times for dehydration due to staff not offering her water (Resident #45 was unable to ask or pick up a water pitcher herself). FM AAAAA stated Resident #45 had not been feed any meals one day until she arrived to bring food and feed her. She stated the agency CNA (could not remember a name) was not aware that Resident #45 required assistance for feeding. During a telephone interview on 10/19/2024 at 10:10 AM, CNA BBBBB stated Resident #45 did not always get fed when agency staff would take care of her. When asked if staff would offer Resident #45 something to drink, CNA BBBBB stated, .The agency staff don ' t always know who requires assistance with meals .they don ' t know she [Resident #45] can ' t get the pitcher and drink herself if no one tells them . During an interview on 10/21/2024 at 10:45 AM, CNA KKKK was unaware that meal percentages less than 25% must be reported to the nurse per the CNA job description. During an interview on 10/21/2024 at 10:50 AM, CNA GGGGG was asked when a meal percentage should be reported to the nurse. She stated, If a patient goes 2 days without wanting to eat, I report to the nurse. When asked if less than 25% eaten by a resident should be reported to the nurse, CNA GGGGG stated, No. They have never told me any specific percentage to report to the nurse. During an interview on 10/21/2024 at 10:55 AM, CNA HHHHH was asked if administration had ever discussed meal percentages less than 25% needed to be reported to the nurse and she stated, No. During an interview on 10/21/2024 at 4:02 PM, Licensed Practical Nurse (LPN) EEEE was asked if Resident #45 or any resident had ever missed being fed a meal. He stated, Maybe and that staff probably needed to monitor this more often. When LPN EEEE was asked how agency staff would be made aware of the needs of a resident, LPN EEEE stated he had told them at times but could not say he did this all the time. During a telephone interview on 10/28/2024 at 3:54 PM, the RD stated Resident #45 was dependent for meals. When asked how she (RD) made recommendation for meals and fluid intake, the RD responded that she based the recommendations on facility documentation. The RD was then asked to look back at the meal percentages documentation and confirm the missed documentation. The RD stated the meal intake documentation had been an issue and was insufficient. Continued interview revealed the RD had addressed her concern with incomplete meal percentage documentation, but documentation was still not being completed. During an interview on 10/29/2024 at 10:01 AM, LPN EEEE stated Resident #45 required total assistance and was an assisted diner. When asked how meal intakes were monitored, LPN EEEE stated, .The CNA ' s put the information in the Kiosk but he did not check to see if it was actually there . During an interview on 10/29/2024 at 11:20 AM, DON acknowledged missed documentation for meal percentages and fluid intake 11/2023 to 10/2024 for Resident #45. When asked if Resident #45 had ever not been fed, the DON stated she was unable to confirm the resident was fed due to the missed documentation. Further interview revealed the DON ' s expectation for meal percentages and fluid intake was to be documented for breakfast, lunch, and dinner daily. Observation of Resident #45 ' s tray on 10/29/2024 at 6:25 PM, revealed Resident #45 ate less than 25% for dinner and drank no fluids. Resident #45 ' s food was barely touched, and the lids remained in place on the drinks. During an interview on 11/6/2024 at 10:20 AM, the RD stated Resident #45 had a 10% weight loss on 3/27/2024 at 6 months that started on 9/13/2023. Between this time, Resident #45 triggered for a slow weight decline on 12/20/2024. During an interview on 11/1/2024 at 10:05 AM, the MDS Coordinator confirmed Resident #45 had not been care planned for a significant weight loss. Continued interview revealed the MDS Coordinator also acknowledged Resident #45 was listed as dependent with eating/dining on the MDS and as assist on the care plan. During an interview on 11/1/2024 at 10:10 AM, the DON acknowledged there was no care plan related to Resident #45 ' s significant weight loss. When asked what the expectations were for a significant weight loss, the DON stated, It should have been care planned. Review of the medical record revealed Resident #58 (Resident #45 ' s roommate) was admitted to the facility on [DATE] with diagnoses which included Atherosclerosis of native arteries of other extremities