**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to provide the necessary care and services for 1 of 11 (Resident #8) residents reviewed for transfer status. The facility failed to ensure that Resident #8, who was a 2 person assist in May 2025 and was changed to a mechanical transfer on 8/14/2025, did not suffer a decline in mobility. An Immediate Jeopardy (IJ) was identified on 8/15/2025. The IJ template was provided to the facility on 8/15/2025 at 4:45PM. While the IJ was removed on 8/16/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure put residents at risk for decline in activities of daily living, decreased mobility, and serious harm. Findings included: Review of Resident # 8's Face sheet on 8/12/2025 reflected an [AGE] year-old, female admitted to the facility 12/13/2023 with a diagnosis of vascular dementia (dementia caused by problems with the blood vessels in the brain), unspecified abnormalities of gait and mobility (difficulties with walking), and hypertension (high blood pressure). Review of Reentry MDS for Resident #8 dated 2/17/2025 reflected a BIMS score of 15 (indicating no cognitive impairment). Resident #8's ability to move from Lying to Sitting, ability to move from sit to stand, and Toilet transfer is listed as partial/moderate assist. There are no categories of mobility for which Resident #8 had refused to be assessed. Speech Therapy, Physical Therapy, and Occupational Therapy sections reflected 0 minutes for each category for the period prior to last MDS. Restorative Program reflected 0 minutes of restorative therapy for the period prior to last MDS. Review of Reentry MDS for Resident #8 dated 05/22/2025 reflected a BIMS score of 15 (indicating no cognitive impairment). Resident #8's ability to move from Lying to Sitting, ability to move from sit to stand, and Toilet transfer is listed as partial/moderate assist. There are no categories of mobility for which Resident #8 had refused to be assessed. Speech Therapy, Physical Therapy, and Occupational Therapy sections reflected 0 minutes for each category for the period prior to last MDS. Restorative Program reflected 0 minutes of restorative therapy for the period prior to last MDS. Review of Orders for Resident #8 reviewed on 8/13/2025 reflected no order for mechanical lift transfer. Review of Care plan for Resident #8 in EMR (electronic medical record) reflected no problems or interventions related to mobility risks or transfers. Review of Paper Care Plan for Resident #8 reflected a Problem Area, Problem Start Date: 09/20/2024, Category: ADLs Functional Status/Rehabilitation Potential, [Resident #8's] ability to (ADL: e.g., transfer, walk in room, walk in corridor, dress, eat, toilet, maintain personal hygiene) has deteriorated R/T disease process Edited: 05/22/2025 Edited By: [ADON]. Approach section listed, Follow PT/OT/ST recommendations. Edited: 05/22/2025 Edited By: [ADON], Provide assistance for ADL as needed. Edited: 05/22/2025 Edited By: [ADON], Transfer extensive assist 1-2 Edited: 05/22/2025 Edited By: [ADON], and Report any further deterioration in status to physician. Edited: 05/22/2025 Edited By: [ADON]. Problem Area started on 04/29/2024, revised by ADON on 05/22/2025 reflected: [Resident #8] is at risk for skin impairment, age related, impaired mobility. The Approaches listed for the problem area reflected, PT/OT to evaluate for rehab potential. Edited: 05/22/2025 Edited by: ADON. Problem area dated 02/20/2024, Revised 07/25/2025 and Edited by Activity Director, reflected: [Resident #8] also enjoys going outside to feed the cat. In the related Approach area, it reflected, Staff will encourage, assist, or plan out of door activities for fresh air weather permitting. Edited: 05/22/2025 Edited by: ADON and Staff will encourage or assist involvement in social groups of interest such as bible study, current events, trivia. Problem area dated 2/26/2024, edited by ADON on 5/22/2025, reflected Category: Cognitive Loss/Dementia [Resident #8] appears to have recall deficit as evidenced by: Periods of paranoia, making false accusations then denies making them, lack of acceptance or understanding of safety issue related to her living environment, Poor decision making. Goal for this problem area reflected a long-term goal target date of 8/22/2025, reflected [Resident #8] will understand helpful reminders, will have needs met by staff as identified or anticipated, will have minimal negative emotional distress related to cognitive issues. As evidenced by documentation in the medical record. Edited: 5/22/2025 Edited By: ADON. Related approaches dated 5/22/2025 reflected, Continue to assess periodically for changes in cognition; adjust approaches to offer more assistance as needed. Review of Resident #8's Progress Notes in Paper Chart since 5/9/2025 -8/4/2025, reflected there were no notes indicating the resident was out of bed, nor are there any notes indicating refusals to get out of bed. There are no notes indicating a refusal of Physical or Occupational therapy during this time frame. Review of Physician Assessment for Resident #8 dated 7/12/2025 signed by Medical Director reflected fatigue, WC mobility, and weakness were chosen to describe Resident #8's general condition and extremities. There were handwritten notes reflecting, Pt. refuses BP meds and noncompliance with medications. There were no further notes regarding mobility or refusals of care. Review of Resident #8's most recent Occupational Therapy Discharge Summary prior to start of survey, for dates of service from 11/15/2024 to 11/18/2024, reflected, Discharge Recommendations: DC to this LTC facility under care of nursing. Restorative Program Established/Trained= Not indicated at this time Functional Maintenance Program Established/Trained=Not indicated at this time. Document was signed by OT F. Review of Resident #8's Summary of Occupational Therapy Daily skilled services signed by OT F dated 11/18/24 reflected, Pt (patient) declined to get out of bed, but finally agreed to work in the bed with therapy. Therapist went to pt's room x3 (three times) in order to get pt to participate. Once pt finally did agree to do therapy she was actually very cooperative and did everything requested of her. Pt education on the importance of movement/getting out of bed due to having pneumonia. Review of Physical Therapy