**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility investigation review, observations, and interview, the facility failed to ensure each resident's environment was safe and each resident received adequate supervision to prevent accidents and hazards for 1 of 1 (Resident #8) residents reviewed for smoking, and 1 of 5 (Resident #98) reviewed for wandering and elopement. On 2/7/2024 Resident #8, a moderately cognitively impaired, legally blind resident, was observed to be smoking unsupervised in the smoking area. Resident #8 had a lit cigarette and burn marks on his clothing. On 9/21/2022, Resident #98, a vulnerable, severely cognitively impaired resident exited the facility without staff knowledge or supervision through a malfunctioning facility door, down the ramp and into the facility's back parking lot, and when bleach wipes were found in Resident #40's, a cognitively impaired resident, room. The facility failed to ensure fall interventions were implemented in accordance with the care plans for 2 of 6 (Resident #9 and #26) residents reviewed for falls. Immediate Jeopardy (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 follow the Safe-Smoking Screen for Resident #8, and when the facility failed to ensure a safe and secure environment for Resident #98, a vulnerable and severely cognitively impaired resident assessed for wandering and elopement behaviors, who eloped from the facility. The Administrator and the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-689 on 2/12/2024 at 6:49 PM, in the Conference Room related to Resident #8's unsupervised smoking. The Administrator, Interim Director Of Nursing, and the Assistant Director of Nursing were notified of the Immediate Jeopardy (IJ) for F-689 on 2/14/2024 at 2:15 PM, related to the elopement of Resident #98. An extended survey was conducted from 2/8/2024 to 2/14/2024. The facility was cited at F-689 for unsupervised smoking and elopement at a scope and severity of J which is Substandard Quality of Care. The facility was cited F-689 for unsupervised smoking and elopement which is Substandard Quality of Care. The findings include: 1. Review of the facility's policy titled Tobacco and Electronic Cigarette/Vaping Use, revised 11/2022, revealed .Residents are allowed to use tobacco products .in designated areas only .The designated smoking area for residents is the patio outside the resident dining area .These residents will be supervised and established smoking times will be observed .Smoking will be allowed as weather permits and residents must wear a smoking apron while smoking . Review of the facility's policy titled Resident Elopement, dated 1/2021, revealed .One of the most challenging issues related to care of the resident with dementia is wandering behavior. The most dangerous form of wandering is elopement, in which the confused resident leaves the nursing home and possibly experiences injuries such as hypothermia, a serious fall, or is hit by a car. These injuries may result in death .Elopement occurs when a resident leaves the premises or safe area without authorization or necessary supervision to do so .The Charge Nurse will assume control of the search and gather all available staff to begin an immediate preliminary search of the area and premises .While staff is conducting the search, the Charge Nurse will notify the Administrator and Director of Nursing (DON) and determine if others are needed to participate in the search .While a resident who was missing is found, the nurse will .Examine the resident for possible injuries .Notify the Attending Physician for consultation .Notify the Administrator or designee .Notify the resident's designated representative .Notify the Medical Record .Discuss with the Administrator, DON, or designee if it is prudent to provide the resident with 1:2 or other level of supervision .Complete an incident report .Complete appropriate documentation in the resident's medical record .Re-evaluate the resident's risk for possible elopement regardless if this event may constitute an elopement or not .Follow-up investigation .DON or designee will obtain video evidence to establish timeline of events and resident exit point .DON or designee is responsible [for] obtaining staff, resident and bystander statements regarding incident .DON will moderate an adhoc [impromptu meeting conducted for a particular purpose] QAPI [Quality Assurance and Performance Improvement] Meeting, within 24 hours after event .Corrective actions will be developed with intent to mitigate root cause and prevent future similar events . 2. Review of the medical record revealed Resident #8 was readmitted to the facility on [DATE], with diagnoses including Cognitive Communication Deficit, Tobacco Use, Shortness of Breath, Dementia, Depression, and Legal Blindness. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #8 was assessed with a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired, exhibited wandering behaviors, assessed for tobacco use, and had severe vision impairment (no vision or sees only light, colors or shapes; eyes do not appear to follow objects). Review of the Care Plan revised 1/31/3024, revealed the following interventions for smoking, .Observe clothing and skin for signs of cigarette burns .Smoking Assessment to be done quarterly .for smoking safety .requires a smoking apron .staff to accompany to smoking area and supervision noted . The care plan did not include information on how the resident should wear the smoking apron and the facility's policy did not address how to wear the smoking apron. Review of the Smoking-Safety Screen (tool used to assess a resident to safely smoke) dated 2/2/2024, revealed Resident #8 had a visual deficit, dexterity problems and a Team decision was made that required the resident to have supervision to smoke. Observation in the dining room on 2/6/2024 at 7:49 AM, revealed Resident #8 wanted to smoke, and Registered Nurse (RN) #1 put a smoking apron on Resident #8 and scanned her badge to unlock the door to the smoking area and assisted the resident out to the smoking area. RN #1 stated, .let me know when you want in, well I guess I'll sit out here with you . Resident #8 lowered the lit cigarette and it touched the smoking apron and left a brown stain. RN #1 asked the resident to hold the cigarette up. Observation in Resident #8's room on 2/6/2024 at 2:56 PM, revealed Resident #8 was wearing a pair of black sweatpants with 2 holes that were charred around the edges that appeared to be burn marks in the upper leg of the sweatpants. Observation on 2/7/2024 at 7:51 AM, revealed Resident #8 was outside on the patio in the smoking area unattended and unsupervised by staff, smoking a cigarette, with no staff within view of the resident. Resident #8 had on a smoking apron underneath his jacket and had a Wander Guard. The temperature outside was 36 degrees. Observation in the dining room on 2/7/2024 at 7:55 AM, revealed the Activities Director entered the dining room area from the skilled unit hallway and went to her desk. Resident #8 was observed knocking on the patio door to alert staff to let him back into the facility. The Activities Director walked over to the locked patio door, unlocked the door, and assisted Resident #8 back into the facility. During an interview on 2/9/2024 at 11:20 AM, RN #1 was asked if they supervise Resident #8 when he is smoking. RN #1 confirmed that staff does not always go out with the resident when he smokes. During an interview on 2/12/2024 at 6:41 PM, the Interim Director of Nursing (DON) was asked when a resident with a BIMS score of 8, legally blind, and an elopement risk goes outside to smoke should staff be present during the smoking time for supervision. The Interim DON stated, .Yes . During an interview on 2/13/2024 at 9:44 AM, the Social Worker was asked if he ever saw Resident #8 smoke outside by himself. The Social Worker stated, .I noticed he was not able to handle the cigarettes' correctly .BIMS score .decreased .new BIMS score should have been done for safety . During an interview on 2/13/2024 at 11:19 AM, Laundry Staff was asked if she has seen Resident #8 smoking outside unsupervised by himself. The Laundry Staff stated, .yes, I see him outside smoking unsupervised . During an interview on 2/13/2024 at 3:09 PM, Licensed Practical Nurse (LPN) #1 was asked if she unlocked the patio for Resident #8 to go out to smoke on 2/7/2024. LPN #1 stated .yes . LPN #1 confirmed no staff was outside on the patio in the smoking area when Resident #8 was smoking and she did not remain with the resident. The failure of the facility to follow the Safe-Smoking Screen assessment could result in the likelihood of serious harm, serious bodily injury, and/or death and Immediate Jeopardy to Resident #8. 3. Review of the medical record revealed Resident #98 was admitted to the facility on [DATE], with diagnoses of Diabetes, Dementia, Anxiety, Conduct Disorder, Wandering, and Hypothyroidism. Review of the Care Plan dated 5/19/2022, revealed, .The resident is an elopement risk/wanderer r/t [related to] History of wandering and Dementia .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Identify pattern of wandering Is wandering purposeful, aimless, or escapist? Is resident looking for something .Monitor for wander guard placement, correct band, any new skin issues noted to wander guard site, and expiration date that is written on wanderguard alarm, every shift .Resident to be assisted to wanderguard controlled door per staff to assess proper functioning alarm once daily every day shift for proper function of wanderguard equipment .Resident wander alert will be posted at strategic location throughout facility .Wanderguard maybe applied upon as assessment and MD [Medical Doctor] order .Weekly Behavior Assessment on Friday day shift and more often if needed .11/17/2022 .Resident to be assisted to wanderguard controlled door per staff to assess proper functioning alarm once daily every day shift for proper .function of wanderguard equipment .Resident wander alert will be posted at strategic location throughout facility . Review of the facility's Wandering Risk Assessment, dated 8/23/2022, revealed .High Risk for Wandering . Review of the Weekly Behavior Note, dated 9/2/2022, revealed .Observed Behaviors .Refusing Medications .Wandering .Delusional .Agitated .Behavior Management Intervention . Redirection .Food/Fluids .Medication offered .Comments .will become agitated at times, refusing meds and care, redirection occasionally successful . Review of the progress notes dated 9/3/2022, revealed .Resident was wandering in the halls & [and] exit seeking earlier today .requires constant observation since is an active exit seeker & wanderer . Review of the Weekly Behavior Note, dated 9/9/2022, revealed .No Threat . Review of the Weekly Behavior Note, dated 9/12/2022, revealed .No Threat .Behaviors Observed .Wandering .Comments .occasionally wanders, becomes agitated, and resistive to care, redirection occasionally successful . Review of the Weekly Behavior Note, dated 9/16/2022, revealed .No Threat .Observed Behaviors .Combative .Refusing Medication .Potential for elopement .Wandering . Agitated .Comments .occasionally wanders, becomes agitated and resistive to care and medication . Review of the progress notes dated 9/16/2022, revealed .Observed resident ambulating unassisted in hall walls [ways], attempted to sit in chair at the end of hallway, lost her balance and fell to the floor hitting her head on the floor. Laceration noted to L [left] eyebrow and skin tear to L elbow. Areas cleansed and steri striped. Pt [patient] is alert to self per residents normal, confused to place and time . Review of the progress notes dated 9/16/2022, revealed .Resident awake and alert. Ambulating with supervision only. Continuously walking around facility exit seeking. She walks to each door, pushes on it, then walks to the next door. Resident becomes frustrated with staff whenever redirection in [is] tried . Review of the progress notes dated 9/21/2022 at 4:10 PM, revealed .LATE ENTRY .resident had been wandering all day and was noted to be out in back yard near recreation patio .resident was immediately brought inside by staff . Further review of the progress notes dated 9/21/2022 at 4:26 PM, revealed .Resident has had exit seeking behavior today by pushing on doors. Resident redirected . The facility failed to implement effective interventions on 9/21/2022 for Resident #98's wandering and exit seeking prior to the resident's elopement from a safe environment to an unsafe environment. Review of the progress notes dated 9/22/2022, revealed .Behavior noted x [times] 1 when she threw her linen out in the hall . Review of the progress notes dated 9/23/2022, revealed .discussed resident behaviors and elopement at length with [named medical director] .discussed dx [diagnoses] and current medication regime .recommends Risperdal [medication used to treat schizophrenia, bipolar disorder, or irritability .should not be used to treat behavioral problems in older adults who have dementia] 1 mg [milligram] Bid [twice a day] spoke with daughter .explained medication and meeting to discuss resident care .[daughter] concerned that medication is a antipsychotic medication which resident doesn't usually tolerate well .assured [daughter] that [named medical doctor] wants updates from staff on resident behaviors and the medication effectiveness . Review of the Weekly Behavior Note, dated 9/23/2022, revealed .No Threat . Review of the progress notes dated 9/24/2022, revealed .Continue to round on resident every 15 min [minutes] and door checks. Review of the progress notes dated 9/26/2022, revealed .has been wandering in hall all morning with exit seeking behavior. Staff continuing with q [every] 15 min checks and rounding to check all doors . Review of the progress notes dated 9/27/2022, revealed .Resident has been alternating between resting in bed napping and wandering in hall with exit seeking behavior. Resident became aggressive during shower but calmed down as soon as shower was over .Wears pull-ups but will remove pull-up or brief & urinate in room or down the hall and will become very aggressive when staff attempts to provide peri-care . Review of the Weekly Behavior Note, dated 9/30/2022, revealed .No Threat .Rejection of care .Observed Behaviors .Refusing Medications .Potential for elopement .Wandering . Agitated .Comments . frequently wanders, exit seeking, resistive to cares, re-direction occasionally successful . Review of the progress notes dated 10/1/2022, revealed .Resident has had exit seeking /wandering behavior throughout this shift . Review of the progress notes dated 10/2/2022, revealed .Resident continues with wandering & exit seeking behavior today . Review of the progress notes dated 10/5/2022, revealed .Resident will frequently remove her pull-up which allows her to have dribbling urine . Review of the Weekly Behavior Note, dated 10/7/2022, revealed .No Threat .Observed Behaviors .Combative .Refusing Medication .Potential for elopement .Wandering . Agitated .Comments . frequently wanders about facility, exit seeking, resistive to cares at times, re-direction occasionally successful . Review of the Weekly Behavior Note, dated 10/14/2022, revealed .No Threat .Observed Behaviors .Refusing Medications .Potential for elopement .Wandering . Agitated . Comments . occasionally wanders, exit seeking, becomes agitated and resistive to cares and medication . Review of the progress notes dated 10/15/2022, revealed .Resident is alert but confused & combative with exit seeking behavior .Resident is hitting, biting, slapping, yelling, and pinching . Review of the Weekly Behavior Note, dated 10/17/2022, revealed .Observed Behaviors .Cursing . Refusing Medications .Potential for elopement .Wandering . Agitated .Anxiety .Fighting . Comments .Resident wanders, exit seeks, refuses medication and care, resident gets agitated with redirection, interventions attempted with no success at times, family made aware of residents behaviors and has to come out when staff makes aware . Review of the progress notes dated 10/20/2022, revealed .Resident has been wandering in the hall with exit seeking behavior this morning. Refused medication & personal care .was combative . Review of the significant change MDS dated [DATE], revealed Resident #98 was severely cognitively impaired with delusions, physical, verbal, and other behavioral symptoms. Resident #98 rejected care, put other residents at risk of physical injury, significantly intruded on the privacy of others and significantly disrupted care or living environment and wandered, required extensive assist to total assist for activities of daily living (ADLs). Resident #98 had four falls, 2 with no injury and 2 with minor injuries and received antipsychotic, antianxiety, and insulin medications. Review of the progress notes dated 11/12/2022, revealed .Resident exhibiting behavioral issues of fighting, hitting, scratching, clapping, yelling, refusing care, removing clothes & smearing feces, wandering & exit behaviors noted . Review of the facility's Wandering Risk Assessment, dated 11/25/2022, revealed .High Risk for Wandering . Review of the progress notes dated 12/15/2022, revealed .Resident is wandering in the hall, around the nurses station and exit seeking to front entrance . Review of the progress notes dated 12/25/2022, revealed .Resident ambulating in hall to dining area, around nurses station & back to her room. Exit seeking while wandering . Review of the facility's Wandering Risk Assessment, dated 2/27/2023, revealed .High Risk for Wandering . During an interview on 2/8/2024 at 4:25 PM, LPN #1 was asked about Resident #98's getting out of the building. LPN #1 stated, .She was a wanderer but still walking, she would go to doors and push on them sometimes she was redirected and sometimes redirecting aggravated her. She removed brief and walk [walked] in hall and dribble urine in hall. She didn't usually show aggression toward other residents . During an interview on 2/12/2024 at 11:22 AM, the Administrator was asked had there been a Quality Assurance Performance Improvement meeting prior to 2/9/2024. The Administrator stated, .On 2/13/2024 we had an Adhoc meeting with the Medical Director. The Administrator was asked how the staff had been monitoring elopements, wandering residents, and the doors for the prevention of elopement. The Administrator stated, I got here January 3, 2024 and we have not had any elopement drills. I check doors each day to make sure they are locking appropriately . The Administrator was asked have door checks, random monitoring of the doors and wander guard checks been conducted. The Administrator stated, Any documented door checks I believe [named Maintenance Supervisor] told me door checks done in January, I'm not certain about that . The Administrator was asked has any elopement drills been conducted since your arrival. The Administrator stated, No. The Administrator was asked how often elopement drills should be conducted. The Administrator stated, Yes, elopement drills should be done .I believe someone felt that [the new wander guard system] may have negated elopement drills, I would have done one annually . The Administrator was asked has there been a process and procedure put in place for new staff and agency staff to follow related to elopement. The Administrator stated, I have no knowledge of new staff or agency staff having that training . During an interview on 2/12/2024 at 2:33 PM, the Maintenance Assistant Director was asked when the new wander guard system was installed. The Maintenance Assistant Director stated, .Badges for doors opening occurred 2019, by the time we started to upgrade the hospital doors the nursing home decided to upgrade also. We had a wander guard system in nursing home that was prone to problems and outdated. Mid to late 2022 wander guard system was added .We had a couple [elopements] over a period of time. It [wander guard system] would lock the doors but failed to alarm to notify staff [that] residents were at the door. The new system was after she [Resident #98] got out the door on 9/21/2022. So, wander guard was invoiced for 1/3/2023 . During a telephone interview on 2/14/2024 at 10:03 AM, Governing Body Member #1 was asked if the Governing Body was notified about the elopement on 9/21/2022. Governing Body Member #1 confirmed they were made aware of the elopement that occurred on 9/21/2022 and a new door system was installed to fix the problem. Governing Body Member #1 confirmed the facility made improvements and no one can enter the facility without being let in by staff. Governing Body Member #1 confirmed the issue had been resolved and education and in services were given on the new door system. Governing Body Member #1 confirmed that education and orientation with newly hired staff needs to be ongoing and elopement drills should be regularly conducted. During a telephone interview on 2/14/2024 at 10:16 AM, Governing Body Member #2 confirmed that he is the chairman and the Governing Body meets monthly. Governing Body Member #2 confirmed that the board addresses compliance issues, falls, and how to improve the safety of residents and patient satisfaction. Governing Body Member #2 confirmed that at one time there was a problem with an elopement and that the board addressed those issues and those implementations are still secure. Governing Body Member #2 confirmed that drills and education are conducted and that an action plan was made and there are no new issues with the doors to their knowledge. The facility failed to implement effective interventions to prevent the elopement of Resident #98. After Resident #98's elopement on 9/21/2022 the facility took the following actions: The facility did hourly door checks beginning 9/22/2022 through 10/17/2022. The facility implemented 15 minutes checks for Resident #98 beginning on 9/26/2022 at 7:00 PM through 10/13/2022 at 6:30 PM. The facility completed elopement drills on 9/23/2022, 9/26/2022, and 9/27/2022 for all shifts. Ad Hoc meeting on 9/23/2022 to discuss elopement of Resident #98. The facility installed the new door alarm system on 9/29/2022. Ad Hoc meeting on 9/30/2022 to discuss elopement of Resident #98. The facility installed a new wander guard system on 1/3/2023. 4. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses of Dementia, Osteoporosis, Orthostatic Hypotension, Anxiety, Depression, and Macular Degeneration. Review of the quarterly MDS dated [DATE], revealed Resident #9 was assessed with a BIMS score of 3 indicting the resident was severely cognitively impaired, had behaviors directed toward others, range of motion impairment on both upper and lower extremities, wheelchair for mobility, and was incontinent of both bowel and bladder. Review of the Care Plan dated 12/14/2023 revealed, .The resident is at risk for falls r/t Gait / Balance problems .Fall mat at side of bed .Initiated 7/26/2021 . Observation in Resident #9's room on 2/5/2024 at 12:30 PM, 2/6/2024 at 8:15 AM, and 2/7/2024 at 8:00 AM, revealed Resident #9 was in bed, and the bed was in low position with no fall mat at bedside. The facility failed to ensure the intervention of a fall mat was implemented in accordance with Resident #9's care plan. 5. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE], with diagnoses of Orthostatic Hypotension, Cognitive Communication Deficit, Anxiety, Depression, and Irritable Bowel Syndrome. Review of the Care Plan dated 1/15/2024, revealed, .The resident has an ADL self-care performance deficit r/t [related to] Activity Intolerance, Limited Mobility, and Musculoskeletal impairment .The resident has cognitive/communication problem r/t confusion .the resident is at risk for falls r/t Gait/balance problem .Pad sensor alarm at all times in bed and chair .check placement and function every shift for alarm .scoop mattress on bed .initiated 7/21/2022 . Review of the quarterly MDS dated [DATE], revealed Resident #26 was assessed with a BIMS score of 3, indicating the resident was severely cognitively impaired, exhibited physical/verbal behavior toward others, rejection of care, range of motion limitations both extremities lower and upper, and was incontinent of both bowel and bladder. Observations in Resident #26's room on 2/5/2024 at 3:30 PM, 2/6/2024 at 8:21 AM, 2/7/2024 at 9:04 AM, and 2/8/2024 at 9:00 AM, revealed Resident #26 was in the bed and there was no scoop mattress on the bed. The facility failed to follow the care plan for the use of a scoop mattress as a fall intervention. 8. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE], with the diagnosis of Abnormalities of Gait and Mobility, Muscle Weakness, and Lack of Coordination. Review of the admission MDS dated [DATE], revealed Resident #40 was assessed with a BIMS of 9, indicating the resident was moderately cognitively impaired and was assessed for wandering behavior. Review of the Care Plan dated 12/15/2023 revealed, .resident has impaired cognitive function .resident has an elopement risk/wanderer d/t [due to] impaired safety awareness .Wanderguard [electronic device that alarms when resident attempts to exit the building] placement to be placed on LLE [left lower extremity] and checked every day and night shift and documented . Observation in Resident #40's room on 2/5/2024 at 10:38 AM and 2/5/2024 at 11:18 AM, revealed 1 plastic container of sani-cloth bleach wipe sitting in the window sill of Resident #40's room, labeled keep out of reach of children. Observation in Resident # 40's room on 2/5/2024 at 11:55 AM, revealed 1 plastic container of sani-cloth bleach wipes sitting in the window sill and housekeeping staff entered the room and removed the container and put on the housekeeping cart. During an interview on 2/14/24 at 11:21 AM, the Administrator was asked where should cleaning chemicals such as bleach wipes be stored. The Administrator confirmed that chemicals should be stored under lock and key, out of reach of residents, and not in resident's rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Blood Glucose Monitoring User Guide, policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when multi-use blood glucose meters (a device used to check blood sugar levels with the use of a blood sample) were not cleaned and disinfected with facility required bleach cleansing wipes to prevent cross-contamination of bloodborne pathogens for 4 of 5 sampled residents (Residents #1, #14, #25, and #33) reviewed for blood glucose monitoring. Observations on 2/7/2024 and 2/8/2024 revealed Licensed Practical Nurses (LPN) #1 failed to clean and disinfect the multi-use blood glucose meters before and after use on each resident in accordance with recommendations and facility policy, failed to perform hand hygiene, and failed to don gloves during medication administration. Observations on 2/7/2024 revealed LPN #2 failed to clean and disinfect the blood glucose meters before use on each resident in accordance with recommendations and facility policy, failed to perform hand hygiene, and failed to don clean gloves during medication administration. The facility's failure to ensure staff properly disinfected the multi-use blood glucose meter in accordance with recommendations and the facility's policy, that was used for multiple residents, placed the residents at risk for potential contamination with bloodborne pathogens and had the likelihood to cause harm, serious injury, and/or death resulted in Immediate Jeopardy. The facility had 5 residents receiving blood glucose monitoring with a multi-use blood glucose meter and the facility's failure had the potential to affect the 5 residents receiving blood glucose monitoring with a multi-use blood glucose meter. The facility failed to ensure practices to prevent the potential spread of infections when 1 of 4 (Certified Nurse Assistant (CNA) #1) staff members placed a soiled meal tray on the meal cart with clean meal trays. Immediate Jeopardy (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 disinfect a multi-use blood glucose meter during medication administration. The Administrator and the Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy (IJ) for F-880 on 2/8/2024 at 6:23 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-880 at a scope/severity of J. The Immediate Jeopardy began on 2/8/2024 and is ongoing. The findings include: 1. Review of the facility's policy titled, Glucometer Cleaning, revised 5/2013, revealed .Routine cleaning of the glucometer is needed to promote a clean, safe environment, and prevent the spread of infection .Clean the outside of the glucometer surface front, back, and sides before and after each finger stick by using a bleach cleansing wipe .Allow meter to dry completely between uses .Never place glucometer directly on any surface, place on a barrier (i.e. paper towel) must be utilized at all times to prevent contamination . Review of the facility's policy titled Eye Drop Administration, revised 4/2021, revealed .To assure correct administration of eye drops .Wash hands .Position resident with head back .Remove cap from bottle and place on a clean, dry surface .Use gauze to pull down lower eyelid to form a pouch, instructing resident to look up .Instill medication as follows: Place hand against resident's forehead to steady if needed .Instill required number of drops inside the lower eyelid close to outer corner of eye (Do not let dropper touch any part of the eye) .Wipe off excess solution with gauze .Recap the bottle .Wash hands . Review of the (named) glucose monitor user's guide titled, Blood Glucose Monitoring System dated 2/2023, revealed .Cleaning and Disinfecting Procedures for the Meter .The meter should be cleaned and disinfected between each patient [resident] .The following products have been approved for cleaning and disinfecting .Dispatch Hospital Cleaner Disinfectant Towels with Bleach .Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol .Clorox Healthcare Bleach Germicidal and Disinfectant Wipes .Medline Micro-Kill Bleach Germicidal Bleach Wipes .glucose manual revealed the following steps .Wash hands with soap and water .Put on single use medical protective gloves .Inspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be cleaned from the surface of the meter .To clean the meter, use a moist (not wet) lint-free cloth dampened with mild detergent. Wipe all external areas of the meter including both the front and back surfaces until visibly clean .To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use . Review of the facility's policy titled Blood Glucose Level - Obtaining a Fingerstick, revised 5/2023, revealed .A licensed nurse will obtain a blood sample to determine the resident's blood glucose level to immediately determine accurate capillary glucose levels and to screen for hypoglycemia and hyperglycemia .The following are the steps to be taken to obtain a Finger stick blood glucose level: Verify there is a physician's order for this procedure .Place equipment and supplies so it can be easily reached, using a barrier between table and glucometer .Wear gloves .Choose a site .Clean selected finger with alcohol .Obtain a blood sample by using a sterile lancet .Place a drop of blood on the reagent strip .Wipe the finger with a cotton ball .Dispose of the lancet in a sharps container .Clean equipment according to policy .Remove gloves and discard appropriately. Wash hands . 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Hypertension and Diabetes. Review of the Physician's Order dated 8/27/2022, for Resident #25 revealed, .Accuchecks BID [twice a day] for blood sugar . Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #25 was severely impaired cognitively for daily decision making. Review of the Physician's Order dated 1/9/2024 for Resident #25 revealed to perform Accuchecks twice a day for blood sugar. Review of the Physician's Order dated 1/25/2024, for Resident #25 revealed, .If blood sugar is > [greater than] 400, Administer 10 units of Novolog [an agent used to lower blood sugar] 100 units/ml [millimeter] .blood sugar < [less than] 100 notify MD [Medical Doctor] STAT [immediately] . Observation in Resident #25's room on 2/7/2024 at 3:51 PM, revealed LPN #1 performed a blood glucose check on Resident #25 using a multi-use blood glucose meter. LPN #1 failed to perform hand hygiene, failed to don gloves before and after checking the resident's blood glucose level, and failed to clean or disinfect the multi-use blood glucose meter before and after use. 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Hypertension, Heart Failure, and Diabetes. Review of the Physician's Order dated 9/14/2023, for Resident #1 revealed, .Humulin R Injection Solution 100 UNIT/ML [milliliters] (Insulin Regular (Human) [an agent used to lower blood sugar] Inject as per sliding scale . Review of the significant change MDS dated [DATE], revealed Resident #1 scored a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Observation in Resident #1's room on 2/7/2024 at 4:02 PM, revealed LPN #1 performed a blood glucose check on Resident #1 using a multi-use blood glucose meter. LPN #1 failed to perform hand hygiene, failed to don gloves, and failed to clean and disinfect the multi-use blood glucose meter before and after use. 4. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Dementia, Kidney Failure, and Diabetes. Review of the Physician's Order dated 2/17/2023, for Resident #14 revealed, .Novolog Injection Solution [an agent used to lower blood sugar] 100 unit/ml .Inject 5 unit subcutaneously one time a day . Review of the Physician's Order dated 1/1/2024, for resident #14 revealed, .Accu check one time a day for DM [Diabetes Mellitus] . Review of the quarterly MDS dated [DATE], revealed Resident #14 had a BIMS score of 3, which indicated the resident was severely cognitively impaired. Observation in Resident #14's room on 2/7/2024 at 4:07 PM, revealed LPN #1 performed a blood glucose check on Resident #14 using a multi-use blood glucose meter. LPN #1 failed to perform hand hygiene, failed to don gloves, and failed to clean and disinfect the multi-use blood glucose meter before and after use. Observations during medication administration on Hall 1 on the medication cart on 2/8/2024 at 11:12 AM, revealed LPN #1 removed a bottle of Novolog Insulin, the multi-use blood glucose meter and supplies, an alcohol pad, insulin syringe, and entered Resident #14's room, placed the medication and supplies on a barrier. LPN #1 obtained Resident #14's blood glucose level with the multi-use blood glucose monitor and failed to clean and disinfect before and after use. LPN #1 administered 5 units of Novolog Insulin to Resident #14's left upper arm and placed the trash into the biohazard sharps container and exited the room. LPN #1 failed to use hand hygiene and don gloves prior to administering Resident #14's insulin. 5. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Hypertension, Chronic Obstructive Pulmonary Disease, and Diabetes. Review of the admission MDS dated [DATE], revealed Resident #33 scored a BIMS of 6, which indicated the resident was severely cognitively impaired. Review of the Medication Administration Record for 2/2024, revealed Resident #33 received blood glucose monitoring twice per day. Observation during medication administration on Hall 1 medication cart on 2/7/2024 at 7:56 PM, revealed LPN #2 removed a multi-use blood glucose meter and supplies, a bottle of Latanoprost Ophthalmic Solution Eye 0.005 % (percent), and Metformin 1000 milligram (mg) 1 tablet from a drawer on the medication cart. LPN #2 entered Resident #33's room and placed the multi-use blood glucose meter and supplies, the Metformin tablet, and eye drops on the Resident's bedside table. LPN #2 failed to cleanse the bedside table and place a barrier between the supplies and the bedside table. LPN #2 washed her hands and donned clean gloves, instilled 1 drop of the resident's eyedrop into each eye, and recapped the eye drops. Without washing her hands, LPN #2 administered the 1000 mg Metformin 1 tablet, and without washing her hands, obtained Resident #33's blood glucose level using the multi-use blood glucose meter. LPN #2 failed to cleanse the multi-use blood glucose meter prior to using it on Resident #33. After completing the blood glucose test, LPN #2 placed the testing strip and lancet into the biohazard sharps container, removed her soiled gloves and washed her hands. LPN #2 gathered the multi-use blood glucose meter and supplies and eye drops, exited the room and entered Hall 1 medication storage room and placed the multi-use blood glucose meter on the countertop in Hall 1 medication storage room. LPN #2 failed to place the multi-use blood glucose meter on a clean barrier in the medication room. 6. During an interview on 2/7/2024 at 8:10 PM, LPN #2 confirmed she does not clean the multi-use blood glucose meter before use. During an interview on 2/8/2024 at 6:11 PM, the Assistant Director of Nursing (ADON) was asked how a multi-use blood glucose meter should be cleaned and how often. The ADON stated, .Before and after use .use the orange-colored top Sani Wipes .orange has bleach . During an interview on 2/13/2024 at 9:01 AM, LPN #3 confirmed she did not know the correct technique for cleaning a multi-use blood glucose meter until 2/9/2024. During an interview on 2/13/2024 at 10:25 AM, LPN #4 was asked when her last skills check off was on how to properly clean a multi-use blood glucose meter. LPN #4 confirmed she was unsure and stated she could not remember. During an interview on 2/13/2024 at 10:27 AM, LPN #1 confirmed she had not had a skills check off on how to properly clean a multi-use blood glucose meter. The facility failed to ensure staff used an Environmental Protection Agency (EPA) approved disinfectant wipe, resulting in Immediate Jeopardy due to the potential of transmitting blood-borne pathogens between patients and healthcare professionals. 7. Observation and interview during dining on Hall 1 on 2/5/2024 at 11:57 AM, revealed CNA #1 exited Resident #1's room with a used meal tray, placed the used meal tray on the meal cart which contained clean meal trays waiting to be delivered to other Resident rooms. CNA #1 was asked whose used meal tray did she place on the meal cart. CNA #1 stated, [Named Resident #1], she has finished eating. Observation revealed CNA #1 placed the used meal tray back on the clean meal cart, and then removed a clean meal tray and entered Resident #25's room. During an interview on 2/13/2024 at 8:47 AM, the Interim Director of Nursing (DON) was asked should a meal tray that a resident had eaten off of be placed on the meal cart above the clean meal trays that were to be served to other residents. The Interim DON stated, Cannot be put back in the cart until all the clean meal trays are off because it is an infection control issue if you put a dirty food meal tray in with a clean one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility investigation, policy review, medical record review, observation, and interview, the facility neglected to provide adequate supervision to a cognitively impaired, vulnerable resident with a history of wandering and exit-seeking behaviors for 1 of 5 sampled residents (Resident #11) reviewed at risk for wandering and elopement. Resident #11 exited the facility without staff supervision or staff knowledge through an unlocked door and was found approximately 5-6 minutes later, sitting in a chair at a picnic table on the back patio, approximately 13 feet from the door of the facility, and approximately 147 feet from the driveway beside the nursing home. A Certified Nursing Assistant brought the resident back into the facility and left her alone in a chair beside an exit door even though the resident had demonstrated exit seeking behavior prior to this occurrence. The facility's failure resulted in Immediate Jeopardy for Resident #11. