**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure 1 of 6 residents (Resident #54) reviewed were free from neglect. 1. On 11/17/24 at 7:03:01 p.m. Resident #54 left the building unnoticed by staff, despite the wander guard alarm alarming at the exit door. Facility failed to implement immediate action to prevent neglect due to lack of supervision of 6 cognitively impaired individuals with known elopement risk which could result in falls, injuries, dehydration, and death. An Immediate Jeopardy (IJ) was identified on 12/6/24. The IJ template was provided to the facility on [DATE] at 2:45 pm. While the IJ was removed on 12/7/24, the facility remained out of compliance at a level of potential for more than minimal harm and a scope of isolation, because all staff had not been trained on door codes, what to in case of door alarms, and procedure for a resident elopement. These failures could affect residents who were identified as elopement risks and place them at risk of serious bodily harm, physical impairment, or death. The findings included: Record review of Resident #54's, face sheet dated 12/9/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #54 had diagnoses which included hypertensive heart disease, hypertension, muscle weakness, schizoaffective disorder, bipolar type, and reduced mobility. The face sheet indicated Resident #54 was discharged on 11/29/24 to another nursing facility. Record review of Resident #54's quarterly MDS dated [DATE] revealed she had a BIMS of 00, which indicated severe cognitive impairment. Resident #54 required supervision and wore a wander guard. During an observation of a facility video dated 11/17/24 indicated Resident #54 exited the facility by pushing on the 15 second emergency exit (alarm sounding) at 7:03:00 pm. Resident #54 was wearing a t-shirt, pajama pants, and tennis shoes. CNA A arrived at the door at 7:11:20 pm and exited the building. CNA A was viewed entering back into the building at 7:11:50 pm, indicated 30 seconds elapsed looking for Resident #54. Upon entering back into the building at 7:11:50, CNA A turned off the door alarm and did not do a head count of all residents. Afterwards the facility failed to investigate and take measures to prevent recurrence. Even after Resident #54 was returned to the facility, the facility failed to ensure that residents, who require wander guard bracelets, were monitored, and supervised appropriately to prevent further neglect. Record review of a progress note of Resident #54 dated 11/18/24 at 12:10 am by ADON LVN . indicated, this ADON LVN received a call regarding resident at 9:46 pm asking if we had a resident by the name of Resident #54. ADON LVN enquired about how resident had come to be at apartment. ADON LVN also brought resident back to facility and facilitated safe return and delegated that agency nurse perform skin assessment and assign one on one monitoring and fill out event for elopement. CNA asked to assist resident out of wet clothes get into dry bed clothes. No injuries or wounds noted. Resident placed on 1 on 1. ADON LVN spoke to CNA A and MD to report elopement and subsequent actions. Resident denies pain or discomfort and just wishes to go to bed. No acute distress noted. During an interview on 12/5/24 at 3:15 pm, MOTP A stated that on 11/17/24 at roughly 9:15 pm her son came inside and said there was a lady wandering out on the road and in the apartment complex. She stated, he stated she looked lost and confused because she was walking in a circle. She stated, let's go get her. She stated her son went back out in the rain and dark and finally found her and brought her back to the apartment. She stated Resident #54 seemed confused, was cold and shivering. She stated Resident #54 was only wearing a t-shirt, pajama pants, and tennis shoes. She stated she wrapped Resident #54 in a towel and did not recognize her as any of her neighbors. She stated that her son went and got MOTP B to see if she knew who Resident #54 was. She stated when MOTP B showed up they asked Resident #54 some questions and then they found the wander guard on Resident #54's leg. She stated when they found the wander guard, they realized that Resident #54 was probably from the nursing facility across the street. She stated MOTP B called the facility and ADON LVN came and picked Resident #54 up. During an interview on 12/5/24 at 3:45 pm, MOTP B stated MOTP A's son came to her apartment and stated he saw someone in the parking lot out on the road kind of wandering and walking in a circle out there. She stated it was dark and raining. She stated her primary concerns were to not let her go to highway off the road because they have been having issues with drag racers on that road. She stated that MOTP A's son told her they found Resident #54, she was wandering and they took her inside their apartment. She stated when she got to their apartment Resident #54 was sitting on the couch and wrapped up in a towel and shivering. She stated Resident #54 was wearing a t-shirt, pajama pants, and tennis shoes. She stated she tried to ask Resident #54 her name and where she was from but Resident #54 told her another town and her name. She stated when she came back to the living room MOTP A told her she believed the woman was hurt. She asked MOTP A why and MOTP A told her she had a bandage on her leg. She stated she went to Resident #54 and asked her if she was hurt and if she could look at her leg. She stated that was when she found Resident #54 was not hurt but had a wander guard on, and stated to MOTP A, I bet she was from that facility across the street. She stated she called the facility and asked if they were missing any residents. She stated the woman who answered (ADON LVN) stated no, what were you talking about. She stated were you missing anyone by the name of Resident #54. She stated ADON LVN replied, oh shit and stated she would be right there to pick her up. She stated ADON LVN did come and picked her up immediately. During an interview at 12/6/24 at 8:40 AM, CNA A stated she was the aid who was in the video. She stated she was helping another resident in their room. She stated when she exited their room, she heard the alarm going off down hallway B. She stated there were two nurses sitting at the nursing station not doing anything. She stated she was not sure how long the alarm had been going off. She stated most of the day, another resident with a wander guard had been setting off the alarm. She stated as she was walking down hallway B and saw the resident and assumed he was the one that set the door off. She stated she went to the door, exited the facility, looked outside, and came back in. She stated she did not see any resident. She stated upon entering back into the building she turned the alarm off. She stated because she saw the other resident, she did not do a head count of the facility for all residents. She stated the two nurses sitting at the nurse's station, stated they did not answer the alarming door because they did not know the codes. She stated that the headcount should have been done for Resident #54's safety. She stated it was lucky that Resident #54 did not get hurt. Attempted to reach out to agency staffing company on 12/5/24 and 12/6/24, could not contact two nurses notated sitting at nurses' station. During an interview on 12/6/24 at 10:40 am, LVN A (agency nurse) stated when she first worked for the facility the facility gave her an onboarding packet. She stated the packet did not contain any door codes for the facility. She stated the standard for any facility was if a door alarm was going off and was triggered by a wander guard, move the resident from the door. She stated if the resident that triggered the door was still by the door, move the resident away from the door. She stated if the door was activated and there was no resident near the door, you were to go search outside for the resident. She stated then return inside the building and initiate a resident head count. She stated if the head count was missing any resident, to call the admin, the DON, the charge nurse whoever you can, to inform them of an elopement. She stated at the facility, the codes for the doors were not given. She stated she did not know the codes for any of the doors to go in or out other than the breakroom door. She stated the protocol for any alarming door was to find the resident that set it off. She stated most of the time the resident that triggered the alarm was still standing near the door. She stated but if a door alarm was triggered and the door opened, she would have looked outside first. She stated after she looked outside, if she did not know the door code, she would request help from staff that did know the code. She stated not knowing the code to a door is no excuse to not check the door or on any resident in the area. During an interview on 12/5/24 at 12:40, pm ADON LVN stated the normal protocol for possible elopement was that if an alarm was sounding at any door in the building the individual (employee) goes to the door. She stated they should go outside to look for the resident. She stated if the resident was still there setting off the alarm to remove the resident from the door and then reset the alarm. She stated that she did not know the full story and has not seen the video. She stated that was the door in which Resident #54 exited through. She stated employee CNA A went and looked outside, came back inside, reset the door alarm, and went back to work. She stated that at roughly 9:40 pm the facility received a call from someone outside the facility. She stated they asked her if they had a resident by the name of Resident #54 that stayed in the facility. She stated that they did. She stated the caller informed her that they had her at the apartment across the street. She stated she would come get Resident #54 immediately. She stated she had no idea what Resident #54 was doing or where exactly the resident went for 2 hours and 40 mins. She stated that rounding should be completed every 2 hours on all residents. She stated she was not sure if a head count was completed for the entire facility on the 17th at 7pm by employee CNA A. She stated multiple times throughout the day there was another resident activating the front door alarm with his wander guard. She stated because the alarm had gone off so many times during the day, the staff was desensitized to the alarm going off in the building. She stated that normally Resident #54 sits at the nurse's station each night after she gets done walking. She stated she believed the facility would have noticed at some point Resident #54 was missing. She stated when she received the call from MOTP B at 9:40 pm, she had the staff initiate a head count of all residents while she went and picked up Resident #54. She stated when she got back to the facility, Resident #54 was taken to her room, her wet clothing was removed, and she was put to bed. She stated to her knowledge no other residents were reviewed or rounded on because Resident #54 was safe and back in the facility. She stated she did not know there were two nurses sitting at the nurse's station did not even check the door. She stated she was lucky that Motp found Resident #54, it could have been much worse if Resident #54 got hurt. During an interview on 12/6/24 at 11:15 am, ADON LVN stated she did not give out any of the door codes to any agency staff. She stated that there was a list of topics that were covered with the agency staff, she stated but I won't lie to you the topics to cover were done extremely fast so the agency staff can get out on the floor and start working. She stated there was a binder at the nurse's station that had all the door codes and policies/procedures for anyone to pick up and review. During an observation on 12/6/24 at 11:20 am, there were no policies or procedures in the binder only signature sheets of staff that had completed orientation. No door codes were found in the binder. During an interview on 12/6/24 at 11:45 am, the DON stated Resident #54 did exit the building through the fire emergency exit door on hallway B at 7:00 pm on 11/17/24. She stated the video showed CNA A go down to the door, exit the building, return inside the building, and turn off the alarm. She stated she was not sure why CNA A did not do a head count of all residents when she deactivated the alarm. She stated she was not sure why the alarm went off for that long of a time. She stated there were 2 agency nurses working that night. She stated her expectation of a door alarm going off should be acknowledged immediately. She stated if the resident was not by the door, the employee should go outside, do an observation around the facility, and look any resident, if no resident was found outside the employee should let the charge nurse and the DON know immediately. She stated that she knew Resident #54 was picked up and brought back to the facility. She stated a head count of all residents was done at 9:40 pm. She stated that Resident #54 was rounded on every 15 minutes. She stated she did not know if all other residents with wander guards were monitored after the return of Resident #54. She stated that all agency staff should have known to go and check the alarming door. She stated it did not matter if the door codes were known or not by any staff. She stated the residents are the priority and should have been checked on. She stated the ADON LVN does all the trainings for the facility. She stated this should never have happened and the head count should have been done. Record review of facility's policy titled Abuse, Neglect, and exploitation dated 10/2023 inidcated: the facility will provideprotection for the health, welfare, and rights of each resident by developing and implementing written polices and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Record review of facility's policy titled emergency procedure-missing resident dated 10/2023 inidcated: Any staff member may implement the protocol for a missing resident immediately upon discovering that a resident cannot be located. 1. Announce code pink with the resident's room/unit number. 2. Note the time that the resident was dicovered missing. 3. Report to the nursing station to see if the resident was signed out. 4. Notify the admin, dom, and DON, if not on the premises. 5. activate recall roster if necessary. An Immediate Jeopardy was identified on 12/6/24 at 2:45 pm. The Administrator and DON were informed, and Immediate Jeopardy Template was provided. The Administrator and DON were notified that a Plan of Removal was requested at that time. A Plan of Removal was accepted on 12/7/24 at 6:03 PM and reflected the following: 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #54 returned to the nursing home. Resident was assessed with no injuries. Resident behaving per norm. Increased supervision implemented with Resident #54 which included resident in line of sight of an employee at all times until discharge. Elopement assessment updated. RP & MD informed. (Resident #54 has since been discharged on 11/29/2024 to a secured unit) Person(s) Responsible: Charge Nurse, Assistant Director of Nursing, and/or Designee Date: 11/18/24. 2. How the Facility Identified Other Possibly Affected Residents: Action: Resident head count performed no additional findings. Person(s) Responsible: Charge Nurse and/or Designee Date: 11/17/2024 Action: All residents received an elopement assessment. Residents' current elopement assessment will reflect on their face sheet and care plan. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/18/2024 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Elopement binder reviewed to ensure it matches the current residents who were deemed as elopement risks per their elopement assessments. Person(s) Responsible: Director of Nursing and/or Designee Date: 11/18/2024 Action: Sign on door verified for placement notifying visitors to, Please do not allow residents to follow you out. Person(s) Responsible: Administrator Date: 11/18/2024 Action: Sign posted by keypads stating: When alarms were sounding, and the door was disengaged perform a resident head count. Person(s) Responsible: Director of Regulatory Compliance Date: 11/18/2024 Action: All doors checked for functionality. No concerns noted. Person(s) Responsible: Maintenance Director and/or Designee Date: 11/17/2024 Action: Check for all residents with roam alerts for functionality. No concerns noted. Person(s) Responsible: Administrator and/or Designee Date: 11/18/2024. Action: Elopement drill performed each shift (6a-6p and 6p-6a). Person(s) Responsible: Administrator, Maintenance Director, and/or Designee Date: 11/19/2024 Action: Education provided to direct care staff, to include agency staff, regarding missing resident/elopement & over the facility's abuse & neglect policy. Direct care staff will be educated on the elopement binder, its location, and its contents (shows which residents were elopement risks/wander guard residents). Direct care staff, including agency staff, will know when the door was alarming, to respond to the alarming door immediately. If the door was disengaged (open) and alarming the direct care staff will ensure all residents were in house by performing a head count (signs placed for reminders for staff to ensure all residents were in house when alarms were sounding, and the door was disengaged by keypads). Direct care staff, including agency staff, will know the door codes/door code location through this education. Direct care employees will be educated prior to working their next shift. All new and temporary direct care staff will be educated prior to working. Person(s) Responsible: Administrator and/or Designee Date: 12/6/2024 Action: Residents deemed an elopement risk, that require a roam alert/wander guard will be rounded on every 2 hours to ensure facility was aware of residents' whereabouts. Person(s) Responsible: Charge Nurse, Certified Nurse's Aides, and/or Designee Date: 12/6/2024 4. How the Corrective Actions Will be Monitored, by whom, and for how long: Action: All residents with exit seeking behaviors will be reviewed during clinical meeting to ensure safety. Appropriate supervision will occur until residents with exit seeking behaviors, that have a greater need than the roam alert system, were appropriately placed. No concerns noted. Person(s) Responsible: Director of Nursing and/or Designee Date: 11/17/2024 Action: Elopement drill performed weekly x4 weeks to ensure staff's retention of education to prevent recurrence. Person(s) Responsible: Administrator and/or Designee Date: 11/17/2024 QAPI- Action: Ad hoc QAPI performed with medical director to inform them of the incident and the facility's plan to remove the immediacy. No further direction required. Person(s) Responsible: Administrator Date: 11/18/2024 State Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 12/6/24 to 12/7/24 as follows: Record review of resident assessment: Record review of progress note of Resident #54 dated 11/18/24 at 12:10 am submitted by ADON LVN indicated, this LVN received a call regarding resident at 9:45 pm asking if we had a resident by the name of Resident #54. ADON LVN enquired about how resident had come to be at apartment. ADON LVN also brought resident back to facility and facilitated safe return and delegated that agency nurse perform skin assessment and assign one on one monitoring and fill out event for elopement. CNA asked to assist resident out of wet clothes get into dry bed clothes. No injuries or wounds noted. Resident placed on 1 on 1. ADON LVN spoke to CNA A and MD to report elopement and subsequent actions. Resident denies pain or discomfort and just wishes to go to bed. No acute distress noted. Record review of progress notes of Resident #54 dated 11/17/24 at 10:24 pm submitted by ADON LVN indicated: Resident Refused Skin Assessment: No Temperature--Location, if applicable.: Warm Color--Location, if applicable.: Expected color for ethnicity. Moisture--Location, if applicable.: Dry Skin Turgor: Normal Capillary Refill: Less than 3 seconds Was Resident at risk for developing pressure injuries? No Risk Factors: Moisture, Incontinence Were contractures present? No Alterations in Skin Integrity. Note location of any noted areas. Enter measurements in box provided.: None. Notifications if Applicable: Physician Notified MD, Responsible Resident Representative Notified. Guardian Interventions: No new or additional interventions required at this time. [Corporation] Assessment for Risk of Elopement completed 11/18/24. Indicated yes to all: Does the resident have a diagnosis of Dementia, OBS, Alzheimer's, I/DD, Delusions, Hallucinations, Anxiety, Depression, Schizophrenia, or other Mental Illness? Yes Does the resident ambulate independently, with or without the use of an assistive device (i.e., walker, cane, or wheelchair)? Yes If the resident has wandering behavior, was it tied to resident's past (i.e., their prior work, takes long walks, seeking someone they cannot find)? Yes Was the resident ambulatory (able to walk without someone assisting them) yet cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficits, appears disoriented)? Yes Has the resident verbally expressed the desire to go home, packed belongings to go home, talked about going on a trip, or stayed near an exit door? Yes Does the resident have a history of leaving the facility without Informing staff? Yes Does the resident wander without a sense of purpose (i.e., confused, moves aimlessly, may enter other resident rooms, and explore their belongings)? Yes Record review of observations initiated by the facility on 11/17/24 at 10:07 pm of Resident #54 for increased rounding indicated: times starting at 10:07 pm and every 15min interval after that with sign off sheet until 11:45 pm. Sheet dated 11/18/24 had monitoring every 15min, all day long, no time was missed, signatures provided. Sheet dated 11/19/24 had monitoring every 15min up until 12:00 pm. Record review of facility Resident head count dated 11/17/24 at 9:40 pm indicated all residents were in the building except Resident #54. At which time ADON LVN was going to pick up Resident #54. Record review of the facility Resident observation summary report for all residents dated 11/17/24 to 11/19/24 completed for [corporation] assessment for risk of elopement for all residents in the facility completed daily by all nurses in the facility. Record review of door checks (door locking mechanism) log sheet dated 11/11/24 to 11/15/24 all indicated a pass. Door check log sheet dated 11/18/24 all indicated a pass. Record review of Code Pink drill documentation form dated 12/6/24 at 5:02 pm indicated all staff acted correctly. Signature pages presented. Record review of Code Pink drill documentation form dated 11/27/24 indicated all staff acted correctly. Signature pages presented. Record review of drill dated 11/19/24 time stamped 5:30 am indicated: The Administrator hid as an unaccompanied resident which would activate a missing resident situation. Informed staff that we were looking for an unaccounted resident. Verbally alerted staff to the Code Pink status. Staff immediately met at the Nurses Station and received direction from the charge nurse to begin looking for a missing resident. Staff searched all hallways/rooms/dining area/lobby, and closets. Within 5 minutes the Mock resident was found in the kitchen. Signed and dated by the Administrator. Record review of drill dated 11/18/24 time stamped 5:00 pm indicated: The Maintenance Director chose an employee to hide as an unaccompanied resident which would activate a missing resident situation. Informed staff that we were looking for an unaccompanied resident. Verbally alerted staff to Code Pink status. Staff immediately met at the Nurses Station and received direction from the charge nurse to begin looking for missing resident. Staff searched all hallways/rooms/dining area/lobby, and closets. Within 3 minutes the Mock resident was found in the Beauty Shop. Signed and dated by the Maintenance Director. Record review of Ad hoc QAPI meeting dated 12/6/24 indicated: An ad hoc QAPI meeting was performed with the MD to review the incident regarding Resident #54. The MD was agreeable with the plan of action. The MD completed a telehealth visit with Resident #54 with no concerns. Record review on 12/8/24 of Agency orientation to the facility book and for the rest of the staff, located at nurses' station, binder contained: policy's abuse, neglect, and exploitation, wandering and elopement, comprehensive care plans, advanced directives, change in residents' condition or status, fall prevention program, and resident rights. Binder also contained: Note that stated, door codes-if they do not work, please call the admin or the DON, and then list all door codes for the entire facility for going in or out of the facility. Binder also contained completed orientations of nursing and agency staff. Record review on 12/9/24 of In-service titled visual rotation risk of elopement, led by the Administrator indicated: go into the MAR and check residents that have wander guards. All residents with wander guards were rounded on, the even hours were rounded on by CNA's and odd hours were rounded on by Nurses. The sign off sheet would be reviewed by both the nurses and CNA's when the rounding was completed. Record review on 12/9/24 of in-service titled Door alarm education and elopement policy, instructed by a group of people, but the Administrator did educate. The Administrator stated the education included door alarms, how to react and what to do. He stated the education included elopement, education, and abuse/neglect. He stated that if the alarm was sounding the door should be observed immediately. He stated then if the door opens even with the alarm going off, the employee should go outside, and check the area. He stated the employee should walk the entire facility and check the surrounding area. He stated if no resident was seen/found the employee was to come back inside, turn off the alarm, make sure door was locked, and then inform staff to initiate a head count for the entire facility. He stated that if the door was alarming and the door did not open to look in the surrounding area inside the building to find the possible resident that set the alarm off and redirect the resident from the door. Record review on 12/9/24 of in-service titled abuse, neglect, and exploitation, instructed by ADON LVN completed on 11/18/24. ADON LVN stated that due to the elopement the facility did do an in-service on abuse, neglect, and exploitation. She stated during the education she did go over the whole policy, and she discussed with staff what constitutes as abuse, neglect, and exploitation. She stated she also covered what to do if abuse or neglect were to occur and/or was witnessed in the facility. She stated the process was to report any incident directly to the Administrator because he was the abuse neglect coordinator. During an interview on 12/7/24 at 10:15 am, LVN C (day nurse) stated there were 3 in-services that she could remember but it was basically a big training yesterday while she was on shift. She stated first was elopement and what to do if a door alarm was going off. She stated if a door alarm was going off and opened upon arrival with no resident in site, she would go outside and search the surrounding area. She stated if no resident was found outside, she would return back inside, and inform staff of a possible elopement. She stated she would inform the charge nurse, the DON, or the Administrator of a possible elopement. She stated she would then start a head count of all residents in the facility. She stated there was a binder now at the nurse's station with all the policies and procedures. She stated the binder included abuse neglect, elopement, and other policies and procedures. She stated that one sheet in the book also contained the alarms and codes to all doors in the facility. She stated they also would do rounding on all residents with wander guards every two hours. She stated for abuse/neglect, if she were to witness or observe anything of that nature to separate or remove the resident from the situation, also to immediately inform the Administrator of the incident, and give report to the Administrator. During an interview on 12/7/24 at 10:25 am, CNA B (Day shift) stated she did have to do in-services before she could come on to work today. She stated the categories of the in-services included elopement, where to find guidance, and abuse/neglect. She stated the main topic at hand was what to do if a door alarm was going off in the facility. She stated they emphasized the importance of going to the door immediately and checking for any residents at the door. She stated if a resident with a wander guard was still at the door and the door was still locked to re-direct the resident away from the door. She stated but if the door alarm was going off and the door could open, it was vital to go outside, and look for the resident. She stated if no resident was found outside, she was to inform staff to start a resident head count. She stated the second topic was where to find all the policies and procedures in the building. She stated there was a new binder at the nurse's station that contained all the policies and procedures for given situations. She stated also within the binder were all the codes for all the doors in the building. During an interview on 12/7/24 at 10:30 am, LVN D (Night Nurse) stated before he was allowed to work last night he had to go through a few trainings. He stated he used to be an agency nurse, but now worked full time for the facility. He stated he forgot his phone at work, so he was here at this time. He stated most of the trainings were related to door alarms in the facility. He stated if an alarm was going off in the facility, he was to immediately check the door. He stated if the resident that set off the alarm was still in the area and the door was still locked then he was to re-direct the resident from the door. He stated however, if the door alarm was going off and the door opens, even if there was a resident with a wander guard standing next to the door, he was to go outside the facility and look around the building. He stated if no resident was found outside, he was to turn off the door alarm, make sure the door locks, and get with all the staff to do a resident head count. He stated he was also in-serviced on a new binder that would be at the nurse's station. He stated the new binder contained all the door codes and alarms. He stated the binder also contained all the policies and procedures given for different situation, like a quick reference guide. He stated other than that the last in-service was related to abuse/neglect. He stated it went over what to look for, how to react, and who to report to if he were to witness anything like that. During an interview on 12/7/24 at 10:35 am, RN A (Day Nurse) she stated there were 3 total in-services. She stated there was training about elopement and risk of elopement for residents in the facility. She stated, for example if there was a door going off in the facility to immediately go and check the door. She stated if the resident who set the alarm off was still standing there, to redirect the resident. She stated however if there was no resident at the door and the alarm[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure implementation of written policies and procedures that prohibit and prevent neglect for 1 of 6 residents (Resident #54) reviewed were free from neglect. 