**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews, the facility failed to implement a care plan for risk of elopement for 3 of 14 sampled residents (Resident #5, Resident #6, and Resident #7) reviewed for elopement. The facility also failed to implement a care plan for 2 of 16 sampled residents (Resident #9 and Resident #18) reviewed for safe smoking/tobacco use, and failed to implement interventions on care plans for 3 of 16 sampled residents (Resident #5, Resident #10, and Resident #12) reviewed for safe smoking. The facility's failure to implement the care plans and interventions for Resident #5, Resident #6, Resident #7, Resident #9, Resident #10, Resident #12 and Resident #18 placed them in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator and Director of Nursing Services(DNS) were notified of the Immediate Jeopardy on 11/3/2022 at 1:45 PM in the Administrator's office. The Facility was cited Immediate Jeopardy at F-656. The facility was cited at F-656 at a scope and severity of L. The Immediate Jeopardy was removed onsite and was effective from 8/23/2022 to 11/3/2022 at 11:00 PM. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 11/3/2022 at 11:00 PM. The corrective actions were validated onsite by the surveyors on 11/4/2022 at 1:15 AM. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Elopement, dated 4/2017, revealed, .To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements .Newly admitted or re-admitted residents are assessed for elopement risk .If an elopement risk is determined an individualized plan is established and intervention is initiated to mitigate that risk . Review of the facility's policy titled, Accidents and Supervision, dated 10/2022, revealed, .The resident environment will remain as free of accident hazards as is possible .Implementing interventions to reduce hazard(s) and risk(s) . Review of the facility's policy titled, Care Plans and Baseline Care Plans, revised 10/2022, revealed, .Care plans will be developed for all patients and residents based upon the RAI [Resident Assessment Instrument] manual and CMS [Center for Medicare and Medicaid Services] guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status . Review of the Quality Assurance and Performance Improvement (QAPI) Meeting minutes dated 8/23/2022, revealed, .Care plans reviewed to ensure elopement prevention/approaches are in place and UTD [up to date] .In compliance 8/23/2022 . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Dementia, Nicotine Dependence, and Other Symptoms and Signs involving Cognitive Functions and Awareness. Review of the undated Care Plan for Resident #5 revealed a focus for smoking, .At risk for smoking related injury . Interventions included, .Assist to and from Designated Smoking area .Assure smoking material is extinguished prior to patient leaving smoking area .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources .Place patient in position to assure visualization of ashtray . Review of the care plan detail for Resident #5 on 11/2/2022, revealed, .10/10/2022 .RESOLVED: At risk for elopement related to: Anger at placement in center . Review of the medical record for Resident #5 revealed there was no care plan focus for elopement after 10/10/2022, prior to surveyor request for documentation on 10/31/2022. Review of Resident #5's Elopement Risk Evaluation dated 8/23/2022 revealed question #7 answered as yes, the resident does wander aimlessly about the facility and/or exhibits night wandering. Continued review revealed resident was at risk for elopement. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis Following Cerebral Infarction, Muscle Weakness, and Tobacco Use. Review of the undated Care Plan for Resident #9 revealed she had no focus for smoking. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Tobacco Use. Review of the undated Care Plan for Resident #10 revealed a focus for .[Named resident] is at risk for smoking related injury . Interventions included, .Assist resident to and from designated smoking area .Assure smoking material is extinguished prior to leaving smoking area .Provide resident a smoking apron while smoking .Resident not to have smoking materials on person .Storage of smoking materials per facility policy . Review of the medical record revealed Resident #12 (who resides on the Secured Unit) was admitted to the facility on [DATE] with diagnoses which included Nontraumatic Intracranial Hemorrhage, Cognitive Communication Deficit, and Tobacco Use. Review of the undated Care Plan revealed Resident #12 had a focus related to, .at risk for smoking related injury . Interventions included, .supervise resident while smoking and Assure smoking material is extinguished prior to patient leaving smoking area .Complete smoking safety assessment per Center policy .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources .Patient not to have cigarettes or smoking material on person .Provide smoking apron while smoking . Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Dependence on Oxygen, and Anxiety. Review of the undated Care Plan for Resident #18 revealed no focus for tobacco use. Observation and interview on 11/2/2022 at 12:10 PM, revealed Resident #9 and Resident #10 outside from the Sun Room, smoking with no supervision, no smoking aprons, or staff present on the patio. Continued observation of the patio revealed no smoking aprons available for residents as per individualized care plan. Observation on the Secured Unit on 11/2/2022 at 12:40 PM, revealed 9 residents sitting in the Secured Day Room area which opens to the outside patio. Continued observation revealed two residents (Resident #5 and Resident #12) outside smoking on the patio with Resident #12 sitting with her back to the glass panel which prevented visualization while she was smoking, and Resident #5 sitting at the patio table. Neither residents were wearing a smoking apron and no staff members were outside supervising the two residents as per individualized care plan. Observation and interview on 11/2/2022 at 2:52 PM revealed Resident #9 and Resident #10 outside smoking on the patio that exits from the Sun Room. Both residents were unsupervised and not wearing a smoking apron. Resident #9 had her cigarette pouch with the lighter in the side of the pouch. Resident #10 was sitting in his electric wheel chair and brought out his cigarette from his bag hanging on the side of the wheel chair and pulled out his lighter to light his cigarette and began smoking. Resident #9 and Resident #10 confirmed they are free to smoke at any time. Resident #18 was sitting outside and revealed he had a tobacco pouch in his mouth and showed the surveyor his tobacco can that was in his pocket. Resident #18 confirmed he keeps his tobacco in his pocket and doesn't leave it at the nurses station. Observation and interview on 11/2/2022 at 4:30 PM, revealed Resident #9 outside smoking. Resident #9 was asked if she ever wears a smoking apron and she stated, The aprons are just worn out and we don't have enough. Today when staff brought another resident out they pulled off the apron I had on and gave it to him. During an observation and interview on 11/3/2022 at 8:50 AM, LPN (Licensed Practical Nurse) #6 confirmed the Secured Unit has one smoking apron that has a tear in it. LPN #6 stated, We do the best we can. Observation and interview on 11/3/2022 at 8:57 AM, the Administrator stated, The smoking aprons should be hanging on the wall as you go out to the patio where residents smoke or in the cabinets in the Sun Room. Continued observation and interview in the Sun Room as you walk out to the patio, the Administrator confirmed no smoking aprons were hanging on the wall or in the cabinets. The Administrator stated, I ordered 6 yesterday. I promise the aprons are usually hanging here on the wall. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbance, Other Symptoms and Signs involving Cognitive Functions and Awareness, and Disorientation. Review of the undated care plan history for Resident #6 revealed assessment/focus for short attention span evidenced by wandering in and out of activities initiated on 3/3/2022 and revised for elopement risk on 11/1/2022 after surveyor request for documentation on 10/31/2022. Review of Resident #6's Clinical Health Status Evaluation dated 10/7/2022 (readmission date) revealed she was at risk for elopement. Continued review revealed question #5 related to history of elopement was answered yes, which prompted to implement care plan and care plan was not updated to reflect risk for elopement. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease and Wandering. Review of the undated care plan history for Resident #7 revealed a focus for fall risk related to medication, impaired cognition and wanders initiated 9/28/2022. Continued review revealed a focus for risk of elopement related to wandering initiated 11/1/2022, after surveyor request for documentation on 10/31/2022. Review of Resident #7's Elopement Risk Evaluation dated 8/23/2022 revealed she was at risk for elopement. Continued review revealed question #5 related to history of elopement was answered yes, which prompted to implement care plan and care plan was not updated to reflect risk for elopement. Observation and interview on 11/1/2022 at 5:03 PM and 5:52 PM, revealed the DNS (Director of Nursing Services) confirmed the QAPI plan of action included review of the care plans for those at risk for elopement to ensure facility compliance. She confirmed any time there was a positive risk assessment she expected the care plan to be updated to reflect the outcome of the assessment. Observation and interview with the MDS (Minimum Data Set) Coordinators and the ADON (Assistant Director of Nursing) on 11/2/2022 at 4:55 PM, revealed MDS Coordinator #1 reviewed Resident #5's care plan and confirmed there was no care plan for elopement prior to 11/1/2022. She confirmed there had been a care plan for elopement due to anger at placement that had been resolved on 10/10/2022. MDS Coordinator #1 confirmed Resident #6 and Resident #7 did not have a care plan for elopement prior to 11/1/2022. During a telephone interview on 11/2/2022 at 9:16 AM, RN (Registered Nurse) #1 confirmed interventions for resident's at risk for elopement would be reflected in their care plan. During an interview on 11/2/2022 at 4:45 PM, the ADON confirmed she had changed Resident #5's care plan on 11/1/2022 from risk due to anger on placement to wandering because she did not display anger at placement anymore. She stated she did not know why the care plan indicated the change was a revision rather than initiation. She confirmed she had added elopement due to dementia to Resident #6 and Resident #7 because anyone on the Secured Unit should have a care plan for elopement. She stated the MDS Coordinator updated the care plans when a risk was identified. Review of the resident's care plans revealed they were not updated until the surveyor requested a copy of the care plan. The surveyors verified acceptable Immediate Action Removal Plan on 11/3/2022 at 11:15 PM by: 1. On 11/3/2022 the ADON and Director of Clinical Operations (DCO) reviewed the Care Plans for Residents #6, and #7 to assure accuracy. 2. On 11/3/2022 ADON and DCO reviewed all care plans to ensure all were updated and current for elopement risk and proper interventions were put into place. 3. All new admissions, readmissions and any resident who has had a change in condition will be audited to ensure the Interdisciplinary Team (IDT) or a member of the team reviews the elopement risk assessment for accuracy, care plan development if an elopement risk is identified and that proper interventions have been put in place for safety. During clinical start-up meeting, the IDT will review progress notes and clinical alerts to monitor for any condition changes that would require a new elopement risk assessment. The Administrator, Director of Clinical Operations, Regional [NAME] President or another member of the Support Center will review weekly to ensure compliance. 4. Any issues noted will be corrected immediately and reported to the Administrator and the QAPI committee. QAPI meetings will be held weekly and as needed until the jeopardy is cleared. 5. All smoking assessments were updated for all residents who smoke by DNS and ADON on 11/3/2022. Also care plans and [NAME] were updated by the members of the nursing management team on 11/3/2022. 6. Monitoring: all new admit, readmits or change in status will have IDT review of their smoking risk assessment to determine accuracy, supervision status and additional safety intervention. A member from the IDT will confirm the care plan/[NAME]/education for any tobacco users.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, Facility Reported Incident (FRI) review, medical record review, observation, and interview, the facility failed to ensure 1 of 14 sampled residents (Resident #4) received adequate supervision to prevent an avoidable accident. The facility failed to ensure safe smoking for 6 of 17 sampled residents (Resident #5, Resident #8, Resident #9, Resident #10, Resident #12, and Resident #18) reviewed for tobacco product use. The facility failed to ensure igniting materials (lighters/matches) were secured in a safe manner for 3 of 17 sampled residents (Resident #8, Resident #9, and Resident #10) reviewed for smoking. The facility's failure to provide adequate supervision resulted in Resident #4's elopement, and failure to supervise residents who smoke, and failure to store igniting materials in a safe manner, placed the residents in 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). The Administrator and Director of Nursing Services (DNS) were notified of the Immediate Jeopardy on 11/3/2022 at 11:55 AM in the Administrator's office. The Facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of L, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 8/22/2022 to 11/4/2022 at 1:15 AM. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 11/4/2022 at 12:55 AM. The corrective actions were validated onsite by the surveyors on 11/4/2022 at 1:15 AM. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Safe Smoking, dated 11/1/2016, revealed .To maximize our ability to provide a safe environment for all residents/patients who smoke, while taking into account non-smoking residents .to assess the ability to smoke safely and determine any measures needed to protect residents from possible self-inflicted injury due to smoking .any resident who identifies themselves as desiring to smoke or use an electronic nicotine delivery system [ENDS] will be assessed for safety related to smoking. This assessment will be reviewed and updated with any change of condition .staff members will monitor or obtain fire igniting materials [matches/lighters] for the benefit of smokers at the nurses' station or other designated location. Other electronic nicotine delivery systems [vaporizers, e-cigatettes] will be treated the same way as fire igniting materials and maintained at the nurses' station or other designated location . Review of the facility's policy titled, Safe Tobacco Use, revised on 11/3/2022, revealed .Tobacco materials (cigarettes/cigars/chewing tobacco/snuff) themselves, in addition to fire igniting materials, may be controlled if smoking policy violations have occurred or as a general policy for all residents . Review of the facility's policy titled, Accidents and Supervision, dated 10/2022, revealed, .The resident environment will remain as free of accident hazards as is possible .Each resident will receive adequate supervision and assistive devices to prevent accidents .Implementing interventions to reduce hazard(s) and risk(s) .Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accident . Review of the medical record revealed Resident #5 (who resides on the Secured Unit) was admitted to the facility on [DATE] with diagnoses which included Dementia, Nicotine Dependence, and Other Symptoms and Signs involving Cognitive Functions and Awareness. Review of the Quarterly MDS assessment for Resident #5 dated 8/27/2022 revealed a BIMS score 7, which indicated severe cognitive impairment. Continued review revealed Resident #5 required supervision with transfers, walk in room, walk in corridor, and locomotion on unit. Review of the undated Care Plan for Resident #5 revealed a focus for, .At risk for smoking related injury . Interventions included, .Assist to and from Designated Smoking area .Assure smoking material is extinguished prior to patient leaving smoking area .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources .Place patient in position to assure visualization of ashtray . Review of Resident #5's (who was severly cognitively impaired) Smoking assessment dated [DATE], revealed Resident #5 exhibited signs of confusion but was able to understand living center's times and place to smoke. Review of the medical record for Resident #8 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Acute Respiratory Failure with Hypoxia, Cognitive Communication Deficit, and Tobacco Use. Review of the Quarterly MDS assessment for Resident #8 dated 9/17/2022 revealed a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed he required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Continued review revealed he was total dependence for bathing. Review of the undated Care Plan for Resident #8 revealed a focus for, .[Named resident] is a smoker . Interventions included, .Instruct resident about smoking risks and hazards and about smoking cessation aids that are available .Instruct resident about the facility policy on smoking: locations, times, safety concerns .Notify charge nurse immediately if it is suspected resident has violated facility smoking policy .Observe clothing and skin for signs of cigarette burns .The resident requires a smoking apron while smoking . Review of Resident #8's Smoking assessment dated [DATE], revealed Resident #8 currently smokes. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis Following Cerebral Infarction, Muscle Weakness, and Tobacco Use. Review of the Quarterly MDS assessment for Resident #9 dated 9/20/2022 revealed a BIMS score of 12, which indicated moderate cognitive impairment. Continued review revealed she required extensive assistance for bed mobility, transfer, dressing, and personal hygiene. Review of the Care Plan for Resident #9 revealed she had no focus for smoking. Review of Resident #9's clinical assessments revealed no smoking assessment. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Tobacco Use. Review of the Annual MDS assessment for Resident #10 revealed a BIMS score of 14, which indicated no cognitive impairment. Continued review revealed he required extensive assistance with bed mobility, dressing, and personal hygiene. Review of the undated Care Plan for Resident #10 revealed a focus for .[Named resident] is at risk for smoking related injury . Interventions included, .Assist resident to and from designated smoking area .Assure smoking material is extinguished prior to leaving smoking area .Provide resident a smoking apron while smoking .Resident not to have smoking materials on person .Storage of smoking materials per facility policy . Review of Resident #10's Clinical Health Status Evaluation dated 7/27/2022, revealed a smoking evaluation completed. The Smoking Assessment for Resident #10 was not completed quarterly, according to the facility's assessment schedule. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Dysphagia, and Gastroparesis. Review of the Quarterly MDS assessment for Resident #11, dated 10/13/2022, revealed a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Continued review revealed she was dependent with transfers and bathing. Review of the undated Care Plan revealed Resident #11 had a focus for .at risk for smoking related injury related to: Limited mobility . Interventions included, .Assure smoking material is extinguished prior to patient leaving smoking area .Complete smoking safety assessment per Center policy .Patient not to have cigarettes or smoking material on person .Place patient in position to assure visualization of ashtray .Provide smoking apron while smoking .Review smoking policy with patient and or family . Review of Resident #11's Smoking assessment dated [DATE], revealed she exhibited signs of confusion and no answer for understanding of the living center's smoking policy. The Smoking Assessment for Resident #11 was not completed quarterly according to the facility's assessment schedule. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included Nontraumatic Intracranial Hemorrhage, Cognitive Communication Deficit, and Tobacco Use. Review of the admission MDS assessment for Resident #12 dated 8/11/2022 revealed a BIMS score of 5, which indicated severe cognitive impairment. Continued review revealed she required supervision with bed mobility, transfers, walking, dressing, and eating. Continued review revealed she required extensive assistance with toilet use and bathing. Review of the undated Care Plan revealed Resident #12 had a focus for .at risk for smoking related injury . Interventions included, .supervise resident while smoking and Assure smoking material is extinguished prior to patient leaving smoking area .Complete smoking safety assessment per Center policy .