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Healthcare Consultant were notified of the Immediate Jeopardy on 3/24/2022 at 1:03 PM, in the Board Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited Immediate Jeopardy at F-600 at a scope and severity of J, which is Substandard Quality of Care. The facility was cited an Immediate Jeopardy at F-610 on 5/30/2020 related to a resident elopement. The Immediate Jeopardy existed from 3/21/2021-3/27/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/25/2022 at 3:26 PM, and was validated onsite by the surveyors on 3/27/2022 through 3/28/2022, through policy review, medical record review, review of education records, auditing tools, observations, and staff interviews. The findings include: Review of the facility's undated policy titled, ABUSE, dated 3/2017, revealed .The facility has a zero tolerance policy for abuse .neglect .Neglect is the failure of the facility, its [it's] employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Review of the facility's policy titled, Resident Elopement, dated 1/2021, revealed .Elopement occurs when a resident leaves the premises or safe area without authorization or necessary supervision to do so .the nurse will .provide the resident with 1:1 [one on one] or other level of supervision . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Closed Fracture of Right Radius, Closed Fracture of Right Ulna, Dementia with Behavioral Disturbance, Anxiety, Hypertension, Insomnia, and Depression. Review of a Wandering Risk assessment dated [DATE], revealed Resident #11 was assessed to be a moderate risk of wandering, with a known history of wandering. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) of 4, which indicated severe cognitive impairment, daily wandering behaviors, and the resident wore a wander guard (a monitoring device to alert staff when a resident attempts to exit a door in the facility). Review of the Care Plan revised 1/14/2022, revealed .The resident is an elopement risk/wanderer .Monitor .every shift for wandering/exit seeking behavior . Review of the Physician's Order dated 1/8/2021 and updated 2/1/2022, revealed .may apply wanderguard [wander guard] bracelet to lower extremity .monitor .every shift for wandering/exit seeking behaviors . Review of the Progress Notes dated 2/14/2022 at 4:37 PM, revealed Resident #11 exhibited episodes of exit-seeking behavior, pushed on exit doors in an attempt to leave the facility, and sat in a chair close to the exit doors. Review of the Progress Notes dated 2/20/2022 at 5:17 PM, revealed Resident #11 was anxious and tried to get out of the facility door that morning. Review of the Progress Notes dated 3/21/2022 at 9:56 PM, revealed .Resident exit seeking . Review of Resident #11's Elopement Occurrence dated 3/21/2022 (documented on 3/23/2022), revealed .Resident .had gotten outside and was found sitting on back patio .she had been sitting at the end of the hall in a .chair resting from walking w/a [with a] CNA [Certified Nursing Assistant] .Resident exited the building .without supervision .Was out for a short period of time . Observation in the resident's room on 3/21/2022 at 9:53 AM, revealed Resident #11 in bed with her eyes closed, dressed appropriately, and appeared clean and well-groomed. Resident was noted to have a cast on her left arm from mid upper arm to fingers with bruises noted to fingers below the cast. Observation in the resident's room on 3/21/2022 at 5:01 PM, revealed Resident #11 eating dinner in her room, wearing a wander guard on her left ankle, appeared to be confused, and mumbled unintelligibly. Observation in the resident's room on 3/22/2022 at 8:18 AM and 3/23/2022 at 8:42 AM, revealed Resident #11 appeared to be confused and a wander guard was observed on her left ankle. Review of the facility investigation dated 3/23/2022, revealed .[Named Resident #11] at approximately 645pm [6:45 PM] was exit seeking .kept stating she was looking to go home .She came to the Administrator office and sat down looking out the window .She got up to leave admin [Administrator] office, [Named MDS Coordinator] was standing in the entry way, [Named Resident #11] pushed the door and it opened, she stepped out onto the front door step .[Named MDS Coordinator] .got a hold of her arm .[Named Resident #11] did not want to come back in .[Named CNA #2] walked up to the door .assisted [Named Resident #11] down the stairs and walked her down the side walk and up to the back door [North Hall Exit Door outside of the Director of Nursing's (DON) Office] .[Named Resident #11] was tired .sat in a .chair at the end of the hall .[Named Resident #11] got out the door and no one was aware of where she was .was found sitting on the back patio [outside of the North Hall Exit Door] .Potential for Improvement .Resident should have had one on one monitoring when she came in after walking outside the building with [Named CNA #2] .Log of increased monitoring should have been utilized .Currently collecting statements from staff that were working that evening . Observation in the facility parking lot on 3/23/2022 at 11:35 AM and 8:00 PM, 3/24/2022 at 7:50 AM and 1:40 PM, 3/25/2022 at 7:30 AM, 12:10 PM, 3:49 PM, and 7:55 PM, 3/26/2022 at 8:00 AM and 12:38 PM, 3/27/2022 at 11:00 AM and 8:00 PM, and 3/28/2022 at 10:00 AM and 10:45 PM, revealed the gate which led from the ramp of the North Hall Exit Door to the sidewalk, and the gate which led from the sidewalk to the parking lot, both stood wide open. During a telephone interview on 3/23/2022 at 9:59 AM, CNA #3 confirmed Resident #11 often exhibited exit-seeking behaviors and that she eloped from the facility on the evening of 3/21/2022, shortly after her shift began. CNA #3 stated, .[Named CNA #2] took her for a walk and sat her down in a seat by the back door .I seen [saw] her sitting down there .went to take care of another patient .they asked if I had seen her .we went looking for her .she was sitting on the patio . CNA #3 confirmed she did not hear Resident #11's wander guard alarm when she left the facility. During a telephone interview on 3/23/2022 at 10:54 AM, CNA #2 confirmed that on the evening of 3/21/2022, when she arrived at work, Resident #11 was standing on the front doorsteps with the MDS Coordinator and LPN #5. CNA #2 stated, .She [Resident #11] was wanting to go out and look for her car .I just put my stuff down, walked with her down the steps and around the building .said she was tired, wanted a seat with a cushion on it, walked her up the ramp to the door where the DON's office is and sat her on the chair [inside the facility beside the North Hall Exit Door] .[Named LPN #4] started her med [medication] pass on that hall .I let her [Resident #11] sit there, went on up and got clocked in .started for the night .pulled my snacks [bedtime residents' snacks] .doorbell rang .it was the granddaughter [Resident #11's granddaughter] .we looked and she [Resident #11] wasn't there [where CNA #2 left her beside the exit door] .I went down to the room .[Resident #11] wasn't in her room .I told the granddaughter that I had left her in that chair .[Named CNA #2] went out the side door .when I got to the back [patio outside the facility] .by the [DON] office door [at the North Hall Exit Door] she was sitting in a chair there [outside the facility on the back patio] . During an interview on 3/23/2022 at 2:43 PM, General Maintenance Staff #1 confirmed he was on call on Monday, 3/21/2022 and received a call that the North Hall Exit Door was not working properly. He confirmed that one of the magnets had dropped down and was not making full contact which would cause the door to open more easily. He stated, .I tightened the bolt . He confirmed there was no one at the door, monitoring the door when he arrived to repair it, and the door had mechanically malfunctioned. During a telephone interview on 3/23/2022 at 5:35 PM, Licensed Practical Nurse (LPN) #4 confirmed CNA #2 took Resident #11 outside to walk around the facility and brought her back in the facility through the North Hall Exit Door beside the DON's office. LPN #4 stated, .[Named Resident #11] was tired .sat in the chair there and rested [beside the exit door] .I .went into [Named Resident #41's] room .when I came out [of Resident #41's room], she was not sitting in the chair anymore .she had walked out [the North Hall Exit Door] .she sat at the picnic table .I hollered for [Named LPN #5] . LPN #4 confirmed that she was in Resident #41's room for approximately 5-6 minutes and stated, .took his temp [temperature], checked his oxygen [saturation level], gave his nighttime medicine . LPN #4 confirmed she did not hear the North Hall Exit Door alarm and when she pushed on the door it was not locked, and opened immediately. LPN #4 stated, .[Named Administrator] was there [when the incident occurred] . LPN #4 confirmed Resident #11 was outside the facility, unsupervised, and without staff's knowledge. During an interview on 3/23/2022 at 6:39 PM, the Administrator confirmed Resident #11 eloped from the facility on the evening of 3/21/2022. The Administrator stated, .One of the girls said [Named Resident #11] was sitting in a .chair in front of the DON office [beside the North Hall Exit Door] . The Administrator confirmed she was then told Resident #11 was not in the chair where staff had left her. The Administrator stated, .I looked .they called and said she was on the back porch [back patio outside of the facility] . The Administrator confirmed staff had left Resident #11 unsupervised in the chair beside the North Hall Exit Door, shortly after she exhibited exit-seeking and wandering behaviors, and attempted to leave the facility. The Administrator confirmed that facility staff should not have left Resident #11 unsupervised near an exit door after she had exhibited wandering and exit-seeking behaviors. Observation in the resident's room on 3/24/2022 at 7:39 AM, revealed Resident #11 rested in the bed with her eyes closed and her room darkened. A staff member was posted outside her room. Observation outside the North Hall Exit Door on 3/27/2022 at 7:30 PM, revealed Licensed Practical Nurse (LPN) #4 identified the location on the patio where Resident #11 was found. Observation outside the North Hall Exit Door on 3/28/2022 at 12:49 PM, revealed the Maintenance Supervisor measured the distance from the North Hall Exit Door to the marked area where Resident #11 was found after she eloped. The distance measured approximately 13 feet. Refer to F-609, F-610, F-689, F-835, and F-867. The surveyors verified the Removal Plan by: 1. The Administrator requested the maintenance staff check the exit door outside the DON office for proper locking and maintenance repaired the door on 3/21/2022 at 7:30 PM. The surveyors interviewed the maintenance staff and observed the doors to ensure they functioned properly. 2. The Administrator requested the Maintenance Director to check all the exit doors in the facility for proper locking mechanism and functionality of the wander guard on 3/23/2022. The surveyors interviewed the Maintenance Director and observed the doors to ensure they functioned properly. 3. The Maintenance Director requested an outside vendor to come in and repair the door at the end of the East Hall and the door by the MDS office. This repair was begun on 3/24/2022. The Maintenance Staff will check all locking doors daily until all repairs have been completed. The surveyors interviewed Maintenance Staff and reviewed door logs. 4. The DON and Assistant Director of Nursing (ADON) conducted an in-service with the Nursing staff (Registered Nurses (RNs), LPNs, and CNAs) on the revised Abuse, Neglect and Misappropriation of Funds Policy, including identification of the reporting requirement and procedures for determining a reportable incident, the type of incident requiring 2 hour reporting requirement versus the type of incident requiring a 24 hour reporting requirement and the procedures for preparing a report and making a report on the State Incident Reporting System, wandering residents, and caring for residents with wander guard. These in-services were either in-person, in a classroom setting or 1:1, either in person or by telephone. Any staff missing the in-services will not work until they receive the education. Any staff who fail to comply with the points of the in-services will be further educated and/or progressive discipline will begin as indicated. Following the in-services, a Post Test will be conducted with all employees. The surveyors interviewed the DON, ADON, and nursing staff on all shifts, reviewed the in-service education, the in-service sign-in logs, and the Post Tests. 5. The Administrator and the Executive Director of Support Services completed the Elopement drill on 3/24/2022 at 6:30 PM and completed the newly developed Evaluation Form. The surveyors reviewed the Elopement Drill sign-in sheet and interviewed staff on all shifts. 6. Wander Risk Assessments were completed on all current residents by the DON, ADON, and/or Charge Nurses. The surveyors reviewed the assessments and interviewed staff on all shifts. 7. The Healthcare Consultant reviewed Care Plans of exit seeking residents with the MDS Coordinator on 3/24/2022. The surveyors reviewed all residents' Care Plans and interviewed the MDS Coordinator and the Healthcare Consultant. 8. On 3/24/2022, the MDS Coordinator reviewed the Weekly Behavior Documentation to ensure behaviors are captured and care planned appropriately. The surveyors reviewed the medical records and interviewed the MDS Coordinator. 9. The Administrator and Executive Director of Support Services completed the Elopement drill on 3/24/2022 at 6:30 PM and completed the newly developed Missing Resident Evaluation Form. The surveyors reviewed the Elopement Drill sign-in sheet, Missing Resident Evaluation Form, and interviewed staff on all shifts. 10. On 3/24/2022, the Administrator and Executive Director of Support Services posted pictures of wandering residents at each Nurses' Station, the hospital Nurses' Station on each floor, Emergency Department, Front Door Registration and in the Maintenance Department. The surveyors observed the pictures posted at the various facility locations and interviewed staff. 11. Beginning on 3/23/2022, Maintenance increased exit door checks for proper locking mechanisms and functionality of the wander guard alarm system from monthly to weekly checks. The surveyors reviewed the door logs and interviewed Maintenance Staff. 12. An outside Healthcare Consultant will provide additional oversight with the development of the Removal Plan/Plan of Correction at least weekly for 3 weeks then monthly for 6 months to ensure compliance. The outside Consultant will report findings to the Administrator, Chief Executive Officer (CEO), the full Quality Assurance and Performance Improvement (QAPI) committee and to determine if the issues have been resolved or if the QAPI initiative should continue. The surveyors interviewed the Healthcare Consultant, the Executive Director of Support, the MDS Coordinator, and the DON. 13. The outside Healthcare Consultant will report findings to the Governing Body, the full QAPI committee, and the CEO to determine if the issues have been resolved or if the QAPI initiative should continue. The surveyors interviewed the Healthcare Consultant, the Executive Director of Support, the MDS Coordinator, and the DON. 14. Beginning 3/25/2022, the Administrator will question management staff at daily stand-up meetings if they have witnessed or have received any abuse or neglect reports for the next 2 months. The Administrator will acknowledge this questioning in the minutes of the daily stand-up meetings. The surveyors interviewed the Healthcare Consultant, the Executive Director of Support, the MDS Coordinator, and the DON. 15. Beginning 3/25/2022, the Executive Director of Support Services and the Healthcare Consultant will audit all records of reported abuse, neglect, exploitation, and/or misappropriation of property for completion of investigation and reporting to the state agency for accuracy and completion, per policy. These will be monitored upon any allegation of abuse, neglect, exploitation, and/or misappropriation of property monthly for 3 months or until the QAPI committee deems satisfactory compliance has been achieved. The surveyors interviewed the Healthcare Consultant, the Executive Director of Support, the MDS Coordinator, and the DON. 16. Beginning 3/25/2022, the MDS Coordinator and DON will monitor Weekly Behavior Notes daily to ensure all behaviors are addressed timely and any exit seeking behaviors are identified. This will continue for 3 months or until the QAPI committee deems satisfactory compliance has been achieved. The surveyors interviewed the Healthcare Consultant, the Executive Director of Support, the MDS Coordinator, and the DON. 17. Beginning 3/24/2022, the DON and/or the ADON will initiate a QAPI program related to review of any Abuse, Neglect and Misappropriation of Property that will include at a minimum: a. Review of education delivered to all staff and confirm all staff have been educated, including contract staff. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should be revised or continued. b. One hundred percent of all education sign-in sheets will be reviewed to ensure that all staff have been properly educated related to Abuse/Neglect Policy, caring for residents with wander guard, and missing residents. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should continue. The surveyors interviewed the DON and ADON. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to report an incident of neglect and elopement for 1 of 5 sampled residents (Resident #11) reviewed for wandering and elopement. The facility's failure to report an incident of elopement and neglect to the State Survey Agency resulted in Immediate Jeopardy when Resident #11, a cognitively impaired, vulnerable resident, eloped through an unlocked exit door on the North Hall, walked outside the facility unsupervised, and sat down in a chair near the facility's parking lot and driveway. Resident #11 was unsupervised and without staff awareness for approximately 5-6 minutes, and the distance the resident traveled was approximately 13 feet from the North Hall Exit Door. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Healthcare Consultant were notified of the Immediate Jeopardy on 3/24/2022 at 1:06 PM, in the Board Room. The facility was cited an Immediate Jeopardy at F-609. The facility was cited F-609 at a scope and a severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 3/21/2021-3/27/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 3/25/2022 at 2:48 PM. The corrective actions were validated onsite by the surveyors on 3/27/2022 and 3/28/2022 by policy review, medical record review, review of education records, auditing tools, observations, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled, .Abuse, Neglect, Misappropriation of Funds Protocol, revised 4/2019, revealed .Reporting Protocols .Neglect is the failure of the facility, its [it's] employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Staff members and persons affiliated with this facility shall not knowingly .fail to report an incident of mistreatment or other offense .or withhold information to reporting agencies .The results of the investigation findings are to be reported in 5 working days .Serious Bodily Injury .2 Hour Limit .All others .Within 24 Hours .The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency .and others as may be required by state or local laws, within five (5) working days of the reported incident . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Closed Fracture of Right Radius, Closed Fracture of Right Ulna, Dementia with Behavioral Disturbance, Anxiety, Hypertension, Insomnia, and Depression. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) of 4, which indicated severe cognitive impairment, daily wandering behaviors, and wore a wander guard (a monitoring device to alert staff when a resident attempts to exit a door in the facility). Review of the Progress Notes dated 3/21/2022, revealed .Resident exit seeking, was assisted down sidewalk by cna [Certified Nursing Assistant] and reentered by back door . During the Entrance Conference on 3/21/2022 at 9:05 AM, the Administrator denied having any reportable incidents that had not been investigated by the State Survey Agency. Review of Resident #11's Elopement Occurrence dated 3/21/2022 and documented on 3/23/2022, revealed .Resident .had gotten outside and was found sitting on back patio .she had been sitting at the end of the hall in a .chair resting from walking w/a [with a] CNA [Certified Nursing Assistant] .Resident exited the building .without supervision .Was out for a short period of time . Review of an undated Witness Statement revealed Licensed Practical Nurse (LPN) #4 documented in her statement, .When I was doing my med [medication] pass I seen [saw] her [Resident #11] sitting in the chair resting so I went in to [Named Resident #41's] room to give medication .when I came out she wasn't sitting there anymore. She had went [gone] out the back door without alarm going off and was sitting at the picnic table .outside . During a telephone interview on 3/23/2022 at 4:50 PM, 2 days after the elopement, the Administrator's Office was called from the telephone in the Board Room and the Administrator was asked again if the facility had any reportable events or incidents for the team to review. The Administrator stated, No .something from 2019 . The Administrator called the team right back and stated she had found one from October and would bring it. The Administrator did not report the incident of elopement to the State Survey Team when asked about reportable incidents. During an interview on 3/23/2022 at 6:39 PM, the Administrator confirmed Resident #11 had eloped on 3/21/2022. The Administrator was asked if she had notified the State or any other entity. She stated, No, Ma'am, I did not. The Administrator was asked if the incident of elopement should have been reported. She stated, Yes, immediately. Observation outside the North Hall Exit Door on 3/27/2022 at 7:30 PM, revealed Licensed Practical Nurse (LPN) #4 identified the location on the patio where Resident #11 was found. Observation outside the North Hall Exit Door on 3/28/2022 at 12:49 PM, revealed the Maintenance Supervisor measured the distance from the North Hall Exit Door to the marked area where Resident #11 was found after she eloped. The distance measured approximately 13 feet. During an interview on 3/28/2022 on 10:14 AM, the Chief Executive Officer (CEO) was asked when he was informed of the elopement. He stated, .I found out about that on Wednesday [3/23/2022], brought to my attention probably around 3:00 [3:00 PM] in the afternoon . The CEO was asked if he should have been informed of the elopement on Monday night after it happened. The CEO stated, I do, and I think that you all should have . Refer to F-600, F-610, F-689, F-835, and F-867. The surveyors verified the removal plan by: 1. On 3/23/2022, the Administrator obtained statements from all staff working on 3/21/2022 concerning the elopement incident of Resident #11. The surveyors reviewed copies of the statements, interviewed the Administrator, the staff, and had staff read and sign their statements. 2. On 3/24/2022, the Healthcare Consultant conducted a one-on-one training with the Administrator reviewing the Abuse, Neglect, and Misappropriation of Funds policy including the reporting of Abuse, Neglect, and Misappropriation of Funds and responsibility to conduct a timely reporting and investigation of potential instances that required reporting to the State Incident Reporting System. The surveyors reviewed the training and interviewed the Administrator. 3. The Administrator completed an investigation of the elopement and entered the information into the State Incident Reporting System concerning the elopement of Resident #11 on 3/24/2022. The surveyors reviewed the completed investigation and interviewed the Administrator. 4. The Administrator and Healthcare Consultant reviewed and revised the Abuse, Neglect, and Misappropriation of Property policy with the approval of the Quality Assurance Committee members and Medical Director on 3/24/2022. The surveyors reviewed the Abuse, Neglect and Misappropriation of Property policy and interviewed the Administrator and Healthcare Consultant. 5. On 3/24/2022, Wander Risk Assessments were completed on all current residents by the DON, Assistant Director of Nursing (ADON) and/or Charge Nurses. The surveyors reviewed the assessments and interviewed the DON and ADON. 6. On 3/24/2022, the DON and ADON conducted an in-service with the Nursing Staff (Registered Nurses (RNs), LPNs, and CNAs) on the Revised Abuse, Neglect, and Misappropriation of Funds Policy including identification of the reporting requirement and procedures for determining a reportable incident, the type of incident requiring a 2-hour reporting requirement versus the type of incident requiring a 24-hour reporting requirement and the procedures for preparing a report and making a report on the State Incident Reporting System (IRS), wandering residents, and caring for residents with a wander guard. These in-services were either in-person, in a classroom setting or 1:1, either in person or by telephone. Any staff missing in-services will not work until they receive the education. Any staff who fail to comply with the points of the in-services will be further educated and/or progressive discipline will begin as indicated. Following the in-services, a Post Test will be conducted with all employees. The surveyors reviewed the training, in-service sign-in sheets, and interviewed nursing staff on all shifts. 7. The Healthcare Consultant reviewed Care Plans of exit seeking residents with the MDS Coordinator on 3/24/2022. The surveyors reviewed the Care Plans of exit seeking residents and interviewed the MDS Coordinator. 8. The MDS Coordinator reviewed the weekly Behavior documentation to ensure behaviors are captured and care planned appropriately on 3/24/2022 . The surveyors reviewed the weekly Behavior documentation and the Care Plans and interviewed the MDS Coordinator. 9. The Administrator will question management staff at daily Stand-up meetings if they have witnessed or have received any abuse or neglect reports for the next 2 months. The Administrator will acknowledge this questioning in the minutes of the daily Stand-up meetings beginning 3/25/2022. The surveyors interviewed the management staff and the Administrator. 10. The Executive Director of Support Services and the Healthcare Consultant will audit all records of reported abuse, neglect, exploitation, and /or misappropriation of property for completion of investigation and reporting to state agency for accuracy and completion per policy beginning 3/25/2022. These will be monitored upon any allegation of abuse, neglect, exploitation, and/or misappropriation of property monthly for 3 months or until the Quality Assurance and Performance Improvement (QAPI) committee deems satisfactory compliance has been achieved. The surveyors interviewed the Executive Director of Support Services and the Healthcare Consultant. 11. The MDS Coordinator and DON will monitor Weekly Behavior Notes daily to ensure all behaviors are addressed timely and any exit seeking behaviors are identified, beginning 3/25/2022 . This will continue for 3 months or until the QAPI committee deems satisfactory compliance has been achieved. The surveyors interviewed the MDS Coordinator and the DON. 12. The DON and/or ADON will initiate a QAPI program related to review of any Abuse, Neglect, and Misappropriation of property that will include at a minimum: a. Review of education delivered to all staff and confirm all staff have been educated including contract staff. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should be revised or continued. b. One hundred percent of all education sign-in sheets will be reviewed to ensure that all staff have been properly educated related to the Abuse/Neglect Policy, caring for residents with a wander guard, and missing residents. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should continue. The surveyors reviewed the sign-in sheets and interviewed the DON and nursing staff. The facility's noncompliance at F-609 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility investigation, policy review, medical record review, observation, and interview, the facility failed to timely and thoroughly investigate an incident of neglect and elopement for 1 of 5 sampled residents (Resident #11) reviewed for wandering and elopement. The facility's failure to timely and thoroughly investigate an incident of elopement and neglect, resulted in Immediate Jeopardy when Resident #11, a confused and vulnerable resident, eloped through an unlocked exit door on the North Hall, walked outside the facility unsupervised, and sat down in a chair near the facility's parking lot and driveway. Resident #11 was unsupervised outside the facility for approximately 5-6 minutes and traveled approximately 13 feet from the facility's North Hall Exit Door. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Healthcare Consultant were notified of the Immediate Jeopardy on 3/24/2022 at 1:06 PM, in the Board Room. The facility was cited an Immediate Jeopardy at F-610. The facility was cited F-610 at a scope and a severity of J, which is Substandard Quality of Care. The facility was previously cited an Immediate Jeopardy at F-610 at a scope and severity of J on a complaint survey on 5/30/2020. The Immediate Jeopardy existed from 3/21/2021-3/27/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, for F-610 was received on 3/25/2022 at 2:48 PM. The corrective actions were validated onsite by the surveyors on 3/27/2022 and 3/28/2022 by policy review, medical record review, review of education records, auditing tools, observations, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, revised 7/2017, revealed .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .The following data, as applicable, shall be included on the Report of Incident/Accident form .The date and time the accident or incident took place .nature of the injury/illness .bruise, fall, nausea .circumstances surrounding the accident or incident .Where the accident or incident took place .name(s) of witnesses and their accounts of the accident or incident .The injured person's account of the accident or incident .time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions .date/time the injured person's family was notified and by whom .condition of the injured person, including his/her vital signs .disposition of the injured .transferred to hospital, put to bed, sent home .Any corrective action taken .Follow-up information .Other pertinent data as necessary or required .signature and title of the person completing the report .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services [DON] within 24 hours of the incident or accident . The facility's policy titled, Abuse, Neglect, Misappropriation of Funds Protocol, dated 4/2019, revealed .The facility has a zero tolerance policy for abuse, involuntary seclusion, neglect and misappropriation of resident property. The facility will attempt to identify and will investigate any reported violation or allegation of abuse .Investigation process .The individual conducting the investigation will, as a minimum .Review the completed Resident Abuse Report .Review the resident's medical record to determine events leading up to the incident .Interview with person(s) reporting the incident .Interview any witnesses to the incident .Interview the resident (as medically appropriate) .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 .Interview the resident's roommate, family members, and visitors .Interview other residents to whom the accused employee provides care or services .Review all events leading up to the alleged incident .The following guidelines will be used when conducting interviews .Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports Note: a copy of such reports must be attached to the Resident Abuse Investigation Report.The results of the investigation will be recorded on the Resident Abuse Investigation Report .The investigator will give a copy of the completed Resident Abuse Investigation Report to the Administrator within 2 working days of the reported incident .The Administrator will inform the resident and his/her representative .of the results of the investigation and corrective action taken within 3 days of the completion of the investigation . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Closed Fracture of Right Radius, Closed Fracture of Right Ulna, Dementia with Behavioral Disturbance, Anxiety, Hypertension, Insomnia, and Depression. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) of 4, which indicated severe cognitive impairment, daily wandering behaviors, and wore a wander guard (a monitoring device to alert staff when a resident attempts to exit a door in the facility). Observation in the resident's room on 3/21/2022 at 5:01 PM, revealed Resident #11 was eating dinner seated in her chair, appeared to have periods of confusion, and a wander guard was observed on her left ankle. The facility's investigation provided to the surveyors on 3/23/2022 at 7:45 PM, included: a. 1 undated handwritten statement by the Minimum Data Set (MDS) Coordinator, revealed .On Monday evening March 21, 2022 I was at the door of administrators office talking with her [Administrator], when [Named Resident #11] came by me and opened up the door, at this time I got a hold of her [Resident #11's] arm to encourage her to come in, but she refused. While pleading with her, I called for [Named Licensed Practical Nurse (LPN) #5] to assist me. He came to door and tried to convince her to come inside to talk. She still refused, then [Named Certified Nursing Assistant (CNA) #2] came up side walk to come in door. She took [Named Resident #11] for a walk around the building. At this time I was no longer needed, and clocked out and went home. This episode occurred around 6:30-7:00 [PM] . b. 1 undated handwritten statement by LPN #4, revealed .On Monday night [3/21/2022] [Named Resident #11] attempted to go out the front door CNA [Certified Nursing Assistant] .met her at the door when she was coming in and took resident for a walk around the nursing home and they came in through the back door .[Named Resident #11] wanted to rest so she [Resident #11] sat in a chair at the end of the hall. When I was doing my med [medication] pass I seen [saw] her [Resident #11] sitting in the chair resting so I went in to [Named Resident #41's] room to give medication and when I came out she [Resident #11] wasn't sitting there anymore. She had went [gone] out the back door without alarm going off and was sitting at the picnic table right outside the door . c. 1 handwritten statement by LPN #5 dated 3/23/2022, revealed .This is an [a] statement for an incident that took place on Mon. [Monday] March 21, 2022. I was passing by front entrance when I saw [Named MDS Coordinator] standing in threshold of main entrance with resident [Named Resident #11] I went to assit [assist]. As we were trying to coax her [Resident #11] back thru [through] door [Named CNA #2] walked up and suggested she walk with her to keep her calm, they walked from main entrance to back door by DON [Director of Nursing] office. I went down to back entrance and CNA and resident came in and resident sit [sat] on chair at end of hall she said she was tired. I went back up hall but in a few minutes was motioned back down hall resident was sitting on bench outside of the door . d. 1 Ad Hoc QAPI [Quality Assurance and Performance Improvement] meeting note dated 3/23/2022 at 3:30 PM, revealed .Monday, 21 March 2022 [3/21/2022]. [Named Resident #11] .was exit seeking .[Named Resident #11] got out the door and no one was aware of where she was. She was found sitting on the back patio . The facility's investigation of the elopement of Resident #11 on 3/21/2022 did not include interviews/statements from other staff working on the day of the elopement, did not include interviews/statements from staff working on previous shifts, did not include a full assessment of the resident after the elopement, did not include elopement or skin assessments of other residents, did not include documentation that all the doors were checked to be assured they could not be opened by the residents, and did not include interviews with the maintenance department staff regarding the security of the doors. The facility failed to provide a thorough and timely investigation of Resident #11's elopement. The investigation was not started until 3/23/2022, 2 days after the resident eloped from the facility. During a telephone interview on 3/23/2022 at 9:59 AM, CNA #3 confirmed she was the CNA assigned to provide care for Resident #11 on Monday, 3/21/2022. She confirmed Resident #11 eloped and she did not know she was out of the building. She confirmed she had not been asked to write a statement about the elopement. During a telephone interview on 3/23/2022 at 10:54 AM, CNA #2 confirmed she worked Monday, 3/21/2022 and confirmed she saw Resident #11 trying to get out the front door. CNA #2 stated, .I just put my stuff down, walked her down the steps and around the building .walked her up the ramp to the door where the DON's office is and sat her on the chair .inside .[Named LPN #4] started her med [medication] pass on that hall .I went on up and got clocked in .I pulled my snacks up .doorbell rang, I went to the door and it was the granddaughter [Resident #11's granddaughter] .we went to the hall and she [Resident #11] wasn't there .we went to her room and she wasn't there . She confirmed the staff started looking for Resident #11. CNA #2 confirmed she had not been asked to write a statement at that time. Observation on the Skilled 1 Hall on 3/23/2022 at 2:30 PM, revealed the double exit doors to the outside courtyard were not locked and opened easily. Outside the doors was an open courtyard that led to 3 steep stairwells. During a telephone interview on 3/23/2022 at 5:35 PM, LPN #4 was asked about the elopement incident that occurred on Monday, 3/21/2022 and stated, .When we got there, she was trying to get out the front door. One of the CNAs and nurses was talking to her by the door. The CNA walked with her outside. She walked her down the sidewalk and they came in the back door by the DON's office. When she came back in, she was tired, so she sat down and rested. She was sitting there for a few minutes. I was passing meds [medications]. I went into [Named Resident #41's] room .took his temp [temperature], checked hid oxygen [saturation level], and gave his nighttime medication .when I came out, she was not sitting in the chair anymore. She had gone out and was sitting there at the picnic table. LPN #4 confirmed she had been in Resident #41's room for 5 to 6 minutes. LPN #4 stated, .I looked down the hall to my left and looked out the door and she [Resident #11] was outside at the picnic table. She was sitting there by herself. The door was not locked .the doors opened for me . During an interview on 3/23/2022 at 6:39 PM, the Administrator confirmed Resident #11 was found outside the facility, unsupervised, on Monday 3/21/2022. She stated, .I called the on-call maintenance man to come in to check the doors to see if it was a door problem and he did come and said he fixed it. The Administrator confirmed she did not know what was wrong with the doors. She stated, I don't remember, other than he said he fixed it. The Administrator was asked if she obtained statements from staff. She stated, .from some of the staff, not all . She was asked when she obtained the statements. The Administrator stated, Today [3/23/2022]. She confirmed she also had the exit doors checked and held a QAPI meeting today. The Administrator confirmed she had someone watching Resident #11's door and stated, .it [the monitoring of Resident #11's door] started today . The Administrator was asked what the facility put in place after the elopement to keep all residents in the facility safe. The Administrator stated, .just keep an eye on her [Resident #11], there were no immediate things put in place at that time . The Administrator confirmed the nursing staff should have assessed the resident for injuries and checked her vital signs at that time. The Administrator confirmed the double exit doors on the Skilled 1 Hall were broken, no one was monitoring them at this time, and she was not aware until today that they were broken. During an interview on 3/25/2022 at 6:24 PM, LPN #4 read her statement and signed it. She confirmed Resident #11 had eloped on 3/21/2022. LPN #4 was asked when the Administrator asked her for a statement. She stated, It was Wednesday, the 23rd [3/23/2022]. LPN #4 was asked who she reported the elopement to. LPN #4 confirmed she reported the elopement to the Administrator on 3/21/2022, right after it happened. During an interview on 3/25/2022 at 6:45 PM, LPN #5 confirmed his statement and signed it. He confirmed Resident #11 had eloped on 3/21/2022, and he had assisted her back to her room. LPN #5 confirmed he was not asked to write a statement about the incident until Wednesday, 3/23/2022, at approximately 5:00 PM to 6:00 PM. LPN #5 was asked if the Administrator was present when the elopement occurred. He stated, Yes. LPN #5 confirmed he administered Resident #11's medications but did not complete a head-to-toe assessment or obtain vital signs after the elopement. During an interview on 3/26/2022 at 9:40 AM, the Executive Director of Support Services was asked if a full inspection of the facility was done to check all the wandering residents and the doors. He stated, .I found out Tuesday [3/22/2022] from [Named Administrator]. I don't know if all the doors were checked. The courtyard doors [the double exit doors on the Skilled 1 Hall] have been broken for a while .the first time we were aware of the doors was when y'all told us .It was not on the door list . During an interview on 3/27/2022 at 11:25 AM, the DON confirmed she was not made aware of Resident #11's elopement on Monday, 3/21/2022. The DON confirmed she was notified of the elopement on Tuesday, 3/22/2022, by the Administrator. The DON was asked what she did when she was made aware. The DON stated, I just said okay . Observation outside the North Hall Exit Door on 3/27/2022 at 7:30 PM, revealed LPN #4 confirmed the location on the patio outside the North Hall Exit Door, where Resident #11 was found. Observation outside the North Hall Exit Door on 3/28/2022 at 12:49 PM, revealed the Maintenance Supervisor used a measuring wheel to measure the distance from the North Hall Exit Door to the chair where Resident #11 was found. The distance measured approximately 13 feet. Refer to F-600, F-609, and F-689. The facility verified the Removal Plan by: 1. On 3/24/2022, the Healthcare Consultant conducted a one-on-one training with the Administrator reviewing the Abuse, Neglect, and Misappropriation of Funds policy including the reporting of Abuse, Neglect, and Misappropriation of Funds and responsibility to conduct a timely reporting, investigation of potential instances requiring reporting to the State Incident Reporting System. The surveyors reviewed the training and interviewed the Administrator. 