**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide and document sufficient preparation and orientation of resident to ensure safe and orderly transfer or discharge from the facility and ensure the orientation was provided in a form and manner that the resident could understand for one (Resident #1) of five residents reviewed for discharge. The facility failed on 8/21/2025 to ensure Resident #1's post-discharge destination and continued care provider could meet Resident #1's needs in that Resident #1 did not go to the Resident Representative's (RP) home, Resident #1 was taken to another family members residence because Resident #1 RP couldn't care for her due to work schedule and on or about 25 or 26 August 2025 Resident #1's RP obtained an order of protective custody for Resident #1 and Resident #1 was arrested and taken to a psychiatric hospital.This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and place the residents at risk for their needs not being met.This failure resulted in an Immediate Jeopardy situation on 9/16/2025. While the IJ was removed on 9/18/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm due to staff needing more time to monitor the effectiveness for the plan of removal for inappropriate discharge. Findings included:Record review of Resident #1's Discharge summary, dated [DATE], revealed a [AGE] year-old female originally admitted on [DATE], re-admitted on [DATE], and discharged on 08/21/2025. Resident #1 had diagnoses which included: Cellulitis of left lower limb (bacterial infection of the skin and underlying tissues), acute respiratory failure with hypercapnia (inability of the lungs to effectively remove carbon dioxide), morbid (severe) obesity with alveolar hypoventilation (breathing disorder), diabetes mellitus (high blood sugar) without complications, unsteadiness on feet, lack oof coordination, generalized anxiety disorder (mental health conditions), dementia in other diseases classified elsewhere (a type of dementia that occurs as a secondary symptoms of another underlying medical condition), severe with mood disturbance, pain unspecified, reduced mobility, difficulty in walking, deficiency of other vitamins, unspecified intellectual disabilities, schizoaffective disorder (mental condition that combines symptoms of schizophrenia and a mood disorder), bipolar (manic depression), fluid overload, unspecified pyuria (high levels of white blood cells in urine), lymphedema (swelling in the body), iron deficiency anemia, pulmonary hypertension (blood pressure in the arteries of the lungs is abnormally high), acute on chronic diastolic (congestive) heart failure, acute embolism and thrombosis of deep veins of unspecified lower extremity (blood clot in the deep veins of the lower leg), acute embolism and thrombosis of superficial veins of left upper extremity (new blood clot forming in a superficial vein in the left arm, or shoulder, which may involve a clot traveling through the bloodstream), muscle weakness, need for assistance with personal care, cognitive communication deficit person's ability to communicate effectively due to underlying impairments), acute cystitis without hematuria (inflammation of the bladder (cystitis) that does not involve blood in the urine (hematuria). The reason for the discharge reflected an incident with another resident causing bodily harm. The discharge effective date was 8/21/2025. Brief history for Resident #1 reflected an increase in unsafe behaviors towards residents. The course of treatment for Resident #1 reflected interventions of increased activities and time in a calming environment. The condition Resident #1 discharged reflected was good. Rehabilitative Potential for Resident #1 reflected fair. The follow-up and discharge medications (instructions to resident) revealed the following medications were sent home for Resident #1: Depakote ER Oral Tablet, Seroquel Calcium Carbonate Tablet Chewable 500 MG, Maalox Regular Strength Suspension Potassium Chloride ER Lasix Oral Tablet 20 MG, Multivitamin-Minerals Oral Tablet, Tylenol Extra Strength Oral Tablet 500 MG, Vitamin B12, Ergocalciferol Capsule 50000 UNIT, Zoloft Oral Tablet, Anoro Ellipta Inhalation Aerosol Powder Breath Eucerin, External Lotion Metformin Gentamicin Sulfate External Ointment 0.1 % Albuterol Sulfate HFA Inhalation Aerosol Solution. Resident #1 was discharged home with no home health. The list of reconciled medications sent with the representative reflected yes. How was the list of reconciled medication sent reflected verbal. Digitally signed by the physician. Record review of Resident #1's quarterly MDS assessment, dated 06/04/2025, revealed Resident #1 did not perform an interview for mental status due to the resident rarely/never understood. Resident #1's behavior revealed no exhibited physical behavioral symptoms directed toward others, no exhibited verbal behavioral symptoms director toward others and no exhibited other behavioral symptoms directed toward others. Record review of Resident #1's Care Plan, dated 02/21/2025, revealed Resident #1 would remain in the facility for long term as she required 24-hour licensed nursing care. Resident #1 required anti-psychotic and anticonvulsant medications for diagnoses of schizophrenia, psychosis, and bipolar disorder could show aggressive behavior during periods of frustration or agitation. Record review of Resident #1's referral from the hospital to Five Points at Highlands, dated 7/28/2023, revealed Resident #1's RP stated she could not care for Resident #1 any longer, and would need somewhere long-term, possibly with a secured unit to prevent Resident #1 from trying to leave. Record review of the NP progress note, dated 08/21/2025, revealed when the NP arrived on the secured unit and there were two officers conversing with the ADON and SW. Resident #1 was in the dining room with the sitter. Police informed staff that they cannot arrest Resident #1 due to her mental capacity, nor could they detain her with OPC because she was in a facility where she could receive medical care. Resident #1's RP was informed that Resident #1 was a danger to others and was receiving immediate discharge notice. The SW explained to Resident #1's RP that she could take Resident #1 to psych hospital, but the officers could not take her. The NP stated Resident #1's RP wanted police to take Resident #1 because she could not force Resident #1 to do anything. The NP encouraged her to call family members to assist her, Resident #1 had an immediate family member, but RP told NP that he will make things worse. Record review of the SW progress note, dated 8/22/2025, revealed the SW notified of the altercation between Resident #1 and another resident. SW contacted Resident #1's RP to notify her of the altercation and the order for immediate discharge. Resident #1's RP came to the facility to pick up Resident #1 and take her home with medication, a rollator, instructions, and community referrals for medical PCP and discharge from the facility. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation of request and/or referral for psych observation for Resident #1. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation that Resident #1's RP declined alternate placement for Resident #1. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation that Resident #1's RP received the facility Ombudsman's contact information to assist discharge to the community. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation of verbal or written notice of intent to leave the facility. In a confidential staff interview on an undisclosed date, it was revealed that Resident #1's was not a safe discharge, and the RP could not properly care for Resident #1 because she had dementia, the resident was obese and had mood disorders and the RP was a small petite elderly woman who Resident #1 could potentially harm. During an interview on 8/28/2025 at 9:10 a.m., with the Administrator revealed there was an unwitnessed incident on the secured unit and when he and the SW notified Resident #1's RP to inform her they were going to send Resident #1 out to the hospital for behavior observation, the RP stated she would just pick Resident #1 up and take her home. The Administrator stated they conducted the discharge process for Resident #1 and the RP was provided with all Resident #1's medications, but her belongings were still in the facility due to the RP stating she could not fit them in the car. During an interview on 08/28/2025 at 09:39 a.m., with Resident #1's RP she revealed that she had received a phone call on 08/21/2025 from the facility SW who stated she had to pick up Resident #1 from the facility immediately because Resident #1 could no longer stay at the facility due to an unwitnessed incident that happened and she was being discharge immediately. The RP told the SW that she had nowhere to take Resident #1 and asked if she could get Resident #1 sent to another facility, because Resident #1 gave up her apartment when she admitted to the facility and would be homeless. She stated the SW insisted the RP pick up Resident #1. The RP stated when she arrived at the facility, they gave her some papers as she put Resident #1 in the car. The RP stated she would never have picked up Resident #1 voluntarily because the RP could not care for Resident #1 properly as Resident #1 required round-the-clock care and the RP stated she worked two part-time jobs. RP revealed Resident #1 never went to her home the RP took her to another family members home until she was able to obtain an order of protective custody and police arrested Resident #1 and took her to a psychiatric hospital. During an interview with the SW on 8/28/2025 at 12:45 p.m., the SW stated Resident #1 discharged on 8/21/2025. The SW stated she informed Resident #1's RP that she could refer Resident #1 to another facility, but Resident #1's RP declined and picked up Resident #1 and took Resident #1 home. The SW stated it was a safe discharge because she had attempted to offer to find placement for Resident #1, but it was declined verbally, and Resident #1 went home with a family member who was provided with referrals for community resources, a walker, and medications. In an interview on 8/28/2025 at 217 pm, with the Administrator revealed Resident #1's RP came and picked up Resident #1 that it was a