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources .Patient not to have cigarettes or smoking material on person .Provide smoking apron while smoking .Review smoking policy with patient and or family . Review of Resident #12's Clinical Health Status Evaluation completed on 8/4/2022, revealed no smoking assessment. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Hemiplegia and Hemiparesis, Iron Deficiency Anemia, and Hypokalemia. Review of the Quarterly MDS assessment for Resident #13 dated 9/22/2022 revealed a BIMS assessment was not done because resident is rarely or never understood and has long and short term memory problems. Continued review revealed she required extensive assistance of 2 or more people for bed mobility, transfer, dressing, toilet use, personal hygiene, and total dependence for bathing. Review of the undated Care Plan revealed Resident #13 had a focus for .at risk for smoking related injuries . Interventions included, .Complete smoking safety assessment .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Provide smoking apron while smoking .Provide smoking assistive device .Storage of smoking materials per Center policy . Review of Resident #13's Smoking assessment dated [DATE], revealed she currently smokes, has quit smoking recently, and resident does not wish to quit smoking. The Smoking Assessment for Resident #13 was not completed quarterly according to the facility's assessment schedule. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses which included Cognitive Communication Deficit, Tobacco Use, and Muscle Weakness. Review of the Quarterly MDS assessment for Resident #14 dated 11/3/2022 revealed a BIMS score of 12, which indicated moderate cognitive impairment. Review of the undated Care Plan for Resident #14, revealed, .has the potential for injury r/t [related to] being a smoker. He has a hx [history] of noncompliance with smoking policy. Gets cigarettes from other residents . Interventions included, .keep all smoking materials at nursing station .observe for burn holes on his skin, on his clothing or bed linen and report concerns .observe for safety when he is smoking .redirect when he is inappropriate in smoking habits .Resident to smoke in designated areas only .to wear smoking apron while smoking for safety . Review of Resident #14's Smoking assessment dated [DATE], revealed he currently smokes. The Smoking Assessment for Resident #14 was not completed quarterly according to the facility's assessment schedule. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Peripheral Vascular Disease, Dysphagia, and Tobacco Use. Review of the Quarterly MDS assessment for Resident #15 dated 9/28/2022 revealed a BIMS score of 11, which indicated moderate cognitive impairment. Review of the undated Care Plan for Resident #15 revealed a focus for, .At risk for smoking related injury related to: Cigarette holes burn in clothing . Interventions included, .Complete smoking assessment per Center policy .Patient not to have cigarettes or smoking material on person .Review smoking policy with patient and or family .Storage of smoking materials per Center policy . Review of Resident #15's Smoking assessment dated [DATE], revealed he currently smokes. The Smoking Assessment for Resident #15 was not completed quarterly according to the facility's assessment schedule. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included Unspecified Convulsions, Tobacco Use, and Personal History of Traumatic Brain Injury. Review of the Quarterly MDS assessment for Resident #16 dated 10/20/2022, revealed a BIMS score of 12, which indicated moderate cognitive impairment. Continued review revealed he required extensive assistance for bed mobility, transfers, toilet use, and personal hygiene. Continued review revealed total dependent with bathing. Review of the undated Care Plan for Resident #16 revealed a focus for, .[Named resident] is at risk for smoking related injuries . Interventions included, .Assist to and from Designated Smoking area .Assure smoking material is extinguished prior to patient leaving smoking area .Complete smoking safety assessment per Center policy .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Place patient in position to assure visualization of ashtray .Provide smoking apron while smoking .Storage of smoking materials per Center policy . Review of Resident #16's Smoking assessment dated [DATE], revealed he exhibits signs of confusion but able to understand the living center's smoking policy. Continued review of the Smoking Assessment revealed, The resident untilizes a burn free bib and is with a staff member when he is outside smoking. The Smoking Assessment for Resident #16 was not completed quarterly according to the facility's assessment schedule. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Infarction, Chronic Pain Syndrome, and Aphasia. Review of the Quarterly MDS assessment for Resident #17 dated 8/23/2022 revealed a BIMS score of 10, which indicated moderate cognitive impairment. Continued review revealed he required limited assistance with bed mobility, transfers, dressing and personal hygiene. Review of the undated Care Plan for Resident #17 revealed a focus for, .is at risk for smoking related injury . Interventions included, .Assure smoking material is extinguished prior to patient leaving smoking area .Complete smoking safety assessment per Center policy .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Provide smoking apron while smoking .Review smoking policy with patient and or family .Storage of smoking materials per Center policy . Review of Resident #17's Smoking assessment dated [DATE], revealed resident currently smokes. The Smoking Assessment for Resident #17 was not completed quarterly according to the facility's assessment schedule. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Dependence on Oxygen, and Anxiety. Review of the Quarterly MDS assessment for Resident #18 dated 8/6/2022 revealed a BIMS score of 14, which indicated no cognitive impairment. Continued review revealed he required limited assistance with bed mobility, supervision for transfer, limited assistance with dressing and supervision for toileting and hygiene. Review of the undated Care Plan for Resident #18 revealed no focus for tobacco use. Review of Resident #18's Smoking assessment dated [DATE] revealed Resident #18 does not smoke. The assessment does not mention the fact that he uses smokeless tobacco. Review of Resident #18's Clinical Health Status Evaluation dated 11/17/2021, revealed a diminished awareness of safety and confusion with memory problem. Observation and interview on 11/2/2022 at 12:10 PM, revealed Resident #8 (Resident Council President), Resident #9, and Resident #10 outside of the Sun Room, smoking with no supervision, no smoking aprons, or staff present on the patio. Continued observation revealed Resident #8 had his cigarettes and a lighter, Resident #9 had a cigarette pouch with a lighter in the side of the pouch, and Resident #10 had a pack of cigarettes in his electric wheel chair with a lighter in his hand. Resident #8, Resident #9 and Resident #10 stated they can come out and smoke whenever they want to smoke. Continued observation of the patio revealed no smoking aprons available for resident. Observation