2. The Administrator completed the investigation of the elopement and entered the information into the State Incident Reporting System related to the elopement of Resident #11 on 3/24/2022. The surveyors reviewed the completed investigation and interviewed the Administrator. 3. The Administrator and Healthcare Consultant reviewed and revised the Abuse, Neglect, and Misappropriation of Property policy with approval of the Quality Assurance Committee members and the Medical Director on 3/24/2022. The surveyors reviewed the Abuse, Neglect and Misappropriation of Property policy and interviewed the Administrator and Healthcare Consultant. 4. On 3/23/2022, the Administrator obtained statements from all staff working on 3/21/2022, 7:00 PM to 7:00 AM, concerning the elopement incident of Resident #11. The surveyors reviewed the statements and interviewed the staff to confirm their statements. 5. Wander Risk Assessments were completed on all current residents by the DON, Assistant Director of Nursing (ADON) and/or Charge Nurses on 3/24/2022. The surveyors reviewed the assessments and interviewed the DON and ADON. 6. The DON and ADON conducted an in-service with the Nursing Staff (Registered Nurses (RNs), LPNs, and CNAs) on the Revised Abuse, Neglect, and Misappropriation of Funds Policy including identification of the reporting requirement and procedures for determining a reportable incident, the type of incident requiring a 2-hour reporting requirement versus the type of incident requiring a 24-hour reporting requirement and the procedures for preparing a report and making a report on the State Incident Reporting System (IRS), wandering residents, and caring for residents with a wander guard on 3/24/2022. These in-services were either in-person, in a classroom setting or 1:1, either in person or by telephone. Any staff missing the in-services will not work until they receive the education. Any staff who fail to comply with the points of the in-services will be further educated and/or progressive discipline will begin as indicated. Following the in-services, a Post Test will be conducted with all employees. The surveyors reviewed the training, in-service sign-in sheets, and interviewed nursing staff on all shifts. 7. The Healthcare Consultant reviewed Care Plans of exit seeking residents with the MDS Coordinator on 3/24/2022. The surveyors reviewed the Care Plans of exit seeking residents and interviewed the MDS Coordinator. 8. The MDS Coordinator reviewed the weekly Behavior documentation to ensure behaviors are captured and care planned appropriately on 3/24/2022 . The surveyors reviewed the weekly Behavior documentation and the Care Plans and interviewed the MDS Coordinator. 9. The Administrator will question management staff at daily Stand-Up meetings if they have witnessed or have received any abuse or neglect reports for the next 2 months. The Administrator will acknowledge this questioning in the minutes of the daily Stand-Up meetings beginning 3/25/2022. The surveyors interviewed the management staff and the Administrator. 10. The Executive Director of Support Services and the Healthcare Consultant will audit all records of reported abuse, neglect, exploitation, and /or misappropriation of property for completion of the investigation and reporting to state agency, for accuracy and completion per policy beginning 3/25/2022. These will be monitored upon any allegation of abuse, neglect, exploitation, and/or misappropriation of property monthly for 3 months or until the Quality Assurance and Performance Improvement (QAPI) committee deems satisfactory compliance has been achieved. The surveyors interviewed the Executive Director of Support Services and the Healthcare Consultant. 11. The MDS Coordinator and DON will monitor Weekly Behavior Notes daily to ensure all behaviors are addressed timely and any exit seeking behaviors are identified, beginning 3/25/2022. This will continue for 3 months or until the QAPI committee deems satisfactory compliance has been achieved. The surveyors interviewed the MDS Coordinator and the DON. 12. The DON and/or Assistant Director of Nursing (ADON) will initiate a QAPI program related to review of any Abuse, Neglect, and Misappropriation of property that will include at a minimum: a. Review of education delivered to all staff and confirm all staff have been educated, including contract staff. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should be revised or continued. b. One hundred percent of all education sign-in sheets will be reviewed to ensure that all staff have been properly educated related to Abuse/Neglect Policy, caring for residents with wander guard, and missing residents. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should continue. The surveyors interviewed the DON and ADON. The facility's noncompliance at F-610 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, facility investigation reviewed, medical record review, observation, and interview, the facility failed to provide supervision and a safe environment to prevent elopement for 1 of 5 sampled residents (Resident #11) reviewed for wandering behaviors and elopement; failed to conduct fall investigations, implement, and follow fall interventions for 2 of 9 sampled residents (Resident #10 and #11) reviewed for falls; failed to perform neurochecks after falls and accurately assess for fall risk for 9 of 9 sampled residents (Resident #4, #6, #7, #10, #11, #19, #20, #35, and #38) reviewed for falls; and failed to ensure the environment was free of accident hazards when unsecured sharps and chemicals were observed in 1 of 3 Shower Rooms (Skilled 1 Hall). The facility's failure to provide supervision and ensure a safe environment resulted in Immediate Jeopardy when Resident #11, a cognitively impaired, vulnerable resident, exited the facility unsupervised through the North Hall Door unsupervised, and was found approximately 5-6 minutes later, sitting in a chair at a picnic table on the back patio, 13 feet from the door of the facility, and 134 feet from the driveway in front of the nursing home. The facility's failure to thoroughly and timely investigate and follow care planned interventions for falls, resulted in Actual Harm when Resident #10 sustained a fall which resulted in a fracture (broken bone) of the right 5th metacarpal bone (5th long bone of the right hand) and Resident #11 sustained a fall which resulted in a fracture of the left radius and ulna bones (bones of the forearm). Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Healthcare Consultant were notified of the Immediate Jeopardy on 3/24/2022 at 1:07 PM, in the Board Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The facility was previously cited an Immediate Jeopardy in F-689 at a scope and severity of J on a complaint survey on 5/30/2020. The Immediate Jeopardy existed from 3/21/2021 through 3/27/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/25/2022 at 3:26 PM, and was validated onsite by the surveyors on 3/27/2022 through 3/28/2022 through policy review, medical record review, review of education records, auditing tools, observation, and staff interviews. The findings include: Review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, dated 7/2017, revealed .All accidents or incidents involving residents .on our premises shall be investigated and reported to the Administrator .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .The following data, as applicable, shall be included on the Report of Incident/Accident form .date and time .nature of injury .circumstances surrounding the accident or incident .Where the accident or incident took place .names(s) of witnesses and their accounts of the accident or incident .injured person's account of the accident or incident .time .time the person's Attending Physician was notified .the time the physician responded and his or instructions .date/time the injured person's family was notified and by whom .condition of the injured person, including his/her vital signs .disposition of the injured .corrective action taken .Follow-up information .signature and title of the person completing the report .facility is in compliance with current rules and regulations governing accidents .Nurse Supervisor/Charge Nurse and or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident .Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence .Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident .analyze any individual resident vulnerabilities . Review of the facility's policy titled, Care of Residents at Risk for Wandering, dated 6/2020, revealed .This policy serves to provide guidelines to staff regarding causes of and injury prevention strategies for residents at risk for wandering .Signs of wandering .Residents, speaking about being unhappy and desiring to leave the facility .speaking about going to visit a loved one . Review of the facility's policy titled, Resident Elopement, dated 1/2021, revealed .One of the most challenging issues related to care of the resident with dementia is wandering behavior. The most dangerous form of wandering is elopement, in which the confused resident leaves the nursing home .It is the intent of the facility to be aware of its resident's usual habits and locations .Elopement occurs when a resident leaves the premises or safe area without authorization or necessary supervision to do so .Procedure to follow in event of missing resident .Staff will also search the unit in order to identify any other residents that may be missing .the Charge Nurse will notify the Administrator and Director of Nursing .When a resident who was missing is found, the nurse will .Examine the resident for possible injuries .Notify the Attending Physician for consultation .Notify the Medical Director .Discuss with the Administrator or DON [Director of Nursing], or designee if it is prudent to provide the resident with 1:1 [one to one] or other level of supervision .Complete an incident report .Complete appropriate documentation in the resident's medical record .The supervisor or designee will also instruct staff members to verify any other resident that has been identified as at risk for wandering is in the building to affirm their safety .If the resident uses an electronic device that alarms, the Charge Nurse or designee will .note location of the device on the resident's body .Test any electronic protection device both on the resident and attached to or associated with any doorways .In the event that there is an equipment or doorway malfunction, provide supervision of that area .provide 1:1 observation to the resident .Re-evaluate the resident's risk for possible elopement .Follow-up Investigation .DON or designee will obtain video evidence to establish timeline of events and resident exit point .responsible [for] obtaining staff .statements regarding incident .ensure notification of medical director, CEO [Chief Executive Officer], administrator, resident family, and primary physician .will moderate an adhoc [done for a particular purpose] QAPI [Quality Assurance Performance Improvement] Meeting, within 24 hours after event, to discuss possible contributing factors and discover primary root cause of the event . Review of the facility's policy titled, Falls Management Program, dated 2/2022, revealed .Purpose: To provide a coordinated system to minimize the incidence of falls among residents identified to be at risk for fall/injury. To keep our residents .safe .Within 24 hours of admission to the facility, the nurse will complete the Falls Risk Assessment on all residents .Procedure: Nurses will document at the time of the fall regarding the intervention put in place. MDS [Minimum Data Set] will add the intervention to the care plan .When a resident falls .Neuro checks are to be initiated immediately and continue as follows .Every fifteen minutes times four .Every thirty minutes times two .Every two hours times two .Every four hours times 24-48 hours .depending upon severity of injury .The nurse is to complete the incident report and notify the physician and family .that a fall has occurred .If the fall is with injury the physician, family or responsible party should be notified immediately. This should be documented in the appropriate space on the incident report as in the patient record .medical record should be flagged with a Q [Every] SHIFT sticker for frequent monitoring and documentation .Review of the current care plan for any necessary updates/revisions. Any updates/revisions should be noted on the CNA [Certified Nursing Assistant] Assignment Sheet . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Closed Fracture of Right Radius, Closed Fracture of Right Ulna, Dementia with Behavioral Disturbance, Anxiety, Hypertension, and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for mental Status (BIMS) score of 4, which indicated severe cognitive impairment, 1 fall since admission or prior assessment, and exhibited wandering behaviors 1 to 3 days of the 7 day look back period. Review of the Wandering Risk Assessment, dated 1/7/2022, revealed Resident #11 was a moderate risk for wandering and had a known history of wandering. Review of a Progress Note dated 1/7/2022 at 5:45 PM, revealed .res [resident] trying to get out of facility went to door thinking her daughter was outside, nurse talked to res and got her away from the front door and res was mad and stated I will get out .Im [I'm] going home . Review of a Progress Note dated 1/7/2022 at 5:53 PM, revealed .res at door again for second time looking out and pushing on door CNA to get her .she stated that's [that's] my family and I will leave .res sitting in chair by door in front by nurses [nurses'] desk . Review of the significant change MDS dated [DATE], revealed Resident #11 had a BIMS of 4, which indicated severe cognitive impairment, daily wandering behaviors, and wore a wander guard (a monitoring device to alert staff when a resident attempts to exit a door in the facility). Review of the Care Plan revised 1/14/2022, revealed .The resident is an elopement risk/wanderer .Assess for fall risk .Distract resident from wandering by offering pleasant diversions .Monitor for wanderguard [wander guard] placement .every shift for wandering/exit seeking .Document wandering behavior and diversional interventions in behavior log .Weekly behavior assessment every Friday . Review of a Weekly Behavior Note dated 1/14/2022, revealed potential for elopement and wandering behaviors were not documented. Review of a Progress Note dated 1/21/2022 at 3:10 PM, revealed .res pacing up and down hallways [hallways] looking out doors and pushing on them to see if she can get out , she stated Ill [I'll] find one unlocked and Ill be gone . Review of a Weekly Behavior Note dated 1/29/2022, revealed no documentation in the following sections: Behaviors Noted, Safety, Observed Behaviors, Behavior Management Intervention, Outcome of Interventions, Behavior Triggers, and Frequency of Behaviors. Review of a Progress Note dated 2/14/2022 at 4:37 PM, revealed .res is having episodes of exit seeking behavior, going to doors and pushing on them trying to get them open, gets angry when you tell her they are locked .walks off or sits down in chair close to doors . Review of a Weekly Behavior Note dated 2/19/2022, revealed .Behaviors Noted .no . There was no documentation of the potential for elopement, wandering, and anxiety behaviors. Review of a Progress Note dated 2/20/2022 at 5:17 PM, revealed .res was anxious this am [morning] trying to get out front door . Review of a Weekly Behavior Note dated 2/25/2022, revealed .Behaviors Noted .no . There was no documentation of the potential for elopement, wandering, and anxiety behaviors. Review of a Progress Note dated 3/21/2022 at 9:56 PM, revealed .Resident exit seeking, was assisted down sidewalk by cna [Certified Nursing Assistant] and reentered by back door . Review of the facility investigation dated 3/23/2022, and provided to the survey team on 3/24/2022, revealed .Monday 21 March 2022 [3.21/2022]. [Named Resident #11] had been visiting with her daughter in room [ROOM NUMBER] .daughter left at 5:45pm [5:45 PM] [Named Resident #11] at approximately 645pm [6:45 PM] was exit seeking .kept stating she was looking to go home to take care of the boys .came to the Administrator office and sat down .watching for her family .She got up to leave admin [Administrator] office, [Named MDS Coordinator] was standing in the entryway, [Named Resident #11] pushed the door and it opened, she stepped out onto the front door step .[Named MDS Coordinator] .got a hold of her arm to keep her from going outside .hollered for [Licensed Practical Nurse (LPN) #5] to come help .[Named CNA #2] .walked up to the door .assisted [Named Resident #11] down the stairs and walked her down the side walk and up to the back door [North Hall Exit Door outside of the Director of Nursing (DON) Office] .