safe discharge as the RP was responsible for making decisions for Resident #1 care. The Administrator stated if the RP could not take care of Resident #1 the RP would have elected someone who could. The Administrator stated that if the RP couldn't find Resident #1 placement at another facility, he would have to consult with his superiors on Resident #1's return to the facility as days had passed so Resident #1 would have to go through the referral process and start the admission process again. Record review of facility Discharge or Transfer policy dated 12/2017 revised 2/12/2025 under Resident Discharge to the Community states For resident who want to be discharged o the community, this nursing home must determine if appropriate and adequate supports are in place, including capacity and capability for the resident's caregivers home. Family members, significant others or the resident's representative should be involved in this determination, with the resident's permission, unless the resident is unable to participate in the discharge process. A referral to the Local Contact Agency may be appropriate for many individuals, who could be transitioned to a community setting of their choice. The nursing home staff is responsible for making referrals to the LCA, if appropriate, under the process that the State has established. Nursing home staff should also make the resident and if applicable, the resident representative, aware that the local ombudsman is available to provide information and assist with and traditions from the nursing home. For residents who have been in the facility for a longer time, it is still important to inquire, as needed, whether the resident would like to talk with LCA experts about returning to the community. If the resident is unable to communicate their preference or is unable to participate in discharge planning, the information should be obtained from the resident's representative. Discharge planning must include procedures for: -Documentation of referrals to local contact agencies, the local ombudsman, or other appropriate entities made for this purpose. -Documentation of the response to referrals; and -For residents for whom discharge to the community has been determined to not be feasible, the medical record must contain information about who made that decision and rational for that decision. Discharge planning must identify the discharge destination, and ensure it meets the resident's health and safety needs, as well as preferences. If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility must treat this situation similarly to refusal of care, and must: -Discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; -Document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed; -Document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings; -Determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary. The referral should be made at the time of discharge. An Immediate Jeopardy was identified on 9/16/25 and the Administrator was notified of the Immediate Jeopardy on 9/16/25 at 6:28 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The facility's POR for Immediate Jeopardy was accepted on 9/18/25 at 3:11 p.m. and reflected the following: . Interventions: 1. Resident #1 currently does not reside in the facility as of 8/21/25. The SW, and Administrator reached out to the RP of Resident #1 to discuss alternative placement due to increased behaviors. Resident #1's RP came to the facility to pick up the resident and take her home with medications, rollator, community resources for medical PCP. 2. All residents discharged in the past 30 days had their charts audited by the RCN, DON, and ADONs to ensure that all residents were discharged safely to their destination. 18 residents were discharged to the hospital. 3 residents discharged home. Initiated 9/16/25 and Completion Date 9/17/25. 3. The Administrator, DON, ADONs, and SWs were in-serviced 1:1 by ADO, RCN on 9/16/25 on the following topics. Initiated 9/16/25 and Completion Date 9/17/25. A. Discharge or Transfer to Another Facility Policy: New Process: Initiated 9/16/25 and Completion Date 9/17/25. In the future, if there is an emergency discharge scenario- all listed IDT members and PCP/MD will have a meeting to plan a safe discharge with all necessary community services. The charge nurses will report to DON and ADON if any part of the discharge process is overlooked or not completed. When a resident is discharged home, the following IDT members will perform the following: DON: Collaborate with IDT in the planning and ensure residents have all necessary post discharge providers in place for continuity of care. The DON's last day is 9/19/25. ADON A will be trained to follow the DON responsibilities on 9/17/25 and will resume the responsibilities for the discharge process on 9/19/25. ADONs: Family members will be educated on the care of the residents, including medications and psychology/psychiatry services to facilitate a safe discharge to a safe destination. The resident's attending physician and psych MD will be notified for the order and approval to discharge. ADONs A, B, and C are responsible for educating the PCP and psych services on upcoming discharges home as well as the community services for continuity of care. Social Workers: Ensure location and discharge address to Home Health Care if needed, order DME if needed. The SW will get in contact with resident and/or RP/family within 48 hours to ensure the resident is doing well and adjusting well in discharge location. The SW will document in Point Click Care ( PCC) in progress notes. The Administrator will check on all 48-hour discharge follow-ups during facility morning and end of day meetings on PCC. Administrator: Will ensure that every discharge has an IDT meeting completed and all providers for care are involved, and community resources are set up for discharge. The Administrator will ensure that all medications, DME and home health services are in place prior to discharge home. The SWs will document in PCC under progress notes the discharge location, post discharge services, home health services and caregiver support as needed. The Administrator is responsible for training the IDT on the discharge process and will check for every planned/unplanned discharge to ensure the process is followed for all discharges home by reviewing the documentation in PCC under progress notes and d/c summary. The Administrator will inquire about upcoming and unplanned discharges 5 days a week during morning facility and end-of-day meetings. The Administrator will report to the ADO weekly on the Operations Call for all home discharges. The ADO will audit all home discharges on PCC and verify with the facility IDT. Resident Rights Policy: All residents have the right to safely discharge with education provided for care, services, and medication. Behavioral Management Policy: Residents with behavioral or psychology diagnosis will have the appropriate care and services during admission and upon discharge. The SW will ensure that psychology services are in place when discharging a resident home. The MD was notified of the immediate jeopardy on 9/16/25 by the Administrator. An AD HOC (as needed) QAPI meeting was completed with interdisciplinary team which included the MD, Administrator, DON, Admissions, and BOM to discuss the citations and plan of removal. Initiated 9/16/25 and Completion Date 9/17/25. The Administrator/designee will test the IDT and charge nurses on the discharge process. Return demonstration via testing will need to be 100% prior to their shift. If 100% is not achieved- re-education will be provided until 100% compliance is achieved. Initiated 9/16/25 and Completion Date 9/17/25. Residents who have increased behaviors will be monitored every shift for safety by the nurse charge and will report daily to the DON and ADONs and notify the MD. There are 3 residents that are currently be monitored for behaviors (see attached). Training: ADON A will be responsible for educating and testing PRN and staff that are on vacation during this time period. ADON A will update the Administrator on the progress with education and testing 5 days a week until completed. Initiated 9/16/25 and Completion Date 9/17/25. For all immediate discharges: the Administrator will notify the Area Director of Operations prior to discharge. The ADO will verify the discharge process was followed correctly for a safe discharge. Initiated 9/18/25 and Completion Date 9/18/25. In-services: All charge nurses were in-serviced on the following topics by the Administrator, DON, ADONs. All nurses not present and PRN staff will be in-serviced prior to their next shift. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior to their assigned shift. Initiated 9/16/25 and Completion Date 9/17/25. Discharge or Transfer to Another Facility Policy: New Process: The charge nurse will educate the resident RP/family on medication review, count narcotics if any, and complete the DC summary in PCC at the time of discharge. The Charge Nurses will report to the DON and ADONs if any part of the discharge process is overlooked or not completed. Monitoring of the plan of removal included:Record review of facility in-services titled Behavior Management and documentation, Discharge Planning Process and Documentation, Discharge Planning Process policy, and Resident Rights, dated 9/16/25 though 9/18/25, reflected staff were educated by the Administrator, DON, and ADONs.Record review of a one-on-one in-service titled Resident Rights, dated 9/16/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO. Record review of a one-on-one in-service titled Discharge Plannings Process and Documentation, dated 9/16/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO.Record review of a one-on-one in-service titled Behavior Management and Documentation, dated 9/16/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO. Record review of a one-on-one in-service titled Notify ADO of any Immediate Discharge, dated 9/18/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO.Record review of 30-Day Discharges identified two additional residents had discharged from the facility Resident, Resident #2 left against medical advice and resident #3 discharged back home after five days of respite care. Record review of the Administrator, DON, ADONs, SWs