with ulceration, Osteomyelitis, and Non-pressure chronic ulcer of other part of left foot with unspecified severity. Review of the admission MDS assessment for Resident #58 dated 8/24/2024, revealed a BIMS score of 15 which indicated no cognitive impairment. During an interview on 10/22/2024 at 12:07 PM, Resident #58 was asked if she had ever witnessed staff offering or assisting Resident #45 with any fluids to drink. Resident #58 stated when she was in the room, she did not observe staff offer anything to Resident #45. She stated, .When she [Resident #45] does get something to drink, she gulps it down because she is so thirsty . Resident #58 was then asked if she witnessed staff assisting Resident #45 with meals. Resident #58 stated Resident #45 was not fed dinner one day and the night shift (7 PM-7 AM) nurse (unknown) came in and fed her. Trays for Resident #45 ' s hall were scheduled to come to the floor at 5:35 PM. During an interview on 10/29/2024 at 12:10 PM, Resident #58 was asked if staff had offered Resident #45 water any time they came into the room. Resident #58 stated, .Not that I have seen .They still don ' t offer her anything to drink when I am in the room . During an interview on 10/22/2024 at 12:13 PM, CNA IIIII stated she was unable to access the Kiosk to view the resident care plan and ADL needs. When asked how she knew what kind of needs a resident required, CNA IIIII stated she had to ask another staff member about each resident when she did not receive report. During an interview on 10/22/2024 at 12:40 PM, CNA KKKKK was asked where to go into the Kiosk to find out what type of care each resident required. CNA KKKKK stated she did not have access to login into the Kiosk. CNA KKKKK was then asked how she documented meal percentages and other information, and she stated, .Under someone else ' s name . During an interview with the RD on 11/1/2024 at 11:11 AM, this surveyor noticed 2 clear bags with meal tickets in them labeled, Residents who did not get fed .10/25/2024 and 10/26/2024 . When asked about the 2 clear bags, the RD stated, .The Dietary Manager just reported this to me .I am going to look at them while I am in the facility . During an interview on 11/1/2024 at 11:20 AM, the Dietary Manager (DM) was asked about the 2 clear bags lying on the desk with meal tickets in them. The DM stated, .I was working the dish line and noticed some of the breakfast trays had not been touched .the food was untouched, and the juice still had the lids on them .I decided to keep the meal tickets that were on these trays . During an interview on 11/4/2024 at 8:42 AM, Dietary Aide (DA) BBBBBB stated there were trays that would come back to the kitchen untouched. DA BBBBBB was asked to elaborate on what he meant by untouched. He stated that the tops remained intact on the juice and the food was not touched (unstirred). Continued interview revealed when asked how many times untouched trays came back to the kitchen, DA BBBBBB stated, All the time. 7. Review of medical record revealed Resident #46 was admitted to the facility on [DATE] and discharged on 1/24/2024 with diagnoses which included Cerebral Infarction, Dementia with severe Psychotic Disturbance and Type II Diabetes Mellitus. Review of the Care Plan dated 11/16/2023, revealed Resident #46 had goals and interventions which included .11/16/2023 at risk for malnutrition .Allow adequate time to eat; provide cues; encouragement, and assistance .Dietary Supplements as ordered .Monitor meal intake and offer substitute if resident eats less than 75% .Monitor and encourage fluids and notify MD [Medical Director] if inadequate fluid taken .Dietary Consult as needed .incontinence will be managed by staff without evidence of skin breakdown .has a Stage 2 ulcer to coccyx . Review of the admission MDS dated [DATE], revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 1 which indicated severe cognitive impairment. Resident #46 required set up assistance with eating, had no concerns related to nutrition, had an unhealed pressure ulcer/injury at a stage 2. Review of Resident #46 ' s Patient Weight Report dated 12/9/2023 through 1/23/2024, revealed: 12/9/2023: 162 lbs; 1/2/2024: 145.3 lbs; 1/9/2024: 148.0 lbs; 1/16/2024: 144.0 lbs; 1/23/2024: 140.0 lbs. Resident #46 suffered a significant and severe weight loss of approximately 8.64% over 1 month from 12/9/2023 to 1/9/2024. Resident #46 lost a total of 14 lbs in 1 month. Additionally, Resident #46 lost an additional 8 