1. On 11/17/24 at 7:03:01 p.m. Resident #54 left the building unnoticed by staff, despite the wander guard alarm alarming at the exit door. 2. Facility failed to follow policy for emergency procedure-missing resident. 3. Facility failed to implement immediate action to prevent neglect due to lack of supervision of 6 cognitively impaired individuals with known elopement risk which could result in falls, injuries, dehydration, and death. An Immediate Jeopardy (IJ) was identified on 12/6/24. The IJ template was provided to the facility on [DATE] at 2:45 pm. While the IJ was removed on 12/7/24, the facility remained out of compliance at a level of potential for more than minimal harm and a scope of isolation, because all staff had not been trained on door codes, what to in case of door alarms, and procedure for a resident elopement. These failures could affect residents who were identified as elopement risks and place them at risk of serious bodily harm, physical impairment, or death. The findings included: Record review of Resident #54's, face sheet dated 12/9/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #54 had diagnoses which included hypertensive heart disease, hypertension, muscle weakness, schizoaffective disorder, bipolar type, and reduced mobility. The face sheet indicated Resident #54 was discharged on 11/29/24 to another nursing facility. Record review of Resident #54's quarterly MDS dated [DATE] revealed she had a BIMS of 00, which indicated severe cognitive impairment. Resident #54 required supervision and wore a wander guard. During an observation of a facility video dated 11/17/24 indicated Resident #54 exited the facility by pushing on the 15 second emergency exit (alarm sounding) at 7:03:00 pm. Resident #54 was wearing a t-shirt, pajama pants, and tennis shoes. CNA A arrived at the door at 7:11:20 pm and exited the building. CNA A was viewed entering back into the building at 7:11:50 pm, indicated 30 seconds elapsed looking for Resident #54. Upon entering back into the building at 7:11:50, CNA A turned off the door alarm and did not do a head count of all residents. Afterwards the facility failed to investigate and take measures to prevent recurrence. Even after Resident #54 was returned to the facility, the facility failed to ensure that residents, who require wander guard bracelets, were monitored, and supervised appropriately to prevent further neglect. Record review of a progress note of Resident #54 dated 11/18/24 at 12:10 am by ADON LVN . indicated, this ADON LVN received a call regarding resident at 9:46 pm asking if we had a resident by the name of Resident #54. ADON LVN enquired about how resident had come to be at apartment. ADON LVN also brought resident back to facility and facilitated safe return and delegated that agency nurse perform skin assessment and assign one on one monitoring and fill out event for elopement. CNA asked to assist resident out of wet clothes get into dry bed clothes. No injuries or wounds noted. Resident placed on 1 on 1. ADON LVN spoke to CNA A and MD to report elopement and subsequent actions. Resident denies pain or discomfort and just wishes to go to bed. No acute distress noted. During an interview on 12/5/24 at 3:15 pm, MOTP A stated that on 11/17/24 at roughly 9:15 pm her son came inside and said there was a lady wandering out on the road and in the apartment complex. She stated, he stated she looked lost and confused because she was walking in a circle. She stated, let's go get her. She stated her son went back out in the rain and dark and finally found her and brought her back to the apartment. She stated Resident #54 seemed confused, was cold and shivering. She stated Resident #54 was only wearing a t-shirt, pajama pants, and tennis shoes. She stated she wrapped Resident #54 in a towel and did not recognize her as any of her neighbors. She stated that her son went and got MOTP B to see if she knew who Resident #54 was. She stated when MOTP B showed up they asked Resident #54 some questions and then they found the wander guard on Resident #54's leg. She stated when they found the wander guard, they realized that Resident #54 was probably from the nursing facility across the street. She stated MOTP B called the facility and ADON LVN came and picked Resident #54 up. During an interview on 12/5/24 at 3:45 pm, MOTP B stated MOTP A's son came to her apartment and stated he saw someone in the parking lot out on the road kind of wandering and walking in a circle out there. She stated it was dark and raining. She stated her primary concerns were to not let her go to highway off the road because they have been having issues with drag racers on that road. She stated that MOTP A's son told her they found Resident #54, she was wandering, and they took her inside their apartment. She stated when she got to their apartment Resident #54 was sitting on the couch and wrapped up in a towel and shivering. She stated Resident #54 was wearing a t-shirt, pajama pants, and tennis shoes. She stated she tried to ask Resident #54 her name and where she was from but Resident #54 told her another town and her name. She stated when she came back to the living room MOTP A told her she believed the woman was hurt. She asked MOTP A why and MOTP A told her she had a bandage on her leg. She stated she went to Resident #54 and asked her if she was hurt and if she could look at her leg. She stated that was when she found Resident #54 was not hurt but had a wander guard on, and stated to MOTP A, I bet she was from that facility across the street. She stated she called the facility and asked if they were missing any residents. She stated the woman who answered (ADON LVN) stated no, what were you talking about. She stated were you missing anyone by the name of Resident #54. She stated ADON LVN replied, oh shit and stated she would be right there to pick her up. She stated ADON LVN did come and picked her up immediately. During an interview at 12/6/24 at 8:40 AM, CNA A stated she was the aid who was in the video. She stated she was helping another resident in their room. She stated when she exited their room, she heard the alarm going off down hallway B. She stated there were two nurses sitting at the nursing station not doing anything. She stated she was not sure how long the alarm had been going off. She stated most of the day, another resident with a wander guard had been setting off the alarm. She stated as she was walking down hallway B and saw the resident and assumed he was the one that set the door off. She stated she went to the door, exited the facility, looked outside, and came back in. She stated she did not see any resident. She stated upon entering back into the building she turned the alarm off. She stated because she saw the other resident, she did not do a head count of the facility for all residents. She stated the two nurses sitting at the nurse's station, stated they did not answer the alarming door because they did not know the codes. She stated that the headcount should have been done for Resident #54's safety. She stated it was lucky that Resident #54 did not get hurt. Attempted to reach out to agency staffing company on 12/5/24 and 12/6/24, could not contact two nurses notated sitting at nurses' station. During an interview on 12/6/24 at 10:40 am, LVN A (agency nurse) stated when she first worked for the facility the facility gave her an onboarding packet. She stated the packet did not contain any door codes for the facility. She stated the standard for any facility was if a door alarm was going off and was triggered by a wander guard, move the resident from the door. She stated if the resident that triggered the door was still by the door, move the resident away from the door. She stated if the door was activated and there was no resident near the door, you were to go search outside for the resident. She stated then return inside the building and initiate a resident head count. She stated if the head count was missing any resident, to call the admin, the DON, the charge nurse whoever you can, to inform them of an elopement. She stated at the facility, the codes for the doors were not given. She stated she did not know the codes for any of the doors to go in or out other than the breakroom door. She stated the protocol for any alarming door was to find the resident that set it off. She stated most of the time the resident that triggered the alarm was still standing near the door. She stated but if a door alarm was triggered and the door opened, she would have looked outside first. She stated after she looked outside, if she did not know the door code, she would request help from staff that did know the code. She stated not knowing the code to a door is no excuse to not check the door or on any resident in the area. She stated that the policy is to check any door that was alarmed as fast as possible. She stated that was the number one rule with a door that was alarmed, find the resident than shut off the alarm. During an interview on 12/5/24 at 12:40, pm ADON LVN stated the normal protocol for possible elopement was that if an alarm was sounding at any door in the building the individual (employee) goes to the door. She stated they should go outside to look for the resident. She stated if the resident was still there setting off the alarm to remove the resident from the door and then reset the alarm. She stated that she did not know the full story and has not seen the video. She stated that was the door in which Resident #54 exited through. She stated employee CNA A went and looked outside, came back inside, reset the door alarm, and went back to work. She stated that at roughly 9:40 pm the facility received a call from someone outside the facility. She stated they asked her if they had a resident by the name of Resident #54 that stayed in the facility. She stated that they did. She stated the caller informed her that they had her at the apartment across the street. She stated she would come get Resident #54 immediately. She stated she had no idea what Resident #54 was doing or where exactly the resident went for 2 hours and 40 mins. She stated that rounding should be completed every 2 hours on all residents. She stated she was not sure if a head count was completed for the entire facility on the 17th at 7pm by employee CNA A. She stated multiple times throughout the day there was another resident activating the front door alarm with his wander guard. She stated because the alarm had gone off so many times during the day, the staff was desensitized to the alarm going off in the building. She stated that normally Resident #54 sits at the nurse's station each night after she gets done walking. She stated she believed the facility would have noticed at some point Resident #54 was missing. She stated when she received the call from MOTP B at 9:40 pm, she had the staff initiate a head count of all residents while she went and picked up Resident #54. She stated when she got back to the facility, Resident #54 was taken to her room, her wet clothing was removed, and she was put to bed. She stated to her knowledge no other residents were reviewed or rounded on because Resident #54 was safe and back in the facility. She stated she did not know there were two nurses sitting at the nurse's station did not even check the door. She stated she was lucky that Motp found Resident #54, it could have been much worse if Resident #54 got hurt. She stated the protocol was to check the alarmed door, find the resident, and then initiate a head count. She stated this was not done. She stated the policy for missing resident was not followed. She stated the fact that CNA A went to the door and did not do a headcount was not following the policy. During an observation on 12/6/24 at 11:20 am, there were no policies or procedures in the binder only signature sheets of staff that had completed orientation. No door codes were found in the binder. During an interview on 12/6/24 at 11:45 am, the DON stated Resident #54 did exit the building through the fire emergency exit door on hallway B at 7:00 pm on 11/17/24. She stated the video showed CNA A go down to the door, exit the building, return inside the building, and turn off the alarm. She stated she was not sure why CNA A did not do a head count of all residents when she deactivated the alarm. She stated she was not sure why the alarm went off for that long of a time. She stated there were 2 agency nurses working that night. She stated her expectation of a door alarm going off should be acknowledged immediately. She stated if the resident was not by the door, the employee should go outside, do an observation around the facility, and look any resident, if no resident was found outside the employee should let the charge nurse and the DON know immediately. She stated that she knew Resident #54 was picked up and brought back to the facility. She stated a head count of all residents was done at 9:40 pm. She stated that Resident #54 was rounded on every 15 minutes. She stated she did not know if all other residents with wander guards were monitored after the return of Resident #54. She stated that all agency staff should have known to go and check the alarming door. She stated it did not matter if the door codes were known or not by any staff. She stated the residents are the priority and should have been checked on. She stated the ADON LVN does all the trainings for the facility. She stated this should never have happened and the head count should have been done. She stated that the CNA A should have done a head count, because this was not done, she did not follow the policy for the facility with a missing resident. Record review of facility's policy titled Abuse, Neglect, and exploitation dated 10/2023 indicated: the facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. An Immediate Jeopardy was identified on 12/6/24 at 2:45 pm. The Administrator and DON were informed, and Immediate Jeopardy Template was provided. The Administrator and DON were notified that a Plan of Removal was requested at that time. A Plan of Removal was accepted on 12/7/24 at 6:03 PM and reflected the following: 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #54 returned to the nursing home. Resident was assessed with no injuries. Resident behaving per norm. Increased supervision implemented with Resident #54 which included resident in line of sight of an employee at all times until discharge. Elopement assessment updated. RP & MD informed. (Resident #54 has since been discharged on 11/29/2024 to a secured unit) Person(s) Responsible: Charge Nurse, Assistant Director of Nursing, and/or Designee Date: 11/18/24. 