and Charge Nurses test on discharge process reflected they had 100% accuracy. Record review of the AD HOC QA meeting held on 9/16/25 reflected the meeting consisted of Administrator, DON, MDS, Medical Director, and Business Office Manager.Record review of ,residents identified for monitoring for behaviors, Resident #4, Resident #5 and Resident #6's electronic health records from 9/18/25 to 9/19/25 reflected they were monitored for behaviors. Interview with the ADO on 9/18/23 at 3:15 p.m. He stated he trained the Administrator and DON on the notification to ADO of any immediate discharge. Additionally, re-trained the Administrator, DON, and SWs on the discharge planning process and documentation, resident rights, Behavior management and documentation. Verified via record review signed by the Administrator, DON and both social workers. Interview with Administrator on 9/18/25 at 3:30 p.m., the Administrator stated the ADO re-educated him on the discharge planning process and documentation, resident rights, behavior management and documentation and the ADO trained him on the notification to ADO of any immediate discharge Interview with the DON, on 9/18/25 at 3:45 p.m., the Administrator was asked, what was the facility's monitoring or oversight process for ensuring residents were discharged safely. He responded his plan was for this to be a continuous quality measure; that started with the IDT team which consist of the resident and/or their resident representative, medical director, social worker, nursing, therapy, DON and Administrator which will ensure the resident is prepared, educated and discharged safely. The medical director approved the discharge, the social worker ensured medical equipment was ordered, referrals were placed and community services were set up and documented in PCC, the follow up 48 hours post discharge to make sure discharge was smooth and document response in PCC. The ADONs and/or charge nurse would review and educate resident and/or resident representative on medication and document in PCC. The Administrator would ensure all discharge process were followed. To ensure each steps where completed the Administrator would review the documentation was completed in PCC. The Administrator stated that the steps were the same for an immediate discharge except he had to contact the ADO and inform him of the immediate discharged resident. During an interview on 9/18/25 at 5:00 pm with ADON A revealed that she had been trained by the DON on her duty to sit in fill in as interim DON in the IDT planning and ensure residents have all necessary post discharge providers in place for continuity of care. Verified via record review of Resident #5 who resided on the secured unit showed increased behaviors and charge nurses documented Resident #5 increased behaviors in PCC. Charge nurse contacted ADON A, ADON A contacted the MD, the MD put in a psych evaluation order, Resident #5 RP contacted and Resident #5 discharged to the hospital. Interviews held on 9/18/25 from 3:15 p.m., to 6:00 p.m., and 09/19/25 from 6:00 a.m., to 5:40p.m., which covered staff who work morning, day, night shifts, PRN staff and double weekend staff conducted with the Administrator, DON, ADON A (1st shift/weekdays), ADON B(1st shift/weekdays), ADON C (1st shift/weekdays), RN D (weekdays), RN E (PRN), RN F (overnight/morning), RN G (overnight/morning), RN H (double weekends), LVN I (Overnight), LVN J (morning), LVN K (overnight), LVN L (second shift), LVN M (double weekends) and SW N, SW O indicated they all participated in in-services on resident rights, discharge process and documentation and proficiency test prior to starting their shifts. All staff knew their responsibilities. All staff were knowledgeable, who were a part of the IDT. All staff were able to state that the facility's discharge process to ensure all residents' discharges were safe, all know what was required to be documented and who was responsible for each task and understand that the Administrator would oversee the entire process to make sure it was complete, and he would report any immediate discharges to the ADO. The Administrator was informed that the Immediate Jeopardy was removed on 9/18/2025 at 3:11 p.m. The facility remained out of compliance at a severity level of that was not Immediate Jeopardy and a scope of isolated, due to staff needing more time to monitor the effectiveness of the plan of removal for inappropriate discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and records review the facility failed to ensure each resident received adequate supervision and transferred in a safe manner to prevent an accident for one (Resident #1) of four residents reviewed for accidents and hazards, in that: The facility failed to provide Resident #1 with adequate supervision and assistance with transfers to prevent an accident. On 05/14/25, Resident #1 had an unexpected or unintentional incident, which resulted in an injury to her left knee when transferred by two CNAs from the bed to a dialysis chair. On 05/19/25, the facility sent Resident #1 to the hospital after an x-ray of the bilateral (both) knees, dated 05/16/25 , revealed a possible acute nondisplaced fracture (the bone did not move when the fracture occurred) . follow-up x-rays or CT scan is recommended. On 05/19/25, Resident #1 had surgery to her left distal femur (lower part of thighbone, located just above the knee joint) to repair the fracture. An IJ was identified on 06/20/2025 at 1:30PM. The IJ template was provided to the facility on at 1:30 PM. While the IJ was removed on 06/20/2025 at 9:45PM, the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure placed residents at considerable risk of significant injury, harm, and/or impairment. Findings included: Record review of Resident #1's 5-day MDS Assessment, dated 05/29/25 reflected an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had an admission history and diagnoses of CHF ([congestive heart failure] a chronic condition where the heart is unable to pump blood effectively, leading to a buildup of fluid in the lungs and legs); seizure disorder; CKD dependent on dialysis; and age-related physical debility. A BIMS score of 11 suggested Resident #1 had a moderate cognitive decline. Resident #1 had no behavioral symptoms or rejection of care behavior during the MDS review period. Resident #1 was dependent of staff assistance with ADLs and was frequently incontinent of bladder and always incontinent of bowel. Resident #1 was at risk for pressure ulcers/injuries. Record review of Resident #1s comprehensive care plan, printed 06/09/25, reflected the following: [Resident #1] has surgical site to the left knee and left thigh (Date Initiated: 05/23/25). Interventions included Observe for s/s of infection and Observe for s/s of pain during treatment and medicate PRN per physician's orders. [Resident #1] has an ADL Self Care Performance Deficit (Date Initiated: 03/31/25). Interventions included Bed mobility: requires staff x1 for assistance; Encourage the resident to use bell to call for assistance; and Transfer: require a Mechanical Lift as a Mechanical Aid and 2 staff members to assist in transfers (Date Initiated: 05/20/25 by DON); [Resident #1] has a history of making false accusations/fabrications on staff, refusal of care, and refusal of medications (Date Initiated: 03/31/25; Revision on: 05/27/25). Interventions included Educate [Resident #1/RP/CG] of causative factors and measures to prevent false accusations; and Monitor/document/report and Psych Services to eval and treat as needed. Record review of Resident #1's active physician orders reflected:- Order date 03/28/25: Acetaminophen Oral Tablet 325 mg. Give 2 tablets by mouth three times a day for Pain. Give 2 tablets to equal 650 mg, not to exceed 3000 mg a day. [Discontinued 05/19/25] - Order date 03/28/25: Resident to have pain consult with pain management NP to assess for pain medication needs and /or modifications. [Discontinued 05/19/25] - Order date 03/28/25: DIALYSIS DAYS MONDAY-WED-FRI [Discontinued 05/19/25] - Order date 03/28/25: NO BP/BLOOD DRAW OR FINGER STICK TO RIGHT ARM [Discontinued 05/19/25] - Order date 03/31/25: Anticoagulant Monitoring: monitor for signs and symptoms of adverse reaction: . rash . tissue necrosis . hemorrhage . purple toe syndrome, Increased fracture risk with long term use. Every shift. [Discontinued 05/19/25] - Order date 05/16/25: Xray of left Femur 2V (two views), Bilateral (both sides) Hip 2V, and Left Tibia & Fibula (the bones that make up the lower leg) 2V. - Order date 05/15/25: Tylenol Extra Strength Oral Tablet 500 mg. Give 2 tablets orally every 8 hours as needed for Pain. Two tablets to equal 1000 mg. - Order date 05/22/25: Norco tablet 5-325 mg. Give 1 tablet by mouth every 6 hours as needed for Pain. - Order date 05/23/25: Cleanse left knee surgical site with wound cleanser, pat dry apply Betadine then cover with protective dressing change every Tuesday - Thursday and as needed. Every day shift every Tuesday, Thursday for wound care. - Order date 05/23/25: Cleanse left thigh surgical site with wound cleanser, pat dry apply Betadine then cover with protective dressing change every Tuesday - Thursday and as needed. Every day shift every Tuesday, Thursday for wound care. - Order date 05/23/25: PT to eval and treat. - Order date 05/23/25: PT to eval and treat as indicated. PT Clarification: Patient to receive skilled PT services 3x/week for 60 days. - Order date 05/27/25: [Provider Name] may provide psychiatric services. - Order date 05/23/25: Acetaminophen Oral Tablet 325 mg. Give 2 tablets by mouth three times a day for Pain. Give 2 tablets to equal 650 mg, not to exceed 3000 mg a day. - Order date 05/23/25: Resident to have pain consult with pain management NP to assess for pain medication needs and /or modifications. Record review of Resident #1's May 2025 MAR did not reflect a nurse initial that indicated Tylenol Extra Strength Oral Tablet 500 mg. Give 2 tablets orally every 8 hours as needed for Pain. Two tablets to equal 1000 mg were administered to Resident #1 on 05/15/25 for pain as needed. The MAR revealed that Resident #1 received Acetaminophen Oral Tablet 325 mg. Give 2 tablets by mouth three times a day (9AM, 1PM, 5PM) for Pain as ordered; except on Mondays at 9:00 AM when Resident #1 was at dialysis. On 