lbs from 1/9/2024 to 1/23/2024. Resident #46 ultimately lost a total of 22 lbs (13.25%) over 6 weeks from 12/9/2024 to 1/23/2024. Resident #46 was discharged on 1/24/2024 to another long-term care nursing facility. Review of the ADL verification worksheet for Resident #46 dated 12/9/2023 through 1/23/2024, revealed of the 141 meals delivered, 121 meals had no documentation of the percentage of total meal consumption. (85.81% of meal percentages were not documented). Review of the undated Weight Loss Documentation, revealed an unknown author documented, Resident #46 had a weight loss of 11.1% (18 pounds) for 30 days. There was an undated Weight Loss Documentation form with only Resident #46 ' s name, Resident ID, Room Number and Physician Name filled in. At the bottom of this form there was a preprinted statement stating Reviewed with Interdisciplinary Team: This undated form did not have any weight loss data documented and there was no evidence the facility held an Interdisciplinary Team Meeting to discuss Resident #46 ' s significant and severe weight loss, instituted or carried out any interventions after the first 14 lbs. or subsequent weight loss. During an interview on 10/17/2024 at 3:00 PM, FM ZZZZ stated Resident #46 had been losing weight and she had been told Resident #46 was not fed some nights because he was asleep. FM ZZZZ stated she had requested Resident #46 have double portions. When she was asked who she requested the double portion, she could not remember who she had asked. During an interview on [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility document review, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision for 1 (Resident #29) of 7 sampled residents reviewed for wandering/elopement. The facility's failure to supervise and prevent Resident #29, with a known history of exit seeking behaviors and who was actively exhibiting delusions and auditory hallucinations from eloping to an unsafe environment, resulted in Immediate Jeopardy (IJ) when Resident #29 was found outside of the facility in the parking lot at 9:15 PM on 9/24/2022. According to staff statements, the resident was last seen in her wheelchair ambulating through the facility hallways around 8:30 PM. The facility's staff were unaware Resident #29 had exited the facility until a food delivery service driver alerted a staff member the resident was in the parking lot in a wheelchair near the exit/entrance gate. Resident #29 was exhibiting exit seeking behaviors, delusions, and auditory hallucinations the day of the elopement. Resident #29 stated her boyfriend (she had no boyfriend) was talking to her telepathically instructing her to leave the facility and meet him outside and they would go to a friend's house. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Regional Administrator, the Director of Nursing (DON), and the Regional Nurse Consultant were notified of the IJ for F-689 on 8/28/2023 at 1:41 PM in the Regional Administrator's office. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective on 9/24/2022, removed on 9/25/2022 and corrected on 9/26/2022. The IJ has been lowered to a scope and severity of D. The IJ was cited as past non-compliance and the facility is not required to submit a plan of correction. The findings include: Review of the facility's policy titled, Elopement and Wandering Patients, revised 6/21/2022, revealed, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so .The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment or risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary .Adequate supervision will be provided to help prevent accidents or elopements . Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included [NAME] Sequard Syndrome (a rare neurological condition characterized by a lesion in the spinal cord which results in weakness or paralysis on one side of the body and a loss of sensation on the opposite side), Bipolar Disorder, and Schizoaffective Disorder. Review of the Psychiatric Note by the Psych Nurse Practitioner (NP) dated 6/13/2022 revealed, .Continue psychiatric care for a resident who has diagnoses of schizoaffective disorder bipolar type, acute delusional process, depression, anxiety and insomnia .Due to inability to discuss medical course, discuss risk versus benefit of any medical or medication intervention patient is deemed to lack capacity for medical decision making at this time. A POA [Power of Attorney] or surrogate decision maker should be utilized