and interviews on the Secured Unit on 11/2/2022 at 12:40 PM, revealed CNA #3 sitting at a table in the Day Room with 9 cognitively impaired residents sitting around her. The Day Room opens to the outside patio. Continued observation revealed 2 residents (Resident #5 and Resident #12) outside smoking on the patio with Resident #12 sitting with her back to the glass panel, which prevented visualization of the resident smoking, and Resident # 5 sitting at the patio table. Neither residents were wearing a smoking apron and no staff members were outside supervising the 2 residents. Continued observation of the secured unit revealed 2 other residents pacing the hall. CNA #3 confirmed Resident #5 and Resident #12 were outside smoking. CNA #3 stated, We watch them from the inside [referring to watching the residents from the inside Secured Day Room through the glass panel to patio]. Observation and interview on 11/2/2022 at 2:52 PM revealed Resident #8, Resident #9 and Resident #10 outside smoking on the patio that exits from the Sun Room. All 3 residents were unsupervised and not wearing a smoking apron. Resident #9 had her cigarette pouch with the lighter in the side of pouch and she was smoking. Resident #10 was sitting in his electric wheel chair brought out his cigarette from his bag hanging on the side of the wheel chair and pulled out his lighter to light his cigarette and began smoking. Resident #18 was sitting outside and revealed he had a tobacco pouch in his mouth and showed this surveyor his tobacco can that was in his pocket. Resident #18 confirmed he keeps his tobacco in his pocket and doesn't leave it at nurses station. Observation and interview on 11/2/2022 at 4:30 PM revealed Resident #8 and Resident #9 outside smoking. Resident #9 was asked if she ever wears a smoking apron and she stated, The aprons are just worn out and we don't have enough. Today when staff brought another resident out to smoke they pulled off my apron and gave it to them. Observation and interview in Resident #10's room on 11/2/2022 at 5:45 PM, it was noted an electronic nicotine delivering system (vaporizer) was lying on the overbed table. The Administrator confirmed the electronic nicotine delivering system was on the overbed table. Resident #10 confirmed his cigarettes and lighter were in the bag hanging on his electronic wheel chair. Continued interview with the Administrator outside of Resident #10's room, she stated, We try to keep stuff out of the room. During an interview on 11/3/2022 at 8:20 AM, the DNS printed the smoking assessments completed over the last year and confirmed the smoking assessments were not completed quarterly, and some questions on the assessments are not completed for the following residents: Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, and Resident #17. During an observation and interview on 11/3/2022 at 8:50 AM, LPN #6 confirmed the Secured Unit has one smoking apron that has a tear in it. LPN #6 stated, We do the best we can. Observation and interview on 11/3/2022 at 8:57 AM, the Administrator stated, The smoking aprons should be hanging on the wall as you go out to the patio where residents smoke or in the cabinets in the Sun Room. The Administrator confirmed no smoking aprons were hanging on the wall or in the cabinets in the Sun Room. The Administrator stated, I ordered 6 yesterday, I promise the aprons are usually hanging here on the wall. During an observation and interview in the smoking area of patio that exits from the Sun Room on 11/3/2022 at 9:15 AM, the Maintenance Director confirmed candy wrappers and paper were in the cigarette receptacle where the residents drop their cigarette butts. Continued observation and interview on the Secured Unit outside smoking area on 11/3/2022 at 9:20 AM, the Maintenance Director confirmed cigarette butts were in a terra [NAME] pot and no other cigarette butt receptacle was present. The Maintenance Director confirmed the fire extenquisher hanging outside on the patio has not been checked since 2020. The Maintenance Director stated, I will be honest with you. I didn't even know that the fire extenquisher was out here. During an interview on 11/3/2022 at 8:55 AM, the Administrator stated, The smoking assessments should say whether the resident wears a smoking apron or not. During an interview on 11/3/2022 at 9:32 AM, the Administrator confirmed the employees should know what type of receptacle they should be using to put cigarette butts in when the residents smoke. During an interview on 11/3/2022 at 12:00 PM, Resident #8 stated, I understand the smoking is a safety issue. It should have been dealt with before. During an interview on 11/3/2022 at 4:50 PM, CDO (Clinical Director of Operations) confirmed a resident with confusion would not be a safe smoker. The CDO stated, We need to fix that smoking assessment to require supervision if the resident exhibits confusion. She stated, I will contact the Senior [NAME] President of Clinical Operations to request the Smoking Assessment to reflect a confused resident should automatically be supervised. The CDO confirmed the facility did not have a policy to address smokeless tobacco use. The surveyors verified acceptable Immediate Action Removal Plan on 11/4/2022 at 1:15 AM by: 1. On 11/2/2022, the Assessment Nurses and the Nurse Manager spoke to each known tobacco user regarding the smoking policy and ensured residents did not have smoking materials on their person or in their room. During the process, the team found 5 of 16 residents had cigarettes, lighters, and vaping materials on their person. 2. The Administrator met with the Administration Team on 11/2/2022 and educated them on the smoking policy and in-serviced them that supervised smokers can only smoke with a staff member present in the smoking area. Tobacco users were re-educated regarding the Smoking policy by the Social Services Director and the Activities Director. 3. The facility placed all smoking materials in a ziplock bag and labeled them with the resident's name and safe smoking information and secured them at nurse's station. 4. A list of residents who smoke was placed on the wall in the laundry room, which is directly off the smoking area. 5. Designated supervised smoking times will begin 11/4/2022 for those residents who require supervision. 6. On 11/3/2022, Director of Clinical Education in-serviced all available staff members regarding tobacco policy, designated supervised smoking times, signing out smoking materials for residents, and will continue to provide education. All staff must receive the in-service before they work another shift. 7. All smoking assessments were updated for all residents who smoke by the DNS and the ADON on 11/3/2022. Also care plans and Kardex were updated by the members of the nursing managment team on 11/3/2022. 8. All new admits, re-admits, and upon change of status residents will have a new Safe Smoking Assessment. 9. The IDT team will conduct random observations of the smoking area 7 times a day for 30 days to validate adherence to the Tobacco/Smoking policy. 10. The corporate office updated the Safe Smoking Policy to Safe Tobacco Policy to reflect the addition of oral tobacco products. 