Summary of Daily Skilled Services dated 11/18/2024 and signed by PT H, reflected, Patient requiring encouragement in order to participate proceeding to perform LE/UE (Lower Extremity/Upper Extremity) therex (therapeutic exercise) in all tolerable planes working on str (strength), endurance/ROM (range of motion) w cuing and breaks taken throughout session PRN (as needed).Review of Resident #8's Occupational Therapy Evaluation and Plan of Treatment dated 8/14/2025 and signed by OT G reflected, Personal Hygiene= Substantial/maximal assistance and Transfers section reflected, Recommended use of [mechanical] lift for all transfers. In the section labelled Reason for Therapy there is a note reflecting the following: Reason for Skilled Services: Patient requires skilled OT (occupational therapy) services to assess safety and Independence with ADLs (activities of daily living), develop and instruct on compensatory strategies, develop and instruct in exercise program, increase safety awareness, facilitate sitting tolerance and postural control, provision of pain management techniques, provision of modalities and strengthening, increase functional activity tolerance, and develop and instruct on adaptation techniques in order to enhance patient's quality of life by improving ability to return to prior level of skill performance. Review of Summary of Daily Skilled Services dated 8/14/2025 signed by OT G, the Response to Tx (treatment) section reflected Response to Session Interventions: actively participates with skilled interventions. Interview with Resident #8 on 8/12/25 at 9:41AM she stated I don't know when the last time I got up. Last time there were two people. Maybe seven days ago. She stated that she could not remember doing any therapy in the facility. She stated that she walked in the facility using a cane and now could no longer get out of bed. Observation of two person transfer on 8/13/2025 at 2:30PM with CNA A and CNA B revealed Resident #8 was lying in bed attempting to sit up. CNA A and CNA B watched Resident #8 attempt to sit up and did not offer assistance. Resident #8 stated that she was not able to sit up or stand on her own. She stated that she needed help. CNA A and CNA B did not assist after requests from resident. After 15 minutes of attempting to sit from a lying position, she refused to attempt any longer and requested to go stay in bed. She stated, I used to be able to sit and stand, but I can't anymore. No gait belt was observed in the room or in possession of the CNAs for the transfer and they were later found to be unable to properly apply a gait belt. In an interview with LVN D on 8/13/2025 at 2:47PM reflected that Resident #8 was known to be a two-person transfer. He stated that for a normal two-person transfer, if a person was struggling to sit up, the staff would assist the resident to a sitting position. In an interview with LVN C on 8/14/25 at 6:10AM she stated she had worked at the facility full time since September or October of 2024. She stated that she currently worked primarily night shifts but worked days and nights previously. She stated that Resident #8 was almost a mechanical lift now. She stated she knows Resident #8 was able to stand in May, but now she cannot. She stated she was transferring mostly by herself from the bed to the wheelchair and back at the beginning of the year with little assistance from staff. She stated that she could recall last seeing her transfer in March with little assistance from staff. She stated the last time she saw her transfer was around May with assist of two staff, where they had to physically assist her to sit up, which was not normal previously. She stated that she told dayshift at that time that the resident had shown a decline. She could not recall the date. She stated the resident refuses to get up at times. She stated that Resident #8 used to get up to feed the cats. She stated that refusals should be documented in the chart. She stated that residents have the right to refuse, but that staff should be building a relationship with the resident and try to find out the source of the refusals. She stated that residents should receive ongoing education and encouragement from staff with refusals of care. She stated that not getting out of bed can result in a decline in mobility. She stated that improper transfers can result in injuries.In an interview with CNA A on 8/14/25 at 8:45AM, she stated in the transfer with Resident #8 on 8/13/25 she should have assisted her to sit up. She denied having a gait belt for the transfer. She stated she does not use a gait belt on anyone in the facility during transfers. She stated she did not assist the resident with the transfer on 8/13/2025 because she was nervous. She stated it has been more than 3 months and less than 6 months since she's seen Resident #8 up out of bed. She stated the resident refuses to get out of bed a lot. She stated she does inform the nurse. She stated that the level of struggle she saw on 8/13/2025 from Resident #8 attempting to sit up for a transfer was new. She stated in the past, Resident #8 could help more. She stated the resident refuses a lot to get out of bed. She stated she does inform the nurse when the resident refuses. She stated that not providing assistance with transfers for residents that require assistance, can lead to residents feeling discouraged. She stated that if residents do not get out of bed they can lose their strength and ability to get out of bed. In an interview with CNA B on 8/14/2025 at 9:28AM, she said she worked at the facility for about a month. She said she had assisted Resident #8 out of bed with two people approximately two weeks ago. She stated she has seen the resident up, probably twice since she started working at the facility. She stated that she let her take her time to do some and then assisted when her when she needed it. She stated at that time she was not able to stand for the transfer. She stated they did get her in the wheelchair with two people. She stated each person stood on one side of the resident. She stated they then put their arm under her arm, and with the other hand, held on to the resident's pants. She stated that Resident #8 was able to sit up on her own two weeks prior during the transfer. She stated the resident refuses at times. She stated that not providing assistance