2. How the Facility Identified Other Possibly Affected Residents: Action: Resident head count performed no additional findings. Person(s) Responsible: Charge Nurse and/or Designee Date: 11/17/2024 Action: All residents received an elopement assessment. Residents' current elopement assessment will reflect on their face sheet and care plan. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/18/2024 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Elopement binder reviewed to ensure it matches the current residents who were deemed as elopement risks per their elopement assessments. Person(s) Responsible: Director of Nursing and/or Designee Date: 11/18/2024 Action: Sign on door verified for placement notifying visitors to, Please do not allow residents to follow you out. Person(s) Responsible: Administrator Date: 11/18/2024 Action: Sign posted by keypads stating: When alarms were sounding, and the door was disengaged perform a resident head count. Person(s) Responsible: Director of Regulatory Compliance Date: 11/18/2024 Action: All doors checked for functionality. No concerns noted. Person(s) Responsible: Maintenance Director and/or Designee Date: 11/17/2024 Action: Check for all residents with roam alerts for functionality. No concerns noted. Person(s) Responsible: Administrator and/or Designee Date: 11/18/2024. Action: Elopement drill performed each shift (6a-6p and 6p-6a). Person(s) Responsible: Administrator, Maintenance Director, and/or Designee Date: 11/19/2024 Action: Education provided to direct care staff, to include agency staff, regarding missing resident/elopement & over the facility's abuse & neglect policy. Direct care staff will be educated on the elopement binder, its location, and its contents (shows which residents were elopement risks/wander guard residents). Direct care staff, including agency staff, will know when the door was alarming, to respond to the alarming door immediately. If the door was disengaged (open) and alarming the direct care staff will ensure all residents were in house by performing a head count (signs placed for reminders for staff to ensure all residents were in house when alarms were sounding, and the door was disengaged by keypads). Direct care staff, including agency staff, will know the door codes/door code location through this education. Direct care employees will be educated prior to working their next shift. All new and temporary direct care staff will be educated prior to working. Person(s) Responsible: Administrator and/or Designee Date: 12/6/2024 Action: Residents deemed an elopement risk, that require a roam alert/wander guard will be rounded on every 2 hours to ensure facility was aware of residents' whereabouts. Person(s) Responsible: Charge Nurse, Certified Nurse's Aides, and/or Designee Date: 12/6/2024 4. How the Corrective Actions Will be Monitored, by whom, and for how long: Action: All residents with exit seeking behaviors will be reviewed during clinical meeting to ensure safety. Appropriate supervision will occur until residents with exit seeking behaviors, that have a greater need than the roam alert system, were appropriately placed. No concerns noted. Person(s) Responsible: Director of Nursing and/or Designee Date: 11/17/2024 Action: Elopement drill performed weekly x4 weeks to ensure staff's retention of education to prevent recurrence. Person(s) Responsible: Administrator and/or Designee Date: 11/17/2024 QAPI- Action: Ad hoc QAPI performed with medical director to inform them of the incident and the facility's plan to remove the immediacy. No further direction required. Person(s) Responsible: Administrator Date: 11/18/2024 State Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 12/6/24 to 12/7/24 as follows: Record review of resident assessment: Record review of progress note of Resident #54 dated 11/18/24 at 12:10 am submitted by ADON LVN indicated, this LVN received a call regarding resident at 9:45 pm asking if we had a resident by the name of Resident #54. ADON LVN enquired about how resident had come to be at apartment. ADON LVN also brought resident back to facility and facilitated safe return and delegated that agency nurse perform skin assessment and assign one on one monitoring and fill out event for elopement. CNA asked to assist resident out of wet clothes get into dry bed clothes. No injuries or wounds noted. Resident placed on 1 on 1. ADON LVN spoke to CNA A and MD to report elopement and subsequent actions. Resident denies pain or discomfort and just wishes to go to bed. No acute distress noted. Record review of progress notes of Resident #54 dated 11/17/24 at 10:24 pm submitted by ADON LVN indicated: Resident Refused Skin Assessment: No Temperature--Location, if applicable.: Warm Color--Location, if applicable.: Expected color for ethnicity. Moisture--Location, if applicable.: Dry Skin Turgor: Normal Capillary Refill: Less than 3 seconds Was Resident at risk for developing pressure injuries? No Risk Factors: Moisture, Incontinence Were contractures present? No Alterations in Skin Integrity. Note location of any noted areas. Enter measurements in box provided.: None. Notifications if Applicable: Physician Notified MD, Responsible Resident Representative Notified. Guardian Interventions: No new or additional interventions required at this time. [Corporation] Assessment for Risk of Elopement completed 11/18/24. Indicated yes to all: Does the resident have a diagnosis of Dementia, OBS, Alzheimer's, I/DD, Delusions, Hallucinations, Anxiety, Depression, Schizophrenia, or other Mental Illness? Yes Does the resident ambulate independently, with or without the use of an assistive device (i.e., walker, cane, or wheelchair)? Yes If the resident has wandering behavior, was it tied to resident's past (i.e., their prior work, takes long walks, seeking someone they cannot find)? Yes Was the resident ambulatory (able to walk without someone assisting them) yet cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficits, appears disoriented)? Yes Has the resident verbally expressed the desire to go home, packed belongings to go home, talked about going on a trip, or stayed near an exit door? Yes Does the resident have a history of leaving the facility without Informing staff? Yes Does the resident wander without a sense of purpose (i.e., confused, moves aimlessly, may enter other resident rooms, and explore their belongings)? Yes Record review of observations initiated by the facility on 11/17/24 at 10:07 pm of Resident #54 for increased rounding indicated: times starting at 10:07 pm and every 15min interval after that with sign off sheet until 11:45 pm. Sheet dated 11/18/24 had monitoring every 15min, all day long, no time was missed, signatures provided. Sheet dated 11/19/24 had monitoring every 15min up until 12:00 pm. Record review of facility Resident head count dated 11/17/24 at 9:40 pm indicated all residents were in the building except Resident #54. At which time ADON LVN was going to pick up Resident #54. Record review of the facility Resident observation summary report for all residents dated 11/17/24 to 11/19/24 completed for [corporation] assessment for risk of elopement for all residents in the facility completed daily by all nurses in the facility. Record review of door checks (door locking mechanism) log sheet dated 11/11/24 to 11/15/24 all indicated a pass. Door check log sheet dated 11/18/24 all indicated a pass. Record review of Code Pink drill documentation form dated 12/6/24 at 5:02 pm indicated all staff acted correctly. Signature pages presented. Record review of Code Pink drill documentation form dated 11/27/24 indicated all staff acted correctly. Signature pages presented. Record review of drill dated 11/19/24 time stamped 5:30 am indicated: The Administrator hid as an unaccompanied resident which would activate a missing resident situation. Informed staff that we were looking for an unaccounted resident. Verbally alerted staff to the Code Pink status. Staff immediately met at the Nurses Station and received direction from the charge nurse to begin looking for a missing resident. Staff searched all hallways/rooms/dining area/lobby, and closets. Within 5 minutes the Mock resident was found in the kitchen. Signed and dated by the Administrator. Record review of drill dated 11/18/24 time stamped 5:00 pm indicated: The Maintenance Director chose an employee to hide as an unaccompanied resident which would activate a missing resident situation. Informed staff that we were looking for an unaccompanied resident. Verbally alerted staff to Code Pink status. Staff immediately met at the Nurses Station and received direction from the charge nurse to begin looking for missing resident. Staff searched all hallways/rooms/dining area/lobby, and closets. Within 3 minutes the Mock resident was found in the Beauty Shop. Signed and dated by the Maintenance Director. Record review of Ad hoc QAPI meeting dated 12/6/24 indicated: An ad hoc QAPI meeting was performed with the MD to review the incident regarding Resident #54. The MD was agreeable with the plan of action. The MD completed a telehealth visit with Resident #54 with no concerns. Record review on 12/8/24 of Agency orientation to the facility book and for the rest of the staff, located at nurses' station, binder contained: policy's abuse, neglect, and exploitation, wandering and elopement, comprehensive care plans, advanced directives, change in residents' condition or status, fall prevention program, and resident rights. Binder also contained: Note that stated, door codes-if they do not work, please call the admin or the DON, and then list all door codes for the entire facility for going in or out of the facility. Binder also contained completed orientations of nursing and agency staff. Record review on 12/9/24 of In-service titled visual rotation risk of elopement, led by the Administrator indicated: go into the MAR and check residents that have wander guards. All residents with wander guards were rounded on, the even hours were rounded on by CNA's and odd hours were rounded on by Nurses. The sign off sheet would be reviewed by both the nurses and CNA's when the rounding was completed. Record review on 12/9/24 of in-service titled Door alarm education and elopement policy, instructed by a group of people, but the Administrator did educate. The Administrator stated the education included door alarms, how to react and what to do. He stated the education included elopement, education, and abuse/neglect. He stated that if the alarm was sounding the door should be observed immediately. He stated then if the door opens even with the alarm going off, the employee should go outside, and check the area. He stated the employee should walk the entire facility and check the surrounding area. He stated if no resident was seen/found the employee was to come back inside, turn off the alarm, make sure door was locked, and then inform staff to initiate a head count for the entire facility. He stated that if the door was alarming and the door did not open to look in the surrounding area inside the building to find the possible resident that set the alarm off and redirect the resident from the door. Record review on 12/9/24 of in-service titled abuse, neglect, and exploitation, instructed by ADON LVN completed on 11/18/24. ADON LVN stated that due to the elopement the facility did do an in-service on abuse, neglect, and exploitation. She stated during the education she did go over the whole policy, and she discussed with staff what constitutes as abuse, neglect, and exploitation. She stated she also covered what to do if abuse or neglect were to occur and/or was witnessed in the facility. She stated the process was to report any incident directly to the Administrator because he was the abuse neglect coordinator. During an interview on 12/7/24 at 10:15 am, LVN C (day nurse) stated there were 3 in-services that she could remember but it was basically a big training yesterday while she was on shift. She stated first was elopement and what to do if a door alarm was going off. She stated if a door alarm was going off and opened upon arrival with no resident in site, she would go outside and search the surrounding area. She stated if no resident was found outside, she would return back inside, and inform staff of a possible elopement. She stated she would inform the charge nurse, the DON, or the Administrator of a possible elopement. She stated she would then start a head count of all residents in the facility. She stated there was a binder now at the nurse's station with all the policies and procedures. She stated the binder included abuse neglect, elopement, and other policies and procedures. She stated that one sheet in the book also contained the alarms and codes to all doors in the facility. She stated they also would do rounding on all residents with wander guards every two hours. She stated for abuse/neglect, if she were to witness or observe anything of that nature to separate or remove the resident from the situation, also to immediately inform the Administrator of the incident, and give report to the Administrator. During an interview on 12/7/24 at 10:25 am, CNA B (Day shift) stated she did have to do in-services before she could come on to work today. She stated the categories of the in-services included elopement, where to find guidance, and abuse/neglect. She stated the main topic at hand was what to do if a door alarm was going off in the facility. She stated they emphasized the importance of going to the door immediately and checking for any residents at the door. She stated if a resident with a wander guard was still at the door and the door was still locked to re-direct the resident away from the door. She stated but if the door alarm was going off and the door could open, it was vital to go outside, and look for the resident. She stated if no resident was found outside, she was to inform staff to start a resident head count. She stated the second topic was where to find all the policies and procedures in the building. She stated there was a new binder at the nurse's station that contained all the policies and procedures for given situations. She stated also within the binder were all the codes for all the doors in the building. During an interview on 12/7/24 at 10:30 am, LVN D (Night Nurse) stated before he was allowed to work last night he had to go through a few trainings. He stated he used to be an agency nurse, but now worked full time for the facility. He stated he forgot his phone at work, so he was here at this time. He stated most of the trainings were related to door alarms in the facility. He stated if an alarm was going off in the facility, he was to immediately check the door. He stated if the resident that set off the alarm was still in the area and the door was still locked then he was to re-direct the resident from the door. He stated however, if the door alarm was going off and the door opens, even if there was a resident with a wander guard standing next to the door, he was to go outside the facility and look around the building. He stated if no resident was found outside, he was to turn off the door alarm, make sure the door locks, and get with all the staff to do a resident head count. He stated he was also in-serviced on a new binder that would be at the nurse's station. He stated the new binder contained all the door codes and alarms. He stated the binder also contained all the policies and procedures given for different situation, like a quick reference guide. He stated other than that the last in-service was related to abuse/neglect. He stated it went over what to look for, how to react, and who to report to if he were to witness anything like that. During an interview on 12/7/24 at 10:35 am, RN A (Day Nurse) she stated there were 3 total in-services. She stated there was training about elopement and risk of elopement for residents in the facility. She stated, for example if there was a door going off in the facility to immediately go and check the door. She stated if the resident who set the alarm off was still standing there, to redirect the resident. She stated however if there was no resident at the door and the alarm was sounding, she would exit the facility. She stated she would search the surrounding area for any possible residents. She stated she would return inside and start a head count of all residents in the facility. She stated if there was no resident found, to turn the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 2 (Resident #54, Resident #52) of 6 residents reviewed. 