**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on (Named Glucometer-a device/meter used to check blood sugar levels with the use of a blood sample) User's Guide review, policy review, job description review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a multi-use blood glucose meter was not cleaned and disinfected with an Environmental Protection Agency (EPA) approved disinfecting wipe to prevent the cross-contamination of bloodborne pathogens for 2 of 2 (Residents #2 and Resident #15) sampled residents reviewed for blood glucose monitoring. Licensed Practical Nurse (LPN) A failed to clean and disinfect the multi-use blood glucose meter before and after use on each resident in accordance with User's Guide recommendations and facility policy. LPN B failed to perform hand hygiene and glove changes between medication administration of different routes, failed to clean, rinse, and dry a nebulizer mask after use, and failed to perform hand hygiene when changing gloves during resident care for 1 of 4 (Resident #8) residents reviewed for medication administration. LPN B failed to clean soiled items removed from a resident's room prior to storing in a medication cart and failed to clean the medication cart after placing soiled items on it for 1 of 2 (Hall B) medication carts. The facility failed to establish and implement a program to identify, report, investigate, and control infections and communicable diseases when they failed to track infections by organism for 4 of 4 months (April, May, June, and July 2025) reviewed for tracking and trending of infections. The facility's failure to ensure staff properly disinfected the blood glucose meter that was used for multiple residents, in accordance with recommendations and the facility's policy, placed the residents at risk for potential contamination with bloodborne pathogens and the likelihood to cause serious injury, harm, impairment, and/or death resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to appropriately clean and disinfect a multi-use blood glucose meter during medication administration for Resident #2 and #15. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy for F880 on 8/12/2025 at 7:18 PM, in the Conference room. The facility was cited Immediate Jeopardy at F-880. The facility was cited at F-880 at a scope and severity of J. The Immediate Jeopardy for F-880 began on 8/12/2025 and continued through 8/13/2025. The Immediate Jeopardy was removed 8/14/2025. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 8/13/2025 at 4:19 PM, and was validated onsite by the surveyors on 8/14/2025 through review of in-services, audits, and staff interviews conducted on all shifts. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled, .Fingerstick Glucose, dated 3/19/2012, revealed .Purpose.To obtain a blood sample to determine the resident's blood glucose level.Preparation.Disinfected blood glucose meter.Ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses.Clean and disinfect reusable equipment between uses according to the manufacturer's instructions with an EPA registered disinfectant (follow manufacturers instructions for application) and according to current infection control standards of practice. After cleaning, place on a barrier and/or return to designated storage container. Review of the (Named Glucometer) User's Guide with a revised date of 3/2024, revealed .Cleaning and Disinfecting Your [Named Glucometer].Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and lancing device surface, so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface.Cleaning and Disinfecting Your Meter.Wash hands with soap and water and dry thoroughly.Inspect for blood, debris, dust, or lint anywhere on the meter or lancing device.To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port.To disinfect your meter, clean the meter with one of the validated .EPA registered wipes.Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use.Wipe meter dry or allow to air dry.Wash hands with soap and water and dry thoroughly.If the meter or lancing device is being operated by a second person who is providing testing assistance to the use, the meter or lancing device should be disinfected prior to use by the second person. Review of the facility's policy titled, Medications, Nebulizer (Handheld), dated 8/25/2014, revealed .The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway.Rinse and disinfect the nebulizer equipment according to facility protocol, or.Wash pieces with warm, soapy water.Rinse with hot water.Place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes).Rinse all pieces with sterile water (NOT tap, bottled, or distilled).Allow to air dry on a paper towel.When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Review of the facility's policy titled, Eye Drop Administration, dated 11/1/2008, revealed .To administer ophthalmic solution into and around the eye in a safe and accurate manner.Perform hand hygiene. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 6/2010, revealed .This facility considers hand hygiene the primary means to prevent the spread of infections.Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions.After removing gloves.In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol [chemical names for alcohol] for all the following situations.after removing gloves.Washing hands.Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least fifteen (15) seconds under a moderate stream of running water, at a comfortable temperature. Hot water is unnecessarily rough on hands.Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of sink.dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel.Discard towels into trash.Using Alcohol-Based Hand Rubs.Apply product to palm of hand and rub hands together.Cover all surfaces of hands and fingers until hands are dry.Follow manufacturers' directions for volume of product to use. Review of the facility policy titled, Infection Prevention Surveillance, dated 10/31/2017, revealed, .Systematically complete surveillance of infections among residents, staff and other personnel routinely in facility.Surveillance of healthcare- associated infections is done by.Review of culture reports and other pertinent lab data. Review of the facility Infection Control job description dated 10/2020, revealed, .Plan, develop, implement, evaluate and oversee the infection prevention and control program in accordance with current regulations and guidelines governing skilled nursing facilities.Verify that laboratory support is available including microbiological and serological services.Review and analyze infectious disease laboratory reports and consult with the Director of Nursing in developing the care plan for assuring that aseptic techniques are implemented. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with a re-entry date of 10/21/2023, with diagnoses including Hemiplegia, Chronic Right Heart Failure, Diabetes Mellitus (DM), and Chronic Obstructive Pulmonary Disease. Review of the Care Plan with a revised date of 2/7/2024, revealed, .I have a dx [diagnosis] of TYPE 2 DM WITH HYPERGLYCEMIA [high blood glucose level] and am at risk for complications of this disease such as slow / nonhealing wounds, hypo [low]/ hyperglycemia .Fasting Serum Blood Sugar as ordered by doctor. Review of the Physician Order dated 10/20/2023, revealed, .Insulin Aspart Injection Solution [a medication used to treat diabetes] 100 UNIT [the basic measure for the amount of insulin]/ML [milliliter].Inject 5 units subcutaneously [beneath the skin] before meals for diabetes. Review of the Physician's Order dated 11/28/2023, revealed, .NovoLOG Injection Solution [a medication used to treat diabetes] 100 UNIT/ML.Inject as per sliding scale: if 0 - 200 = 0 U [unit]; 201 - 300 = 5 U; 301 - 400 = 8 U; 401 - 500 = 12 U; 501 - 650 = 15 U; 651 - 999 = call MD [Medical Doctor], subcutaneously before meals and at bedtime for diabetes. Review of the Physician Order dated 6/20/2024, revealed, .Lantus Subcutaneous Solution [a medication used to treat diabetes] 100 UNIT/ML.Inject 46 unit subcutaneously two times a day related to.DIABETES MELLITUS. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #2 had moderately impaired cognition. Active diagnoses included Diabetes Mellitus. Review of the Medication Administration Record (MAR) dated 8/12/2025, revealed Resident #2 received insulin before meals. Documentation on Resident #2's MAR revealed blood glucose levels were checked at 7:00 AM and 11:00 AM. During an observation and interview on Hall A on 8/12/2025 at 11:31 AM, revealed LPN A stated, This is my last one [blood glucose check], I saved him [Resident #2] for you to see because he gets scheduled insulin. LPN A then obtained Resident #2's blood glucose reading and returned to the Hall A medication cart with a dirty glucometer. LPN A cleaned the meter using (Named) hand sanitizing wipes, which were 70% ethyl alcohol. LPN A was asked are those (70% ethyl alcohol hand sanitizing wipes) what you use to disinfect the glucometers. LPN A stated, Yes, that's what we use. During an interview on 8/12/2025 at 2:36 PM, LPN A was asked did everyone (residents) have their own glucometer or is the same glucometer used for everyone who is on that medication cart. LPN A stated, Weclean and reuse, we do have extra ones. Each resident has a meter, but we use them as needed. So, we just use one meter, clean it and re-use for everyone until we need a new one. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Polycythemia Vera [a type of blood cancer]. Review of the Care Plan dated 7/26/2025, revealed .I have DIABETES Mellitus with Polyneuropathy [a nerve disorder that impacts nerve functions in the body] and am at risk for complications such as slow / nonhealing wounds, vision impairment, hypo / hyperglycemia.Diabetes medication as ordered by doctor.I have impaired immunity r/t [related to] dx [diagnosis] of POLYCYTHEMIA VERA. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #15 was cognitively intact. Active diagnoses included Diabetes Mellitus. Review of the Physician's Order dated 8/9/2025, revealed .Insulin Lispro Injection Solution.Inject as per sliding scale: if 0 - 200 = 0 units; 201 - 300 = 5 units; 301 - 400 = 8 units; 401 - 500 = 12 units; 501 - 650 = 15 units, subcutaneously with meals related to TYPE 2 DIABETES. Review of the Physician's Order dated 8/9/2025, revealed .Insulin Glargine Solution [a medication used to treat diabetes] 100 UNIT/ML.Inject 40 unit subcutaneously two times a day for diabetes. Review of the MAR dated 8/12/2025, revealed Resident #15 received insulin with meals. Documentation on Resident #15's MAR revealed blood glucose levels were checked at 7:00 AM and 11:00 AM. Observation and interview in Resident #15's room on 8/12/2025 at 4:38 PM, revealed LPN A entered the room, cleaned Resident #15's left hand first finger with an alcohol prep pad and picked up a lancet to obtain the blood specimen. LPN A was stopped by the surveyor and asked if the glucometer had been cleaned. LPN A stated, It was cleaned when I did it last with [named Resident #2]. The surveyor and LPN A exited Resident #15's room and returned to Hall A medication cart. LPN A confirmed the glucometer was last cleaned with (named) hand sanitizing wipe from the following previous blood glucose check on Resident #2. LPN A opened Hall A medication cart, removed a bottle of (named) bleach germicidal wipes, and stated, .They brought me these.The DON asked me what I was using and I told her those other wipes [hand sanitizing wipes] and she said ‘No, don't use those' and gave me these. LPN A again confirmed she had not re-cleaned the glucometer since last using the (named) hand sanitizing wipes. During an interview in the conference room on 8/12/2025 at 7:05 PM, the DON confirmed glucometers should be cleaned with an approved cleaning wipe, that hand sanitizing wipes are not appropriate for cleaning glucometers, and that the inappropriate cleaning of a glucometer can put the residents at risk for infection. The DON was asked if the staff received any in-services or training related to infection control. The DON stated, We had a skills fair in January [2025] .We have in-services quarterly for sure . The DON was unable to provide documentation for infection control training or in-services. During a phone interview on 8/14/2025 at 9:16 AM, the Medical Director confirmed staff should use an EPA approved disinfectant that kills bloodborne pathogens to clean blood glucose monitors, and if the blood glucose monitor is improperly cleaned it can transmit bloodborne diseases like hepatitis and Human Immunodeficiency Virus (HIV). 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including,Chronic Obstructive Pulmonary Disease, Dementia, Retention of Urine, and Solitary Pulmonary Nodule. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 5 which indicated Resident #8 had severely impaired cognition, required assistance with activities of daily living (ADL's), and was noted for an indwelling catheter. Review of the Care Plan dated 7/10/2024, revealed, .ENHANCED BARRIER PRECAUTIONS: I have a [named indwelling catheter] and wound and am at risk for MDRO [multidrug-resistant organisms] transmission.require use of INDWELLING [named] CATHETER r/t [related to] dx of Obstructive Uropathy and chronic urinary retention secondary to hx [history] of trauma to bladder / ureter. I have personal hx of recurrent UTI [urinary tract infection] .at risk for alteration in VISION STATUS r/t need for Rx [prescription] eye drops as ordered. My vision is adequate at baseline.at risk for alteration in RESPIRATORY STATUS r/t dx of COPD, former smoker with current use of Snuff, hx of Pulmonary Nodule. Review of the Physician's Order dated 8/9/2024, revealed .Arnuity Ellipta Inhalation Aerosol Powder Breath Activated [a medication used to control asthma] 100 MCG [microgram]/ACT [actuation].1 inhalation inhale orally in the morning related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE [COPD]. Review of the Physician's Order dated 1/29/2025, revealed .Ipratropium-Albuterol Solution [a medication used to control the symptoms of lung diseases] 0.5-2.5 (3) MG [milligram]/3ML 1 vial inhale orally two times a day for COPD. Review of the Physician's Order dated 2/10/2025, revealed .Provide with Enhanced Barrier Precautions during high contact resident care activities r/t Indwelling Foley and Pressure Wound two times a day. Review of the Physician's Order dated 8/7/2025, revealed .Brimonidine Tartrate Ophthalmic Solution [a medication used to lower the pressure in the eye] 0.2 % [percent] .Instill 1 drop in both eyes three times a day related to.DIABETES MELLITUS. Observation in Resident #8's room on 8/12/2025 at 8:47 AM, revealed