with transfers for those residents that need it, can lead to resident' potentially giving up and possibly not wanting to try to get up. She stated that if residents do not get out of bed when they are able, they might lose their ability to get out of bed. In an interview with ADON on 8/14/2025 at 7:07AM, she stated that Resident #8 was a two-person transfer. She stated that she frequently refuses therapy. She stated there are no therapy notes for 2025. She stated she would print the last three therapy assessments for review by surveyor. She stated that there was no documentation of refusals of therapy in resident records for nursing in the last 3 months or therapy services documentation in 2025. She stated the Care Plan for the resident included being resistive to care at times, but did not include refusals of therapy. She stated she was not sure if the physical or occupational therapist spoke directly to the resident regarding her therapy opportunities and the risks of not participating in rehabilitative services. She stated that the Resident #8 refused therapy to her after her most recent hospitalization at the end of May, but that she did not document the refusal. In an interview with OT G on 8/14/2025 at 11:40AM, she stated that she worked with a different company than the previous therapists at the facility. She stated she started in the facility as a PRN (As needed) Occupational Therapist when the new company took over at the beginning of the month. She stated that she met Resident #8 on the morning of 8/14/2025. She stated that she reviewed her records. She stated that after speaking with Resident #8, she is going to recommend a mechanical lift for her transfers. She stated she has never seen it documented who has a gait belt in the facility, but if you are standing and moving them, they should have a gait belt on unless they are independent transfers or a mechanical lift is used for transfer. She stated that during transfers staff can hurt the resident's shoulders, cause shearing, or staff could drop them without a gait belt or with improper use of gait belt. She was not sure if Resident #8 was a mechanical lift prior to this assessment but stated that if a resident was screened previously as partial assist and then they are later screened as requiring a mechanical lift, that it would be considered a change in condition for the resident. In an interview with RNC on 8/14/2025 at 12:04 PM, she stated that she had been in the facility for 8 days, since the change of ownership. She stated that she was functioning as the Director of Nursing prior to the DON taking on her role at the facility. She stated that there was not a DON prior to the change of ownership, which would make the ADON responsible for supplies and resident care prior to 8/5/2025. She stated that the current owners use a different therapy company than was used previously by the facility. She stated that all residents who were not independent or mechanical lift transfers should have a gait belt on for transfers. She stated that if a resident was reaching and trying to sit up during a transfer that she would assist them with sitting position. She stated that if a resident made an effort to transfer, she would assist them with the rest of the transfer. She stated that Resident #8 should be assessed quarterly by therapy services. She stated that if there are any signs of decline, residents should be evaluated by therapy and treated per their recommendations. She stated that their responsibility as a facility is to maintain or improve status of residents, unless the situation can be helped. She stated that if a resident screens as needing a mechanical lift, when their previous recommendation was for partial assistance with transfers, that it would indicate a change in condition. She stated that if we are not assisting a resident to get out of bed, they can decline. She stated that residents do have the right to refuse care. She stated that she expected staff to encourage residents to get out of bed, to educate them regarding the consequences of not getting out of bed, to get family involved if applicable, and to perform passive range of motion if they continue to refuse to help prevent a decline in mobility. She stated that staff should try to find the source of why the resident is refusing care and address their underlying concerns. In an interview with Resident #8 on 8/14/2025 at 1:05PM she stated that she feels unhopeful when she attempts to transfer. She stated that she trusts one male staff member to transfer her. Resident observed lying in bed during the interview. In a phone interview with facility NP on 8/15/2025 at 12:04PM, she stated that she does not know of any degenerative conditions for Resident #8 that would make a decline in mobility unavoidable. She stated that the resident has some conditions which could cause pain, but that the resident nor the facility has reported an increase in pain. She stated that Resident #8 cannot transfer or stand without assistance from staff. She stated that to her knowledge, the resident could stand briefly to be assisted to the wheelchair. She stated that a new order for a mechanical lift would constitute a change in condition regarding the mobility status for Resident #8. She stated that she knows the resident to refuse care and transfers at times. She stated that she last observed the resident get up with staff assistance of 3-4 staff, gait belt, and walker on 5/23/25 when she ordered a urine culture for the resident. She stated that the extra staff present during the transfer where there to assist with collecting the urine sample. She stated that she knows Resident #8 to be a 2-person transfer. She stated that she saw a note from the morning stating that Resident #8 is now a mechanical lift transfer. She stated that when a resident is refusing to get out of bed, they should be evaluated to see if there is a change in condition. She stated that when a resident is refusing, the facility needs to ensure they are doing what they can and that it isn't just easier for staff not to get her up. She stated that not getting out of bed could contribute to a decline in mobility. She stated that not using a gait belt or using gait belts in properly could result in a fall or injuries to the resident. She stated it was a fundamental skill for a CNA