1. The facility failed to provide supervision for Resident # 54, who had a history of exit seeking behaviors, to prevent her from eloping from the facility on 11/17/24. 2. The facility failed to ensure that smoking materials (lighters, cigarettes) were not stored properly for 1 (Resident #52) of 17 residents listed as smokers. An Immediate Jeopardy (IJ) was identified on 12/6/24. The IJ template was provided to the facility on [DATE] at 2:45 pm. While the IJ was removed on 12/7/24, the facility remained out of compliance at a level of potential for more than minimal harm and a scope of pattern, because all staff had not been trained on door codes, what to in case of door alarms, and procedure for a resident elopement. These failures could affect residents who were identified as elopement and smoking risks and placed them at risk of serious bodily harm, physical impairment, or death. The findings included: Record review of Resident #54's, face sheet dated 12/9/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #59 had diagnoses which included hypertensive heart disease, hypertension, muscle weakness, schizoaffective disorder, bipolar type, and reduced mobility. The face sheet indicated Resident #54 was discharged on 11/29/24 to another nursing facility. Record review of Resident #54's quarterly MDS dated [DATE] revealed she had a BIMS of 00, which indicated severe cognitive impairment. Resident #54 required supervision and wore a wander guard. During an observation of facility video dated 11/17/24 indicated Resident #54 exited facility by pushing on 15 second emergency exit (alarm sounding) at 7:03:00 pm. Resident #54 was wearing a t-shirt, pajama pants and tennis shoes. CNA A arrives at door at 7:11:20 pm exits the building. CNA A was viewed entering back into building at 7:11:50 pm indicated 30 seconds elapsed looking for Resident #54. Upon entering back into building at 7:11:50 CNA A turned off door alarm and does not do a head count of all residents. Record review of progress note of Resident #54 dated 11/18/24 at 12:10 am by ADON LVN . indicated, this ADON LVN received a call regarding resident at 9:46 pm asking if we had a resident by the name of Resident #54. ADON LVN enquired about how resident had come to be at apartment. ADON LVN also brought resident back to facility and facilitated safe return and delegated that agency nurse perform skin assessment and assign one on one monitoring and fill out event for elopement. CNA asked to assist resident out of wet clothes get into dry bed clothes. No injuries or wounds noted. Resident placed on 1 on 1. ADON LVN spoke to CNA A and MD to report elopement and subsequent actions. Resident denies pain or discomfort and just wishes to go to bed. No acute distress noted. During an interview on 12/5/4 at 3:15 pm, Motp A stated that on 11/17/24 at roughly 9:15 pm her son came inside and said there was a lady wandering out on the road and in the apartment complex. She stated, he stated she looked lost and confused because she was walking in a circle. She stated, let's go get her. She stated her son went back out in the rain and dark and finally found her and brought her back to the apartment. She stated Resident #54 seemed confused, was cold and shivering. She stated Resident #54 was only wearing a t-shirt, pajama pants and tennis shoes. She stated she wrapped Resident #54 in a towel and did not recognize her as any of her neighbors. She stated that her son went and got the apartment manager Motp B to see if she knew who Resident #54 was. She stated when Motp B showed up they asked Resident #54 some questions and then they found the wander guard on Resident #54's leg. She stated when they found the wander guard, they realized that Resident #54 was probably from the nursing facility across the street. She stated Motp B called the facility and ADON LVN came and picked Resident #54 up. During an interview on 12/5/24 at 3:45 pm, Motp B stated Motp A's son came to her apartment and stated he saw someone in the parking lot out on the road kind of wandering and walking in a circle out there. She stated it was dark and raining. She stated her primary concerns was to not let her go to highway off the road because they have been having issues with drag racers on that road. She stated that Motp A's son told her they found Resident #54 was wandering and took her inside their apartment. She stated when she got to their apartment Resident #54 was sitting on the couch and wrapped up in a towel and shivering. She stated Resident #54 was wearing a t-shirt, pajama pants, and tennis shoes. She stated she tried to ask Resident #54 her name and where she was from but Resident #54 told her another town and her name. She stated when she came back to the living room Motp A told her she believed the woman was hurt. She asked Motp A why and Motp A told her she had a bandage on her leg. She stated she went to Resident #54 and asked her if she was hurt and if she could look at her leg. She stated that was when she found Resident #54 was not hurt but had a wander guard on, and stated to Motp A, I bet she was from that facility across the street. She stated she called the facility and asked if they were missing any residents. She stated the woman who answered (ADON LVN) stated no, what were you talking about. She stated were you missing anyone by the name of Resident #54. She stated ADON LVN replied, oh shit and stated she would be right there to pick her up. She stated ADON LVN did come and picked her up immediately. During an interview at 12/6/24 at 8:40 AM, CNA A stated she was the aid who was in the video. She stated she was helping another resident in their room. She stated when she exited their room, she heard the alarm going off down hallway B. She stated there were two nurses sitting at the nursing station not doing anything. She stated she was not sure how long the alarm had been going off. She stated most of the day, another resident with a wander guard had been setting off the alarm. She stated as she was walking down hallway B and saw the resident and assumed he was the one that set the door off. She stated she went to the door, exited the facility, looked outside, and came back in. She stated she did not see any resident. She stated upon entering back into the building she turned the alarm off. She stated because she saw the other resident, she did not do a head count of the facility for all residents. She stated the two nurses sitting at the nurse's station, stated they did not answer the alarming door because they did not know the codes. She stated that the headcount should have been done for Resident #54's safety. She stated it was lucky that Resident #54 did not get hurt. During an interview on 12/5/24 at 12:40, pm ADON LVN stated the normal protocol for possible elopement was that if an alarm was sounding at any door in the building the individual (employee) goes to the door. She stated they should go outside to look for the resident. She stated if the resident was still there setting off the alarm to remove the resident from the door and then reset the alarm. She stated that she did not know the full story and has not seen the video. She stated that was the door in which Resident #54 exited through. She stated employee CNA A went and looked outside, came back inside, reset the door alarm, and went back to work. She stated that at roughly 9:40 pm the facility received a call from someone outside the facility. She stated they asked her if they had a resident by the name of Resident #54 that stayed in the facility. She stated that they did. She stated the caller informed her that they had her at the apartment across the street. She stated she would come get Resident #54 immediately. She stated she had no idea what Resident #54 was doing or where exactly the resident went for 2 hours and 40 mins. She stated that rounding should be completed every 2 hours on all residents. She stated she was not sure if a head count was completed for the entire facility on the 17th at 7pm by employee CNA A. She stated multiple times throughout the day there was another resident activating the front door alarm with his wander guard. She stated because the alarm had gone off so many times during the day, the staff was desensitized to the alarm going off in the building. She stated that normally Resident #54 sits at the nurse's station each night after she gets done walking. She stated she believed the facility would have noticed at some point Resident #54 was missing. She stated when she received the call from MOTP B at 9:40 pm, she had the staff initiate a head count of all residents while she went and picked up Resident #54. She stated when she got back to the facility, Resident #54 was taken to her room, her wet clothing was removed, and she was put to bed. She stated to her knowledge no other residents were reviewed or rounded on because Resident #54 was safe and back in the facility. She stated she did not know there were two nurses sitting at the nurse's station did not even check the door. She stated she was lucky that Motp found Resident #54, it could have been much worse if Resident #54 got hurt. During an interview on 12/6/24 at 11:15 am, ADON LVN stated there was a binder at the nurse's station that has all the door codes and policies/procedures for anyone to pick up and review. During an observation on 12/6/24 at 11:20 am, there were no policies or procedures in the binder only signature sheets of staff that had completed orientation. No door codes were found in the binder. During an interview on 12/6/24 at 11:45 am, the DON stated Resident #54 did exit the building through the fire emergency exit door on hallway B at 7:00 pm on 11/17/24. She stated the video showed CNA A go down to the door, exit the building, return inside the building, and turn off the alarm. She stated she was not sure why CNA A did not do a head count of all residents when she deactivated the alarm. She stated she was not sure why the alarm went off for that long of a time. She stated there were 2 agency nurses working that night. She stated her expectation of a door alarm going off should be acknowledged immediately. She stated if the resident was not by the door, the employee should go outside, do an observation around the facility, and look any resident, if no resident was found outside the employee should let the charge nurse and the DON know immediately. She stated that she knew Resident #54 was picked up and brought back to the facility. She stated a head count of all residents was done at 9:40 pm. She stated that Resident #54 was rounded on every 15 minutes. She stated she did not know if all other residents with wander guards were monitored after the return of Resident #54. She stated that all agency staff should have known to go and check the alarming door. She stated it did not matter if the door codes were known or not by any staff. She stated the residents are the priority and should have been checked on. She stated the ADON LVN does all the trainings for the facility. She stated this should never have happened and the head count should have been done. An Immediate Jeopardy was identified on 12/6/24 at 2:45 pm. The Administrator and DON were informed, and Immediate Jeopardy Template was provided. The Administrator and DON were notified that a Plan of Removal was requested at that time. A Plan of Removal was accepted on 12/7/24 at 6:03 PM and reflected the following: 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #54 returned to the nursing home. Resident was assessed with no injuries. Resident behaving per norm. Increased supervision implemented with Resident #54 which included resident in line of sight of an employee at all times until discharge. Elopement assessment updated. RP & MD informed. (Resident #54 has since been discharged on 11/29/2024 to a secured unit) Person(s) Responsible: Charge Nurse, Assistant Director of Nursing, and/or Designee Date: 11/18/24. 2. How the Facility Identified Other Possibly Affected Residents: Action: Resident head count performed no additional findings. Person(s) Responsible: Charge Nurse and/or Designee Date: 11/17/2024 Action: All residents received an elopement assessment. Residents' current elopement assessment will reflect on their face sheet and care plan. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/18/2024 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Elopement binder reviewed to ensure it matches the current residents who were deemed as elopement risks per their elopement assessments. Person(s) Responsible: Director of Nursing and/or Designee Date: 11/18/2024 Action: Sign on door verified for placement notifying visitors to, Please do not allow residents to follow you out. Person(s) Responsible: Administrator Date: 11/18/2024 Action: Sign posted by keypads stating: When alarms were sounding, and the door was disengaged perform a resident head count. Person(s) Responsible: Director of Regulatory Compliance Date: 11/18/2024 Action: All doors checked for functionality. No concerns noted. Person(s) Responsible: Maintenance Director and/or Designee Date: 11/17/2024 Action: Check for all residents with roam alerts for functionality. No concerns noted. Person(s) Responsible: Administrator and/or Designee Date: 11/18/2024. Action: Elopement drill performed each shift (6a-6p and 6p-6a). Person(s) Responsible: Administrator, Maintenance Director, and/or Designee Date: 11/19/2024 Action: Education provided to direct care staff, to include agency staff, regarding missing resident/elopement & over the facility's abuse & neglect policy. Direct care staff will be educated on the elopement binder, its location, and its contents (shows which residents were elopement risks/wander guard residents). Direct care staff, including agency staff, will know when the door was alarming, to respond to the alarming door immediately. If the door was disengaged (open) and alarming the direct care staff will ensure all residents were in house by performing a head count (signs placed for reminders for staff to ensure all residents were in house when alarms were sounding, and the door was disengaged by keypads). Direct care staff, including agency staff, will know the door codes/door code location through this education. Direct care employees will be educated prior to working their next shift. All new and temporary direct care staff will be educated prior to working. Person(s) Responsible: Administrator and/or Designee Date: 12/6/2024 Action: Residents deemed an elopement risk, that require a roam alert/wander guard will be rounded on every 2 hours to ensure facility was aware of residents' whereabouts. Person(s) Responsible: Charge Nurse, Certified Nurse's Aides, and/or Designee Date: 12/6/2024 4. How the Corrective Actions Will be Monitored, by whom, and for how long: Action: All residents with exit seeking behaviors will be reviewed during clinical meeting to ensure safety. Appropriate supervision will occur until residents with exit seeking behaviors, that have a greater need than the roam alert system, were appropriately placed. No concerns noted. Person(s) Responsible: Director of Nursing and/or Designee Date: 11/17/2024 Action: Elopement drill performed weekly x4 weeks to ensure staff's retention of education to prevent recurrence. Person(s) Responsible: Administrator and/or Designee Date: 11/17/2024 QAPI- Action: Ad hoc QAPI performed with medical director to inform them of the incident and the facility's plan to remove the immediacy. No further direction required. Person(s) Responsible: Administrator Date: 11/18/2024 State Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 12/6/24 to 12/7/24 as follows: Record review of resident assessment: Record review of progress note of Resident #54 dated 11/18/24 at 12:10 am submitted by ADON LVN indicated, this LVN received a call regarding resident at 9:45 pm asking if we had a resident by the name of Resident #54. ADON LVN enquired about how resident had come to be at apartment. ADON LVN also brought resident back to facility and facilitated safe return and delegated that agency nurse perform skin assessment and assign one on one monitoring and fill out event for elopement. CNA asked to assist resident out of wet clothes get into dry bed clothes. No injuries or wounds noted. Resident placed on 1 on 1. ADON LVN spoke to CNA A and MD to report elopement and subsequent actions. Resident denies pain or discomfort and just wishes to go to bed. No acute distress noted. Record review of progress notes of Resident #54 dated 11/17/24 at 10:24 pm submitted by ADON LVN indicated: Resident Refused Skin Assessment: No Temperature--Location, if applicable.: Warm Color--Location, if applicable.: Expected color for ethnicity. Moisture--Location, if applicable.: Dry Skin Turgor: Normal Capillary Refill: Less than 3 seconds Was Resident at risk for developing pressure injuries? No Risk Factors: Moisture, Incontinence Were contractures present? No Alterations in Skin Integrity. Note location of any noted areas. Enter measurements in box provided.: None. Notifications if Applicable: Physician Notified MD, Responsible Resident Representative Notified. Guardian Interventions: No new or additional interventions required at this time. [Corporation] Assessment for Risk of Elopement completed 11/18/24. Indicated yes to all: Does the resident have a diagnosis of Dementia, OBS, Alzheimer's, I/DD, Delusions, Hallucinations, Anxiety, Depression, Schizophrenia, or other Mental Illness? Yes Does the resident ambulate independently, with or without the use of an assistive device (i.e., walker, cane, or wheelchair)? Yes If the resident has wandering behavior, was it tied to resident's past (i.e., their prior work, takes long walks, seeking someone they cannot find)? Yes Was the resident ambulatory (able to walk without someone assisting them) yet cognitively impaired with poor decision-making skills (i.e., intermittent confusion, cognitive deficits, appears disoriented)? Yes Has the resident verbally expressed the desire to go home, packed belongings to go home, talked about going on a trip, or stayed near an exit door? Yes Does the resident have a history of leaving the facility without Informing staff? Yes Does the resident wander without a sense of purpose (i.e., confused, moves aimlessly, may enter other resident rooms, and explore their belongings)? Yes Record review of observations initiated by the facility on 11/17/24 at 10:07 pm of Resident #54 for increased rounding indicated: times starting at 10:07 pm and every 15min interval after that with sign off sheet until 11:45 pm. Sheet dated 11/18/24 had monitoring every 15min, all day long, no time was missed, signatures provided. Sheet dated 11/19/24 had monitoring every 15min up until 12:00 pm. Record review of facility Resident head count dated 11/17/24 at 9:40 pm indicated all residents were in the building except Resident #54. At which time ADON LVN was going to pick up Resident #54. Record review of the facility Resident observation summary report for all residents dated 11/17/24 to 11/19/24 completed for [corporation] assessment for risk of elopement for all residents in the facility completed daily by all nurses in the facility. Record review of door checks (door locking mechanism) log sheet dated 11/11/24 to 11/15/24 all indicated a pass. Door check log sheet dated 11/18/24 all indicated a pass. Record review of Code Pink drill documentation form dated 12/6/24 at 5:02 pm indicated all staff acted correctly. Signature pages presented. Record review of Code Pink drill documentation form dated 11/27/24 indicated all staff acted correctly. Signature pages presented. Record review of drill dated 11/19/24 time stamped 5:30 am indicated: The Administrator hid as an unaccompanied resident which would activate a missing resident situation. Informed staff that we were looking for an unaccounted resident. Verbally alerted staff to the Code Pink status. Staff immediately met at the Nurses Station and received direction from the charge nurse to begin looking for a missing resident. Staff searched all hallways/rooms/dining area/lobby, and closets. Within 5 minutes the Mock resident was found in the kitchen. Signed and dated by the Administrator. Record review of drill dated 11/18/24 time stamped 5:00 pm indicated: The Maintenance Director chose an employee to hide as an unaccompanied resident which would activate a missing resident situation. Informed staff that we were looking for an unaccompanied resident. Verbally alerted staff to Code Pink status. Staff immediately met at the Nurses Station and received direction from the charge nurse to begin looking for missing resident. Staff searched all hallways/rooms/dining area/lobby, and closets. Within 3 minutes the Mock resident was found in the Beauty Shop. Signed and dated by the Maintenance Director. Record review of Ad hoc QAPI meeting dated 12/6/24 indicated: An ad hoc QAPI meeting was performed with the MD to review the incident regarding Resident #54. The MD was agreeable with the plan of action. The MD completed a telehealth visit with Resident #54 with no concerns. Record review on 12/8/24 of Agency orientation to the facility book and for the rest of the staff, located at nurses' station, binder contained: policy's abuse, neglect, and exploitation, wandering and elopement, comprehensive care plans, advanced directives, change in residents' condition or status, fall prevention program, and resident rights. Binder also contained: Note that stated, door codes-if they do not work, please call the admin or the DON, and then list all door codes for the entire facility for going in or out of the facility. Binder also contained completed orientations of nursing and agency staff. Record review on 12/9/24 of In-service titled visual rotation risk of elopement, led by the Administrator indicated: go into the MAR and check residents that have wander guards. All residents with wander guards were rounded on, the even hours were rounded on by CNA's and odd hours were rounded on by Nurses. The sign off sheet would be reviewed by both the nurses and CNA's when the rounding was completed. Record review on 12/9/24 of in-service titled Door alarm education and elopement policy, instructed by a group of people, but the Administrator did educate. The Administrator stated the education included door alarms, how to react and what to do. He stated the education included elopement, education, and abuse/neglect. He stated that if the alarm was sounding the door should be observed immediately. He stated then if the door opens even with the alarm going off, the employee should go outside, and check the area. He stated the employee should walk the entire facility and check the surrounding area. He stated if no resident was seen/found the employee was to come back inside, turn off the alarm, make sure door was locked, and then inform staff to initiate a head count for the entire facility. He stated that if the door was alarming and the door did not open to look in the surrounding area inside the building to find the possible resident that set the alarm off and redirect the resident from the door. Record review on 12/9/24 of in-service titled abuse, neglect, and exploitation, instructed by ADON LVN completed on 11/18/24. ADON LVN stated that due to the elopement the facility did do an in-service on abuse, neglect, and exploitation. She stated during the education she did go over the whole policy, and she discussed with staff what constitutes as abuse, neglect, and exploitation. She stated she also covered what to do if abuse or neglect were to occur and/or was witnessed in the facility. She stated the process was to report any incident directly to the Administrator because he was the abuse neglect coordinator. During an interview on 12/7/24 at 10:15 am, LVN C (day nurse) stated there were 3 in-services that she could remember but it was basically a big training yesterday while she was on shift. She stated first was elopement and what to do if a door alarm was going off. She stated if a door alarm was going off and opened upon arrival with no resident in site, she would go outside and search the surrounding area. She stated if no resident was found outside, she would return back inside, and inform staff of a possible elopement. She stated she would inform the charge nurse, the DON, or the Administrator of a possible elopement. She stated she would then start a head count of all residents in the facility. She stated there was a binder now at the nurse's station with all the policies and procedures. She stated the binder included abuse neglect, elopement, and other policies and procedures. She stated that one sheet in the book also contained the alarms and codes to all doors in the facility. She stated they also would do rounding on all residents with wander guards every two hours. She stated for abuse/neglect, if she were to witness or observe anything of that nature to separate or remove the resident from the situation, also to immediately inform the Administrator of the incident, and give report to the Administrator. During an interview on 12/7/24 at 10:25 am, CNA B (Day shift) stated she did have to do in-services before she could come on to work today. She stated the categories of the in-services included elopement, where to find guidance, and abuse/neglect. She stated the main topic at hand was what to do if a door alarm was going off in the facility. She stated they emphasized the importance of going to the door immediately and checking for any residents at the door. She stated if a resident with a wander guard was still at the door and the door was still locked to re-direct the resident away from the door. She stated but if the door alarm was going off and the door could open, it was vital to go outside, and look for the resident. She stated if no resident was found outside, she was to inform staff to start a resident head count. She stated the second topic was where to find all the policies and procedures in the building. She stated there was a new binder at the nurse's station that contained all the policies and procedures for given situations. She stated also within the binder were all the codes for all the doors in the building. During an interview on 12/7/24 at 10:30 am, LVN D (Night Nurse) stated before he was allowed to work last night he had to go through a few trainings. He stated he used to be an agency nurse, but now worked full time for the facility. He stated he forgot his phone at work, so he was here at this time. He stated most of the trainings were related to door alarms in the facility. He stated if an alarm was going off in the facility, he was to immediately check the door. He stated if the resident that set off the alarm was still in the area and the door was still locked then he was to re-direct the resident from the door. He stated however, if the door alarm was going off and the door opens, even if there was a resident with a wander guard standing next to the door, he was to go outside the facility and look around the building. He stated if no resident was found outside, he was to turn off the door alarm, make sure the door locks, and get with all the staff to do a resident head count. He stated he was also in-serviced on a new binder that would be at the nurse's station. He stated the new binder contained all the door codes and alarms. He stated the binder also contained all the policies and procedures given for different situation, like a quick reference guide. He stated other than that the last in-service was related to abuse/neglect. He stated it went over what to look for, how to react, and who to report to if he were to witness anything like that. During an interview on 12/7/24 at 10:35 am, RN A (Day Nurse) she stated there were 3 total in-services. She stated there was training about elopement and risk of elopement for residents in the facility. She stated, for example if there was a door going off in the facility to immediately go and check the door. She stated if the resident who set the alarm off was still standing there, to redirect the resident. She stated however if there was no resident at the door and the alarm was sounding, she would exit the facility. She stated she would search the surrounding area for any possible residents. She stated she would return inside and start a head count of all residents in the facility. She stated if there was no resident found, to turn the alarm off upon entering the facility, make sure the door locks, and then do a head count of the entire facility of all residents. She stated another in-service covered the new binder at the nurse's station. She stated the new binder had all the policies and procedures for quick referencing. She stated there were also a sheet that had all the codes for all the doors in the facility. She stated another part of the training included rounding on all elopement risk residents in the facility every 2 hours. During an interview on 12/7/24 at 10: CNA C (night shift) stated before she could start working for the day she was in-serviced on a few different topics. She stated the first topic was elopement. She stated the primary key in this in-service was when a door was alarming, was the door still locked or could the door be opened. She stated if the door was still locked, she was to re-direct the resident that set off the alarm away from the door. She stated but if the door could be opened, she would inform the nurse or charge nurse and then go outside the facility to do a walk around. She stated if she was to return to the facility without seeing any residents, she would inform the charge nurse or nurse and a resident head count would be initiated. She stated the other new thing, which she felt was a great idea, was a new binder at the nurse's station. She stated in the binder was the policies and procedures for different events that could occur in the facility and what to do if they were to occur. She stated that also in