for medical decision making or higher level decision .Patient's mother identified as a surrogate decision maker . Review of the Treatment/Order Update/Change in Condition for Resident #29 dated 9/24/2022, revealed an order for, .Check WanderGuard each shift . A Wanderguard is a monitoring devise used to monitor wandering patients and alert caregivers when a resident exits a door equipped with a sensor. Review of the June, July, August and September 2022 Treatment Administration Records (TAR) for Resident #29, revealed documentation only on June 24th, 25th, and 26th on the 7 AM-7 PM shift regarding the presence of a Wander Guard on the resident's left ankle. The facility failed to document the presence of a Wander Guard for 119 of 122 days reviewed. Review of the Nursing Admission/readmission Form for Resident #29 dated 7/13/2022, completed by Registered Nurse (RN) #1 revealed, .AMBULATORY RISK FACTOR: Can the patient ambulate independently (with or without the use of an assistive device) or propel self in wheelchair/motorized chair? Answered yes .Does the patient have a history of eloping from home or facility? Answered no .Does the patient make comments of leaving the facility? Answered yes .Does the patient demonstrate exit seeking behavior? Answered yes .Does the patient wander about the facility? Answered yes .Consider all factors when determining a patient's elopement risk assessment. If the answer to the Ambulatory Risk Factor is 'YES' AND ANY of the Definitive Risk Factors answers is 'YES', the patient is identified as being at high risk for elopement .INTERVENTIONS: Wanderguard bracelet initiated . Review of the medical record for Resident #29 revealed no order for a wanderguard dated 7/13/2022. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #29 dated 9/2/2022, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Continued review revealed no behaviors including wandering exhibited during the assessment period, no wander guard bracelet, and she required total assistance of 2 people for Activities of Daily Living (ADL). Continued review revealed she was totally dependent upon 2 or more staff for transfers. Review of the Care Plan Report for Resident #29 revealed Problems/Assessments for, .has exhibited Wandering Behavior Wears Wanderguard to right ankle .9/24/2022 Resident exhibited exit seeking behavior . Continued review of the Care Plan Report for Resident #29 revealed interventions included: .Assess potential physical causes for wandering (need for toilet, water, food, pain relief EFFECTIVE 9/26/2022 .Place in Special Care Unit. Ensure all door alarm/locks are armed to reduce the risk of [Named resident] leaving secure area EFFECTIVE 9/26/2022 .Provide diversional activities (folding, rummaging box, packing/unpacking.) EFFECTIVE 9/26/2022 .Redirect [Named resident] behavior/activity when wandering is observed EFFECTIVE 9/26/2022 .Use wander guard/location monitor daily EFFECTIVE 9/26/2022 .Exit seeking behavior. Alarms on the 200, 300 double doors after 5pm EFFECTIVE 9/26/2022 .Monitor resident's location to ensure safety EFFECTIVE 9/26/2022 .Transfer via [named mechanical total body lift]. Continued review of Resident #29's Care Plan Report revealed no documentation the resident was care planned for wandering or exit seeking behaviors nor the presence of a Wanderguard prior to 9/24/2022. Review of the Nurse's Event Note for Resident #29 dated 9/24/2022, revealed, .elopement .Time 21:15 [9:15 PM] .STEPS IMPLEMENTED TO PREVENT RECURRENCE: One on one monitoring until in bed. Q [every] 30 minute rounding while in bed . Continued review revealed the resident was educated on the Leave Of Absence (LOA) policy. Review of the medical record for Resident #29 revealed a Clinical Note dated 9/24/2022, .This nurse was notified by CNA [Certified Nurse Assistant] 1 [CNA #10] that resident was brought into facility after being found around the facility gated entrance/exit. This nurse entered resident room. Resident sitting up in w/c [wheelchair] in room with hat on. No acute distress noted. This nurse proceeded to ask CNA 1 what exactly happened. CNA 1 told this nurse to ask CNA 2 [CNA #8] because he saw her first. CNA 2 reported resident was spotted at the gate while getting his food delivery. He went inside to get CNA 1 so they could bring resident inside .During resident interview, resident reported she pushed the door open, and she was going to see her boyfriend . Review of the Psychiatric Notes for Resident #29 