LPN B pulled Resident #8's left lower eye lid down with a gloved hand, instilled 1 drop of Brimonidine 0.2 % in inner canthus of eye and repeated with right eye, and placed the medication on the resident's over bed table without a clean barrier. Arnuity Ellipta Inhalation 100 mcg was administered with the same gloves and placed on the over bed table without a barrier. Ipratropium/ albuterol 0.5mg -2.5mg per 3 ml nebulizer medication administered via (by way of) a nebulizer mask. LPN B removed her or his gloves and donned new gloves without performing hand hygiene. A nebulizer treatment was completed, the mask was removed from the resident, placed back in plastic bag, and put in the top drawer of Resident #8's nightstand without cleaning, rinsing, or drying the mask. The eye drop bottle and inhaler were removed from the over bed table and placed on top of Hall B medication cart, and then back into the cart. LPN B did not clean the top of the medication cart once the medications where removed. During an interview in the DON's office on 8/13/2025 at 2:38 PM, the DON confirmed staff should perform hand hygiene with glove changes, nebulizers should be cleaned, rinsed, and dried after use prior to being stored, staff should change gloves and perform hand hygiene before administering medications for different routes, soiled items removed from a resident's room should be cleaned/disinfected before being put in a medication cart, and medication carts should be clean/disinfected after soiled items were placed on top of them. 4. Review of the INFECTION CONTROL LOG, monitoring documents dated 4/2025, 5/2025, 6/2025, and 7/2025, revealed .INFECTION RELATED DX [diagnosis].UTI [urinary tract infection] by DX.increased WBC [white blood cells] by DX.cellulitis by DX.PNA [pneumonia] by DX.wound care by DX.Asp. PNA [aspiration pneumonia].abscessed tooth by DX.vag [vaginal] itching by DX.eye infection by DX.skin care under breast (yeast) by DX.poss [possible] cellulitis by DX.URI [upper respiratory infection] by DX.kidney stones by DX.PEG [percutaneous endoscopic gastrostomy tube] (feeding tube inserted through the abdominal wall directly into the stomach) site redness by DX.mouth abscess by DX.yeast by DX.skin cyst by DX.other categories.organism. There was no documentation listed in the Infection Control Log, that named the organism that was being tracked. During an interview on 8/13/2025 at 4:00 PM, the IP/DON confirmed that she does not track the infection by the organisms in the INFECTION CONTROL PROGRAM. The IP/DON was unable to provide any documentation that infection organisms were being tracked to rule out cross contamination or outbreaks of infections. The surveyors verified the Removal plan by: [NAME] Community Living Center Immediate Jeopardy -Summary & Removal Evidence Facility: [NAME] Community Living Center Tag: F-880 - Infection Prevention & Control Date IJ Identified: 08/12/2025 Date of Compliance 08/13/2025 What Happened (Noncompliance) On 08/12/2025, a Licensed Practical Nurse (LPN A) used a blood glucose meter on Resident #2, cleaned it only with a Spectrum Advanced Hand Sanitizing Wipe (not EPA-approved for bloodborne pathogen disinfection), then attempted to use the same glucometer on Resident #15 without re-cleaning with an approved disinfectant. -This failed to follow manufacturer instructions and facility policy, creating the lil<elihood of serious harm through potential transmission of HIV, Hepatitis B, or Hepatitis C. Residents affected were cognitively vulnerable and had comorbidities including diabetes, heart failure, and blood disorders. Infection prevention policy not reinforced consistently; staff competency gaps identified. No consistent real-time monitoring of glucometer cleaning/disinfection practices prior to IJ. Risk for exposure to multiple residents who had blood glucose checks with an Improperly disinfected device. Immediate Corrective Actions Taken (IJ Removal) Ceased use of all glucorneters until disinfected with EPA-registered bleach wipes per manufacturer instructions. Removed all non-approved wipes from medication carts and point-of-care areas; secured approved bleach wipes at all use points.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility investigation review, timeanddate.com weather website review, police report review, observation, and interview, the facility failed to provide adequate supervision to ensure the resident environment was free of accident hazards for 1 of 3 (Resident #1) residents reviewed with wandering/exit seeking behaviors. On 2/9/2025 between 7:00 PM and 7:20 PM, Resident #1, a vulnerable resident with Dementia, who experienced hallucinations, exit seeking behaviors and was cognitively impaired, eloped through an unlocked and unsecured door that malfunctioned on C Hall. Resident #1 exited the facility, left his wheelchair at the door, went down a steep embankment, and was found on the ground at the driveway entrance, beside a two-way street, and sustained head injuries that required hospital transfer and evaluation in the local Emergency Department (ED). The temperature outside on 2/9/2025, between 7:00 PM and 7:20 PM, was 37 degrees Fahrenheit. Resident #1 was observed, lying on the ground beside the road by an unknown passerby who called 911. The facility staff was not aware Resident #1 had exited the building. The police department contacted the facility and reported Resident #1 was lying on the ground, down a steep embankment at the end of the facility drive (that was approximately 110 yards from the facility), by the roadside. The facility's failure resulted in Immediate Jeopardy for Resident #1. 