**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of 3 residents (Resident #1) reviewed for transfers. The facility failed to ensure that CNA A and LVN B transferred Resident #1 using a gait belt as per facility protocol, and dried the resident off before transfer, which resulted in a fall and a comminuted fracture (a fracture where the bone breaks into three or more pieces) to the left humeral neck (top part of the arm bone) and fractures to the glenoid bone (where the head of the arm bone connects to the shoulder), which were discovered from X-Ray results on 02/21/25. An Immediate Jeopardy (IJ) situation was identified on 06/02/25. While the IJ was removed on 06/09/25, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risks of accidents, and could result in serious harm, injury, impairment, and death. The findings include: Record review of Resident#1's face sheet dated 05/28/25 revealed he was a [AGE] year-old male resident with an initial admission date of 11/27/24 with diagnosis that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Non-Dominant side (paralysis of the left side of the residents body due to a stroke), Vascular Dementia (Brain damage caused by multiple strokes), and Aphasia (Language disorder caused by brain damage). Record review of Resident #1's quarterly MDS dated [DATE] reflected that Resident #1 had a BIMS (Brief Interview for Mental Status) of 12, meaning mildly impaired or moderate cognitive impairment. Resident #1 had impairment to one side. Resident #1 required Substantial/maximal assistance (help of 1-2 staff members) with showers and sitting to standing and was totally dependent (help of 2 or more staff members) for toileting. Record review of Resident #1's Significant Change MDS dated [DATE] reflected that Resident #1 had a BIMS (Brief Interview for Mental Status) of 12 meaning Resident #1 was mildly impaired or had moderate cognitive impairment. Resident #1 was dependent and required the assistance of 2 or more or more helpers for tub/shower transfer, toilet transfer and chair to bed transfer. Resident #1 was listed as Not applicable (due to current injury/illness) for the ability to go up and down a curb and/or up and down one step. Record Review of Resident #1's Care Plan dated 03/06/25 reflected that Focus: The resident has an ADL self-care Performance deficit CVA with left hemiplegia, diabetes with neuropathy, dementia and muscle weakness. Bed mobility: partial assist of 1-2, Transfers: partial to substantial assist 1-2, Eating: set-up to supervision of 1, Toileting: partial assist of 1-2. Provisions are mad to care as needed. Level of assistance may vary depending on my condition. Goal: The resident will maintain or improve current level of function in bed partial to substantial assist of 1-2 by the next review date. Interventions/Tasks: Provide sponge bath when a full bath or shower cannot be tolerated .Allow sufficient time for ADL tasks .Make sure are comfortable and not slippery. Record review of the Facility PIR (Provider Investigation Report) dated 02/25/25 reflected that on 02/10/25 CNA A and CNA B stated that Resident #1 had a slip in the shower chair while transferring from a shower chair to a wheelchair. Resident #1 stated to the facility that Resident #1 had slipped and hit his shoulder while he was in the shower. Resident #1 did not report the incident to the facility until 02/21/25. The PIR Investigation Summary reflected that on 02/10/25 CNA A had taken Resident #1 to the shower room and that Resident #1 had started to slip out of the shower chair. CNA A then called for LVN B who helped to assist the resident immediately by placing their arms (CNA A and LVN B) under Resident #1's arms and pulled Resident #1 back up into the shower chair. LVN B reported that Resident #1 did not report any injuries and subsequent skin assessments found no injuries, bruises, or skin integrity issues. Both CNA A and LVN B had stated that here had been no fall or change of plan as they had prevented Resident #1 from having a fall. Record review of CNA A's witness statement included in the PIR dated 02/24/25 and signed by CNA A, reflected that CNA A had assisted nurse with transfer in the shower room, shower was given to Resident #1, nurse assisted with transferring Resident #1 back to the wheelchair from the shower chair. Record review of LVN B's witness statement included in the PIR and dated 02/24/25 and signed by LVN B, reflected that LVN B had assisted CNA A with a transfer of Resident #1 from a wheelchair to a shower chair and then from a shower chair to wheelchair on 02/10/25. She stated Resident #1 had no complaint of pain upon transferring of Resident #1 to a wheelchair. Record review of the facility Incident Accident Log found no evidence of Resident #1 having a fall, near fall or injury for the dates of 02/04/25 to 02/21/25. Record review of a document entitled Radiology Report for Resident #1, dated 02/21/25, reflected Left Shoulder X-ray Complete 2 or more views .Significant Findings .Multiple views of the left shoulder show a comminuted fracture (a fracture where the bone breaks into three or more pieces) to the left humeral head/neck (top part of the arm bone). Fracture of the glenoid (where the head of the arm bone connects to the shoulder) is also noted .No soft tissue swelling is seen. Record review of a document titled After Visit Summary, dated 02/22/25, found an order for an appointment to a named Orthopedic Surgeon was to be made as soon as possible. This order was put into place to address the right humorous comminuted fracture after