11. On 11/3/2022 the Senior [NAME] President of Clinical Operations submitted a request to (Named Electronic Medical Record Company) representative to revise the Smoking/Tobacco Assessment. 12. All nurses were educated on the change to the Smoking/Tobacco Assessment. 13. The Administator will hold an ad hoc QAPI meeting 11/4/2022 to discuss the revised Tobacco policy and the procedures for designated supervised smoking times. Any issues with complaince identified will be immediately corrected and reported to the Administrator and the QAPI team. Review of the facility's policy titled, Elopement, dated 4/2017, revealed, .To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements .Newly admitted or re-admitted residents are assessed for elopement risk .If an elopement risk is determined an individualized plan is established and intervention is initiated to mitigate that risk . Review of the facility's policy titled, Accidents and Supervision, dated 10/2022, revealed, .The resident environment will remain as free of accident hazards as is possible .Each resident will receive adequate supervision and assistive devices to prevent accidents .Implementing interventions to reduce hazard(s) and risk(s) .Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accident . Review of the facility's policy titled, Policy and Procedure, Dementia, Family Questionnaire, dated 5/2021, revealed, .To assess appropriate diagnosis and placement possibilities in The Memory Care Unit .To serve as a guide to the resident's initial care plan and overall approach assisting the resident to a positive adjustment to placement in The Memory Care Unit .families continue to be an integral part of the resident's life .family members are included, if possible, in the assessment and reassessment of .Elopement risk assessment . Review of the FRI #202282221816 revealed the facility reported the elopement of Resident #4 to the State Agency and the local police department. The investigation states Resident #4 eloped from the Secure Unit on 8/22/2022 at approximately 5:30 PM. Continued review revealed the investigation alleges Resident #4 set off an alarm on the back door of the Secured Unit and then was able to push on the entrance door until the alarm sounded and the doors opened. The investigation alleges staff responded to the alarming doors. The investigation alleges Resident #4 was let out of the facility by a staff member that works as needed and then walked approximately 1200 feet from the front door. The investigation alleges the nearest busy street was 1584 feet and the next busy street was 2112 feet. There were statements provided by staff, in-services provided to all disciplines, except dietary. Elopement drills were provided to all shifts and Quality Assurance Performance Improvement (QAPI) meeting minutes were copied and provided. Confirmation received from Administrator for QAPI meeting minutes provided to surveyor voluntarily for removal from the facility. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Other Symptoms and Signs Involving Cognitive Functions and Awareness, Unspecified Dementia, Alzheimer's Disease, and Other Specified Personal Risk Factors, Not elsewhere Classified. Review of the Special Care Unit Criteria Review (facility document used during preadmission review) for Resident #4 dated 8/18/2022, revealed, .Describe resident's special concerns .Wanders, Sleepwalks, Exit Seeking . Continued review revealed the review was signed by the Memory Care Director (MCD), DNS, and the Administrator. Review of Resident #4's Clinical Health Status Evaluation dated 8/22/2022 at 11:35 AM, revealed questions answered as yes which included the resident was physically able to leave the building on her own, she was cognitively impaired, she made repetitive statements about going home, there was a history of wandering or elopement, the resident wandered aimlessly about the facility and/or exhibited night wandering. Continued review revealed resident was at risk for elopement and was placed on the secured unit. Review of the Progress Notes for Resident #4 revealed, .8/22/2022 20:15 [8:15 PM] .this evening around dinner time, [Named CNA (Certified Nursing Assistant)], asked me if I had seen [Named Resident] #4 .[Named CNA] stated that the resident went to the bathroom during dinner trays being passed and staff told pt [patient] to return to dinning [dining] area to eat .the alarm was not heard during this elopement, if so, actions would have been taken more promptly then [than] they were . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had a BIMS score of 3, which indicated severe cognitive impairment. Observation of (Named Street) on 11/4/2022 at 5:20 PM to 5:40 PM, revealed 153 total vehicles, an average of 7.65 vehicles per minute passed the area where Resident #4 crossed the street and was walking along the side of the road. Included in the total of 153 vehicles were 5 postal delivery semi-trucks and 3 ambulances. Continued observation revealed 26 small postal delivery trucks parked in back of the post office. During an interview on 10/31/2022 at 3:20 PM, the MCD stated on 8/22/2022 at the time of Resident #4's elopement there was 1 LPN (Licensed Practical Nurse) and 1 CNA assigned on the secured unit. She stated after investigation she felt Resident #4 had eloped, from the secure unit by following someone out the entrance doors. She stated the evening meal trays were brought in through the side door and the tray cart blocked the entrance/exit door to the hall[TRUNCATED]

Based on the job description review and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well being of the residents. Administration failed to provide oversight, ensure a safe environment, complete a thorough investigation of resident elopement, and conduct an ad hoc Quality Assurance and Performance Improvement (QAPI) Committee meeting that identified the appropriate root cause of an elopement to implement appropriate interventions. Administration failed to ensure Elopement Books were updated, failed to educate all staff on elopement risks, failed to update the care plans, which placed 3 of 14 sampled residents (Resident #5, Resident #6, and Resident #7) in Immediate Jeopardy (IJ) when a resident (Resident #4,) a cognitively impaired resident with wandering and exit seeking history and behaviors, exited the facility and was located across a busy street walking along the roadside. Administration also failed to ensure resident care plans and interventions for safe smoking were implemented, Safe Smoking Evaluations were accurately completed, and supervision was provided to residents who smoke for 6 of 17 sampled residents (Residents #5, Resident #8, Resident #9, Resident #10, Resident #12, and Resident #18), who use tobacco products, and 3 of 17 residents (Residents #8, Resident #9, and Resident #10) who use igniting materials (lighters/matches) were secured in a safe manner, which placed all 92 residents residing in the facility in IJ, at a severity level of L, which had the potential to result in serious injury, harm, impairment, or death. The Administrator was notified