[Named Resident #11] was tired, so she sat in a geri [geriatric] chair at the end of the hall where [Named CNA #2] and [LPN #4] were working. [Named Resident #11] got out the door and no one was aware where she was. She was found sitting on the back patio [outside of the North Hall Exit Door] drinking a [named beverage] . Review of an Incident Reporting System report dated 3/24/2022, revealed .Date of Occurrence .3/21/2022 .Time of Occurrence .7:20 PM .Resident sitting in chair at end of hall by exit door. Resident exited door, without supervision, to sit at picnic table outside. Staff was unaware that resident was outside. When she was not in chair staff began to look for her .No injuries noted .3/23/2022 Medical Director .notified of incident .3/23/2022 One on one supervision implemented for resident. Annual Survey team is here for our annual and is investigating . Review of the medical record, revealed a Head-to-Toe Nursing Assessment was not completed and vital signs were not obtained after Resident #11 eloped from the facility on 3/21/2022. Review of a Weekly Behavior Note dated 3/25/2022, revealed .Behaviors noted .no .Observed Behaviors .Potential for elopement .Wandering .Restless . The Weekly Behavior Note documented Resident #11 had no behaviors and then documented Resident #11 had potential for elopement, wandering, and restless behaviors. Observation in the resident's room on 3/21/2022 at 5:01 PM, revealed Resident #11 seated in her chair eating dinner, appeared to have periods of confusion, and a wander guard was observed on her left ankle. Observation in the resident's room on 3/22/2022 at 8:18 AM and 3/23/2022 at 8:42 AM, revealed Resident #11 appeared confused and a wander guard was observed on her left ankle. Observation in the facility parking lot on 3/23/2022 at 11:35 AM and 8:00 PM, 3/24/2022 at 7:50 AM and 1:40 PM, 3/25/2022 at 7:30 AM, 12:10 PM, 3:49 PM, and 7:55 PM, 3/26/2022 at 8:00 AM, 12:38 PM, 3/27/2022 at 11:00 AM and 8:00 PM, and 3/28/2022 at 10:00 AM and 10:45 PM, revealed the gate which led from the ramp at the North Hall Exit Door to the sidewalk, and the gate which led from the sidewalk to the parking lot, both were wide open. During a telephone interview on 3/23/2022 at 9:59 AM, CNA #3 confirmed Resident #11 eloped from the facility on 3/21/2022. CNA #3 confirmed she entered the facility for her shift at 6:23 PM. CNA #3 stated, .I was trying to come in .she [Resident #11] wanted out the front door, we tried to get her back .she wouldn't come back .she sat down with [Named Administrator] in the office .[Named CNA #2] took her for a walk and sat her down in a seat by the back door .I seen [saw] her sitting down there .went to take care of another patient .they asked if I had seen her .we went looking for her .went out the front door to make sure she didn't get out the front .walked all the way around to [Named DON] office [North Hall Exit Door] and she was sitting on the patio .I cannot tell you [how she got out the door] .still wonder that . CNA #3 confirmed she was not asked to write a statement after Resident #11 eloped from the facility unsupervised and stated, .usually they'll have us all write a statement .anyone who was involved or knew about it . CNA #3 confirmed that there was not a lock on the gate which led from the handicap ramp to the sidewalk behind the facility, or on the gate which led from the sidewalk to the back parking lot. During a telephone interview on 3/23/2022 at 10:54 AM, CNA #2 confirmed that when she came to work on 3/21/2022, Resident #11 was on the front doorstep with the MDS Coordinator and LPN #5. CNA #2 stated, .She was wanting to go out and look for her car .I just put my stuff down, walked with her down the steps and around the building .walked down where the big white tree was blooming .she was tired .walked her up the ramp to the door where the DON's office is and sat her on the chair there . CNA #2 confirmed she left Resident #11 on a chair inside the facility, beside the North Hall Exit Door, and outside the DON's office. CNA #2 stated, .[Named LPN #4] started her med [medication] pass .she [Resident #11] wanted to sit there .I went on up and clocked in .pulled my snacks .doorbell rang, I went to the door and it was the granddaughter [of Resident #11] .she said where is she [Resident #11] .looked [down the hall at the chair where she had left Resident #11] and she wasn't there. We went down to her room and she wasn't there .I told the granddaughter I had left her in that chair [beside the North hall Exit Door] .went down the side door in the lobby [door from the Dining Room out to the smoking patio] and when I got back there by the office [DON office] she was sitting in a chair outside [on the back patio] .[Named Administrator] asked me where she was .I said she's sitting out there on the patio .I didn't hear an alarm .[Named Administrator] called maintenance and asked them to check the alarms on the doors . CNA #2 confirmed she had not been asked to write a statement regarding the incident of elopement and staff did not conduct a building inspection to ensure no other wandering residents had gotten out of the facility. During an interview on 3/23/2022 at 2:43 PM, General Maintenance Staff #1 confirmed the Administrator called him on 3/21/2022, at approximately 7:00 PM, and notified him that the North Hall Exit Door wasn't working properly. General Maintenance Staff #1 confirmed the door mechanically malfunctioned, that it was not making full contact, which would make the door easier to open, and no one was posted to monitor the door when he arrived for the repair. During a telephone interview on 3/23/2022 at 5:35 PM, LPN #4 confirmed that on the evening of 3/21/2022, Resident #11 was exit-seeking, so CNA #2 walked with her outside, down the sidewalk, and around to the back door by the DON's office. Resident #11 was tired after the walk outside, so she sat down and rested in a chair beside the North Hall Exit Door. LPN #4 confirmed she entered Resident #41's room and Resident #11 was left alone. LPN #4 stated, .She was sitting there .I was passing my meds [medications] .went into [Named Resident #41's] room .took his temp [temperature], checked his oxygen [saturation level], and gave his nighttime medicine . LPN #4 confirmed she was in the room [ROOM NUMBER]-6 minutes. LPN #4 confirmed that Resident #11 was not in the chair when she exited Resident #41's room and stated, .looked down the hall to my left and looked out the door and she was outside at the picnic table . LPN #4 stated, .She walked out the door .didn't alarm, or lock . LPN #4 confirmed Resident #11 sat in a chair at the picnic table on the back patio by herself. LPN #4 stated, .When I went out to get her the door just opened. LPN #4 confirmed the DON was not in the facility when the incident occurred, but the Administrator was there. LPN #4 confirmed that she was asked to write her statement regarding this incident on 3/23/2022, 2 days following the incident of elopement. During an interview on 3/23/2022 at 6:39 PM, the Administrator confirmed that on the evening of 3/21/2022, Resident #11 was exit-seeking. The Administrator stated, .[Named Resident #11] was starting to get anxious .sat in my office a little while .got up from my office, pushed the door [Front Lobby Door], it opened and [Named MDS Coordinator] went out with her .on the steps and couldn't get her back in. [Named CNA #2] was walking up and walked [Named Resident #11] down the stairs and around the building .towards the parking lot .went back in my office .one of the girls said she was sitting in a chair in front of the DON office and now they couldn't find her .so we looked .they told me she was sitting on the back porch [patio outside the North Hall Exit Door] . The Administrator confirmed that after the resident was found she called maintenance to come check the North Hall Door to see if there was problem with the door. The Administrator confirmed maintenance came and repaired the door. The Administrator was asked what she told staff to do after Resident #11 eloped from the facility on 3/21/2022. The Administrator confirmed she did not begin her investigation into the incident of elopement, conduct an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting, and notify the Medical Director until 3/23/2022, 2 days following the incident of elopement. The Administrator confirmed that no specific interventions were implemented until 3/23/2022. The Administrator stated, .Oh yes, we did watch that door .I don't have a log .[Named LPN #4 [watched the door] while passing medicines down that hall . The Administrator confirmed the door would not have been monitored while LPN #4 was in residents' rooms. The Administrator confirmed that when the doors were checked on 3/23/2022 the South Hall Exit Door, across from Resident #11's room, did not alarm and someone was stationed outside her room to monitor the door. The Administrator confirmed the facility staff should not have left Resident #11 sitting by the door alone. The Administrator stated, .we knew she was exit-seeking .we brought her in and sat her right in front of the door . The Administrator confirmed a head-to-toe assessment should have been conducted after Resident #11 was found and the physician should have been notified. The Administrator was asked why the physician was not notified after the incident of elopement. The Administrator stated, I didn't think of it. Observation in the resident's room on 3/24/2022 at 7:39 AM, revealed Resident #11 in bed with her eyes closed and her room dark. A staff member was posted outside her room. During an interview on 3/25/2022 at 6:45 PM, LPN #5 confirmed he was not asked to write a statement regarding Resident #11's incident of elopement until late in the afternoon on Wednesday, 3/23/2022. LPN #5 confirmed he did not obtain vital signs or perform a head-to-toe assessment when Resident #11 was brought back into the facility, after she eloped. During an interview on 3/26/2022 at 9:40 AM, the Executive Director of Support Services confirmed he was not made aware that Resident #11 had eloped from the facility until Tuesday, 3/22/2022. During an interview on 3/26/2022 at 11:55 AM, the DON confirmed she was not notified until 3/22/2022, that Resident #11 had eloped from the facility on 3/21/2022. The DON was asked if the facility's Elopement policy was followed. The DON stated, No, ma'am. During an interview and observation on 3/27/2022 at 7:30 PM, LPN #4 identified the location where she first observed Resident #11 sitting in a chair at the picnic table, on the patio outside the facility. During an interview on 3/28/2022 at 10:14 AM, the Chief Executive Officer (CEO) confirmed he was not made aware of the incident of elopement until the afternoon of 3/23/2022, and that he should have been made aware of the elopement the day it occurred. The CEO confirmed that the facility's chain of command consisted of the Administrator reporting to the Executive Director of Support Services and the Executive Director of Support Services reported to him. The CEO was aware that the Administrator had engaged the services of a Nurse Consultant but was not aware that an Acting Administrator had been retained. During an interview and observation on 3/28/2022 at 12:50 PM, the Maintenance Supervisor used a measuring wheel to measure the distance Resident #11 ambulated when she eloped from the facility on 3/21/2022. The measurements revealed the following: a. The distance from the threshold of the North Hall Exit Door of the facility, to the chair on the patio outside the facility, where Resident #11 was found, was 13 feet. b. The distance from the patio chair where Resident #11 was found, to the end of Ramp #1, the handicap ramp, on the North end of the facility, was 94 feet. c. The distance from the end of Ramp #1 to the parking lot was an additional 13 feet, for a total of 107 feet from the chair to the parking lot. d. The distance from the end of Ramp #1 to the driveway was 40 feet, for a total of 134 feet from the patio chair to the driveway. The Maintenance Supervisor confirmed the driveway was called the driveway in front of the nursing home. Review of the medical record, revealed a Fall Risk Evaluation was not completed when Resident #11 was admitted to the facility, per facility policy. Review of a Fall Risk Evaluation, dated 4/7/2021, revealed Resident #11 had 1 to 2 falls in the past 3 months. The Fall Risk Evaluation did not have a score to determine whether Resident #11 was at low, moderate, or high risk for falls. Review of a Fall Risk Evaluation, dated 7/7/2021 and 10/7/2021, revealed the Fall Risk Evaluation did not have a score to determine whether Resident #11 was at low, moderate, or high risk for falls. Review of a Progress Note dated 10/8/2021 at 9:23 AM, revealed .Resident questioned about fall 10/7/2021 .remembered falling and stated .I'm sore all over . There was no documentation of an Incident Report, that a fall investigation was completed, that staff statements were obtained, or interventions were implemented following Resident #11's fall on 10/7/2021. There was no documentation of the fall in the medical record. Review of a Fall Risk Evaluation, dated 1/7/2022, revealed the Fall Risk Evaluation did not have a score to determine whether Resident #11 was at low, moderate, or high risk for falls. The Fall Risk Evaluation documented the resident had no falls in the past 3 months. Review of the Care Plan revised 1/14/2022, revealed .The resident is at risk for falls d/t [due to] Gait/balance problems .Anticipate and meet The resident's needs .Apply Gripper socks before transfers and ambulation .Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .Bed Alarm while in bed .Ensure that The resident is wearing appropriate footwear .when ambulating . Review of an Incident Report dated 3/10/2022, revealed .When CNA opened door to resident's room, she was lying on her back nude in the floor .called nurse for assistance. Resident was alert but confused which is her normal baseline .Noted resident to have a small skin tear on Lt [left] elbow and wrist displaced & [and] painful. Resident has a large hematoma [collection of blood under the skin] on Lt occipital [back of the head] area .Predisposing Situation Factors .Improper Footwear .Ambulating without Assist . Review of the facility investigation dated 3/10/2022 at 11:58 AM, revealed .Resident was not utilizing walker for ambulation and had no shoes/socks on feet at time of fall .returned from ER [Emergency Room] at approx. [approximately] 4pm [4:00 PM] with fracture of the ulnar and radial bones (L) [left] arm in sling .3/11/22 [2022] .transported to [Named Orthopedic Clinic] .able to do a close [closed] reduction of fracture and applied splint . The facility investigation did not contain statements from staff working that shift, documentation that neurochecks were performed before Resident #11 went to the ER or after she returned to the facility, or interventions to prevent further falls from occurring. Review of a radiology report dated 3/10/2022 at 12:43 PM, revealed Resident #11 had a .Comminuted [multiple breaks] intra-articular [fracture that affects the wrist joint] distal radius and a comminuted transverse [perpendicular to the shaft or long part of the bone] distal ulnar fracture .Moderate posttraumatic soft tissue edema about the left wrist . Review of a radiology report dated 3/10/2022 at 12:23 PM, revealed Resident #11 had a computed tomography (CT) scan of the head which identified a left occipital scalp hematoma and no acute intracranial findings. No fall intervention was put into place until 3 days after the fall with major injury. Observation in the resident's room on 3/21/2022 at 9:53 AM, revealed Resident #11 in bed with her eyes closed, dressed, and appeared clean and well-groomed. Resident #11 was noted to have a cast on her left arm from mid upper arm to fingers with bruises noted to fingers below cast. During an interview on 3/25/2022 at 3:27 PM, the DON confirmed there was not a fall investigation and interventions were not implemented for Resident #11's fall on 10/7/2021. The DON stated, .There was not because I did not know that a fall had occurred . The DON confirmed there was only an incident report and a summary statement she had typed up related to Resident #11's fall on 3/10/2022. The DON stated, .This represents the entire investigation . The DON confirmed that staff statements were not obtained, neuro checks were not documented, and no new interventions were implemented to prevent further falls, after Resident #11's fall on 10/7/2021. The DON confirmed she would expect to see additional fall interventions implemented for a resident who was at high risk for falls. The DON stated, .I would try to move them closer to the desk [Nurses' Station] .more frequent checks from staffing . Resident #11's room was at the far end of the South Hall, away from the Nurses' Station and in close proximity to the South Hall Exit Door. The DON confirmed that due to Resident #11's severe cognitive impairment, reminders to use the call light would not be an effective intervention. The DON stated, .she would not remember that. During an interview on 3/25/2022 at 6:06 PM, the DON confirmed neuro checks should have been performed after Resident #11's fall with a head injury and radial and ulnar fractures on 3/10/2022. The facility's failure to investigate Resident #11's fall on 10/7/2021 and implement appropriate fall interventions, resulted in Actual Harm when Resident #11 fell and sustained a fracture of the right radius and ulna bones on 3/10/2022. Review of the medical record, revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Muscle Wasting and Atrophy, Depressive Disorder, Dementia, Insomnia, Anemia, Malignant Neoplasm of Bronchus and Lung, and Metabolic Encephalopathy. Review of a Fall Risk Evaluation, dated 10/7/2021, revealed Resident #10 had multiple falls in the last 3 months. The Fall Risk Evaluation did not have a score to determine whether Resident #10 was at low, moderate, or high risk for falls. Review of the Care Plan dated 10/13/2021, revealed .resident is at risk for falls r/t [related to] Ga[TRUNCATED]

Based on policy review, job description review, and interview, the facility Administration failed to administer the facility in a manner that ensured supervision, oversight, and provision of a safe environment for Resident #11 who was assessed to be at risk for wandering and failed to thoroughly and timely investigate and report an incident of elopement for Resident #11. The facility Administration failed to conduct a thorough and timely investigation and follow care planned interventions related to falls when Resident #10 fell and suffered a fracture (broken bone) of the right 5th metacarpal bone (5th long bone of the right hand) and Resident #11 sustained a fall which resulted in a fracture of the left radius and ulna bones (bones of the forearm). Facility Administration failed to administer the facility in a manner that provided a safe and secure environment for the residents, when they failed to ensure doors were secured, failed to provide supervision of wandering residents, failed to ensure a thorough and timely investigation was conducted, and failed to report an elopement for Resident #11. These failures resulted in Immediate Jeopardy (IJ) for Resident #11, a cognitively impaired resident with a history of exit-seeking behaviors, when she exited the facility without staff knowledge, and the facility was unaware of Resident #11's location for 5 to 6 minutes after a staff member had previously brought the resident back into the building and left the resident unattended. The facility's failure to ensure staff followed the Care Plan for use of a gait belt to prevent falls and to complete an incident report and investigation resulted in Actual Harm when Resident #10 fell and suffered a fracture of the right hand and when Resident #11 fell and suffered a fracture of the left radial and ulnar bones. 