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. A partial extended survey was conducted on 4/29/2025 through 4/30/2025. The Administrator was notified of the Immediate Jeopardy (IJ) on 4/29/2025 at 10:20 AM, in the private dining room. 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 2/9/2025 through 4/29/2025. The Immediate Jeopardy was removed on 4/30/2025 when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyor on 4/30/2025. The facility is required to submit a plan of correction. The findings include: 1. Review of the undated facility policy titled, Emergency Procedure-Missing Resident, revealed .Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety . Review of the undated facility policy titled, Accidents and Incidents-Investigating and Reporting, revealed .Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, Hallucinations, Depression, and Anxiety. Review of the Comprehensive Care Plan dated 9/23/2024, revealed Resident #1 was at risk for elopement related to severe confusion, was mobile with a wheelchair and able to walk, and had a history of trying to open exit doors to facility, especially when looking for spouse. The goal listed for Resident #1 was will not leave facility unattended. Review of the Wander Evaluation assessment dated [DATE], revealed Resident #1 was a wandering/elopement risk as a result of being cognitively impaired, had poor decision-making skills, could ambulate with and without assistive device (wheelchair), and frequently looked for his spouse. Review of a Progress Note dated 12/28/2024 at 5:29 AM, revealed . [Resident #1] has been up all night, actively attempting to open doors .voices concerns about his wife's illness .resident also told this nurse that someone came into his room and put glue on his head . Review of the Significant Change Minimum Data Set (MDS) dated [DATE], revealed Resident #1's Brief Interview for Mental Status (BIMS) score of 7 indicated severe cognitive impairment. Further review of the MDS revealed Resident #1 experienced hallucinations and delusions, independently propelled a wheelchair for mobility, and required supervision and/or assistance with all aspects of personal care. Wandering behavior was not identified on the MDS assessment, although the medical record revealed Resident #1 exhibited wandering and exit seeking behavior. Review of a progress note dated 2/9/2025 at 10:13 PM, revealed .At 1925 [7:25 PM] a .police officer alerted the 6p-6a [6:00 PM - 6:00 AM] staff that they had observed [Resident #1] at the entrance drive at the front of the facility and that he [Resident #1] had fallen and injured the back of his head, this resident eloped from facility through the exit door at the end of C-Hall, staff was unaware that this client was missing from the facility due to clinical staff observing him wandering on A-Hall and ambulating without his w/c [wheelchair], it was noted that the door alarm did not function properly at the time of this [resident]'s elopement therefore clinical staff was not alerted to resident elopement from the facility . Review of a body audit assessment dated [DATE] at 11:55 PM, revealed an abrasion to back of head with small amount of blood oozing (bleeding). 3. Review of the weather history for [NAME], TN on 2/9/2025 at approximately 7:20 PM, according to timeanddate.com weather website, the temperature outside was 37 degrees Fahrenheit. 4. Review of the facility investigation dated 2/9/2025, revealed the following: a. Review of the facility incident report dated 2/9/2025 at 7:30 PM, by LPN A revealed .Police notified clinical staff .[Resident #1] lying on the ground at the entrance driveway, at the front of the facility and he [Resident #1] had fallen and injured the back of his head, this nurse observed .police, fire and rescue, and ambulance .