of the Immediate Jeopardy on 11/4/2022 at 12:25 PM in the Administrator's office. The facility was cited an Immediate Jeopardy IJ at F-835 at a scope and severity of L. The Immediate Jeopardy was removed onsite and was effective from 8/22/2022 to 11/4/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the Jeopardy, was received on 11/4/2022 at 11:25 AM. The corrective actions were validated onsite by surveyors on 11/4/2022 at 7:40 PM. The facility's noncompliance at F-835 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions. The findings include: Review of the Job Description for the Administrator revealed, .Directs, oversees and manages the 24/7 day to day operations of the [Named Company] post-acute care center .Key Responsibilities Ensure the patient and resident is the center of every decision; Serve as the center abuse coordinator. Strives to ensure the safety of all residents within the center; ensures education and understanding of all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect, or misappropriation by protecting, investing and making any required reporting; .Ensure adoption of [Named Company]'s policies, guidelines and standards; .Ensure that quality care and services is provided to all patients, residents and that it meets the satisfaction of the patient, resident, family, physicians and other partners; .Lead an effective Quality Assurance and Process Improvement (QAPI) Program; . Accidents: Failure to ensure adequate supervision for 1 of 14 sampled residents (Resident #4), which resulted in an elopement. Failure to ensure safe smoking/tobacco use for 12 of 16 sampled resdents (Resident #5, Resident 8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, and Resident #18) reviewed for smoking/tobacco use. Failure to secure igniting materials (lighters/matches) for 3 of 17 sampled residents (Residents #8, Resident #9, and Resident #10) which placed all 92 residents in the facility at risk. Refer to F689. Care Plans: Failure to ensure care plans were developed 3 of 14 sampled residents (Residents #5, Resident #6, and Resident #7) reviewed for elopement. The facility failed to implement 2 of 16 sampled residents (Resident #9 and Resident #18) reviewed for safe smoking/tobacco use. The facility failed to implement interventions for care plans on 3 of 16 sampled residents (Resident #5, Resident #10, and Resident #12) reviewed for safe smoking. Refer to F656. QAPI: Failure to identify the root cause of an avoidable accident. Failed to implement plan of action interventions for an elopement. Refer to F867 During an interview on 11/1/2022 at 1:28 PM, the Administrator confirmed the investigation did not determine exactly how Resident #4 eloped from the Secure Unit on 8/22/2022. The Administrator voluntarily provided the surveyors the QAPI Committee Meetin minutes. She confirmed she did not measure the exact distance to where Resident #4 was found. She accepted the distance measurement to where Resident #4 was located from Licensed Practical Nurse #2. Continued interview the Administrator confirmed she could not recall exactly where Resident #4 had been located after eloping from the facility. She stated she did not recall being aware of Resident #4 crossing the street. She stated she trusted LPN #2 and believed she was honest in making any statements about where she located Resident #4 after the elopement. The Administrator did not correctly identify the root cause of the elopement, and failed to implement interventions/actions discussed in the plan of action. During an interview on 11/1/2022 at 3:00 PM, a Dietary Chef confirmed he had not been in-serviced on elopement by the facility or his agency. Observation and interview on 11/1/2022 at 4:55 PM, revealed the Administrator reviewed the elopement books with the surveyors. The elopement books were noted to have numerous resident face sheets and elopement assessments that revealed numerous residents who were not at risk for elopement. During interview the Administrator stated, I decided to make a book for identification purposes, and she confirmed that the elopement book did not contain only the residents at risk for elopement. The Administrator confirmed that the elopement books were not up to date related to the plan of correction noted in the QAPI meeting documentation completed on 8/23/2022. During an interview on 11/3/2022 at 8:55 AM, the Administrator confirmed, The smoking assessments should say whether the resident wears a smoking apron or not. Observation and interview on 11/3/2022 at 8:57 AM, the Administrator stated, The smoking aprons should be hanging on the wall as you go out to the patio where residents smoke or in the cabinets in the Sun Room. The Administrator confirmed no smoking aprons were hanging on the wall or in the cabinets in the Sun Room. The Administrator stated, I ordered 6 yesterday, I promise the aprons are usually hanging here on the wall. During an interview on 11/3/2022 at 9:32 AM, the Administrator confirmed the employees should know what type of receptacle they should be using to put cigarette butts in when the residents smoke. The surveyors verified acceptable Immediate Action Removal Plan on 11/4/2022 at 7:40 PM by: 1. On 11/4/2022 the surveyors verified the Regional [NAME] President and DCO conducted training with the Administrator and DON regarding the following topics utilizing resources from CMS Appendix PP, Quality Initiative Organizations and Diversicare policy: a. CMS AQPI Training 8/22 Alliant QIO Fishbone Diagram Worksheet b. QAPI Center Plan: Diversicare of Smyrna Policy c. Elopement- Diversicare of Smyrna Policy d. CMS Resident Rights Training 8/22 e. Diversicare Safe Tobacco Use Policy f. TN Elopement and Prevention Training 8/22 g. Phase III ROP F689-Accidents, Hazards, Supervision h. Phase III ROP F656- Care Plan i. Phase III ROP F835- Administrator j. Phase III ROP F867-QAPI 2. An Ad hoc QAPI meeting was held 11/4/2022 with the Administrator, Director of Nursing, Social Services Director, Nurse Assessment Coordinator, Activities Director, Maintenance Director, Housekeeping/Laundry Director, DCO, Sales/Marketing Director, ADNS, Staffing/Workforce Manager, Director of Care Coordination, Human Resources, Memory Care Director, Business Office Manager, and 2 Unit Managers.