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 Acting Administrator was notified of the Immediate Jeopardy on 3/27/2022 at 5:39 PM, in the Board Room. The facility was cited an Immediate Jeopardy F-600, F-609, F-610, F-689, F-835, and F-867. The facility was cited at F-600, F-609, F-610 and F-689 at a scope and a severity of J, which is Substandard Quality of Care. The facility was previously cited F-610, F-689, F-835, and F-867, at a scope and severity of J on a complaint survey on 5/30/2020. The Immediate Jeopardy was removed onsite and existed from 3/21/2022 through 3/27/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/28/2022 at 4:47 PM. The corrective actions were validated onsite by the surveyors on 3/28/2022 by policy review, medical record review, review of education records, auditing tools, observations, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled, Administrator, revised 5/2013, revealed .A licensed administrator shall be responsible for the day-to-day functions of the facility .The administrator shall be a licensed nursing home administrator in this state and is responsible for .Managing the day-to-day functions of the facility .Ensuring that each resident's right to fair and equitable treatment, self-determination, individual privacy, property and civil rights including the right to lodge a complaint, are strictly enforced .Implementing established resident care policies, personnel policies and other operational policies and procedures necessary to remain in compliance with required laws, regulations, and guidelines .Serving as liaison to the governing board medical staff and other professional and supervisory staff .In the absence of the administrator, the Director of Nursing or designee is authorized to act in the administrator's behalf . Review of the facility's Administrator job description dated 7/10/2017, revealed .Provides leadership for the Nursing Home; plans, organizes, and supervises nursing home staff and resources. Oversees all activities of a nursing home in accordance with established policies and federal and state guidelines .Recommends and leads changes to improve the nursing home .Reports to the CEO and/or designee .KNOWLEDGE .Quality/Safety Standards .Healthcare Laws and Regulatory Agency Standards .The ability to effectively lead others in achieving essential duties .BEHAVIOR .Core Values/Standards of Conduct .Abuse and Neglect .JOB SPECIFIC CORE COMPETENCIES .Nursing Home Management .Knowledge of nursing home administrative practices, aging, and long-term care, gerontology and aging and health behavior .ESSENTIAL FUNCTIONS .Ensures department employees are accountable and adheres to all [Named Facility] policies and procedures, government laws and regulatory agency standards .Provides training of staff to maintain high standards of quality patient care .Provides leadership and supervises nursing home staff .Investigates and resolves staff issues .Promotes efficiency and effectiveness of job responsibilities .Maintains a quality conscious workforce . Review of the facility's Director of Nursing job description dated 7/10/2017, revealed .The Director of Nursing assumes authority, responsibility, and accountability for the delivery of nursing services in the facility. In collaboration with facility Administration, allocates department resources .to enable each resident to attain or maintain the highest practical, physical, mental, and psychosocial well-being .Reports to the Facility Administrator .Supervisory Responsibilities: Nurses and clinical staff .CORE COMPETENCIES .Communications .Healthcare Laws and Regulatory Agency Standards .ABILITIES .ability to effectively lead others in achieving essential duties .ability to effectively converse and actively listen to others concerning [Named Facility] matters .JOB SPECIFIC CORE COMPETENCIES .Abuse and Neglect .Knowledge of long-term care management, policies, personnel management .Knowledge of current federal and state laws and regulations that apply to the practice of nursing in a long-term care setting .strong organizational .skills and the ability to prioritize responsibilities .Ability to define problems, collect data, establish facts, and draw valid conclusions .ESSENTIAL FUNCTIONS .Directs and conducts the day-to-day activities of the nursing home in accordance with established policies. Implements changes to improve nursing home and reviews ongoing activities. Communicates directly with residents, families, medical staff, nursing staff, interdisciplinary team members, and Department Heads to coordinate care and services, promote participation in care plans, and maintain a high quality of care and life for residents. Collaborates with other departments, medical professionals, consultants and organizations including government agencies .to develop, support and coordinate resident care .Develops, maintains, and implements nursing policies and procedures that conform to current standard of nursing practice .while maintaining compliance with state and federal laws and regulations .Communicates and interprets policies and procedures to nursing staff, and monitors staff practices and implementation .daily or weekly management team meetings to discuss resident status .resident complaints or concerns .Evaluates the work performance of all nursing personnel .Ensures delivery of compassionate quality care .Exercises overall supervision of resident assessment and care plans .Reviews 24-hour report from every unit daily to monitor and ensure effective responses to .unexplained injuries, falls, behavioral episodes .Monitors complaint reports daily .for allegations of potential abuse or neglect .participates in these investigations .OTHER DUTIES .Creates, procures and implements ongoing education for staff members . During an interview on 3/23/2022 at 4:50 PM, the Administrator confirmed the last reportable or incident was 11/2019 and 10/2021. During an interview on 3/23/2022 at 6:39 PM, the Administrator confirmed she had an unusual incident of elopement to occur on 3/21/2022 and staff searched for the resident before the resident was located sitting outside on the back patio. The Administrator confirmed she called General Maintenance Staff #1 to come check the North Hall Exit Door, after Resident #11 was found outside the door, which did not alarm or lock down, although she wore a wander guard (a monitoring device to alert staff when a resident attempts to exit a door in the facility). The Administrator confirmed the door was fixed and the doors have been an ongoing problem. The Administrator confirmed she did not start the investigation, have staff to write statements, and notify the Medical Director, until today (3/23/2022). During the interview with the Administrator on 3/23/2022 at 6:39 PM the Administrator was asked what interventions were implemented after the elopement to ensure the safety of the residents. The Administrator stated, .other than just them keeping a close eye on her there were no specific interventions put into place .before today . The Administrator was asked if the North Hall Exit Door was monitored until General Maintenance Staff #1 arrived. The Administrator stated, We did watch the door, I don't have it on a log .As Licensed Practical Nurse [LPN] #4 was passing the meds [medications] .If she was in a room there would not have been [anyone monitoring the door] . The Administrator confirmed that when the doors were checked today, the locking mechanism on the South Hall Exit Door, across from Resident #11's room, was repaired but the door would not alarm today. The Administrator stated, .That's why someone is sitting outside her room . The Administrator confirmed she was just made aware that the 2 doors on the Skilled 1 Hall opened to an outside courtyard which had 3 sets of steep steps. The Administrator stated, .I was on the phone with maintenance .didn't know if I needed to station someone . The Administrator stated, .Right now nobody is [monitoring those doors] but I'll be watching until he [General Maintenance Staff #1] gets here . The Administrator was asked what problems she identified from the investigation of the elopement incident. The Administrator stated, To me one of the biggest problems, we knew she was exit-seeking .we brought her in and set her right in front of the door .should have brought her back to sit with me .we should not have left her alone in front of the door . The Administrator confirmed she did not notify the State or any other entity of Resident #11's elopement from the facility, but the incident should have been reported immediately. The Administrator confirmed staff should have performed a head-to-toe assessment and obtained vital signs, after Resident #11's elopement from the facility. During an interview on 3/24/2022 at 1:20 PM, the Director of Nursing (DON) confirmed the plan of care for gait belt use had not been followed when Resident #10 fell on 3/6/2022 and suffered a right-hand fracture. Education was done with all staff on 10/2021 and re-education was done with two staff members after the fall on 3/6/2022 resulting in a right-hand fracture. No incident report or investigation was done at the time of the resident's fall. The incident report was completed on 3/8/2022, 2 days after the fall with major injury occurred. The DON confirmed she was notified of the fall on 3/7/2022 and started her investigation at that time. During an interview on 3/25/2022 at 3:29 PM, the DON confirmed an investigation was not conducted on Resident #11's fall on 10/7/2021 and fall interventions were not implemented. The DON stated, .I didn't know a fall happened . The DON confirmed that neurochecks were not documented for Resident #11's fall with major injury on 3/10/2022, fall interventions were not implemented after the fall, and staff statements were not obtained. During an interview on 3/26/2022 at 9:40 AM, the Executive Director of Support Services confirmed he was not made aware of the elopement until Tuesday, 3/22/2022, by the Administrator. During an interview on 3/27/2022 at 11:25 AM, the DON confirmed she was notified of Resident #11's elopement on 3/22/2022, by the Administrator. The DON confirmed the Administrator did not report the elopement. The DON confirmed she did not investigate Resident #11's elopement. During an interview on 3/28/2022 at 10:14 AM, the Chief Executive Officer (CEO) confirmed he was notified of the elopement on Wednesday, 3/23/2022. The CEO was asked if he should have been notified of the elopement on Monday, after it occurred. The CEO stated, I certainly do, and I think you guys [State Survey Team] should have been too .given the fact you guys were in the house it's puzzling . The CEO confirmed he had notified the Board about Resident #11's elopement but had not notified them of the IJ. The CEO confirmed he approved the Nurse Consultant that the Administrator consulted but was not aware there was an Acting Administrator on board. During an interview on 3/28/2022 at 5:55 PM, the Healthcare Consultant stated, .She [the Administrator] pretty much knew she should have reported .She knew the 2-hour part and it was just the decision part that was not right . Refer to F-600, F-609, F-610, F-689, and F-867. The surveyors verified the Removal Plan by: 1. The Nursing Home Administrator hired a Healthcare Consultant to also evaluate policies and procedures, investigations of accidents/incidents for any improvements, and to work with the Administrator and DON to ensure compliance with regulations, effective 3/24/2022. This was verified by the surveyors through interviews with the Acting Administrator and Nurse Consultant. 2. The Maintenance Director requested an outside vendor to come in and repair the door at the end of the East Hall and the door by the MDS Office. This repair was begun on 3/24/2022. The Maintenance staff will check all locking doors daily until all repairs have been completed and more often if necessary. This was verified by the surveyors through interview with the Maintenance Director, Acting Administrator, and Nurse Consultant. 3. The Administrator requested the maintenance staff to check the exit door outside the DON Office for proper locking, repaired, and checked all exit doors in the facility for proper locking mechanism and functionality of the wander guard on 3/21/2022. This was verified by the surveyors through review of the door logs and interview with the Maintenance Director. 4. The DON and ADON conducted an in-service with the Nursing Staff (Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)) on Revised Abuse, Neglect and Misappropriation of Funds Policy including identification of the reporting requirement and procedures for determining a reportable incident, the type of incident requiring a 2-hour reporting requirement versus the type of incident requiring a 24-hour reporting requirement and the procedures for preparing a report and making a report on the State IRS, wandering residents, and Caring for Residents with Wander guards on 3/24/2022. These in-services were either in-person, in a classroom setting or 1:1, either in person or by telephone. Any staff missing in-services will not work until they receive the education. Any staff who fail to comply with the points of the in-services will be further educated and/or progressive discipline will begin as indicated. Following the in-services, a Post Test will be conducted with all employees. This was verified by the surveyors through the in-service education provided, review of the Post Test, and interview with nursing staff on all shifts and the DON and ADON. 5. The Administrator and Executive Director of Support Services completed the Elopement drill and completed the newly developed evaluation form on 3/24/2022. This was verified by the surveyors through review of the evaluation form and interview with the nursing staff and Administration. 6. Wander Risk Assessments were completed on all current residents by the DON, ADON and/or Charge Nurses on 3/24/2022. This was verified by the surveyors through record review, review of the assessments, and interviews with staff and administration. 7. The Healthcare Consultant conducted a one-on-one training with the Administrator reviewing Abuse, Neglect and Misappropriation of Funds policy including the reporting of Abuse, Neglect, and Misappropriation of Funds and responsibility to conduct a timely reporting, investigation of potential instances requiring reporting to the State Incident Reporting System on 3/24/2022. This was verified by the surveyors through interview with the Acting Administrator and Nurse Consultant. 8. The Administrator completed the investigation of the elopement and entered the information into the State IRS concerning the elopement of Resident #11 on 3/24/2022. This was verified by the surveyors through interview with the Acting Administrator and Nurse Consultant. 9. The Administrator and Healthcare Consultant reviewed and revised the Abuse, Neglect & Misappropriation of Property policy with approval of the Quality Assurance committee members and Medical Director. This was verified by the surveyors through review of the policy and interview with the Acting Administrator and Nurse Consultant. 10. On 3/23/2022, the Administrator obtained a statement from all staff working on 3/21/2022, 7:00 PM to 7:00 AM, concerning the elopement incident of Resident #11. This was verified by the surveyors through investigation review, and interview with staff and the Administrator. 11. The Consultant reviewed Care Plans of exit seeking residents with the MDS Coordinator on 3/24/2022. This was verified by the surveyors through record review, review of the Care Plans of exit seeking residents, and interview with the Healthcare Consultant and MDS Coordinator. 12. The MDS Coordinator reviewed weekly Behavior Documentation and all orders and documentation for the past 24 hours to ensure behaviors and medication or incidents were captured, and care planned appropriately on 3/24/2022. This was verified by the surveyors through record review and interview with the MDS Coordinator. 13. The Administrator and Executive Director of Support Services posted pictures of wandering residents at each Nurses' Station, hospital Nurses' Station on each floor, Emergency Department, Front Door Registration and in the Maintenance Department on 3/24/0222. This was verified by the surveyors through observation of the pictures posted, staff and the Healthcare Consultant interviews. 17. Beginning 3/24/2022, an Outside Healthcare Consultant will provide additional oversight with the development of the Removal Plan/Plan of Correction (AOC/POC) beginning 3/24/2022. Monitoring will consist of implementation of the AOC/POC at least weekly for 3 weeks then monthly for 6 months to ensure compliance. The outside Consultant will report findings to the Administrator, CEO, the full Quality Assurance Performance Improvement (QAPI) committee and to determine if the issues have been resolved or if the QAPI initiative should continue. This was verified by the surveyors through interview with the acting Administrator and the Healthcare Consultant. 18. The Healthcare Consultant will report findings to the Governing Body, the full QAPI committee, and the CEO to determine if the issues have been resolved or if the QAPI initiative should continue. This was verified by the surveyors through interview with the Acting Administrator and the Healthcare Consultant. 19. The Administrator will question management staff at Daily Stand-up meetings if they have witnessed or have received any abuse or neglect reports for the next 2 months, beginning 3/25/2022. The Administrator will acknowledge this questioning in the minutes of the Daily Stand-Up meetings. This was verified by the surveyors through interview with the Acting Administrator and Healthcare Consultant. 20. The Executive Director of Support Services and the Healthcare Consultant will audit all records of reported abuse, neglect, exploitation, and/or misappropriation of property for completion of investigation and reporting to state agency for accuracy and completion per policy beginning 3/25/2022. These will be monitored upon any allegation of abuse, neglect, exploitation, and/or misappropriation of property monthly for 3 months or until QAPI committee deems satisfactory compliance has been achieved. This was verified by the surveyors through interview with the Acting Administrator and Healthcare Consultant. 21. The MDS Coordinator and DON will monitor Weekly Behavior Notes daily to ensure all behaviors are addressed timely and any exit seeking behaviors are identified beginning 3/25/2022. This will continue for 3 months or until QAPI committee deems satisfactory compliance has been achieved. This was verified by the surveyors through interview with the Acting Administrator and Healthcare Consultant. 22. The Director of Nursing and/or Assistant Director of Nursing will initiate a QAPI program related to review of any Abuse, Neglect, and Misappropriation of property that will include at a minimum of a review of education delivered to all staff and confirm all staff have been educated, including contract staff. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should be revised or continued beginning 3/24/2022. One hundred percent (%) of all education sign-in sheets will be reviewed to ensure that all staff have been properly educated related to Abuse/Neglect policy, Caring for Residents with a Wander Guard, and Missing Residents. This was verified by the surveyors through review of the QAPI meeting, interview with the QAPI members, Acting Administrator and the Healthcare Consultant. 23. The Director of Maintenance will conduct monthly elopement/missing resident drills for 3 months, with at least one on night shift beginning 3/24/2022. Re-education will be conducted at the time of the drill if corrective action is needed. This was verified by the surveyors through staff interview and review of in-service sign in sheets, and interviews with the Acting Administrator, Healthcare Consultant, and Director of Maintenance. 24. The DON and the MDS Coordinator will review the Care Plan of all new residents who score high on their Elopement Assessment and/or are identified to be a potential for elopement for appropriate interventions on the Care Plan beginning 3/24/2022. This review of the Care Plan will continue for 6 weeks until 100 % compliance with the facility policy. This was verified by the surveyors through record review and interview with the DON and the MDS Coordinator. 