[Resident #1] was .transferred to the hospital .after checking all the doors and windows in the facility, staff had found that [Resident #1] had eloped out of the exit door on C-Hall and through the gate leading to the property at the front of the facility, the alarm for the exit door on the C-Hall was not functioning and gave no alert to staff that the exit door had been breached .Injuries observed at time of incident . b. A signed, written statement dated 2/9/2025, by Certified Nursing Assistant (CNA) B revealed, .Me [CNA B] and [named CNA C] found that [Named Resident #1] got out on C Hall. The doors on C Hall was [were] open and the [door] codes was [were] not working we went out the doors to find that the gate was wide open and that's how he [Resident #1] got out. No alarm went off to let us know the door had came [come] open . c. A signed, written statement dated 2/9/2025, by CNA C revealed, .I heard a knock on the front door it was the police they asked me do we [facility] have a [named Resident #1], I say [said] yes, [police officer] told me that [Resident #1] had fell [fallen] outside and he finna [fixing to] go to the hospital so I ran and found [named Licensed Practical Nurse (LPN) A]. d. A signed, written statement dated 2/9/2025, by LPN A revealed, .At 1930 [7:30 PM], [named CNA C] alerted this nurse that the police need to speak [with] this nurse regarding a [Resident #1]. Upon speaking [with] the police officer it was apparent that [named Resident #1] had somehow eloped from the facility with his w/c [wheelchair] and made it to the end of the facility driveway in front of the building before falling and injuring himself .This nurse observed police, fire and rescue, and EMT[Emergency Medical Technician]/ambulance on [named street] in front of the facility. The police officer stated that [Resident #1] was being .transferred to the hospital in [relation to] .striking and injuring the back of his head upon falling to the ground .[Resident #1] had pushed the Exit Doors open at the end of C-Hall, pushed the double gate open at the front of the facility, and made his way down the hill to the parking lot entrance . e. A signed, written statement dated 2/9/2025, by the former Maintenance Director revealed, .I got here at 8:00 PM [on 2/9/2025]. I checked the door on C Hall and one door was open so I shut the door . f. Review of the hospital medical record dated 2/9/2025 at 8:00 PM, revealed Resident #1 was evaluated in the ED for head injuries sustained during the fall. A Computerized Tomography Scan report (CT scan/CAT scan provides detailed images inside of the body) of the head dated 2/9/2025 at 10:12 PM, revealed posterior scalp (back of the head) swelling and a laceration (open area of the skin). The hospital Discharge summary dated [DATE], revealed Resident #1 was diagnosed with head trauma, contusions (bruising) and abrasions (scrape, graze or superficial injury) sustained during the fall. g. Review of an e-mail correspondence dated 2/10/2025 at 9:07 AM, written by the Administrator to the Ombudsmen revealed, .I wanted to inform you that [Resident #1] exited the facility and made it to the end of the driveway. [Resident #1] was taken to the hospital . h. Review of the Ad Hoc (special) QAPI (Quality Assurance and Performance Improvement) meeting minutes dated 2/10/2025, revealed .Maintenance has identified a defect in door closure . 5. Review of the local Police Department report dated 2/9/2025 at 7:32 PM, revealed .E [Emergency] 911 call stating [caller] found a male laying in the roadway unconscious, caller's husband did stop and has the male sitting up now .EMS [Emergency Management Service] in route .Nursing Home .was notified .and they [nursing home staff] advised he [Resident #1] is a patient there [at nursing home]. [Nursing home staff] advised the male will be transported to the ER [Emergency Room] due to injuries . 6. Observations during a facility tour with the Administrator on 4/28/2025 beginning at 12:30 PM, revealed the following: a. The Exterior C Hall door was locked and unable to be opened by pressing on the lever. The doors were not equipped with delayed egress (a door locking system that temporarily prevents a door from opening immediately after an exit attempt, providing a short delay for a security response). A keypad was observed on the wall adjacent to the door. The Administrator made multiple unsuccessful attempts to open the exterior door entering a code into the keypad. The Administrator was unable to unlock/open the C Hall door. The Administrator stated the door would open if the fire alarm sounded. b. A resident room at the end of C Hall beside the C Hall exterior door was inspected. The resident room had two windows, each window was unlocked and opened by the surveyor. The alarm attached to each window failed to alarm when the window was opened. The Administrator stated the alarm should sound when the window is opened but the batteries in the window alarms must not be working. c. The Exterior A Hall doors were locked, unable to be opened by pressing on the lever, and were not equipped with delayed egress. A keypad was observed on the wall adjacent to the door. The Administrator made multiple unsuccessful attempts to open the exterior door entering a code into the keypad. The Administrator was unable to