05/14/25, Resident #1 did not receive the Acetaminophen dose on Wednesday, 05/14/25 at 9:00 AM or 1:00 PM. A comment was not entered in the comment section to explain why the doses were not administered. Record review of Resident #1's admission Fall Risk assessment dated [DATE], completed by ADON B, reflected a score of 12 that suggested Resident #1 was a High Risk for falls. Record review of Resident #1's progress notes indicated the following:- 05/15/25 at 9:20 PM, RN E documented [Resident #1] complained of pain to the left leg when turned/repositioned. pain started today. Assessed resident for injury. No injury noted. Resident moaned when left leg is moved. notified NP. Received order for x-ray, 1000 mg Tylenol . Administered Tylenol . - 05/16/25 at 8:12 AM, RN E documented X-ray results for left tibia/fibula, right femur received and relayed to NP. All results were negative. No new orders received. - LATE ENTRY (entered on 05/20/25 at 5:34 PM) effective date 05/16/25 at 4:28 PM, ADON B entered an Event Note: Level of pain 7 out of 10; Resident c/o (complained of) pain. X-ray of left femur (thigh), bilateral (both) hips, and left tibia and fibula (the two bones that make up the lower leg). - 05/17/25 at 2:33 PM, RN F documented New order STAT of x-ray of bilateral knees. [Resident #1] complained of pain to knee. - 05/19/25 at 12:00 AM (midnight), RN F documented Received bilateral knees x-ray result with impression that there is possible acute nondisplaced fracture of the distal left femur and relayed it to NP (on call for PCP), new order received to transfer to hospital for evaluation and treatment. Non-emergency transportation called. Night nurse to follow up. Limited movement initiated and maintained to left leg. - 05/19/25 at 1:25 AM, RN P documented [Resident #1] was transferred to hospital by [non-emergency transportation] for abnormal x-ray result. - LATE ENTRY (entered on 05/27/25 at 3:03 PM) effective date 05/20/25 at 5:17 PM, DON entered Received report at 1:31 PM from [hospital] that [Resident #1] has a nondisplaced fracture of distal femur and would be having surgery to repair. Record review of Incident Report #805, dated 05/15 /25 3:46 PM, completed by RN E indicated the incident occurred in the Resident's Room Incident description: Resident complained of pain in left lower leg when turned/repositioned. Resident description: Resident stated that the pain started today. When asked if she fell, she stated No. When asked if anyone hurt her she said No. When asked what happened her reply was that she didn't know her knee just started hurting. Immediate Action Taken: Assessed resident for injury. No injury noted. Resident moaned when left leg is moved. No s/sx of distress noted. Notified NP. Received order for x-ray bilateral hips, left femur, tibia, fibula. 1000 mg Tylenol every 8 hours PRN. Administered Tylenol 1000 mg to relieve pain. Level of Pain: 5. Record review of Resident #1's x-ray results dated 05/15/25 at 8:16 PM reflected examination of the left tibia/fibula, right femur, and bilateral hips had no evidence of an acute fracture. The reading physician (physician responsible for reading x-ray results and report impression of findings) read the results on 05/15/25 at 9:30 PM. Record review of Resident #1's x-ray results dated 05/16/25 at 1:46 PM reflected examination of bilateral knees that revealed a possible acute nondisplaced fracture of the distal left femur seen. The reading physician (physician responsible for reading x-ray results and report impression of findings) read the results on 05/16/25 at 3:25 PM. Record review of Resident #1's hospital visit summary (05/19/25 - 05/22/25) revealed Resident #1 admitted on [DATE] at 1:33 AM. The admission diagnosis reflected femur fracture. The admitting physician documented that [Resident #1] chief complaint was severe left leg pain. The admitting physician's history and physical summary indicated [Resident #1] . landed on her left knee 5 days ago. She had left knee x-ray done 2 days ago that showed possible knee fracture and acute nondisplaced fracture of left distal femur. [Resident #1] has persistent and worsening left lower extremity pain prompting them to send her to our ED for further evaluation. CT left lower extremity showed nondisplaced distal femoral fracture [Final Result time 05/19/25 at 2:22 AM]. Orthopedic surgery was consulted with plan to proceed with surgery at this morning [05/19/25]. Record review of a facility submitted SRI dated 05/20/25 and a 5-day PIR (Provider Incident Report)dated 05/27/25 reflected the internal investigation was UNFOUNDED. The 5-day PIR included written and signed witness statements from RN F, Resident #1 signed by ADON A, and TT C. The facility conducted In-services dated 05/20/25 on ANE, Resident Rights, and Change of Condition Notification. Record review of a written statement dated 05/19/25, RN F wrote On 05/14/25, [Resident #1] went to dialysis, came back and did not tell (RN F) about having pain. At 3:30 PM, the assigned CNA (CNA G) informed (RN F) and RN E at the nurse's station that [Resident #1] was complaining about pain to her left (knee) leg. RN E and (RN F) quickly went to see (Resident #1), assessed her. [Resident #1] said that she had pain to her left (knee) leg. RN E had already assumed his afternoon shift and he acknowledged to call the doctor and (RN F) left for home. RN F signed and dated (05/19/25) the statement. Record review of an undated written statement, ADON A wrote [Resident #1] stated that her leg started to hurt last Wednesday when 1 male and 1 female picked her up under her arms to put her in the chair for dialysis. She said her leg dropped and she told them it hurt. She went to dialysis and when she came back the nurse gave her pain medicine. Resident #1 and ADON A signed the statement. ADON A wrote Writer next to her name. Record review of an undated written statement, TT C wrote On Wednesday, 14th May 2025, (TT C) was called to assist to transport [Resident #1] to dialysis den (facility area where in house dialysis is given)for her dialysis schedule. (TT C) and a female aid transferred her from bed in the transport chair without moaning or groaning or complaint of pain, neither did any of her body part was dropped or rub against any hard surface. She was successfully and comfortably transported to dialysis den. TT C signed the statement. During an interview and record review on 06/08/25 at 1:44 PM, the NFA stated that he assisted the former administrator with completing self-reports before her last day worked for the facility. The NFA said that he was not the administrator over the facility at the time of the incident. The NFA said that he called in the self-report on 05/20/25 and completed the 5-day provider investigation report (PIR) on 05/27/25. Record review of the 5-day PIR reflected . An x-ray was ordered; no confirmed injuries were found initially, but the resident was sent to the hospital for further evaluation. The hospital determined the resident had a non-displaced distal femur fracture and will undergo surgery. The NFA said that he was unaware that the x-rays that resulted no confirmed injuries were of the hips, the right thigh, and the left lower leg. The NFA said that he did not know that there was a second set of x-rays done STAT on 05/16/25 of Resident #1's knees and the findings determined the possible non-displaced fracture and that was why Resident #1 was sent to the hospital but not until 05/19/25. The NFA said that he reported the investigation the way the DON informed him. During observation and interview on 06/08/25 at 3:42 PM, Resident #1 was lying in a left lateral position in bed. Resident #1 was oriented to self, situation, and time of day (with prompts). Resident #1 with fair recall of immediate and past events. Resident #1 stated two (unidentified) staff dropped her on her (left) knee when transferred from bed to dialysis chair prior to going to dialysis. Resident #1 said that the staff transferred her from the bed by lifting her under her arms to the dialysis chair. Resident #1 said she told the staff that they hit her knee on the floor and her knee hurt. Resident #1 said that the nurse administered pain medicine when she returned from dialysis. Resident #1 said that the male staff pushed her to dialysis in the dialysis chair. Resident #1 said she had to go to the hospital and had surgery to her knee. Resident #1 said that she still had stitches in her knee and had an appointment to follow up with the surgeon to remove the stitches. There were no fall mats noted on the bedside floor or in the room. Resident #1 denied she had a fall and restated that staff dropped her on her (left) knee during a transfer. During an interview and record review on 06/09/25 at 2:06 PM, the DON said that she learned about the x-ray results of Resident #1's knees that indicated a possible acute fracture during the morning meeting on 05/19/25. The DON said that there were previous x-ray results that were negative. The DON said that she told the staff to send Resident #1 to the hospital by non-emergency transport to get a second opinion of the x-ray results and she immediately implemented an internal investigation. The DON said that Resident #1 never told staff how she hurt her knee. The DON said that staff did not report a fall and Resident #1 never told staff that she fell or that someone hurt her. The DON said that Resident #1 was wheelchair bound and needed staff assistance to transfer. Record review of the 5-day PIR reflected [Resident #1] initially reported left leg pain during repositioning by staff. When asked what happened, [Resident #1] was unsure and denied any fall. With further questioning, she mentioned a fall at dialysis. When asked the dialysis staff they denied any fall. [Resident #1] stated she had been dropped in her room, but staff involved in her care denied any fall. When asked her again [Resident #1] changed her story and said there was no fall in the room and that it might have occurred while being transferred to a chair at dialysis. She eventually retracted this as well stating she had not fallen but her leg dropped a little . The DON said that she sent ADON A to the hospital to interview Resident #1 (on 05/19/25) after the hospital informed Resident #1 would have surgery to repair the fracture of the left knee. The DON said that ADON A reported that Resident #1 said that two staff members dropped her knee to the floor when transferred from the bed to the dialysis chair. The DON said that Resident #1 just had surgery and was still under the influence of anesthesia and had ADON A return to the hospital the next day (05/20/25) to interview Resident #1 again and [Resident #1] told a different story. Continued record review of the undated written statement signed by Resident #1, written and signed by ADON A, reflected . 