Based on facility policy review, Facility Reported Incident (FRI) review, medical record review, interviews, and observations, the facility's Quality Assurance Performance Improvement (QAPI) failed to identify the root cause of an avoidable accident, and failed to implement a plan of action interventions for an elopement. The facility's QAPI Committee also failed to recognize unsafe smoking practices and storage of igniting materials.The facility's failure to identify the root cause of an avoidable accident and implement plan of action interventions, and failure to recognize and prevent unsafe smoking and storage of igniting materials, placed all 92 residents residing in the facility in 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) at a scope and severity level of L. The Administrator and Director of Nursing Services (DNS) were notified of the Immediate Jeopardy on 11/4/2022 at 12:25 PM in the Administrator's office. The Facility was cited Immediate Jeopardy at F-867. The facility was cited at F-867 at a scope and severity of L. The Immediate Jeopardy was removed onsite and was effective from 8/22/2022 to 11/4/2022 at 6:50 PM. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 11/4/2022 at 6:25 PM. The corrective actions were validated onsite by the surveyors on 11/4/2022 at 6:50 PM. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's undated policy titled, QAPI Center Plan, revealed, .Quality Assurance and Performance Improvement (QAPI) .Develop and implement an improvement or corrective plan; And continuously monitor the effectiveness of our interventions .QAPI program accomplishes this by ensuring our data collection tools and monitoring systems are in place and are consistent thus allowing for retrospective responsive review, proactive analysis, system failure analysis, and corrective action .Action plans are implemented as needed to prevent recurrence . Review of the QAPI Meeting minutes, voluntarily provided to the surveyors by the Administrator, dated 8/22/2022, revealed, .On 8/22/2022 around 5:30 PM [Named Resident] .was inadvertently let out of the center .All residents with an assessment reflecting a high risk for elopement considered higher risk-the DNS completed an audit to ensure compliance with the elopement guidelines: .Wander guards verified in place and operable on 2 residents .6 Residents total at risk for elopement via the elopement assessment and DNS review .Care plans reviewed to ensure elopement prevention/approaches are in place and UTD [up to date] .Elopement books reviewed to ensure UTD .In compliance 8/23/2022 . Continued review revealed the meeting was attended by the Administrator, DNS, Medical Director, Director of Clinical Operations [DCO], Unit Manager 1, Unit Manager 2, Assistant Director of Nursing (ADON), Memory Care Director (MCD) Maintenance Director, and a representative from nursing staff. Accidents: Failure to ensure adequate supervision for 1 of 14 sampled residents (Resident #4), which resulted in an elopement. Failure to ensure safe smoking/tobacco use for 12 of 16 sampled resdents (Resident #5, Resident 8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, and Resident #18) reviewed for smoking/tobacco use. Failure to secure igniting materials (lighters/matches) for 3 of 17 sampled residents (Residents #8, Resident #9, and Resident #10) which placed all 92 residents in the facility at risk. Refer to F689. Care Plans: Failure to ensure care plans were developed 3 of 14 sampled residents (Residents #5, Resident #6, and Resident #7) reviewed for elopement. The facility failed to implement 2 of 16 sampled residents (Resident #9 and Resident #18) reviewed for safe smoking/tobacco use. The facility failed to implement interventions for care plans on 3 of 16 sampled residents (Resident #5, Resident #10, and Resident #12) reviewed for safe smoking. Refer to F656. Observation and interview on 11/1/2022 at 4:55 PM, revealed the Administrator reviewed the elopement books with the surveyors. The elopement books were noted to have numerous resident face sheets and elopement assessments that revealed numerous residents were not at risk for elopement. During the interview the Administrator confirmed she had decided to make a book for identification purposes and the elopement books did not contain only the residents at risk for elopement. The Administrator confirmed the elopement books contained information for residents that were no longer in the facility, she confirmed the elopement books were not up to date related to the plan of correction noted in the QAPI meeting documentation completed on 8/23/2022. Observation and interview on 11/1/2022 at 5:03 PM and 5:52 PM, revealed the DNS confirmed elopement assessments should be completed upon admission, readmission and a significant change in status. She confirmed residents with a cognitive impairment that were admitted to the Secure Unit were at risk for elopement. She confirmed there were 14 residents in the Secured Unit on 8/23/2022. The DNS reviewed the elopement books on 11/1/2022 at 5:52 PM and confirmed the elopement books were not up to date. She stated, I done the elopement evaluations in the computer system, and I only found 6 residents that were at risk for elopement, only those residents at risk for elopement should have been placed in the book. She confirmed the QAPI plan of action included review of the care plans for those at risk for elopement to ensure facility compliance. She confirmed any time there was a positive risk assessment she expected the care plan to be updated to reflect the outcome of the assessment. The surveyors verified the acceptable Imedicate Action Removal Plan on 11/4/2022 at 6:50 PM by: 1. On 11/4/2022 the surveyors verified the Regional [NAME] President and Director of Clinical Operations conducted training with the Administrator and DON regarding the following topics utilizing resources from CMS Appendix PP, Quality Initiative Organizations and Diversicare policy: a. CMS AQPI Training 8/22 Alliant QIO Fishbone Diagram Worksheet b. QAPI Center Plan: Diversicare of Smyrna Policy c. Elopement- Diversicare of Smyrna Policy d. CMS Resident Rights Training 8/22 e. Diversicare Safe Tobacco Use Policy f. TN Elopement and Prevention Training 8/22 g. Phase III ROP F689-Accidents, Hazards, Supervision h. Phase III ROP F656- Care Plan i. Phase III ROP F835- Administrator j. Phase III ROP F867-QAPI 2. An Ad hoc QAPI meeting was held 11/4/2022 with the Administrator, Director of Nursing, Social Services Director, Nurse Assessment Coordinator, Activities Director, Maintenance Director, Housekeeping/Laundry Director, DCO, Sales/Marketing Director, ADNS, Staffing/Workforce Manager, Director of Care Coordination, Human Resources, Memory Care Director, Business Office Manager, and 2 Unit Managers. 3. The meeting included discussing F867 and the overall impact that QAPI can have when discussing issues that arise in the facility. Administrator explained that when the elopement occurred on 8/22/2022, the facility failed to properly identify the root cause analysis of the elopement which resulted in continued risk of elopement with the potential of serious harm. Administrator and Director of Clinical Operations discussed the need for the whole QAPI committee to be involved in finding root causes of incidents so that it is a collaborative effort. Ad hoc QAPI meetings will be held in the future when an incident arises or safety concerns are identified so that the whole committee can be involved. 4. Oversight and monitoring-The Regional [NAME] President, Director of Clinical Operations or a Diversicare Support Center Leadership team member will provide on-site oversight including review of process compliance, monitoring audits and any current investigations regarding accidents/hazards/supervision a minimum of 2 days per week x 4 weeks, then weekly for 2 weeks then monthly x 3 months. Members of the oversight team will participate in the weekly adHoc QAPI meetings each week via zoom or phone until Jeopardy is cleared.