unlock/open the door. d. The Laundry Room exterior door was inspected. The doorknob fell off of the door during the surveyor's attempt to open the exterior door. The laundry room staff member stated, .The maintenance person was made aware of the broken doorknob a long time ago . e. The interior service hall door leading from the front lobby to the back service hall was open. The Administrator stated the service hall door should not be left ajar and should be closed and locked at all times. During an interview on 4/28/2025 at 1:05 PM, the Administrator was asked if the facility doors were a resident safety concern. The Administrator stated, Yes, they are . During an interview on 4/28/2025 at 1:13 PM, the former Maintenance Director stated the Administrator notified him of Resident #1's elopement from the facility on 2/9/2025, .when I got to the facility, I noticed [Resident #1]'s wheelchair was at the end of C-Hall by the double door going outside. One of the doors had malfunctioned, the magnets that hold the doors closed had to be replaced. The C-Hall doors had not been closing properly for close to a year . Observation on 4/29/2025 at 1:20 PM, revealed Resident #1 sitting in a wheelchair near the nurse's station. Resident #1 was awake, confused, and unable to answer questions. During an observation and interview on 4/29/2025 beginning at 1:45 PM, the Regional Director of Maintenance (RDM) measured the distance from the exterior C Hall door, down a steep embankment to the estimated location Resident #1 was found on the ground at the end of the drive near the two-way street. The distance was approximately 110 yards (330 feet). The RDM stated the keypad code to all exterior doors had been reset. During an interview on 4/30/2025 at 3:04 PM, CNA C verified his/her signed written statement dated 2/9/2025. CNA C stated Resident #1 would sometimes leave the facility with family members and would frequently be difficult to redirect upon return to the facility. CNA C stated the C Hall door was open and no alarm had sounded when Resident #1 exited the facility on 2/9/2025. Attempts to interview LPN A and CNA B by phone during the survey were unsuccessful. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F689 was received on 4/29/2025 and validated onsite by the surveyor on 4/30/2025 through observation of exterior doors including keypad enabling exterior doors to open and staff interview. The Removal Plan included the following: On April 29, 2025, at 10:30 PM, the State Agency informed the Administrator that the facility had failed to provide adequate supervision to prevent the elopement of Resident#1, a vulnerable individual who exited the facility unnoticed and without supervision. On February 9, 2025, at 7:30 PM, facility staff were notified by local law enforcement that the residents (resident) were (was) not present in the building. The resident had been transported to the emergency room. 1. On February 9, 2025, at 7:28 PM, missing resident procedures were initiated, and all residents were accounted for. 2. On February 9, 2025, the LPN notified both the Director of Nursing and the Administrator. The Administrator instructed the LPN to contact the Maintenance Supervisor and directed that a CNA be stationed at the door until maintenance arrived. The LPN also attempted to contact the resident's next of kin; however, the call went to voicemail. The resident had a BIMS score of 0, indicating severe cognitive impairment. 3. On February 9, 2025, at 7:50 PM, the Maintenance Supervisor arrived at the facility. He inspected all exit doors to ensure proper functionality. A CNA remained Stationed at the door until the necessary repairs were completed. 4. On February 9, 2025, the Director of Nursing informed the resident's physician to provide an update on the status of the missing resident. The Administrator also sent an email to the Ombudsman regarding the situation. 5. An in-service training on elopement procedures was conducted. The elopement book and care plans were audited and reviewed. Additionally, a visual check every hour was implemented for all residents identified as at risk for elopement. 6. A Quality Assurance and Performance Improvement (QAPI) committee meeting was held to review the incident involving Resident #1. QAPI minutes included: The QAPI committee reviewed the incident, the actions taken, and the existing policy. After careful consideration, no recommendations for changes were made. The care team conducted a 100% (percent) audit of the care plans for all residents identified as being at risk for elopement. The Maintenance Supervisor conducted elopement drills across all shifts on 2-9-25 (2025). Correction: This practice of elopement drills will continue under the oversight of the Director of Nursing or Administrator for the next four weeks, with the results presented at each monthly QAPI committee meeting for review and recommendations. Any