1 male and 1 female picked her up under her arms to put her in the chair for dialysis. She said her leg dropped and she told them it hurt. She went to dialysis . The DON said that ADON A obtained the statement from Resident #1 at the hospital on [DATE], but Resident #1 changed her story. When asked if staff should pick a resident up under her arms to transfer, the DON replied, absolutely not. The DON demonstrated how the staff transferred Resident #1 from the bed to the dialysis chair. The DON said that TT C and CNA D clasped each other's arms like a bridge underneath Resident #1's legs and to support Resident #1's back, lifted her up off the bed and placed in the dialysis chair. The DON said that TT C was very tall, and CNA D was short. The DON said that the only thing she can figure that happened was CNA D may have bumped Resident #1's leg on the floor because the transfer was uneven, but it could not cause a fracture. The DON said that she consulted with the PCP (also the Medical Director) and he told her that he reviewed some old medical records and found that Resident #1 had brittle bones from osteoarthritis. Record review of Resident #1's admission record and admission MDS did not reflect an admission history or diagnosis of osteoarthritis. The diagnosis of Unilateral osteoarthritis resulting from hip dysplasia, right hip, entered during stay and the onset date reflected 05/15/25. The DON said that TT C was a CNA but was employed as the van driver. She could not think of the name of the female CNA (CNA D), but a statement was provided with the 5-day PIR. The investigator verified there was not a statement by a female CNA. During an interview on 06/10/2025 2:13 PM, the DOR said that she was familiar with Resident #1 who received physical therapy services effective 05/23/25. The investigator explained to the DOR the transfer technique used for Resident #1 the DON described and demonstrated. The DOR replied that she never heard of a 2-person transfer technique by clasping arms together to lift someone in a seated position. The DOR said that the therapy department educated staff on supervision with assisted devices and transfers whenever a resident received physical therapy services to ensure understanding on how to assist the resident. The DOR said the only transfer techniques are 1- and 2-person transfer with a gait belt and a mechanical lift. During an interview on 06/10/25 at 2:30 PM, RN F said that he worked 7A - 3P during the week. RN F said that he was familiar with Resident #1 as he was always her assigned nurse. RN F said that Resident #1 was weight-bearing during transfer. RN F said that Resident #1 required a gait belt for transfer and could stand from a seated position on the bed and step then pivot to sit in a wheelchair or dialysis chair. RN F stated that a CNA would bring the dialysis chair from the dialysis den (a room where residents go to receive dialysis by a third-party dialysis provider) to the resident's room, transfer the resident to the dialysis chair, and then push the resident to the dialysis den in the dialysis chair. RN F said that he assisted Resident #1 to bed when she returned from dialysis (Wednesday, 05/14/25) and she did not complain of pain to the left knee. RN F said that Resident #1 usually received dialysis in the morning and returned to her room shortly before or sometimes after his shift ended. RN F said on 05/15/25, CNA G approached the nurses' station and reported Resident #1 complained of pain of her left leg. RN F said that it was shift change and he had given hand-off report to RN E. RN F said that he accompanied RN E to Resident #1's room and observed RN E assess Resident #1. RN F said that RN E said that he would notify the doctor and RN F left. RN F said that he received hand-off report on 05/16/25 that Resident #1 had x-rays done for complaint of pain. RN F said on 05/16/25, he reviewed the x-rays and saw that they were of the right and left hips, the left lower leg, and the right thigh. RN F said that he called the x-ray company and asked where the results for Resident #1's left knee were. RN F said that the x-ray representative said that the results were of the areas ordered. RN F said that he was sure that Resident #1 complained of knee pain, obtained an order for a STAT x-ray of Resident #1's right and left knees and notified the x-ray company. RN F said that the x-ray company came out on 05/16/25 to do the x-rays. RN F said on 05/17/25 the facility did not receive Resident #1's x-ray results before the end of his shift at 3:00 PM. RN F said that he worked on Sunday, 05/19/25 from 7:00 AM to 11:00 PM. RN F said that he checked for Resident #1's x-ray results that morning and the facility still had not received the x-ray results. RN F said that he followed up with the x-ray company. RN F said that he checked the x-ray company site for the results at the end of his shift, 05/19/25 at 11:00 PM, and the results were posted in the portal. RN F said he saw that Resident #1 had a fracture, called the PCP to obtain an order to send Resident #1 to the hospital for further evaluation. RN F said that he contacted the non-emergency transport company and gave hand-off report to the on-coming nurse (RN P). During an interview on 06/10/25 at 2:51 PM, the Medical Director said that the DON notified him that she initiated an internal investigation of an unknown injury for Resident #1. The Medical Director said that the DON inquired how could [Resident #1] sustain a fracture if the staff denied there was a fall. The Medical Director said that he reviewed Resident #1 past medical history and discovered that she received injections to increase bone formation for osteoporosis back in 2014. The Medical Director said that he provided the health information to the facility to determine factors that could cause the injury if Resident #1 did not fall. The Medical Director emphasized that Resident #1's past health history was not his viewpoint or his determination for the fracture. The Medical Director said that Resident #1's osteoporosis was stable and was not of concern to her left lower extremity. The Medical Director said that it would require force to sustain the non-displaced fracture to Resident #1's distal femur. The Medical Director stated it was probable when asked by the Investigator if an inappropriate and/or unsafe transfer technique could cause the fracture. On 06/10/25 at 4:30 PM, the DON handed the investigator a copy of an email received from the x-ray company dated 06/10/25 at 4:25 PM and a copy of the staffing schedule dated 05/14/25. The DON said that she remembered who the female aide (CNA D) was and that was her name and phone number written on the schedule. The DON said that CNA D was no longer employed at the facility. The DON said that CNA D called off because she had a family emergency and never returned so the facility had to terminate her. Record review of the email received from the x-ray company revealed that the x-ray order of Resident #1's knees was placed on 05/16/25 at 8:32 AM; the order was confirmed 05/16/25 at 9:32 AM; the x-ray tech performed the x-ray on 05/16/25 at 1:32 PM; and the images were sent to the physician who reads the x-ray results on 05/16/25 at 1:56 PM. The email indicated that the results were not uploaded to the facility because of an error and was manually uploaded to the facility on [DATE] as a significant finding after notified that the results were not received. Record review of the schedule dated 05/14/25 reflected CNA D assignment was on a different hall than Resident #1 resided. The schedule reflected a code next to CNA D's name that indicated she was out due to emergency and did not work that day. During an interview on 06/10/25 at 5:25 PM, TT C said that he was the van driver for the facility and did not interact with residents from day-to-day except to transport to and from appointments. TT C said that he heard his name called out in the hallway (05/14/25) while he was getting a resident from their room to take to an appointment. TT C said a female (did not know who the female was) asked him to assist CNA D to transfer Resident #1 to dialysis. TT C said that he entered Resident #1's room and CNA D was standing beside Resident #1 (on the left side) who was sitting on the edge of the bed. TT C said that Resident #1 had on a (facility provided) gown. TT C said that CNA D placed a gait belt around Resident #1's waist and he grabbed the front and the back of the gait belt to lift Resident #1 up and placed her in the dialysis chair. TT C replied no when asked if he reached under Resident #1's arms to lift her when he assisted CNA D to transfer Resident #1 to the dialysis chair. TT C said that he was not sure if the gait belt slipped up under Resident #1's arms when he lifted her up because the belt was too loose. When asked if Resident #1 stepped or walked to the dialysis chair, TT C said no, we lifted her and placed her in the dialysis chair. When asked if Resident #1's feet raised off the floor when he and CNA D lifted Resident #1 to transfer from the bed to the dialysis chair, TT C said that he did not recall. TT C said that he did not know the female aide (CNA D) or her name. During an interview on 06/10/25 at 5:56 PM, RN E said that he was the charge nurse for Resident #1 on the 3PM - 11PM shift. RN E said that CNA G notified him of Resident #1's leg pain on 05/15/25 during shift change around 3:30 PM. RN E said that Resident #1 was in bed when he entered the room to assess Resident #1. RN E said that he assessed Resident #1 thighs and hips for bruising, swelling, or any signs of trauma from a fall and there were no signs of injury. RN E said whenever he tried to reposition Resident #1 or touch the left leg, she cried out and asked not to move her. RN E said that Resident #1 demonstrated decreased mobility