dated 9/26/2022, revealed, .Staff requesting [AGE] year-old patient to be seen today due to behaviors over the weekend .Patient reportedly trying to elope .When asked patient why she tried to leave over the weekend she stated, 'I have a friend next door I wanted to hang out with my friends any [and eat] real food. Nobody cares about me here.' Review of the Psychotherapy Progress Note dated 9/27/2022, revealed, .She had gone outside without advising anybody to 'see my boyfriend.' She does not have a boyfriend though has had a delusional preoccupation with a former male staff member .Session was focused on safety issues and the importance of following protocol for leaving the building . During an interview on 8/23/2023 at 2:24 PM, the Regional Nurse Consultant stated the outcome of the investigation regarding Resident #29 being found outside near the entrance/exit gate on 9/24/2022 determined Resident #29 was safe, because the gate was locked. During an interview on 8/23/2023 at 2:35 PM, the Director Of Nursing stated Resident #29 would hang around the lobby area when activities were going on and when there was a lot of traffic in the front lobby. There was no one stationed at the front lobby during the time of the elopement. She stated she assumed the resident went out the front door. The door would alarm, and it would lock if someone with a wanderguard went towards it. She said the resident was going to see a guy friend. The DON thought it might have been cool that night. She was unsure how long Resident #29 was outside. The DON stated Resident #29 was in the parking lot. The DON confirmed Resident #29 did not have a WanderGuard. During an interview on 8/23/2023 at 3:04 PM, Licensed Practical Nurse (LPN) #15 stated Resident #29 was going to meet her boyfriend on 9/24/2022. LPN #15 stated she asked the resident how she communicated with the boyfriend, and LPN #15 stated Resident #29 pointed to her head. LPN #15 stated she thinks Resident #29 went out the front door. LPN #15 stated the exit doors were always locked. LPN #15 stated she was not actually there during the elopement, she just helped investigate the incident. During an interview on 8/23/2023 at 3:23 PM, the Regional Administrator stated there were cameras in use on 9/24/2022 but did not record. During an interview on 8/23/2023 at 3:58 PM, Resident #29 stated she was at the gate when she was found on 9/24/2022 and was wearing jeans and a shirt. She stated it was cold outside. She stated she doesn't remember who brought her back into the building. During an interview on 8/23/2023 at 4:17 PM, the Regional Administrator stated the facility had a Governing Body meeting to discuss the incident where Resident #29 was found in the parking lot on 9/24/2022. He stated he did not know if the previous Administrator documented the meeting. The Administrator was unable to provide any Governing Body meeting notes regarding this incident. During an interview on 8/24/2023 at 8:36 AM, the Regional Nurse Consultant stated she felt Resident #29 pressed on the front door until it released on 9/24/2022. The Regional Nurse Consultant stated since she had been assigned to the facility, approximately 1 1/2 years ago, the front door had always been locked. The Regional Nurse Consultant stated the door was equipped with a WanderGuard lock, but she couldn't tell for sure it alarmed because it happened a year ago. The Regional Nurse Consultant stated, I feel there are missing pieces. We were confident in our decision that it was not an elopement situation, and I'm not sure where all the pieces have gotten to. We determined it was not going from an safe to an unsafe environment. There are grassy areas and paved areas in the parking lot. We have the ramps built in to transition to one grade to another. Usually the front desk staff is here till 5:00 PM. The Regional Nurse Consultant did not recall asking why the alarm was not going off when the resident was found in the parking lot. The Regional Nurse Consultant confirmed parts of the investigation were missing. The Regional Nurse Consultant stated she could not explain why there was no documentation regarding the presence of a Wander Guard bracelet on the TAR except for the dates including June 24th, 25th, and 26th, 2022. During an observation and interview on 8/24/2023 at 8:55 AM, the Regional Nurse Consultant, the DON and this surveyor walked outside to the parking lot. When asked where Resident #29 was found on 9/24/2022, the DON pointed