and anyone who transfers residents to know how to use a gait belt. She stated she could not recall any injuries with transfers that would have warranted a gait belt. In an interview with ADON on 8/15/2025 at 1:50PM, she stated she could not believe she did not notice that Resident #8 had not been out of bed. She stated she was not aware that Resident had a change in mobility prior to the OT assessment on 8/14/2025. She stated that she could not recall seeing Resident #8 out of bed in the last few weeks. She stated that she was responsible for monitoring resident care and ensuring appropriate care was provided to Resident #8 at the time of the decline. She stated she was responsible for updating care plans at this time also. She stated that gait belt should be included in the care plan for residents that require a gait belt with transfers. She stated that she informed the physician and psychiatry about Resident #8's refusals of care in the past. She stated that she doesn't know exactly why the resident would refuse to get up recently. She stated that in the past she has given reasons like that she does not want to be forced to do things and that she does not want to put on a show for anyone. She did not recall when she stated this, but stated it was not directly related to a recent occurrence. She stated that Resident #8 does not have any family to her knowledge. She stated that Resident #8 is her own responsible party. She stated that staff try to encourage her to get out of bed with things that she likes. She stated that the facility tried to put her on skilled services when she got back from a hospital stay on 6/29/2025, but the resident refused at that time. She stated she does not have any documentation in the resident records to state that she was evaluated and subsequently refused offer of therapy. Observation of Resident #8 on 8/15/2025 at 1:56PM revealed the resident sleeping in her bed. In a follow up interview with RNC on 8/15/2025 at 2:54PM she stated that there was no evidence that an IDT meet was done related to her refusals of care. In a follow up interview with ADON on 8/15/2025 at 2:54PM she stated that there was no QAPI meeting in which Resident #8's refusals of care were discussed. In an interview with the ADMIN on 8/15/25 at 3:43 PM, he stated that he wanted everyone in the building to thrive. He stated everyone who wants to be up out of bed, should be allowed or assisted as needed to get up. He stated that therapy has a role in assisting with mobility needs of the residents. He stated all refusals should be documented. He stated the impact of not getting a resident out of bed could result in weakness. He stated that he would defer to nursing for specifics in the causes of a decline in mobility. He stated refusals for care and therapy should be care planned. He stated that after a few times of refusing, staff should notify the doctor or the NP. He stated that the facility does have to honor a resident's right to refuse. He stated it is the facility's obligation to talk to them and try to find out why they are refusing. He stated they usually have multiple staff attempt to talk to a resident about refusals of care. He stated that psychiatry services can occasionally assist with refusals of care. He stated that he was responsible for ordering the supplies for this facility. He stated there is a supply list at the nurses' station where staff can add needed supplies. He stated he made orders every Tuesday based on the list. He stated he was not aware there was a lack of gait belts available for resident use. He stated he was not aware that gait belts were not being used with residents. He stated that not using a gait belt could cause a fall or injuries, including discomfort to the residents. He stated his expectation was that residents who need gait belts should have them. Review of facility policy on Safe Resident Handling/Transfers (no date) reflected, All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them.Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur.Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment.Review of Facility ADL policy (no date) stated: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care; Transfer and ambulation; Toileting; Eating to include meals and snacks; and Using speech, language or other functional communication systems.Policy Explanation and Compliance Guidelines: Conditions which may demonstrate unavoidable decline in ADLs include: Natural progression of the resident's disease state with known functional decline. Deterioration of the resident's physical condition associated with the onset of an acute physical or mental disability while receiving care to restore or maintain functional abilities. Refusal of care and treatment by the resident or his/her representative to maintain functional abilities after efforts by the facility to inform and educate about the benefits/risks of the proposed care and treatment; counsel and/or offer alternatives to the resident or representative.The facility will maintain individual objectives of the care plan and periodic review and evaluation. The ADMIN was notified of Immediate Jeopardy on 08/15/2025 at 4:35 PM and the need for a Plan of Removal. The Plan of Removal was accepted on 08/16/2025 at 11:18 AM and was as follows: On 8/12/2025 a recertification survey was initiated at facility. On 08/15/2025 the surveyor provided an Immediate Jeopardy (IJ) Template for SNF notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. Notification of the Immediate Jeopardy states as follows: F-676 - Activities of Daily Living (F676 The facility failed to ensure provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: S483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living to include mobility and transfers. Mobility Decline) 1. Immediate Actions Taken for Those Residents IdentifiedAction: Resident #8 immediately evaluated by nursing staff. Care plan updated to reflect current mobility status, interventions to maintain or improve function, and therapy recommendations. Resident requires a mechanical lift. Order placed in Point Click Care (PCC) for mechanical lift transfers. Physical Therapy referral placed in PCC for evaluation and treatment. Person(s) Responsible: Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or DesigneeDate: 08/15/2025 by noon Action: Facility-wide audit of all residents with transfer needs conducted to ensure correct transfer methods are documented, appropriate equipment is available at point of care, and no additional residents have experienced an undocumented decline. If equipment is not available, the DON/Designee will initiate an urgent order through the facility's contracted vendor, provide interim safe transfer methods, and ensure staff are trained on the temporary intervention until the equipment is in place. Any identified changes were addressed immediately through therapy referral and care plan updates. No changes identified.Person(s) Responsible: Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or DesigneeDate: 08/15/2025 by noon Action: All licensed nurses, CNAs, and therapy staff educated on Safe Resident Handling/Transfers policy, proper gait belt use, and immediate reporting of mobility declines to the DON and/or ADON. Competency validation with return demonstration completed prior to resident care. Staff members will be educated prior to working their next shift. Staff who are not present will receive education via the telephone and complete the competency with return demonstration prior to working their next shift. All new hires and agency staff will receive education and competency evaluation with return demonstration prior to providing resident care. Person(s) Responsible: Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or Designee Date: 08/17/2025 by noon 2. How the Facility Identified Other Possibly Affected Residents: Action: 100% audit of all residents requiring assistance with transfers conducted to ensure accuracy of transfer status, care plans, and availability of required equipment. No other residents identified.Person(s) Responsible: Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or Designee Date: 08/15/2025 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Policy on Safe Resident Handling/Transfers reviewed with no changes made. Staff members will be educated on policy prior to working their next shift. Staff who are not present will receive education via the telephone and will sign the in-service sheet prior to working their next shift. All new hires and agency staff will receive education prior to providing resident care.Person(s) Responsible: VP of Clinical Operations, Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or DesigneeDate: 08/15/2025 policy reviewed08/17/2025 by noon for education of all staffAction: Change in Condition Protocol reviewed with no changes made. Staff members will be educated on policy prior to working their next shift. Staff who are not present will receive education via the telephone and will sign the in-service sheet prior to working their next shift. All new hires and agency staff will receive education prior to providing resident care.Person(s) Responsible: VP of Clinical Operations, Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or DesigneeDate: 08/15/2025 policy reviewed08/17/2025 by noon for education of all staff 4. How the Corrective Actions Will be Monitored/Ensure Comprehension, by whom and for how long: Action: All licensed nurses, CNAs, and therapy staff received immediate education on Safe Resident Handling/Transfers policy, including proper use of gait belts and mechanical lifts, and the requirement to report any resident mobility changes to nursing leadership. Staff completed a competency validation with return demonstration prior to providing further resident care. Staff not on-site were educated via telephone and completed competency validation prior to their next scheduled shift. All agency and new hire staff will receive the same education and competency validation prior to resident care assignment. Person(s) Responsible: DON, ADON, and/or DesigneeDate: 08/17/2025 by noon for education of all staffAction: DON/designee will conduct a minimum of 5 random transfer observations per shift for 4 weeks to ensure: proper transfer method is being used per care plan and gait belts/mechanical lifts are available and used appropriately. Results documented on Transfer Audit Log; noncompliance addressed immediately with re-education.Person(s) Responsible: DON, ADON, and/or DesigneeDate: Ongoing x 60 days Action: Interdisciplinary team will review all audit results in QAPI weekly for 8 weeks, then monthly for 4 months. Any identified trends will result in additional training.Person(s) Responsible: Administrator, DON, Rehab DirectorDate: Ongoing QAPI-Action: Medical Director notified of the deficient practice/IJ and Plan of Removal.Person(s) Responsible: DON, Administrator, and/or DesigneeDate: 08/14/2025 Monitoring facility's plan of removal was completed on 8/16/2025 as follows: Review of Resident #8's Occupational Therapy Evaluation and Plan of Treatment dated 8/14/2025 and signed by OT G, reflected that Resident #8 was evaluated on 8/14/2025 by nursing staff and occupational therapist. Resident #8's Care plan was updated on 8/14/2025 to reflect mechanical lift transfer and related care. Resident #8's Physician orders updated on 8/15/2025 to reflect mechanical lift transfer. There is a physician order for PT/OT (physical therapy/occupational therapy) to Evaluate and Treat dated 8/15/2025. In an interview with RNC on 08/16/2025 at 1:00PM, she stated that Resident #8 was transferred to hospital on 8/15/2025 at 8:08AM for sore throat and cough. She was not available for interview at that time. In an interview with ADON on 8/16/2025 at 1:53PM, she stated that the Facility-wide 100% audit of all residents with transfer [

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 eloped from the facility on 2/28//2023 and fractured his right hip, that required surgery to treat. Resident #1 was found 2 ½ blocks away from the facility on the ground, he had fallen and was unable to get up. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 3/1/2023 at 6:06 p.m. The (IJ) Immediate Jeopardy template was provided to the ADM on 3/1/2023 at 6:06pm. While the (IJ) Immediate Jeopardy was removed on 3/3/2023 at 4:40 p.m., the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal. This failure could place all residents that are elopement risk and refuse to wear a wander guard at risk for accidents, harm, and/or death. Findings included: Review of Resident #1's face sheet dated 3/2/2023, reflected a 64- year- old man, admitted to the facility on [DATE]. Resident #1 was diagnosed with Parkinson's disease (a disease of the central nervous system that affects movements), unspecified psychosis (inadequate information to make the diagnosis of a specific psychotic disorder) not due to a substance or known physiological condition, Insomnia ( a common sleep disorder that can make it hard to fall asleep), Paranoid schizophrenia ( a psychological disorder where the lines are blurred between what is real and what isn't), delusional disorder(a belief or altered reality that is persistently held despite evidence or agreement to the contrary) and heart failure (A chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 5 (indicates the resident does not have the cognitive ability to understand). The MDS also reflected Resident # 1 is ambulatory with no assistance. Review of MAR dated 2/1/2023-2/282023, reflected the following orders: Resident to reside on secure unit for personal safety - start 12/29/2020 open ended 9/1/2022- Resident may have trial integration off unit into general population- open ended 9/1/2022- May have wander guard -open ended Record review of Resident #1's care plan dated 2/28/2023, reflected the following: Problem: Resident has been observed to leave the grounds within the past week without notifying staff despite reminders. Interventions: Explain to resident the policy and procedure for leaving the facility and review periodically for continued need for secure placement. The care plan did not reflect any updates of interventions in place for Resident #1 for the period of 9/1/2022 when Resident #1 came off the secure unit through 2/28/2023. Record review of Risk elopement assessments for Resident #1 reflected the following: -12/19/2017 Resident #1 was identified as risk for elopement, -9/19/2021 was not an elopement risk, with no interventions, -11/15/2022 Resident #1 was not an elopement risk, with no interventions, -5/21/2022 reflected it was unknown if Resident # 1 was an elopement risk and to remain on secure unit for safety, and. -2/23/2023 reflected Resident #1 was not a risk for elopement with the following interventions: Frequent monitoring how often not noted, keep behavior logs, review medications, utilizations of sign in/sign out logs, recreational activities, and music. Record review of facility progress notes dated 6/2/2022- 2/28/2023 for Resident #1 reflected, no monitoring notes, no behavioral log, no sign in or out sheets used by Resident #1, or any notes regarding activities or music. There was one progress note dated 2/28/2023 regarding Resident #1's refusal to wear the wander guard. In an interview on 3/1/2023 at 11:10 a.m., the hospital staff reported Resident #1 was brought into the hospital by EMS. She stated it was reported Resident #1 was found on the street trying to get up. The hospital staff stated Resident # 1 had a fractured right hip and was scheduled for surgery later in the day. She stated Resident # 1 was hallucinating and having delusional thoughts since he was admitted . In an interview on 3/1/2023 with concerned citizen stated approximately 5:25am he and his son noticed Resident # 1 had fallen and was trying to get up. He stated they called 911 for assistance, he stated Resident #1 reported that he tripped over the curb and hurt his hip. In an interview on 3/1/2023 at 12:29 p.m., LE stated EMS contacted them to come to the scene on 3/1/2023 around 5:45 a.m., LE stated they spoke with Resident #1 he was able to tell them the facility he came from, that he had fallen and was unable to get up. LE reported, Resident #1 was transported to the hospital due to his injury he sustained from falling. LE stated they went to facility and asked if anyone was missing? LE reported the staff they spoke to was not aware that anyone was missing at the time, LE stated they informed the facility of Resident #1 name and advised that he was transported to the hospital for further medical treatment. Review of Police call for service report dated 2/28/2023, reflected the facility was notified at approximately 5:50am asking if they were missing anyone from the facility. LVN A, reported that she was not aware that anyone was missing at the time. LVN A was advised that Resident # 1 had been injured and was transported to the hospital. In an interview on 3/1/2023 at 10:02 a.m., LVN A stated she was the nurse on duty last night, she stated they work 12 hours shifts 6pm to 6am. She stated Resident #1 has insomnia and walked all night looking for cigarettes. She stated she last saw Resident #1 at approximately 5:10 a.m. walking down the hall, when she was going to check on another resident who had pushed their call light. She stated she was contacted by the local police department at about 5:45 a.m. asking if they were missing anyone. She stated she was not aware that Resident #1 was missing and stated he must have gone out one of the back doors that does not have alarms. She stated Resident #1 had never attempted to elope from the facility. LVN A stated Resident #1 was found 2 ½ blocks from the facility, stated he was headed to the post office to return some counterfeit money. LVN A stated when she looked, it appeared that she had some money missing from her purse she had behind the nurse's station. LVN A stated she immediately contacted the hospital so that she could provide any information they needed for Resident #1, she stated she then made all other notifications to the ADM, DON, and Resident #1's guardian. In an interview on 3/1/2023 at 11:19 a.m., Resident #1's Guardian stated he was admitted to the facility on [DATE] on the secure unit due to being an elopement risk. She stated he had previous elopements at previous placements and had attempted from this facility. Resident #1's Guardian stated she was notified by the facility that the secure unit would be shut down. She stated the facility completed another risk assessment for elopement and indicated Resident #1 was no longer at risk for elopement. Resident #1's Guardian stated Resident #1 was very familiar with the back doors at facility, she stated he often would go out the door when she visited as he was able to go in and out the doors as he pleased. Resident #1's Guardian stated she believed the facility shut down the secure unit due to staffing and census issues. Resident #1's Guardian