of the left leg and she did not usually complain of pain. RN E said that he asked Resident #1 if she fell or if anyone hurt her and she denied. RN E said he asked staff if anyone saw her fall and staff replied that she was bed all day. RN E said that he asked Resident #1 when did the pain start and she replied today (05/15/25). RN E said that he did not remember if he asked what [Resident #1] was doing when the pain started or asked what could have caused the pain. RN E said that he completed an incident report after he spoke with his supervisor (could not recall exactly who he spoke to) about Resident #1 pain. RN E said that it was decided to complete an incident report because Resident #1's complain of pain was unusual. An outbound call on 06/10/25 at 5:00 PM and at 6:30 PM to CNA D was unanswered. The investigator left a message on the voicemail to return call. CNA D did not return the call before the Investigator exited the facility on 06/10/25 at 8:00 PM. Record review of the facility's Safe Patient Handling/Transfer undated policy reflected in its entirety the following: The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment and interventions to provide a comfortable, safe transfer, repositioning and resident movement.1. Nurses will identify residents in need of transfer, repositioning or movement assistance.2. Nurses will assess the risks associated with lifting, transferring, repositioning or movement assistance.3. nurses will be educated in the identification, assessment and control of risks of injury to resident and nurses during patient handling.4. Resident will be evaluated on admission and as needed for alternative means of lifting.5. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to an unacceptable risk of injury.6. Facility staff will report to supervisor the inability to complete resident lifting, transfer, or repositioning if they feel it will either endanger the resident or cause injury to staff.7. Nursing will request therapy disciplines to evaluate resident ability to assist and amount of assistance needed with lifting, repositioning, transferring or mobility.8. Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable. The NFA was notified of an Immediate Jeopardy (IJ) on 06/20/2025 at 3:00 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 06/20/2025 at 7:11PM and included: Plan of Removal for 6/20/25 Problem: F689 Free from Accidents/Hazards The facility failed to provide adequate supervision and assistance to prevent accidents. Interventions: As of 6/10/25, CNA A was in-serviced 1:1 by the DON. All other nursing staff were in-serviced on the same topics by the DON/ADON/Director of Rehab. Completion date will 6/10/25. CNA B is no longer employed with the facility. In-serviced Admin / DON by regional nurse and Area director of operations on gait belt transfers, abuse/neglect, notification of change of condition, and resident rights. Resident #1 was assessed for any additional injuries by DON/ADON on 6/10/25. No additional injuries noted. All other residents that require assistance with transfers were assessed for injuries on 6/10/25 by DON/ADON/Charge nurse. No additional injuries noted. Following the Kardex in Point Click Care for all transfer status and assistance required with return demonstration from staff. Gait belt transfers with return demonstration. Abuse and Neglect (Improper transfers) education Notification of change of condition education Resident Rights education completed 6/10/25 Fall Prevention Policy will be completed 1:1 with CNA A as of 6/10/25 by the Regional Compliance Nurse. This in-service will include reporting to the charge nurse immediately if a resident suffers a fall, has an accident, or is found on the floor. If the charge nurse is not available, staff will report to DON immediately. Staff will not assist a resident off the floor until a charge nurse has been notified and assessed the resident. As of 6/10/25 audits were completed. All residents in the facility received head-to-toe assessment/ pain assessment by the DON/ADON/Tx Nurse for any injuries and/or fractures. No additional issues were found. On 6/10/25, all resident care plans were reviewed and audited for accuracy of transfer status and assistance by DON and ADON and if there is any change of condition- care plans will be updated accordingly. No issues were identified. On 6/10/25, DOR/designee initiated gait belt (1 to 2 person) and mechanical lift training and check offs with return demonstration. All nursing staff will be checked off prior to the start of their next shift. Training and checkoffs will be completed by DON/ADON/and Director of Rehab. The medical director was notified the immediate jeopardy potential by the administrator on 6/10/25. ADHOC QAPI was held with the Medical Director and facility inte

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #1) of four resident reviewed for quality of care. The facility failed to ensure Resident #1 was adequately supervised to prevent her from leaving the facility unsupervised. There was a door near the secure unit that did not have an audible alarm. It was determined the noncompliance was identified as a Past Noncompliance Immediate Jeopardy (IJ). The IJ began on 06/01/2024 and ended on 06/02/2024. The facility corrected the noncompliance before the investigations began. This failure placed residents at risk for harm and/or serious injury. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 05/22/2024, reflected the resident was a [AGE] year-old-female who admitted to the facility on [DATE]. The resident had diagnoses which included: Heart Failure (disease that affects the heart muscle), Schizophrenia (mental illness), cognitive impairment (confusion) end stage renal disease (kidneys have stopped working) and, dependent on dialysis (a machine that cleanses the blood). The MDS reflected she had a BIMS score of 10, which indicated moderate cognitive impairment. The resident was ambulatory with an unsteady gait, used a wheelchair as a walker, and required assist of one staff for activities of daily living. The MDS did not reflect any wandering behavior. Record review of Resident #1's care plan, dated with a review date of 03/30/2024, addressed the resident's impaired cognition due to schizophrenia loss, dialysis, wandering behavior on secured unit, and assistance required for activities of daily living. Record review of Resident #1's clinical record revealed two Elopement Risk Assessments, quarterly elopement risk assessment dated [DATE] reflected she was score of 13 (high risk for elopement). An elopement or attempt risk assessment dated [DATE] reflected she was a score of 26 (high risk for elopement). Record review of the Provider Investigation Report completed by the Administrator, dated 06/02/2024, revealed Resident #1 was independently ambulatory using her wheelchair as a walker, and her own responsible party. There was a family member as the #1 contact in case of emergency contact. Resident #1 could not make decisions for herself but was alert and usually understood. Resident #1 had left the faciity on [DATE] sometime between 9:00 p.m. and 10:00 p.m. The resident had been located at the hospital in the ER on [DATE] at approximately 7:30 p.m. The resident was last seen sitting by one of the exits of the secured unit at some time before 10:00 p.m. on 06/01/2024. The family was notified, and the police were called. The facility staff searched for Resident #1, calling a Code Orange at 10:15 p.m. after observation that Resident #1 was missing. The family was contacted multiple times on 06/01/2024 and returned the call on 06/02/2024 at 11:45 a.m. The family stated they would call around and gave the administrator the Resident #1's last known address. The police used dog and picked up a scent at the local bus stop. The police reviewed the local bus company camera footage and the location of exit. The police contacted the administrator and informed the facility a secondary scent was picked up at the bus station in a city 4 miles away. The Provider Investigation Report reflected a finding of confirmed (for other). The facility started in-service at 12:00 a.m. on 06/02/23 on the elopement procedure policy and procedures with all staff. The facility's DON reassessed all the resident for elopement risk and updated and checked all care plans on 06/02/24. Review of Provider Investigation Report dated 06/02/2024 reflected a finding of confirmed for Other. Review of the External/Internal/Systemic Approach Investigation Summary dated 06/02/2024 completed on 06/02/2024 reflected: . An emergency QAPI meeting was held on 06/02/2024 with Medical Director in attendance . all residents had a new elopement assessment to identify any current patients that are imminent risk for elopement (no other residents were found to be at imminent risk of elopement) . (who was responsible: Nurse Management . who will monitor: Director of Nursing.elopement assessment will be completed upon admission and quarterly by the charge nurse and/or nurse managers and for any resident that triggers an imminent risk for elopement, the elopement response protocol will be initiated Any patient that triggers elopement risk will be placed on 1:1 monitoring until no longer deemed necessary. DON will monitor for compliance for daily times 5 days and weekly times 4 weeks until 06/30/2024 and then monthly on an ongoing basis .Who will monitor: Administrator and or designee tested the functionality of all doors (closure and alarm) and outside gates on the facility property for proper functioning and no issues were identified. Maintenance director or designee to monitor facility doors and gates checked to validate proper functioning daily times 5 days, weekly times 4 weeks , then as needed thereafter. The Director of Nursing During this interview the logs were requested form maintenance department and/or Nurse Manager will monitor weekly for compliance by completing an audit of the elopement assessments. Audits will be completed weekly for 3 weeks until 06/30/2024 and monthly on an ongoing basis Monitoring .Starting 06/01/2024 Director of Nursing and/or Nurse Managers will receive in hand, the resident monitoring/every 2-hour body check documentation at the end of each shift for the first 72 hours, each day for one week, then weekly for 4 weeks. The Administrator will