to the middle of the driveway in front of the entrance/exit gate. The DON stated she was on duty as the Unit Manager the night of 9/24/2022, and did the initial investigation. She stated she had observed Resident #29 sitting at the front entrance, looking at the door, between 8:00 PM and 8:30 PM. She stated she took Resident #29 to her room at that time because she was unattended. The DON stated she notified the former DON and the Administrator that the resident was found outside in the parking lot. She stated after the staff returned Resident #29 to the building, she stayed with her until the staff placed her back in the bed. Continued observation revealed the Regional Maintenance Director measured 105 feet from the front door of the facility to the area where CNA #8 stated the resident was found on 9/24/2022. The facility interviews were not consistent whether Resident #29 was found INSIDE or OUTSIDE the gate. During a telephone interview on 8/24/2023 at 9:12 AM, the former Administrator stated, I do not really remember the elopement. I am no longer there. If it was not reported [to the State Agency], it was because eyes were on her the whole time. I don't recall her seated at the exit gate. I don't remember if we had a QAPI [Quality Assurance Performance Improvement] meeting. I can't speak to something I don't remember. During an interview on 8/24/2023 at 9:56 AM, the Assistant Director of Nursing (ADON) stated Resident #29 had been sent out to the hospital sometime in June of 2022. She stated she assumed the resident's WanderGuard bracelet was removed at that time. She stated she does not recall if a WanderGuard bracelet was applied when she was readmitted . She stated she was not sure how Resident #29 got out the door, into the parking lot on 9/24/2022. She stated she had taken Resident #29 back to her room twice on 9/24/2022 because she was exit seeking. She stated she knew that other staff had taken her back to her room that day as well. During an interview on 8/24/2023 at 10:37 AM, the DON stated Resident #29 was in the hospital from [DATE] to 7/13/2022. During a review of the medical record, the DON confirmed there was no documentation Resident #29 had a WanderGuard on, or was ordered a WanderGuard upon return from the hospital. During an interview on 8/24/2023 at 11:00 AM, the former DON, who no longer is employed by the facility, stated she remembered Resident #29. She stated the resident was unaware of the LOA policy and the resident was wanting to go with her boyfriend/friend to a party. She stated she educated the resident on the LOA policy. The former DON stated the resident was found in the parking lot. She stated she was unsure how the resident got out of the building. The former DON stated Resident #29 used to sit in front of the door in the lobby and order food all the time and could have possibly known the door code. She stated the staff were trying to determine how she got out of the building that night and think someone could have let her out or pushed the code for her to let her out. The former DON stated she could not answer why they did not put a WanderGuard on Resident #29 when the Resident #29 came back to the facility from the hospital on 7/17/2022. The facility was unable to determine the root cause of how Resident #29 got out of the building. During an interview on 8/24/2023 at 11:52 AM, CNA #10 stated she was Resident #29's CNA the night she was found in the parking lot. She stated she did not know how she got out of the building. She stated when she came on duty at 7:00 PM, Resident #29 was rolling up and down the hallways in her wheelchair. She stated she was told she was outside and the CNA that found her stated he needed her help to get her back in the building. She stated when she went outside, Resident #29 was outside the gate and the gate was open. She stated she did not hear any door alarm that night. CNA #10 stated the resident told her she was going home to see her boyfriend or husband and their 8 or 9 kids. During an interview on 8/24/2023 at 12:14 PM, CNA #8 stated he had ordered food from a food delivery service and was notified on his phone his delivery was waiting at the closed gate in the parking lot of the facility. CNA #8 stated he pushed the button in the front lobby to open the exit gate and the food delivery driver drove up to the canopy outside of the front door to meet him. CNA #8 stated the food delivery driver told him there was someone in a wheelchair at the