25. The Administrator and Healthcare Consultant developed a competency checklist for nursing staff on caring for resident with wander guards on 3/24/2022. This Competency will be done following the in-service conducted with all nursing staff (RNs, LPNs, CNAs) with a completion date of 3/24/2022. This was verified by the surveyors through review of check list, interviews with staff on all shifts, Acting Administrator and Healthcare Consultant. 26. The Nursing Home Administrator hired a Healthcare Consultant to also evaluate policies and procedures, investigations of accidents/incidents for any improvements, and to work with the Administrator and DON to ensure compliance with regulations on 3/24/2022. This was verified by the surveyors through interview with the acting Administrator and Nurse Consultant. 27. The Interdisciplinary Team (IDT) will review all incidents from the past 24 hours daily Monday through Friday at the Morning Stand Up meeting; Weekend incidents will be reviewed on Mondays and incidents on Holidays will be reviewed on the next business day, effective 3/29/2022. The team will ensure immediate interventions were placed at the time of the incident and the intervention is appropriate and adequate. The IDT will ensure the Plan of Care is updated to reflect any new interventions and/or recommendations. This will be done indefinitely. All Incidents will be reviewed in QAPI monthly for trending and tracking. This was verified by the surveyors through interview with the Acting Administrator and Healthcare Consultant. The facility's noncompliance at F-835 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, Administration job description review, Director of Nursing (DON) job description review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to neglect, residents with wandering behaviors, investigation of incidents of elopement, and falls, and failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to incidents of elopement, neglect, resident behaviors, falls, and investigation and reporting of incidents. The QAPI committee failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI committee to ensure residents were free from neglect, incidents of elopement, and falls with major injuries resulted in Immediate Jeopardy (IJ) when Resident #11 was left unsupervised beside an exit door, after she exhibited exit-seeking behaviors, exited the facility when the door malfunctioned, and was found 5-6 minutes later on the back patio of the facility, sitting at a picnic table alone. The facility's failure to thoroughly and timely investigate and follow care planned interventions for falls, resulted in Actual Harm when Resident #10 sustained a fall which resulted in a fracture (broken bone) of the right 5th metacarpal bone (5th long bone of the right hand) and Resident #11 sustained a fall which resulted in a fracture of the left radius and ulna bones (bones of the forearm). 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 Acting Administrator was notified of the Immediate Jeopardy for F-867 on 3/27/2022 at 5:39 PM, in the Board Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, F-689, F-835, and F-867. The facility was cited at F-600, F-609, F-610, and F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed from 5/21/2022 through 5/28/2022. The facility was previously cited F-600, F-610, F-835, and F-867, at a scope and severity of J on a complaint survey on 5/30/2020. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 3/28/2022 at 4:47 PM. The corrective actions were validated onsite by the surveyors on 3/28/2022 through policy review, medical record review, review of education records, auditing tools, observations, and staff interviews conducted on all shifts. The findings include: Review of the facility's policy titled Quality Assurance Performance Improvement Program, dated 5/2018, revealed .The [Named Facility] Center's Quality and Assurance Performance Improvement Program is demonstrated through a proactive, comprehensive, ongoing approach to improving the quality and safety of the services it delivers .employs a systems approach to evaluating all the systems and processes, identifying problems that have occurred or that potentially might result from the Facility's practices and getting to root causes of problems rather than just superficially addressing one problem at a time .collaborative and interdisciplinary approach .measures, analyzes, and tracks .adverse Resident events, infection control and other aspects of performance that included care and services furnished in the facility .The purpose .is to facilitate a review of the organization's systems and functions as they impact the organization's customers .We will continuously strive to provide health care, service, and education, which consistently meet or exceeds the expectations of Residents .[QAPI] program will show measurable improvement in resident health outcomes and improvement in resident safety .and by the identification and reduction of medical error .Methodology .The Facility will use the data collected to do the following .Monitor the effectiveness and safety of services and quality of care .Identify opportunities that can lead to improvements and changes in Resident care .Medical records will be reviewed to identify any areas demonstrating a pattern of neglect of concern .Resident Falls .The organization will collect data and investigate all falls monthly .The organization develops and maintains a comprehensive Risk Management Program that protects the life and welfare of Residents .The Director of Nursing is the Facility's Risk Manager, reporting to the Administrator .Activities are reported to the QAPI committee and to the Board .Elements of the Risk Management Program include review of the following .Resident safety .Unexpected or adverse occurrences .Active surveillance for detection and prevention of disease, infection, and potential communicable infective sources . Review of the facility's Administrator job description, dated 7/10/2017, revealed .Provides leadership for the Nursing Home .supervises nursing home staff and resources. Oversees all activities of a nursing home in accordance with established policies and federal and state guidelines .is accountable for all operations and programs .KNOWLEDGE .Quality/Safety Standards .Healthcare Laws and Regulatory Agency Standards .Ensures department employees are accountable and adheres to all .policies and procedures, government laws, and regulatory agency standards .Provides leadership .Able to handle emergency or crisis situations . Review of the facility's Director of Nursing job description, dated 7/10/2017, revealed .The Director of Nursing assumes authority, responsibility, and accountability for the delivery of nursing services in the facility. In collaboration with facility Administration, allocates department resources in an efficient and economic manner to enable each resident to attain or maintain the highest practical physical, mental, and psychosocial well-being .KNOWLEDGE .Healthcare Laws and Regulatory Agency Standards .Knowledge of long-term care management, policies .Develops, maintains, and implements nursing policies and procedures that conform to current standards of nursing practice .knowledge of and application of Key Quality Indicators .overall supervision of resident assessments and care plans .Reviews 24-hour report from every unit to daily monitor and ensure timely, effective responses .unexplained injuries, falls, behavioral episodes . Review of the medical record, revealed Resident #11 sustained a fall on 10/7/2021. An investigation was not conducted, staff statements were not obtained, and no interventions to prevent further falls were implemented at that time. Review of the facility's investigation dated 3/10/2022, revealed Resident #11 was found lying in the floor of her room. She was confused which was her normal baseline, had a small skin tear on her left elbow, her wrist was displaced and painful, and she had a hematoma on the left back side of her head. She was taken to the emergency room (ER) and radiology revealed that her left radial and ulnar bones were broken. The facility's failure to investigate Resident #11's fall on 3/10/2022 and implement appropriate fall interventions from a previous fall, resulted in Actual Harm when Resident #11 sustained a fall which resulted in a fracture of the left radius and ulna bones. Review of the facility's investigation dated 3/23/2022, revealed that on the evening of 3/21/2022, Resident #11, a cognitively impaired, vulnerable resident, exhibited exit-seeking behaviors and attempted to leave the facility. Resident #11 was taken outside to walk around the facility by a staff member, brought back into the facility a few minutes later, and left in a chair beside the North Hall Exit Door. When Nursing staff on the hall entered a resident's room to administer medications, Resident #11 exited the facility unsupervised, through the malfunctioning North Hall Exit Door and was found outside the facility, sitting at a picnic table on the back patio, approximately 5-6 minutes later. The following timeline was documented: a. 3/23/2022 at 3:20 PM Notified the Medical Director of the elopement. b. 3/23/2022 at 3:25 PM Notified Resident #11's Physician of the elopement. c. 3/23/2022 at 3:45 PM An ad Hoc (as needed) QAPI meeting took place. d. 3/23/2022 at 4:00 PM Notified Resident #11's daughter to talk to the family about psychiatric services. e. 3/23/2022 at 4:00 PM One on One observation was implemented with hourly behavior and location log. f. 3/23/2022 All exit doors were checked by maintenance. The door near room [ROOM NUMBER], across the hall from Resident #11's room, had an alarm that did not work. A staff member was told be posted there, monitoring the door as well as Resident #11. g. 3/23/2022 Maintenance were to begin daily exit door checks on 3/24/2022 and log the results. Following Resident #11's incident of elopement, the facility did not convene a QAPI meeting until 3/23/2022, 2 days after the resident eloped from the facility. The State Survey Team entered the facility on 3/21/2022 to begin their annual survey, but they were not notified of the incident of elopement after it occurred. The elopement was discovered by the State Survey Team on 3/23/2022, through medical record review and staff interviews. Review of the medical record, revealed Resident #10 sustained 8 falls in the past 120 days. The intervention of gait belt with all transfers was implemented on 2/4/2022. Review of the facility's investigation dated 3/7/2022, revealed Resident #10 fell on 3/6/2022, and the fall was not documented or reported by staff at that time. On 3/7/2022, the resident had edema, bruising, tenderness, warmth to touch, and complained of pain to her right hand. The facility's investigation revealed, .resident stated that she had fallen yesterday .called the charge nurse [Licensed Practical Nurse (LPN) #3 who worked on 3/6/2022] . LPN #3 confirmed Resident #10 fell on 3/6/2022 and Certified Nursing Assistant (CNA) #1 was present. Gait belt re-education was provided for LPN #3 and CNA #1. During an interview on 3/25/2022 at 3:45 PM, the DON confirmed CNA #1 did not use the gait belt for Resident #10's transfer and was re-educated on the use of a gait belt with all transfers for Resident #10. The facility's failure to follow Care Plan fall interventions resulted in Actual Harm when Resident #10 sustained a fall which resulted in a fractured right fifth metacarpal. During a telephone interview on 3/23/2022 at 4:50 PM, the Administrator was asked if she had any reportable incidents or any incidents that the State Survey Team needed to investigate while in the facility. The Administrator stated, No . During an interview on 3/23/2022 at 6:39 PM, the Administrator confirmed an Ad Hoc QAPI meeting to discuss the incident of elopement was not conducted until 3/23/2022, 2 days after Resident #11 eloped from the facility. The Administrator was asked what interventions the facility put in place immediately after the incident of elopement. The Administrator stated, .there were no specific interventions until today. The Administrator stated, .My Medical Director is on vacation, and I did speak with her and told her the results of QAPI [today about 3:30] .we're doing an hourly behavior log while somebody is with her to see if new trends or patterns exist [begun 3/23/2022] .we are getting a new door system .that's been ongoing . The Administrator confirmed that prior to the incident of elopement that occurred on 3/21/2022, the facility doors were only checked monthly, and she was unaware that the double doors on the Skilled 1 Hall opened freely to an outside courtyard which contained 3 sets of steep steps, the door locking mechanism had been removed and there were hanging wires when the door was opened. The Administrator confirmed the investigation into the incident of elopement was not begun until 3/23/2022 and that she did not notify the state or any other regulatory entity about the elopement. During an interview on 3/27/2022 at 11:25 AM, the DON confirmed she attended QAPI meetings and stated, We had a QAPI meeting Wednesday [3/23/2022] and we discussed [Named Resident #11] but I don't remember discussing wandering residents prior to that. The DON was asked if she was familiar with the resident elopement and Immediate Jeopardy (IJ) that occurred at the facility in 5/2020. The DON stated, I know about it, but I wasn't here at the time. The DON confirmed that she was not familiar with the Plan of Correction (POC) that was implemented after that incident of elopement. The Acting Administrator and DON confirmed that the POC implemented 6/3/2020, following the previous elopement IJ in 5/2020, should still be followed. During an interview on 3/28/2022 at 10:14 AM, the Chief Executive Officer (CEO) confirmed that he was not made aware of Resident #11's elopement on 3/21/2022 until 3/23/2022 at approximately 3:00 PM. The CEO confirmed he should have been notified of the incident on 3/21/2022. The CEO confirmed that he had not yet reported the Immediate Jeopardy to the Hospital Board. During a telephone interview on 3/28/2022 at 12:32 PM, the Chairman of the Board confirmed he was notified of the elopement on Wednesday, 3/23/2022. The Chairman of the Board stated, .[incidents the Board should be notified of] certainly anything that does or could lead to harm of one of the residents . The Chairman of the Board confirmed the Board should have been notified of Resident #11's elopement prior to 3/23/2022. The Chairman of the Board stated, We receive as part of the monthly quality report, sections on the various indicators for the hospital and a separate one for the nursing home .also receive the minutes of the QAPI meeting . The Chairman of the Board was asked if anyone from the Board attended the facility's QAPI meeting. The Chairman of the Board stated, I'm not aware of a separate long term care meeting [QAPI] . During an interview on 3/28/2022 at 5:55 PM, the Healthcare Consultant stated, .She [the Administrator] pretty much knew she should have reported .just the decision part that was not right . Refer to F-600, F-609, F-610, F-689, and F-835. The surveyors verified the Removal Plan by: 1. The DON will begin daily Interdisciplinary Team (IDT) Clinical meetings during the Daily Stand-up Meeting to include the DON, Minimum Data Set (MDS) Coordinator, Dietician, Therapy, and Social Services to review Falls, Incidents, Weight loss, Pressure Wounds, and all at Risk issues that will aid in communicating issues to the Care Plan on 3/28/2-22. On 3/29/2022 and Agenda will be used for meetings. The surveyors reviewed the daily IDT Clinical Meeting/Stand-up Meeting Agenda and interviewed the DON. 2. The Administrator will ensure Clinical Information will be added to the Daily Stand-up Meeting Monday through Friday with Department Heads to review Resident issues and facility issues beginning 3/28/2022. The surveyors reviewed the Daily Stand-up Meeting notes and interviewed the Acting Administrator. 3. The DON and Assistant Director of Nursing (ADON) conducted an in-service on 3/24/2022 with the Nursing Staff (Registered Nurses (RN), LPNs, Certified Nursing Assistants (CNAs)) on the Revised Abuse, Neglect and Misappropriation of Funds Policy, including identification of the reporting requirement and procedures for determining a reportable incident, the type of incident requiring a 2-hour reporting requirement versus the type of incident requiring a 24-hour reporting requirement and the procedures for preparing a report and making a report on the State Incident Reporting System, Wandering/Missing residents, and Caring for Residents with Wander guards (a monitoring device to alert staff when a resident attempts to exit a door in the facility).These in-services were either in-person, in a classroom setting, or 1:1 either in person or by telephone. Any staff missing the in-services will not work until they receive the education. Any staff who fail to comply with the points of the in-services will be further educated and/or progressive discipline will begin as indicated. Following the in-services, a Post Test will be conducted with all employees. The surveyors reviewed the in-services, in-service sign in log, and interviewed nursing staff on all shifts. 4. The MDS Coordinator and DON will monitor Weekly Behavior Notes daily to ensure all behaviors are addressed timely and any exit seeking behaviors are identified beginning 3/25/2022. This will continue for 3 months or until QAPI committee deems satisfactory compliance has been achieved. The surveyors interviewed the MDS Coordinator and the DON. 5. The Administrator and the Healthcare Consultant will audit all records of reported Abuse, Neglect, Exploitation, and/or Misappropriation of Property for completion of investigation and reporting to the state agency for accuracy and completion per policy beginning 3/25/2022. These will be monitored upon any allegation of abuse, neglect, exploitation, and/or misappropriation of property monthly for 3 months or until QAPI committee deems satisfactory compliance has been achieved. The surveyors interviewed the Healthcare Consultant and the Acting Administrator. 6. The Healthcare Consultant conducted a one-on-one training with the Administrator reviewing Abuse, Neglect, and Misappropriation of Funds policy including the reporting of Abuse, Neglect, and Misappropriation of Funds and the responsibility to conduct timely reporting and investigation of potential instances requiring reporting to the State Incident Reporting System (IRS) on 3/24/2022. The surveyors reviewed the training and interviewed the Healthcare Consultant and Acting Administrator. 7. An outside Healthcare Consultant will provide additional oversight with the development of the Removal Plan/POC beginning 3/24/2022. Monitoring will consist of implementation of the Removal Plan/POC at least weekly for 3 weeks then monthly for 6 months to ensure compliance. The outside Consultant will report findings to the Administrator, CEO, and the full QAPI committee and determine if the issues have been resolved or if the QAPI initiative should continue. The surveyors interviewed the Healthcare Consultant. 8. The outside Healthcare Consultant will report findings to the Governing Body, the full QAPI Committee, and the CEO to determine if the issues have been resolved or if the QAPI initiative should continue. The surveyors interviewed the outside Healthcare Consultant. 9. Effective 3/28/2022, the Administrator/Interdisciplinary Team will develop an evaluation process to be conducted yearly through the QAPI program and reported annually to the QAPI Committee and Governing Body that includes a mechanism to ensure the residents with wandering behaviors, exit doors are working correctly, incidents are investigated and reported if necessary, and residents have up to date Care Plans, and are assessed and monitored as defined in the Care Plan. The surveyors reviewed the evaluation process and interviewed the DON and the Acting Administrator. The facility's noncompliance at F-867 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.