review the documentation each week for compliance Facility staff to monitor and validation for proper functioning of all doors, and gates when interruption in electricity are identified daily [NAME] 5 days, weekly times weeks then as needed thereafter when interruptions occur .Facility receptionist to conduct visitor observation for attempting to allow residents to exit facility unsupervised daily times 5 days , weekly times 4 weeks, then as needed thereafter . QAPI committee will review monthly for 3 months and adjust he plan of corrections and processes as needed. The Administrator will monitor daily to ensure compliance for four weeks and will review . Further review of the Providers Investigation Report reflected monitoring and audits by the designated staff (DON Nurse Managers) had occurred. Record review of Resident #1's nursing progress notes from 05/01/2024 until 06/01/2024 reflected Resident #1 was on the secured unit and was only signed out three times a week on Tuesday, Thursday and Saturday for pass by facility staff when she would agree to go to dialysis. The resident was ambulatory on the secured unit utilizing a wheelchair as a walker for mobility. Further review reflected without the wheelchair the resident could only mobilize safely for about 20 feet. Further review reflected Resident #1 was not exit seeking. She would go to the doors but just look out the window and never touch the door, to set off the system. Record review of Resident #1's progress notes reflected dated 06/01/2023 at 10:15 p.m., LVN A noted CNA B was coming back from break and then informed LVN A that she could not locate Resident #1. LVN A stated, after being informed by the CNA, conducted an additional search, and then informed the nurse manager on duty and a code orange meaning elopement was called. The code included notification of the administrative staff, responsible party, police, and the physician. Record Review of the elopement risk assessments reflected the DON had assessed all resident for elopement as part of the plan of correction. Review of the in-service dated 06/01/2024 reflected all staff attended and the subject matter was regarding Facility policy on elopement and reducing the risk for elopement: initiating a frequent monitoring form, elopement forms for new admission, and quarterly or condition change, intervention, put in place immediately with reporting to the nurse in charge, ensuring all doors are closed after exiting the unit and all doors that lead to the outside, all alarms that have been placed on doors are independently functioning and the staff knows to report and how to reset the panel for the system, and the individual alarms. During a power outage (even flickering of power) staff are to check all doors to ensure they are secured, the doors will need to be manually reset (instructions on the manually reset). Further review reflected the staff was also in-serviced on abuse, neglect, and exploitation (types of abuse and who the abuse coordinator is). There were handouts given and a test to ensure competency . The staff was instructed they could not return to work until they had the training and had passed the test. Review of the in-service dated 06/01/2024 was reviewed and reflected abuse and neglect test that was given to the employee after the training. The test including five question concerning abuse and neglect: (questions what identifies abuse & neglect, what are you supposed to do when you observed it or told about it, who do you report, and what so you do if nothing appears to be done about the report.) In an interview on 06/03/24 at 9:20 a.m. with LVN H revealed the LVN had worked at the facility for seven years. LVN H stated Resident #1 was always looking out all the exit doors or sitting in a chair in the hallway. Resident #1 would sometimes talk about how she needed to check on her family. LVN H stated Resident #1 had no change in condition and was not any different after the two days off for LVN H. LVN H works Monday through Friday. LVN H stated Resident #1 never mentioned leaving and had the same behaviors, attending the activities then going back to walking with the wheelchair or sitting in the chair looking at the door or window. LVN H stated all employees got a mass text on Saturday night about Resident #1's elopement. LVN H came and helped but Resident #1 was not found. All staff had in-services on the elopement process and the alarm system for the facility and the secured unit. All staff were re-educated on how to reset the alarm manually. LVN H stated there had not been any problems with the facility alarm system working since the storm the previous week. The LVN stated a company came out and checked it, and everything has been fine. LVN H stated there had been no other elopements. An interview on 06/03/24 at 9:30 a.m. with CNA I revealed the CNA had been in-serviced on the alarm system for the secured unit, if there is no power, staff must protect all the exits. CNA I stated she had been in-serviced on Saturday in person on how to reset the system; the nurse usually does do that, but the Administrator wanted everyone to know. An interview on 06/03/24 at 9:45 a.m. with CNA J revealed Resident #1 would sit by the doors and look out while sitting in her wheelchair. CNA J stated Resident #1 was a pleasant resident. CNA J stated Resident #1 never caused any trouble. Resident #1 would talk about checking on her daughter, never tried to leave the unit. CNA J stated Resident #1 would be taken to the receptionist to take money from her trust fund. Resident #1 wanted to get snacks from the vending machines. CNA J came and helped look for the resident when the facility sent out the mass text. The facility in-serviced CNA J on the elopement process and the new alarms on the doors and how to reset the system and if an alarm sound staff is to react immediately. An interview on 06/03/24 at 9:00 a.m. with the Administrator revealed had been informed by the facility of the elopement around 10:30 p.m. on 06/01/2024, arrived at facility at 10:50 p.m. The Administrator began looking for Resident #1 and had been informed the staff was divided up into internal and the external search parties. The Administrator stated the facility had sent out a mass text and a lot of staff showed up to help. There were already staff driving around the area and the neighborhood, the police had been notified. The Administrator stated police arrived just before 11:00 p.m. and the DON arrived shortly after. The Administrator stated the police had a search helicopter looking for Resident #1 and search dogs, due to area being wooded, dense, close to busy streets and the bus stop. The Administrator stated the DON started trying to contact the family. The Administrator stated when information had been provided of an address in the area where Resident #1 used to live, the facility provided the address to the police; Resident #1 was not there. The Administrator stated the facility staff, drove at different times to the address to check; Resident #1 was not there. All residents had been accounted for, except Resident #1. The police stayed in contact and informed the Administrator of the scent the search dogs had picked up at the bus stop. The police told the Administrator there was a review camera footage and the location of Resident #1's exit. The police were able to determine Resident #1 had traveled to another city near the facility and the search dogs had picked up the scent at that bus station. The search dogs could not pick up Resident #1's scent again after located the scent multiple times at the bus station. The Administrator contacted all the local hospital, called the local news station, provided a picture and details of Resident #1's elopement. The Administrator stated the in-services on the night of the elopement (06/01/24) covering the elopement process, the security alarm system for the units. The Administrator stated the staff was in-serviced on how to conduct a search, and how to manually reset the system on the secured unit, if there was a power outage or power surges. The facility staff had to come in person to in-service on the topics, including abuse and neglect. The staff had to be checked off competency before were allowed to return to work. The Administrator stated the entire staff (160) had been in-serviced. The Administrator stated there was one staff member that phone was broken and would be in-serviced on tomorrow (06/04/24) when the staff returned to work before, the staff went to work. The Administrator informed the surveyor, one of the hospitals had contacted, the facility. Resident #1 had shown up at the hospital around 7:30 p.m. (06/02/24), walked into the emergency room requesting to see a physician because of a cough. Further interview revealed later in the day on 06/03/24, the Administrator had been contacted by the hospital again. The Administrator was told Resident #1 was not injured, the doctor had run some lab work and was going to dialyze Resident #1 (even though the resident was not due until tomorrow, Tuesday) just to be on the safe side, then return the resident to the facility after completed dialysis. An interview on 06/03/24 with MA G at 9:15 a.m. revealed MA G only worked Monday through Friday was not working when Resident #1 eloped. MA G stated Resident #1 was a pleasant lady, but was everywhere on the secured unit, and used a wheelchair for mobility like a walker. MA G had been in-serviced on elopement. MA G had to come up to the facility on Sunday. The MA had been shown how to reset the security system manually and how the alarms on the doors functioned. An interview on 06/03/2024 with Floor Tech at 10:00 a.m. revealed the Floor Tech had been cleaning the floors in the ding room of the secure unit at 7:30 p.m. The Floor Tech noticed Resident #1 sitting in the television room. The Floor Tech stated Resident #1 wanted the Floor Tech to buy a bag of chips and a soda from the vending machine. The Floor Tech had reported to the nurse Resident #1 wanted a snack. The floor tech left the unit around 8:45 p.m. Resident #1 was sitting in the doorway of room, in the wheelchair. The Floor Tech came back when the facility sent out the mass text and tried to look for Resident #1 but did not find the resident. The Floor Tech had been in-serviced on elopement process and