the resident had been admitted to the hospital on [DATE]. Record review of Resident #1 EHR (Electronic Health Record) for Resident #1 from 02/04/25 to 2/11/25 found no evidence of a fall being reported, no documentation of skin or pain assessments. No documentation of Resident #1 slipping from a shower chair. Two progress notes related to the incident of 02/10/25 were found (1) denoting a pain medication ordered and (2) When the facility first found out about the incident: 1. A Progress Note was found on 02/10/25 at 9:17 PM written by LVN E ordering [after being told by Hospice RN D of the fall and need for pain medications] tramadol HCL Oral tablet 50 mg, give 50 mg by mouth three times a day for pain. 2. A Progress Note on 02/21/25 at 9:36 AM by the DON reflected that Resident (#1's) family reported to this nurse, he (Resident #1) still had pain from the fall that happened Monday before last. Skin assessment pain assessment and stat left shoulder x-ray. Notified hospice, family present, notified MD and administrator. Record review of the facility Incident Accident Log found no evidence of Resident #1 having a fall, near fall or injury for the dates of 02/04/25 to 02/21/25. Record review of Resident #1's Active Orders as of 06/08/25 revealed that Resident #1 had 2 active orders for pain medications prior to the left humerus comminuted fracture of 02/10/25 listed as the following: 1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite. 2. Tylenol Oral tablet 325 mg. Give 1 tablet by moth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite. Record review of Resident #1's Active orders as of 06/08/25 revealed that Resident #1 had 4 active orders for pain after to the right humorous comminuted fracture after 02/10/25 listed as the following: 1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite. 2. Tylenol Oral tablet 325 mg. Give 1 tablet by moth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite. 3. Tramadol HCL Oral Tablet 50 mg, Give 50 mg by mouth three times a day for pain. Start Date: 02/10/25, Revision Date: 03/10/25, New orders, give 50 mg by mouth every 8 hours as needed for pain. End Date: Indefinite 4. Hydrocodone-Acetaminophen Oral tablet 5-325 mg, Give 1 tablet by mouth three times a day for pain. Start Date: 03/06/2025. End Date: Indefinite. Record review of Resident #1's weights taken at the facility found that Resident #1 weighed 154.4 LBS on 02/07/25. Interview on 05/28/25 at 9:45 AM with Resident #1 revealed Resident #1 was able to speak with some difficulty but was able to make his needs known. Resident #1 stated arm was broken several months ago. He identified the CNA as the facility CNA not his hospice CNA, and he stated it was just CNA A in the shower room with him when the fall occurred. He stated he hit his shoulder when the fall happened and he had less movement in his left arm and hand than he did before. He indicated with his right arm and hand to his left shoulder and indicated his left hand where it was observed he could still move his pinky and ring finger. Interview on 05/28/25 at 9:58 AM with the Hospice SW C revealed that she had been in the building that morning to visit with Resident #1 to discuss care plan options with Resident #1 since had had come under her hospice agency care on 02/04/25. She stated that Resident #1 told her that he was in pain and that he had a fall in the shower room earlier that morning and that he indicated his left shoulder where the pain was the worst. Hospice SW C stated that she contacted Hospice RN D and reported to her that Resident #1 was complaining of 5/10 pain in his left shoulder and that Resident #1 had told her he had a fall earlier that morning in the shower. Interview on 05/28/25 at 9:58 AM with Hospice RN D revealed that Resident #1 reported to her that he had a fall in the shower room earlier that day (02/10/25). Hospice RN D stated that she did an assessment on Resident #1, she stated that Resident #1 complained of pain in his left shoulder at 5/10 on a pain scale and that Resident #1 had no swelling, no redness no bruising. Hospice RN D stated that she notified the hospice physician and ordered 50 mg Tramadol three times a day. Hospice RN D stated that she had informed facility nurse LVN E about the new order, fall and pain and that another Hospice RN had assessed Resident #1 on 02/13/25 and that Resident #1 did not complain of pain that day. Interview on 05/28/25 at 1:58 PM with CNA A, CNA A reported that CNA A and LVN B were transferring Resident #1 from a shower chair to a wheelchair in the shower room on 02/10/25. CNA A stated that she and LVN B had Resident #1 up from the shower chair and were pivoting him around to sit in the wheelchair and Resident #1 was yelling that he was slipping. CNA A stated that Resident #1 did not have a fall. CNA A stated that he had started to slip a little out of the shower chair but that she and LVN B had caught him. She stated that he did not complain of pain at any time even after she had placed him back into bed. She stated that she had not used a gait belt and she was unaware if there had been a gait belt in the shower room at the time. CNA A stated that resident #1 was still wet at the time of the transfer. Interview on 5/30/25 at 11:48 AM with the Facility Physician revealed the fracture to Resident #1's arm was acute and if the fracture occurred on 02/10/25 then by the time the x-ray was taken on 02/21/25 soft tissue swelling could have been absent. She stated looking at Resident #1's diagnosis, she would not expect Resident #1 had a spontaneous fracture, and