stated Resident #1 refused to wear the wander guard bracelet and was unaware of any other interventions in place. She stated she was not aware of Resident #1 trying to elope since he initially admitted . Resident #1's Guardian stated she was also concerned that the incident happened at 5:45 a.m., but she did not get contacted about the incident until sometime after 7:00 a.m. In an interview on 3/1/2023 at 1:30 p.m. the DON stated LVN A who was on duty that night, contacted her around 6:39 a.m. She stated LVN A reported that the police were just at the facility asking if they had a resident missing. The DON stated LVN A was not aware Resident #1 was missing at the time when she was contacted by the police. The DON stated she advised LVN A to make all notifications, she also stated that LVN A stated Resident #1 must have gone out one of the back doors because they do not lock or alarm. The DON stated none of the doors at the facility alarm when opened unless the resident has on a wander guard bracelet. The DON stated the other residents who are an elopement risk have on a wander guard bracelet and if they get within 10 feet of any of the doors the alarms will sound. The DON stated when she started at the facility in October 2022, Resident #1 was already off the secure unit, she stated he had never tried to elope before this time. The DON was asked about previous care plans and interventions for Resident #1 because he refused to wear the wander guard bracelet, she was not able to locate any documents. The DON was not able to locate any documentation regarding Resident #1's behaviors, monitoring of Resident #1, or any sign-in/or out sheets. In an interview on 3/1/2023 at 4:30 p.m., the ADM stated all residents who have been identified as elopement risk wear a wander guard bracelet, he stated Resident #1 refused to wear his wander guard. The ADM stated he was not aware that Resident #1 tried to elope from the facility in the past he stated it must have been before he started at the facility. The ADM stated all residents have the right to be safe and it is his expectation that all residents are safe in the facility. The ADM stated the alarms on the doors alarm if the resident was wearing a wander guard and they come within 10 feet of any of the doors. The ADM stated they opened back up the secure unit on 2/28/2023. Observation and test on 3/1/2023 of all doors in facility, reflected all doors are able to be opened without any alarms going off coming in or going out the doors. The door where staff believe Resident #1 went out leads out to the side parking lot on the south end of the building. The facility is located 2 blocks from an active railroad and busy street with blinking yellow light for traffic going through. Observation on 3/1/2023 at 3:30pm of secure unit with code required secured doors. Observed two residents residing on the secure unit and staff working on the unit. Reviewed facility Abuse/Neglect policy undated reflected: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Reviewed facility Elopement Risk Assessment policy dated 11/01/2017 reflected the following: All residents are assessed on admission for elopement risk utilizing an elopement risk form. All residents are re-assessed for elopement potential by the MDS nurse /social worker or designee periodically throughout a resident's stay and with a significant change. Interventions will be added to the resident's care plan after analyzing the information obtained. The baseline care plan will identify if a resident is admitted as an elopement risk on admission. Reviewed QAPI - (Quality Assurance and Performance Improvement) held quarterly dated-September 2022- February 2023 to address elopement. An (IJ) Immediate Jeopardy was identified on 3/1/2023 at 6:06 p.m., due to the above failures. The ADM was notified on 3/1/2023. The ADM was provided with the (IJ) Immediate Jeopardy template on 3/1/2023 at 6:06pm, and a Plan of Removal (POR) was requested. A Plan of Removal was accepted on 3/3/2023 at 1:56 p.m. and reads as follows: Plan of Removal Immediate Plan of Removal Identified resident is not currently in the facility: Residents at risk of elopement have the potential to be affected. Elopement risk evaluations done in the past 90 days on current residents in facility reviewed by nursing managers for accuracy on 2/28/23. Any not completed in past 90 days or found to be inaccurate were completed by the Director of Nursing on 3/1/23. Identified residents at risk reviewed using the Elopement Risk Assessment for interventions on 2/28/23, by the Director of Nursing and any issues identified were corrected appropriately at the time of discovery. Care plans were updated to reflect the interventions by the Nurse Assessment Coordinator on 2/28/23. Licensed nurses will be re-educated on Abuse/Neglect, the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. This includes intervening if the resident verbalizes the desire to leave the facility or threatens to leave the facility or refuses to wear a wander guard. Licensed nurses will also be re-educated on documenting in progress notes, adding to the 24-hour report and updating care plans with changes of condition This education will be initiated on 2/28/23 by the Director of Nursing and completed by 3/2/23. The Director of Nursing will monitor for compliance. Any member of target audience not receiving by 3/2/23 will receive prior to next scheduled shift. This education will be presented in the new hire orientation and for any agency staff by the Director of Nursing/charge nurse. New admissions, readmissions and quarterly assessments will be reviewed in morning meeting beginning 3/2/23 Monday thru Friday as part of the clinical morning meeting process to review Elopement risks assessments for accuracy and interventions validated if indicated. The 24-hour report will be reviewed by the Director of Nursing/Assistant Director of Nursing for any documentation that may suggest a resident is expressing desires to leave the facility, if identified, interventions for safety will be implemented and care plan updated. The Medical Director was notified of the Immediate Jeopardy on 3/1/23. Ad Hoc QAPI was held by the administrator on 3/1/23 to discuss the contents of this plan. The administrator will oversee the compliance of this plan. Monitoring of Plan or Removal