the security system on the secured unit and the alarms on the doors and how to reset the system. An interview on 06/03/2024 with LVN E at 11:00 a.m. revealed Resident #1 was very pleasant, unsteady on the feet at times, walked all the time, except when was sitting at an exit and used wheelchair as a walker. LVN E stated Resident #1 was not always alert and oriented. Resident #1 required assistance of the staff to help change clothing and be reminded of when to eat. LVN E stated LVN A was working on the secured unit that night. LVN E had been contacted by phone by LVN A that Resident #1 was missing, a code orange had been called and the whole facility began a head count and started looking for Resident #1 inside and outside the facility, just like the staff had been trained to do. LVN E informed the administrative staff and the police for LVN A. LVN E stated the police had brought search dogs and the police informed the facility the dogs had picked up Resident #1's scent at the bus stop. Resident #1 had taken a bus to another area. LVN E stated on (06/02/24) the hospital had called the facility. Resident #1 had come into the ER and needed to see a doctor. LVN E stated there was no idea how she got out. LVN E had not heard any alarms go off on the unit and alarms were loud. LVN E stated the weather that night was good; it was not raining or storming. LVN E had been in-serviced on the secured unit system, how to check the doors and validate the system, how to manually reset it just in case it was needed, and the process of elopement before leaving the facility that night. In an observation and interview on 06/03/24 at 11:00 a.m. with Maintenance Supervisor revealed the security unit functionality of all doors (closure and alarm) and outside gates on the old unit and new unit were working appropriately. The Maintenance Supervisor had placed all new audible alarms on the doors in the old unit and the new unit. The surveyor observed those working with demonstration from the Maintenance Supervisor on the old unit and the new unit. During this interview the documents were provided for the logs on the checks of the system for the secured unit, old and new, starting on 06/02/24 and was to continue daily for 5 days a week times four weeks. The Maintenance Supervisor stated the facility had just placed an alarm on the door between the two dining rooms on 06/02/24 and explained the door was hooked up to the system and is able to reset , but that it was the only door that did not have an audible alarm on it. In an interview on 06/03/2024 with CNA C at 12:30 p.m. revealed Resident #1 was very pleasant, unsteady on feet at times, but used a wheelchair as a walker. CNA C stated Resident #1 was not always alert and oriented. Resident #1 required assistance of the staff to help change clothing. CNA C had observed Resident #1 on 06/01/24 around 10:00 p.m. sitting at the exit doors, looking out the window eating chips and drinking a coke. CNA C stated Resident #1 never touched the doors and does not set off the alarms. CNA B recalled what Resident #1 was wearing, when the other CNAs came and asked if CNA C had seen Resident #1. CNA C informed CNA B, Resident #1 had not been seen and CNAs began looking. CNA C went to the new unopened secured unit and back around past the vending machines to the other side of the facility that was called A2 (a new memory care unit that has not been licensed yet for usage). There was a door between both dining areas leading off the old unit into the new dining room area. CNA C thought maybe Resident #1 had gotten through the door somehow, CNA C did not find Resident #1. CNA C looked all over the new secure unit that had not been opened. CNA C did not check the doors on the new secured unit to see it any of the doors had been left open. CNA C had been in-serviced on the secured unit system, how to check the doors and validate the system, how to manually reset it just in case it was needed, and the process of elopement before she left the facility that night. An interview on 06/02/24 at 12:45 p.m. with LVN D revealed LVN D had been in-serviced on the elopement process and knew what to do. LVN D did not work on the secured unit, LVN D was still shown how to check all the doors and reset the system manually. An interview on 06/30/24 at 1:45 p.m. with CNA F had been in-serviced on code orange and what to do when a resident elopes. CNA F was shown how the alarms work on the doors in the facility, including the secured unit doors. An interview on 06/03/24 at 2:30 p.m. with LVN A revealed CNA B had taken a break. After the break CNA B could not locate Resident #1 to assist her to go to bed. LVN A stated CNA B reported Resident #1 was missing around 10:15 a.m. the LVN looked for Resident #1 and could not find the resident. LVN A informed the nurse manager on duty, who was LVN E and a Code Orange was called. LVN A stated the staff all looked inside and outside, the police, administration, and responsible party were contacted. LVN A stayed with the residents on the secured unit, until the relief nurse came, then started looking again. LVN A stated the resident never verbalized anything about leaving, Resident #1 would sit and look out the window on the doors or out the window in the room. LVN A stated Resident #1 never touched the doors to set the alarms off. LVN A had been in-serviced on the alarm system and how to check the doors and validate the system, and how to manually reset, just in case it was needed and the process of elopement before leaving the facility that night. An interview on 06/03/2024 with CNA B at 4:00 p.m. revealed CNA B had worked at the facility off and on for the past 7 years. CNA B recalled Resident #1 she was very pleasant, unsteady walking at times, but used a wheelchair as a walker. CNA B stated Resident #1 was not always alert and oriented. Resident #1 required assistance of the staff to help change clothing, and shower. CNA B had observed Resident #1 many times sitting at the exit doors or in the room looking out the window. CNA B stated Resident #1 never touched the doors and did not set off the alarms. CNA B stated Resident #1 would talk about checking on her child but would not talk was leaving. CNA B had been in-serviced on the secured alarm system on the doors. CNA B had been shown how to check the doors and validate the system. CNA B was shown how to manually reset the alarms, and the process of elopement before she left the facility that night. An interview on 06/03/2024 at 2:00 p.m. with the DON revealed that if a resident had left the facility, which should not be leaving, the staff should notify the DON and the Administrator immediately. The staff was supposed to call a code orange immediately start looking for the resident and call the police. The police and the responsible party should be notified. An interview on 06/03/2024 at 2:15 p.m. with the Administrator revealed there had been cooperate intervention, when he requested, when the elopement occurred. An observation on 06/03/24 at 8:30 a.m. revealed the surrounding outside area, the parking lot, and streets adjacent to the facility. The facility was in an industrial/residential area with multiple stores, and multiple businesses. The street in front of the facility was very busy. There was a popular conversion between two street approximately one to two miles away, where the bus stop was, as well as a very busy main four lane street that led to residential areas, and large shopping centers, that has heavy traffic on the road all times of the day and night. Where the resident's scent was picked up at the other bus terminal, was four miles away. The hospital that the resident entered was twenty two miles away. An interview on 06/03/2024 at 3:00 p.m. with the Medical Director revealed, was made aware of Resident #1's elopement from the secured unit. The Medical Director stated there was an emergency QAPI meeting on the morning of 06/02/2024. The committee discussed that the system needed to be updated with new interventions, which was the placement of the green alarm boxes . The Medical Director stated there was corporate assistance in the QAPI meeting. Record review of the facility's Policy and Procedure Elopement Prevention, dated January 2023, reflected Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission .The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, new exit seeking behavior, and upon change of condition 6. Should an elopement episode occur, the contributing factors, as well as interventions tried, will be documented in the nurses' notes . 7. If a resident is discovered to be missing, a search shall begin immediately Record review of the facility's Policy and Procedure Elopement Response, dated January 2023, reflected, Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented .1. It is the responsibility of all personnel to report any resident attempting to leave the premise, or suspected of being missing, to the charge nurse as soon as practical . 2. Determination of missing resident either by routine nursing rounds or door alarms: 4. Should an employee discover the resident is missing from the facility (Code Orange), he/she should charge nurse, . C. Make a thorough search of the building and premises . D. notify the Administrator and the Director of Nursing . E. Notify the responsible party . F Notify the attending physician .H. if necessary, notify . agency . J. make and extensive search of the surrounding area.5. A. Charge nurse on each unit send staff down each hall to check each room, including bathroom, closet, and bed for correct resident 6. A. Charge nurse designates one CNA per hall to remain on unit along with him/herself and sends remaining staff to affected area. B. Charge Nurse assigns staff to specific outside areas to ensure that all surrounding areas are searched C. after 30 minutes , if the resident had not been found, the following call must be made: report missing resident to the police .update all administrative staff Secured Unit. Fire exit doors on the secure unit will meet the following criteria: lock must be electro-magnetic, the lock must release when one of the following occurs: the fire alarm or sprinkler system are activated, power failure to the facility, activation of a switch or button located at the monitoring station and the main nurse's station