identified issues will be promptly addressed by the Administrator. The Maintenance Supervisor has contacted the State system regarding concerns with the exit doors, and the necessary repairs have been completed. All doors will be logged daily, including documentation of door openings and alarm activity, for a period of four weeks. The logging frequency will then transition to twice weekly for two weeks, and subsequently to once monthly for three months. If any additional issues are identified during this period, the matter will be brought to the QAPI committee for review, and daily checks will be reinstated as necessary. Maintenance has begun replacing all window alarms. A log will be maintained and reviewed weekly for four weeks, then biweekly for two weeks, and subsequently monthly for three months to ensure proper functionality. If any additional issues are identified during this period, the matter will be brought to the QAPI committee for review, and daily checks will be reinstated as necessary. In-service training has been initiated to address procedures for emergencies and resident relocations. The training emphasizes that, in the event of a fire, all emergency exit doors will be released and opened to ensure the safety of both residents and staff. Subject: Plan of Correction and Follow-Up Regarding Immediate Jeopardy Removal and Elopement Incident 1. Date of Immediacy Removal The facility alleges that the immediacy has been removed as of April 29, 2025, 2. Door Codes and Keypads Audit An audit of all door codes and keypad systems was completed on April 29, 2025, by the current Maintenance Director. All keypads were reset to factory default, recommended with a new master code, and assigned a universal code. The Maintenance Director tested each keypad multiple times to confirm full operability. 3. Staff Inservice Training Inservice's were conducted for all facility staff by the Director of Nursing and the Regional Nurse Consultant, training included all departments and all shifts, including evening staff. Staff verbalized understanding and demonstrated competence in the major use of secured (security) systems and elopement prevention protocols. An elopement drill was conducted on April 29, 2025, at 6:00 PM. 4. Regional Oversight and Audit On April 29, 2025, Regional Oversight performed a comprehensive follow-up audit of the facility's doors and windows, including a walkthrough with the Life Safety Surveyor. The audit confirmed that all systems were compliant and functioning properly. 5. Emergency Egress Protocol Education Staff education on emergency egress protocols was conducted by the Maintenance Director and Regional Nurse Consultant on April 29, 2025. All staff, including those on the evening shift, were trained. Understanding was verified through staff verbal feedback and real-time demonstration. 6.Window Alarms System Audit A full audit of window alarms was conducted on April 29, 2025, by the Maintenance Director and Regional Maintenance Director. The audit included testing each alarm to confirm activation when windows were raised, replacing batteries as necessary, and ensuring all units were in the on position. 7. Ongoing Compliance Monitoring Daily monitoring is now in place for all residents identified as being at risk for elopement. Clinical staff are responsible for daily risk assessments and documentation. Additionally, all secured doors will be inspected daily, with any discrepancies reported and addressed through the facility's QA PI (Quality Assurance Performance Improvement) process. 8. Third-Party Verification and Resident Care Plan Review Third-party verification was completed on April 29, 2025, by the Life Safely Surveyor. The fire monitoring service has been contacted for an additional full-door inspection. All residents with known elopement or wandering behaviors are undergoing additional nursing assessments. 100 (percent) of their care plans have been reviewed, with no new interventions noted at this time. We trust these comprehensive actions demonstrate our commitment to resident safety and regulatory compliance. Please do not hesitate to contact us with any further questions or requests for documentation. Following the February incident, immediate corrective actions were implemented, including verification of door functionality and the establishment of a comprehensive monitoring process. Since that time, the doors have been functioning properly, and a procedure has been in place to ensure safe evacuation in the event of an emergency. During the revisit on 4/28/2025, it was noted that the doors required a system reset. This was addressed immediately, and the doors resumed properly functioning without delay. Additional measures have since been incorporated into the ongoing monitoring process to ensure sustained functionality and resident safety. The revised Removal Plan reflects both the original and updated interventions.