on 3/2/2023 was as follows: Interview on 3/2/2023 at 3:00 p.m., with hospital staff reported Resident #1 remains in the hospital in recovery from surgery. Hospital staff reported that Resident #1 has refused care by pulling out his picc line and still had delusional thoughts. Resident # 1 is scheduled to return to the facility once released from the hospital. Reviewed elopement risk assessments dated 3/1/2023 completed and updated for Resident #2 and Resident #3, reflected both are at risk for wandering, elopement risk, and will reside on secure unit for their safety and wear a wander guard bracelet. Observation conducted on 3/2/2023 at 3:30 p.m., of Resident #2 and Resident #3, on the secure unit. Resident #2 and Resident #3 appeared to be resting, they did not appear to be in any pain or distress. Resident # 2 and Resident # 3 was observed wearing their wander guard bracelets. In an interview on 3/2/2023 at 2:10 p.m., LVN B stated she completed the elopement drill and has been in-serviced on the policy, procedures and steps to take when there is a missing resident. LVN B stated she had also been in -serviced on abuse/ neglect, elopement, and documentation. She reported the ADM is the abuse/neglect coordinator. In an interview on 3/2/2023 at 2:20 p.m., LVN C stated she participated in the elopement drill today. She reported being in-serviced on abuse/neglect, elopement, and resident documentation. She stated she understood the process when they have a resident missing, she stated she contacts the ADM immediately if she suspected abuse/ neglect, and that she understood the importance of charting on residents. In an interview on 3/2/2023 at 2:30 p.m., LVN D stated she worked the morning of the incident. She stated she worked on 3/1/2023 from 6am to 6pm she was coming on shift when LE came to facility and asked LVN A if they had a resident missing. LVN D stated LVN A was not aware that Resident #1 was missing. She stated whenever, she worked the 6pm to 6am shift she knows she have to walk all night and check on Resident #1 because he walks all through the night. She stated when she worked, she would have to know where all her residents are at all times for safety of the residents. LVN D stated she had participated in the elopement drill at facility and knows that steps to take when they have a resident missing. She stated she had also been in-serviced on abuse/neglect and documentation. In an interview on 3/2/2023 at 2:40 p.m., CNA B stated she participated in the elopement drill today. CNA B stated they learned the code to call code white if they have a missing resident and they step to take to start the search process. She stated she had been trained on abuse/ neglect and documentation, she stated the ADM is the abuse/neglect coordinator and they needed to report immediately when they see or suspect abuse/neglect. In an interview on 3/2/2023 at 2:50 p.m. CNA C stated she participated in the elopement drill today. CNA C stated they learned the code to call code white if they have a missing resident and to start the search process. She stated she had been trained on abuse/ neglect and documentation, she stated the ADM is the abuse/neglect coordinator and they needed report immediately. In an interview on 3/2/2023 at 3:10 p.m., DON stated she and most of the staff have been trained on the elopement drill and what to do when they have a missing resident. She stated any staff that have not been trained are either PRN (as needed) staff or staff that only worked in the summer. DON stated the rest of the staff even agency staff as they come to work have been trained over the elopement process, abuse/neglect, and documentation. In an interview on 3/2/2023 at 3:20 p.m., the ADM stated all staff have been trained on the elopement process. He stated all staff participated in the elopement drill skills test on what to do if they have a missing resident. He stated it is his responsibility to ensure that all the residents in the facility are safe. ADM stated they are also looking at other ways to ensure the safety of the residents while maintain their independence. In an interview on 3/3/2023 at 3:40p.m., the ADM, stated on 3/1/2023 he verbally advised the MD of the IJ (Immediate Jeopardy) concerns identified. Record review of the AdHoc (for particular reason) QAPI(Quality assurance performance improvement) dated 3/1/2023 to address IJ(Immediate Jeopardy). Monitoring completed on 3/3/2023 as follows: Resident # 1 remains in hospital, Resident # 1 is scheduled to return to the facility once released from the hospital Observation made on 3/3/2023 at 4:10 p.m., of Resident # 2 and Resident # 3 on secure unit, no concerns noted during observation. Review of elopement assessments dated 2/28/2023, reflected all residents in facility were re-assessed for elopement risk. Two residents identified for secure unit /wander guard. These residents are currently on secure unit. Review of care plan dated 2/28/2023 for Resident #1 and Resident # 2 with current interventions: 1. Monitor for placement Q shift 2. Monitor for proper functioning 24 hours a day 3. Monitor resident in facility and document attempts to elope out of facility 4. Assess quarterly for continued use of wander guard 5. Explain to resident the policy and procedures for leaving the facility 6. Resident will reside on the secure unit for safety 7. Offer daily activities to address resident's interest 8. Review periodically for continued need for secure placement 3/3/2023 Review of in-services completed: all nursing staff verified completion except one PRN staff. 3/2/2023- Documentation Expectations 3/2/2023- Resident refusal of wander guard / immediate reporting to charge nurse 2/28/2023- Safety 2/28/2023- Elopement Drill / Policy and procedure 2/28/2023- Abuse/Neglect 2/28/2023- Elopement, Care plans, New admissions, elopement risk assessment and Quarterly assessments Record review of in-service sheet dated 2/28/2023 reflected 2 CNA's who work PRN had not completed the training. One nursing staff who only works in the summer had not received the training. In an interview on 3/3/2023 at 4:15pm with BOM (business office manager), stated they have not had any new admissions, readmissions. On 3/3/2023 at 4:40 p.m., the ADM was informed the (IJ)immediate Jeopardy was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.