gate in the parking lot. CNA #8 stated it was dark outside. CNA #8 stated he looked towards the gate and saw a resident in a wheelchair in the parking lot at the gate in the middle of the driveway. CNA #8 stated the door alarm was not sounding. CNA #8 stated he tried to wheel Resident #29 back to the facility but she was locking her wheelchair and screaming, No. CNA #8 stated he tried calling the facility on his phone to get someone to come help him, but no one would answer the phone. CNA #8 stated he left the resident alone in the parking lot to come back inside the facility to get someone to help him. CNA #8 stated he asked CNA #10 to help him get the resident back inside the building. CNA #8 stated Resident #29 told him she was going to a friend's house. During an interview on 8/28/2023 at 2:25 PM, Registered Nurse (RN) #1 stated he did the readmission Assessment for Resident #29 where she was readmitted from the hospital on 7/17/2022. He stated he documented the resident was at high risk for elopement, according to the results of his assessment. He stated he checked the box which indicated a WanderGuard monitor was needed, but he did not write an order for a WanderGuard, nor place one on the resident. He stated the process for obtaining a WanderGuard was to notify the Risk Manager and she would write the order and apply the WanderGuard. When asked what the process to be followed is if the assessment was completed on a resident after office hours, on weekends or holidays, or when the Risk Manager wasn't there, he stated he would call her on the phone. He stated he was not familiar with putting in orders. He stated his only responsibility was to do the assessment. He stated in the past, the WanderGuard monitor and bracelet had been locked up somewhere. During an interview on 8/30/2023 at 1:28 PM, Psychiatric Nurse Practitioner (NP) #2 stated, [Named Resident #29] absolutely lacks capacity. She has no insight into her delusions. Any medication we give her will not work on delusions. She has romantic ideations. The ideations used to be toward the former ADON and he had to quit working there because of her. She had started to threaten his wife. Now she is obsessed with her sister's boyfriend. She may have a high BIMs score, but lacks the capacity to make safe decisions.

Amended from F-865 to F-867 Based on facility policy review, facility document review, medical record review, and interview, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to develop an effective QAPI program that recognized concerns related to exit seeking behavior when a resident exited the facility without staff knowledge, and failed to provide adequate supervision to prevent elopement and failed to ensure a safe environment for 1 (Resident #29) of 7 sampled residents. Failure of the QAPI Committee to provide adequate supervision to prevent elopement placed Resident #29 in Immediate Jeopardy. Resident #29 (a resident who was experiencing auditory hallucinations and delusions, with known wandering and exit seeking behaviors) was able to exit the facility to the parking lot at night on 9/24/2022. The whereabouts of Resident #29 was unknown by staff from approximately 8:30 PM to 9:15 PM. 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. The Regional Administrator, the Director of Nursing (DON), and the Regional Nurse Consultant were notified of the IJ for F-865 on 8/28/2023 at 1:45 PM in the Regional Administrator's office. The facility was cited Immediate Jeopardy at a scope and severity of J. F-865 has been removed from the 2567 and replaced with F-867. The IJ was effective on 9/24/2022, removed on 9/25/2022 and corrected on 9/26/2022. The IJ has been lowered to a scope and severity of D. The IJ was cited as past non-compliance and the facility is not required to submit a plan of correction. The findings include: Review of the facility's policy titled, Elopement/Wandering, Unsafe Resident dated 2/1/2009, revealed, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .will identify residents who are at risk for harm because of unsafe wandering (including elopement) .will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .care plan will indicate the resident is at risk for elopement or other safety issues .Interventions to try to maintain safety will be included in the resident's care plan .document circumstances related to unsafe actions, including wandering by a resident .institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behaviors .all residents admitted to the facility will have an elopement assessment done within first 24 hours .elopement assessment will then be completed every 90 days, and interventions updated as needed .staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility . Review of the facility's QAPI Plan reviewed January 2023, revealed, .The Quality Assurance Performance Improvement (QAPI) Plan is designed to establish and maintain an organized facility-wide program that is data-driven and utilizes a proactive approach to improving the quality of life and services throughout the facility .Establish a facility-wide process to identify opportunities for improvement through continuous attention to quality of care, quality of life and Resident safety .The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand a problem, its causes, and implications of change .The facility uses a thorough and highly organized/structured approach to determine the root cause of identified problems .The Governing Body and the facility administration shall provide general oversight for Quality Assurance and Performance Improvement activities related to Resident care and services throughout the facility . Review of the facility's investigation dated 9/26/2022, revealed Resident #29 eloped on 9/24/2022 at approximately 8:30 PM and was found at 9:15 PM in the parking lot. The facility initiated 1:1 monitoring until bedtime, then every 30-minute rounding was performed for 4 days and ended on the 5th day at 7:00 PM by management. The facility placed alarms on the inside double doors to the unit Resident #29 was housed on that were activated from 5:00 PM to 8:00 AM. Statements were obtained by staff who were working the night of the elopement. None of the statements said any staff saw the resident leave the facility. Residents who had wanderguards were assessed for placement and 100% were present, according to the audit. The resident was educated regarding the Leave of Absence (LOA) policy which included, .Discussed with resident LOA policy that if she wants to go out with her family or her boyfriend we have to ensure that there is no contraindications medically and we have to fill out paperwork releasing her to them for an outing. Explained that under no circumstances is she allowed outside of the facility alone for safety concerns. Resident acknowledge understanding of the policy and repeated policy to Unit manager. 200 Hall nurse present and witnessed conversation . Review of (Certified Nursing Assistant) CNA #8's statement revealed, On September 24, 2022 at approximately 9:00 PM, I stepped outside to meet food delivery driver, when I noticed someone in a wheel chair by the entrance gate. Myself and CNA assigned to 200 Hall went to get resident to bring her in. She began screaming no and putting wheel chair brakes on. Said she was going to her friends house. Once back inside CNA took resident to her bedroom and notified charge nurse . Refer to F-689 During an interview on 8/24/2023 at 8:35 AM, the Regional Nurse Consultant stated she felt like there were pieces missing in regards to the investigation regarding Resident #29 being found outside of the building in the parking lot on 9/24/2022. The Regional Nurse Consultant did not elaborate on what parts of the investigation she felt were missing. She stated she does not recall being involved in a QAPI meeting following the incident, and could not remember if a QAPI was held. She stated she does not know how the resident was allowed to leave the building unattended and unnoticed. During a phone interview on 8/24/2023 at 9:11 AM, the former Administrator stated he did not recall much of the event related to Resident #29's elopement on 9/24/2022. He stated he does not remember if a QAPI meeting was held after the event. He stated he felt sure a Governing Body meeting was held, but can not recall if he documented the meeting. He stated he cannot speak to something he doesn't remember. During an interview on 8/24/2023 at 4:17 PM, the Regional Administrator stated he could not find any documentation a QAPI meeting was held after Resident #29 was found outside in the parking lot on 9/24/2022. The Regional Administrator stated he could not provide any documentation of any type of meeting held after the elopement, including a Governing Body meeting. He confirmed a QAPI meeting should have been held and a thorough investigation should have taken place which would have identified the root cause of the incident.