the binder were all the codes to all the doors in the facility. She stated lastly there was an in-service on abuse/neglect. She stated it covered what to look for in given situations, who to report to, and what to do. The Administrator were informed the Immediate Jeopardy was removed on 12/07/2024 at 1:33pm. The facility remained out of compliance at a severity level of at potential for more than minimal harm that was not immediate and a scope of a pattern due to the facility's need to evaluate the effectiveness of their corrective actions that were put into place. Record review of Resident #52's electronic face sheet revealed a [AGE] year-old male admitted [DATE]. Diagnoses included liver cell carcinoma (liver cancer), personal history of other mental and behavioral disorders, bipolar (episodes of mood swings ranging from depressive lows to manic highs), nicotine dependence, anxiety disorder, and chronic pain. During an observation on 11/18/2024 at 11:05 AM Eight residents were exiting a door in the dining room to the designated smoking area with the MD supervising and handing out cigarettes to each resident and lighting the cigarettes for each resident. Resident #52 was observed lighting his own cigarette with a cigarette and lighter in his possession. The MD did not prov[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 3 (Resident #1, Resident #2, and Resident #3) of 6 residents reviewed for multiple falls. The facility failed to implement appropriate interventions for Resident #1 to prevent 5 falls within 19 hours from [DATE] at 12:30pm to [DATE] at 7:30am, that lead Resident #1's Family Member B calling 911, which resulted in hospitalization with diagnoses of subarachnoid hemorrhage (brain bleed) and L3 fracture (lumbar spine fracture) which resulted in death on [DATE]. The facility failed to identify fall risk or implement any interventions in the Plan of Care for Resident #2 who was a known fall risk and had falls on [DATE] and [DATE]. The facility failed to identify fall risk or implement any interventions in the Plan of Care for Resident #3 who was a known fall risk and had fall on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:07 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. These failures could place the residents at risk for falls, serious injuries, hospitalizations, and death. Findings include: Resident #1 Review of Resident #1's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: heart disease, COPD (lung disease), intervertebral disc degeneration of lumbar region, anxiety, and syncope (fainting) & collapse. Review of Resident #1's electronic records revealed no evidence of completed MDS and Baseline Care Plan. Review of Resident #1's referral paperwork from Hospice to the facility, dated [DATE], revealed: Brief Narrative Statement: . In the last six months, this patient has continued to show decline as evidenced by increased weakness. He continues to have falls related to episodes of syncope. Review of Resident #1's electronic progress note, dated [DATE] 11:50 AM, signed by ADON, revealed: Resident arrived to the facility via facility van, accompanied by family and hospice nurse. resident was weighted on arrival and was offered lunch but refused. resident is not happy to have a roommate and is trying to leave facility. resident's [family member B] is sitting with him to help residents' anxiety. resident was showed around the facility and around his room. Review of Resident #1's electronic progress note, dated [DATE] 12:30 PM, signed by ADON, revealed: Resident was found on the floor by this nurse and the residents [family member B]. Resident was helped back to his wheelchair with the help of a gait belt and two other aides. resident was then brought to the nurse's station and was accompanied by [family member B]. Residents' family member B has asked about restraints and sedatives. nurse educated that restraints are not allowed and that the resident would not be sedated. Review of Resident #1's Morse Fall Scale dated [DATE] at 1:51 PM, signed by ADON revealed score 75% indicating high fall risk. Review of Resident #1's electronic physicians orders revealed: alprazolam (Xanax- sedative for anxiety)) 2mg 1 tablet oral twice a day 12:00 pm- 2:00 pm, 8:00 pm- 10:00 pm; tramadol (narcotic for pain) 50mg 1 tablet oral twice a day 12:00 pm, 9:00 pm; tramadol 50mg 2 tablets twice a day 5:00 am, 4:00 pm. Further review of electronic physicians' orders revealed: tramadol 50 mg 1 tablet oral immediately ordered on [DATE] at 2:18 am and alprazolam 2 mg 1 tablet oral immediately ordered on [DATE] at 2:00 am. According to the Drugs.com website, https://www.drugs.com accessed on [DATE] revealed, Xanax may cause some unwanted effects including: clumsiness or unsteadiness, difficulty with coordination, and lightheadedness. According to the Drugs.com website, https://www.drugs.com accessed on [DATE] revealed, Tramadol may cause some unwanted effects including: change in walking and balance, dizziness, and fainting. Review of Resident #1's electronic MAR, dated [DATE], revealed Xanax 2mg was administered at 2:14 pm on [DATE]. Further review of electronic MAR revealed tramadol 50mg 2 tablets was administered between 4:00-5:00 pm on [DATE]. Review of Resident #1's electronic progress note, dated [DATE] 06:56 PM, signed by ADON, revealed: resident had a fall hospice was notified awaiting call back and resident's family member C was notified. Residents' family member B did not answer the phone at this time. Further review of progress notes, dated [DATE] 6:59 PM, revealed: spoke with hospice and she will be on the way. resident is at the nurse's station and is be watched closely. Review of Resident #1's electronic progress note, dated [DATE] 07:00 PM signed by LVN A, revealed: This nurse was called to the dining room by the laundry staff. upon walking in, the resident was found sitting on the floor leaning up against the wall. the patient had a head laceration to the right side of the forehead. another LVN on shift went to get proper supplies to apply pressure to the wound, while this nurse checked vitals. pt was assisted back to the chair with the assistance of 3 staff. This nurse took the resident to the treatment room and continued to hold pressure. Hospice was notified and is sending a nurse out. This nurse chose to apply an ice pack to reduce swelling until hospice arrives. Review of Resident #1's electronic progress note, dated [DATE] 07:02 PM, signed by ADON, revealed: nurse spoke DON she is aware of the fall with head injury. nurse has spoken with [Facility Medical Director] he is aware and asked to be updated with what hospice nurse decides. Review of Resident #1's Post-Fall Progress Note, dated [DATE] 08:54 PM, (regarding fall at 6:56 pm on [DATE]) signed by LVN A, revealed: Post-Fall Follow-up: . Interventions: Bed in Low Position, Toileting Offered, Other 2: call light within reach Resident Response to Fall Interventions: Current Interventions are Effective. Review of Resident #1's electronic progress note, dated [DATE] 08:59 PM, signed by LVN A, revealed: Hospice in to see resident. resident's forehead was cleaned and steri-striped and covered with a bandage. no new orders at this time. neuros are continued. Review of Resident #1's electronic MAR, dated [DATE], revealed tramadol 50 mg 1 tablet and Xanax 2mg 1 tablet was administered at 9:37 pm on [DATE]. Review of Resident #1's electronic progress note, dated [DATE] 02:07 AM, signed by LVN B, revealed: Resident found in bathroom on floor with head in toilet, noted to have a new head lac about 3cmx0.5cm on right eyebrow. Applied pressure until bleeding stopped. Assisted resident back into bed, vitals taken at this time and within normal limits besides residents BP which was 205/103 and instructed him to use call light if he needs assistance. Also lowered bed into lowest position and turned ion bathroom light for more visibility. Hospice notified of fall and injury, and also that resident had persistent high BP and Hospice Nurse gave an order for a one-time Xanax 2mg po. Given and tolerated well. Attempted to notify residents [family member C] and left a voicemail, attempted to call [family member B], and went straight to voicemail, awaiting a call back. Review of Resident #1's electronic MAR, dated [DATE], revealed tramadol 50 mg 1 tablet and Xanax 2mg 1 tablet was administered between 02:00-3:00 am on [DATE]. Review of Resident #1's Post-Fall Progress Note, dated [DATE] 02:27 AM, signed by LVN B, revealed: Interventions: Bed in Low Position, Toileting Offered, Bell to Ring for Assistance When Out of Room, Night Light added in Bathroom. Resident Response to Fall Interventions: Current interventions are Somewhat Effective. Review of Resident #1's electronic progress note, dated [DATE] 04:03 AM, signed by LVN B, revealed: Resident found in bathroom floor on back. No new injuries noted at this time. Assisted resident back to bed and instructed to use call light for assistance. Resident then rolled towards the wall and started snoring. This nurse notified hospice and [Facility Medical Director] of this fall neither had any new orders. Review of Resident #1's Post-Fall Progress Note, dated [DATE] 04:04 AM, signed by LVN B, revealed: Interventions: Bed in Low Position, Toileting Offered, Non-Skid Slippers, Bell to Ring for Assistance When Out of Room, Night Light added in Bathroom. Resident Response to Fall Interventions: Current Interventions are Not Effective. Referred to Interdisciplinary Team for Further Recommendations. Review of Resident #1's electronic MAR, dated [DATE], revealed tramadol 50 mg 2 tablets was administered at 4:10 am on [DATE]. Review of the Facility Event Summary Report revealed Resident #1 had an unwitnessed fall in his bedroom on [DATE] at 07:00 am. Review of electronic progress notes revealed no evidence of documentation related to fall. Review of Resident #1's electronic progress note, dated [DATE] 07:00 AM, signed LVN C, revealed: Resident very restless and continues to try and get out of wheelchair. Multiple hematomas to midline of forehead. No bruising noted at this time. 2cm skin tear to right mid forehead. Hospice called this AM to attempt to get resident PRN anxiety medication. Hospice to call back with further instruction. Review of Resident #1's electronic progress note, dated [DATE] 07:45 AM, signed by LVN C, revealed: Called residents [family member C] this AM to notify her of behavior and changes to Resident #1. Residents' [family member C] voiced that he had been very difficult to take care of at home and that he kept having repetitive falls and that is why we brought him to you guys. This nurse acknowledged that he had several falls since admission yesterday afternoon and that this nurse was attempting to get medication changes from hospice to hopefully keep his anxiety under control. Residents' [family member C] voiced understanding and agreed that Resident #1 needed the med changes. No new orders at this time. Review of Resident #1's electronic progress note, dated [DATE] 11:30 AM, signed by DON, revealed: Hospice in facility with new order for Ativan .5mg 1 or 2 tabs every 4 hours for anxiety. Resident #1 placed on one-to-one supervision @ 0740 this AM due to increased attempts to get out of wheelchair. Dose of Ativan administered immediately once received at 1100 am. Resident appeared content once one to one was put into place. Resting peacefully in chair with no attempts to get out of chair. Review of Resident #1's hospital clinical record, dated [DATE], revealed: Admitting Diagnosis: Subarachnoid hemorrhage (brain bleed) and L4 vertebral fracture. Resident is going to go to inpatient hospice unit for further care. During an interview on [DATE] at 11:55 am, Residents #1's family member A stated Resident #1 was admitted to the facility under hospice services because he was falling too much at home. Resident #1's Family member C could not take care of him. He stated the facility was fully informed as to Residents #1's fall risk and it was discussed thoroughly. He stated the facility called Resident #1's Family member C at 1:30 am on [DATE] and left a voicemail stating they needed to update her on Resident #1's condition. He stated Resident #1's Family member C tried to return the phone call from 6:30 am until 9:30 am on [DATE], with no answer from the facility. He stated Resident #1's Family member B arrived at the facility at 12:30 on [DATE] and saw Resident #1, with multiple lacerations and bruises to his forehead and top of head, and very lethargic and confused she called 911 and Resident #1 left in an ambulance and went to the emergency room. He stated Resident #1 was admitted to inpatient hospice the next day. He stated resident was diagnosed with brain bleed and L4 fracture. During an interview on [DATE] at 12:10 pm, Resident's #1's family member B stated Resident #1 had fallen while she was in the facility, and she spoke with the facility concerning residents' risk for falls. She stated when Resident #1 was admitted he could communicate. She stated when she arrived at the facility at 12:20 pm on [DATE], Resident #1 was lethargic and mumbling. She said Resident #1's Family member C was only contacted one time at 1:30 am on [DATE] regarding the falls. She stated Resident #1's Family member C spoke to a nurse who was extremely rude at 7:00 am who stated Resident #1 had fallen 12 times and the facility could no longer take care of him. She stated when she arrived at the facility at 12:30 pm an [DATE] and saw Resident #1 with multiple lacerations and bruises to his forehead and top of head, and very lethargic and confused Resident #1 was, she called 911. Resident #1's Family member B stated she was not notified of any of the falls, and she felt as if the facility should have called her when Resident #1's Family member C did not answer. During an interview on [DATE] at 12:40 pm, the DON stated Resident #1 was admitted on Friday [DATE] from home with hospice services. She stated the facility was not aware of the extent of residents falls and behaviors. She stated Resident #1 fell right after arriving to the facility while the family was present. She stated the family then informed her of the extent of resident's multiple falls. She stated the family was requesting 1:1 supervision and she informed the family that the facility could not provide that type of service. She stated she was notified of the fall Friday evening at 6:45 pm and notified the medical director. She stated the medical director originally stated to send him to the emergency room but after realizing the resident was on Hospice services, he told her to contact hospice and let them take the lead. The DON stated she was notified of the fall at 7:00 am on [DATE], and that the resident had had multiple falls through the night, and she placed the resident on 1:1 supervision at that time. During an interview on [DATE] at 12:50 pm, the ADON stated Resident #1's family wanted 1:1 supervision after Resident #1's first fall at 12:30 pm on [DATE], and she informed the family that the facility was not capable of providing that service. The ADON stated that resident flipped over in his wheelchair and landed headfirst possibly causing the first top of the head bruise and swelling at 6:45 pm on [DATE] The ADON stated intervention put in place was sitting resident at the nurses' station and keeping him in line of sight. She stated she was notified of every fall. The ADON stated resident was not at the nurse's station or in line of sight when he fell in the dining room. She said staff were passing trays and could not continuously monitor him. She stated after Resident #1's fall at 6:45 pm on [DATE], the intervention she put in place was resident be placed back in line of sight at the nurses' station. The ADON stated the forehead abrasion was caused by resident hitting the wall and he had glasses on. The ADON stated after the fall at 7:00 am on [DATE], she decided to place the resident on 1:1 supervision. During an interview on [DATE] at 4:30 pm, LVN B stated she arrived for her shift at 6:00 pm on [DATE], and the facility was chaotic. She stated there were too many nurses scheduled and not enough CNAs. She stated no one knew who was responsible for which residents. She stated Resident #1 was not at the nurse's station when she arrived. She stated Resident #1 fell in the dining room around 6:45 pm on [DATE], but she didn't handle the fall as she had not gotten report yet. The LVN stated she was given the medication cart keys and told what hall to pass medications on and she did not receive a report. She stated around 8:00 pm on [DATE], she was told Resident #1 had had 2 falls but was not given a report as to his condition or any increased supervision or interventions. She stated Resident #1 was falling asleep in his wheelchair around 1:00 am on [DATE] and was placed in bed in low position. She stated she notified family, hospice, and ADON of each fall and was not given any extra instructions regarding fall interventions. During an interview on [DATE] at 9:00 am, Resident #1's family member A stated Resident #1 had passed away that morning on [DATE], on hospice services. He stated the justice of the peace officer stated cause of death was subarachnoid hematoma from falls. During an interview on [DATE] at 9:00 am, the DON stated she should have identified the extent of Resident #1's fall risk after the initial fall and should have immediately initiated a care plan with more appropriate interventions. She stated she was not notified of the multiple falls throughout the night until she arrived the next morning. The DON stated all nurses on shift during the incidents were agency nurses who were new to the facility and were not aware of her expectations. She stated she expected her nurses to notify her of each incident at the time they occurred. She stated she should have been more aggressive with the admission and researched the resident prior to admission. During interview on [DATE] at 10:00 am, the Administrator stated she was not aware of Resident #1's fall risk prior to admission. She stated she did not see the referral note regarding falls because it was in a little section at the bottom. She stated placing Resident #1 at the nurse's station was not really an appropriate intervention due to the lay out of the nurse's station. The Administrator stated you could not see the resident from every angle of the nurse's station and most staff were not at the nurse's station because they were working up and down the halls. The Administrator stated educating Resident #1 on the use of the call light was not an appropriate intervention due to the resident being medicated with sedatives and having an impaired cognitive status. She stated she planned on educating her staff of implementing more appropriate interventions. Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on [DATE] with diagnoses to include: repeated falls, muscle weakness, anxiety, and depression. Review of Resident #2's Quarterly MDS assessment, dated [DATE], revealed BIMS score (09) which indicated moderate cognitive impairments and Section J Health Conditions revealed: 0 falls since admission or prior assessment. Review of Resident #2's Comprehensive Care Plan, initiated [DATE], revealed no evidence of falls or fall risk. Review of Resident #2's Morse Fall Scale dated [DATE] at 12:00 PM, signed by LVN D revealed score 55% indicating high fall risk. Review of the Facility Event Summary Report revealed Resident #2 had an unwitnessed fall on [DATE] documented at 8:34 am and [DATE] documented at 05:43 am. Review of Resident #2's electronic progress note, dated [DATE] 04:49 PM, signed by LVN E, revealed: Heard resident yelling Help x4 staff went rushing into room resident noted to be laying on back side assessment completed VS obtained Neuros initiated ROM x 4 extremities without limitations x1 staff assisted resident to bed denies hitting head no visible injuries noted notified [Facility Medical Director] notified DON notified RP verbalized understanding denies pain denies needs care is ongoing. Further review of electronic progress notes did not reveal any documented evidence of fall on [DATE]. Observation of Resident #2 on [DATE] at 2:30 pm, sitting in wheelchair in dining room with houseshoes on her feet. No issues noted. Resident #3 Review of Resident #3's electronic face sheet revealed a [AGE] year-old female admitted to facility on [DATE] with diagnoses to include: Hemiplegia, unspecified affecting right dominant side (paralysis), muscle weakness, anxiety, and lack of coordination. Review of Resident #3's Quarterly MDS assessment, dated [DATE], revealed BIMS score (13) which indicated no cognitive impairments and Section J Health Conditions revealed: 0 falls since admission or prior assessment. Review of Resident #3's Comprehensive Care Plan, last reviewed [DATE], revealed no evidence of falls or fall risk. Review of Resident #3's Morse Fall Scale dated [DATE] at 12:34 AM, signed by LVN H revealed score 70% indicating high fall risk. Review of the Facility Event Summary Report revealed Resident #3 had an unwitnessed fall on [DATE] documented at 04:21 am. Review of Resident #3's electronic progress note, dated [DATE] 02:47 AM, signed by LVN I, revealed: Resident's roommate told this nurse that resident was sitting on the floor. Found resident sitting on the floor in her bathroom next to wheelchair. Resident transferred to wheelchair. Vitals taken. No injuries related to fall. Resident denies pain. Observation of Resident #3 on [DATE] at 2:40 pm, resting in bed in high position. Room appeared cluttered and wheelchair was beside residents bed. During an interview on [DATE] at 10:45 am, the DON stated there had been some confusion and miscommunication regarding care plans and staff's individual responsibilities. She stated she was under the impression that the floor nurses were to update care plans with acute and new issues. The DON stated the MDS coordinator was then responsible for completing the comprehensive care plan after completing the MDS. The DON stated Resident #2's baseline care plan was started by herself but for some reason the document did not submit, and she was not aware. The DON stated the baseline care plan would have triggered the fall risk and then the MDS coordinator would have added the care area of fall risk to the comprehensive care plan. The DON stated that she had recently learned that the facility staff did not know they could complete baseline care plans or add to the comprehensive care plans and thought that only the DON could. The DON stated that all acute concerns and new falls should be added to the comprehensive care plan with appropriate interventions after a resident falls and with each fall thereafter. The DON stated Resident #2 and Resident #3 should have had fall risk with interventions in place on the care plan since they were both high fall risk and had had falls in the facility. The DON stated she was ultimately responsible to ensure completion and accuracy of care plans. During an interview on [DATE] at 3:20 pm, the MDS Coordinator stated she was not responsible for acute issues or any new areas of concerns. She stated she only added care areas to the comprehensive care plan that were triggered from the MDS completion. She stated that when completed quarterly care plan reviews, she only ensured that all care areas triggered by MDS were in place. During an interview on [DATE] at 3:30 PM, the administrator stated she would have a meeting and address the care plan miscommunication. She stated the facility had a morning clinical meeting every day and at that time all new concerns including falls should be addressed and added to the care plan. The Administrator did not state who would be responsible for this responsibility. She stated it was ultimately her responsibility to ensure that care plans were accurate and being completed correctly. During an interview on [DATE] at 3:40 pm, the Director of Clinical Operations stated that comprehensive care plans were a complete overview of resident's care and needs. She stated the MDS Coordinator should not have just added triggered care areas but should have completed a comprehensive thorough overview of the resident and all concerns when performing a care plan review. She stated education would be provided. Review of the facility policy titled, Falls and Fall Risk Managing, revised [DATE], revealed in part: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of the facility's policy Care Plans, Comprehensive Person-Centered revised [DATE] revealed: The comprehensive, person-centered care plan will: A. include measurable objectives and time frames; B. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; C. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . E. Include the resident's stated goals upon admission and desired outcomes G. Incorporate identified problem areas; H. Incorporate risk factors associated with identified problems . Reflect treatment goals, timetables and objective in measurable outcomes; L. Identify the professional services that are responsible for each element of care; M. Aid in preventing or reducing decline in the residents functional status and or functional ; N. Enhance the optimal functioning of the resident by focusing on a rehabilitative program, and O. Reflect current recognized standards of practice for problem areas and conditions . Care plan interventions are chosen only after careful data gathering, proper sequence of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator was notified on [DATE] at 2:07 pm that an Immediate Jeopardy was identified, and a Plan of Removal was requested at that time. The Administrator was provided with the IJ template on [DATE] at 2:07 pm. The following Plan of Removal was accepted on [DATE] at 11:24 am and included: Plan of Removal: 689: Accidents, Hazards, Supervision & Devices Failure Statement: Resident #1 had 5 falls within 19 hours until the facility implemented 1:1 supervision from [DATE] at 12:30pm to [DATE] at 7:30am. All residents who currently reside at the facility that are fall risks can be affected by this deficient practice and any future admissions that have a history of falls. Action: admission Policy and Fall Policy reviewed by Chief Clinical Officer. Current policies do not require any changes at this time. Charge Nurses, CNAs, Administration to be educated on admission Policy and Fall Policy. Person(s) Responsible: Chief Clinical Officer Date: Start: [DATE] End: [DATE]. Action: Review all residents fall risk assessments to ensure they are updated and accurately reflect the resident. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: Start: [DATE] End: [DATE]. Action: Director of Nursing, Assistant Director of Nursing, MDS Coordinator, and/or Designee will review care plans for the residents that are triggering as fall risks and place resident centered interventions in the care plans to attempt to avoid a repeat fall. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, MDS Coordinator, and/or Designee Date: Start: [DATE] End: [DATE]. Action: Administrator, Director Nursing, and Admissions Coordinator educated regarding obtaining fall risk information prior to admission or at admission in order to accurately perform a fall risk assessment and to ensure resident centered interventions are in place to attempt to prevent falls and communication to the nursing staff on residents being admitted that are fall risks and interventions being initiated. Person(s) Responsible: Director of Clinical Practice Date: Start: [DATE] End: [DATE]. Action: Educate Charge Nurses and CNAs over resident person-centered interventions for falls. Education to include what to do if a resident hits their head and/or cannot voice if they hit their head (initiate neuro checks per policy, notify MD, watch for changes from baseline, etc.) Education to include notifying the MD, Director of Nursing and/or Assistant Director of Nursing, and/or the Administrator with multiple falls on a shift/day. Test will be distributed to evaluate the effectiveness of the education. All Charge Nurses, permanent and temporary, will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: Start: [DATE] End: [DATE]. Action: Educate CNAs and Nurses on resident profile that will alert staff of a resident that is a fall risk, interventions will also be located in the resident profile located in the electronic medical record. CNAs and Charge Nurses will complete a return demonstration on pulling the resident profile and where to view interventions. Educate CNAs and Charge Nurses over the definition of line of sight which is within eyesight of a staff member. All CNAs and Charge Nurses, permanent and temporary, will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: Start: [DATE] End: [DATE]. Action: A review of all admissions for potential fall risk will occur prior or at admission. These will be documented x4 weeks to include: Name of Admission, Date of Admission, History of Falls: Y or N, If yes- Interventions to Immediately Occur Upon Admission, CP Reflecting Interventions. Fall risk assessments are completed upon admission, if a resident triggers as a fall risk a care plan will be initiated with person centered interventions. Person(s) Responsible: Administrator and Director of Nursing Date: Start: [DATE] End: [DATE]. Action: Ad hoc QAPI to inform Medical Director of the IJ template for 689 and to educate the medical director that he/she will be consulted regarding all residents, including hospice residents. Person(s) Responsible: Administrator Date: Start: [DATE] End: [DATE]. Monitoring of the facility's Plan of Removal through observations, interviews, and record reviews from [DATE] at 11:25 am through [DATE] at 3:10 pm revealed: Reviewed in-service information and signature sheets for in-service titled, Falls and Fall Risk, Managing. Information included: admission policies, fall policies, and admission checklist. Verified 20 employee signatures. Comparison of schedule from [DATE]- [DATE] including day and night shift revealed all scheduled staff were educated prior to working their next shift. Random interviews with 2 dayshift nurses and 2 dayshift CNAs verified understanding of in-service. Random phone interviews with 2 nightshift nurses and 2 nightshift CNA's verified understanding of in-service titled, Falls and Fall Risk, Managing. During interview with the DON and Director of Clinical Operations stated new Morse Fall Risk assessments were performed on all residents. The facility identified a total of 35 high fall risk residents. During this process 15 residents went from a low fall risk to a high fall risk. Verified list of residents who changed from low fall risk to high fall risk. Random record reviews revealed at least 5 residents had a new Morse Fall Risk Assessment performed on [DATE] which changed resident from a low fall risk to a high fall r[TRUNCATED]