Resident #1 might not be as uncomfortable as someone who did not have paralysis in the affected arm. Interview on 6/2/25 at 5:59 PM with the DON revealed she defined a fall as anytime a resident stumbled, loses balance or their knees touched the floor. She stated staff were always expected to use a gait belt for transfers she stated she had not been aware all CNA's did not have a gait belt and there seemed to be only a few gait belts in the facility at that time. She stated any resident being transferred from a wheelchair to a shower chair, the staff must use a gait belt, the resident should have a shirt on or a gown and once the resident was safely transferred to a shower chair the gait belt and then the shirt/gown should come off. She stated the resident should be completely dried and a gown or a shirt should be placed back on the resident and a gait belt applied to transfer the resident back to a wheelchair. Interview on 6/2/25 at 6:08 PM, the ADM stated a fall was defined as anyone who had lost balance or for example knees gave out and had to be lowered to the floor would be a fall. Also, even if they lost balance of gave out and caught themselves and the staff had to assist them in any manner was considered a fall according to the policy/procedure. Record review of the facility's policy titled Safe Lifting and Movement of Residents, dated 2001 and revised July 2017, reflected: Policy Statement: In order to protect the safety and well being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents . 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on and ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preferences; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff; and g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices . 12. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies; b. Addresses workplace injuries; c. Provides training on safety, ergonomics and proper use of equipment; and d. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies. This was determined to be an Immediate Jeopardy (IJ) on 06/02/25 at 8:00 PM. The ADM and the DON were notified. The ADM was provided with the IJ template on 06/02/25 at 8:00 PM. The following Plan of Removal submitted by the facility was accepted on 06/05/25 at 3:00 PM: [The facility][address and phone number] FTAG 689- The facility failed to protect Resident #1 because CNA A and LVN B did not use proper assistive device and proper procedure drying resident/using gait belt when assisting Residents #1 during shower. Adequate supervision and assisted devices are required to prevent accidents. Focus will be safe transfers and proper supervision. 4. DON and ADON will in-service nursing staff on Safe Transfer. Nursing staff will be able to voice concepts of safe transfer to include residents limitations taken into account to determines how many people are required for transfer, where is the transfer taking place, is the resident dried off from a shower, are clothes donned before applying gait belt. Nursing will turn in a written test of knowledge over Safe Transfer and complete a return demonstration for DOR. Weekend staff and PRN will be provided training by DON and ADON and DOR. DON, will visually monitor each member of the nursing staff safely transfer a residents, every shift, starting on 6/4/2025, until 100% of staff have been monitored. Date initiated: 6/2/2025. A master copy of in-services/training/tests table with employee names is being used to audit. This form will be updated and turned into every day. After meeting with the survey team, additional education provided on 6/4/2025. To include place of transfer, resident ability, number of staff required, resident clothed, resident dry. Date completed: 6/9/2025 5. DON and ADON will in-service ALL staff on the definition of a FALL, AWARENESS, REPORTING, INTERVENTION AND PREVENTION. All staff will complete a written test of knowledge to be placed on file immediately. Weekend staff and PRN will be provided training by DON and ADON and DOR. This training must be completed before returning to the floor. ADON, will visually monitor each charge nurse report a fall, every shift, starting on 6/5/2025, until 100% of staff have been monitored. DON will maintain competency audit and update it daily and give to Administrator daily. Date initiated: 6/2/2025 Date completed: 6/5/2025 Upon hire, and quarterly thereafter 6. DON has reviewed all of May admissions and readmissions up to current date to verify there weren't any appointments or referrals needed. No issues identified. An admission/readmission report has been ran, printed and marked with a check mark for reviewed and no issues or a question mark requiring a hospital request for additional records. Date initiated: 6/2/2025 Date completed: ongoing, daily Upon hire, and quarterly thereafter 4 Skills check off will be completed for Nursing staff, in relation to their roles required for a fall, by DON/ADON. Now, Upon hire, and quarterly. Training must be completed before returning to the floor. DON and Administrator will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep track of competencies/training completed/required. Individual interviews will be conducted for all nursing staff by ADON. During the interview the staff member will recite respective response to a fall, according to their position. These interviews will start on 6/5/2025, every shift until 100% of nursing staff have been interviewed. A spread sheet will indicate all staff have been interviewed and will be updated and provided to the Administrator for review daily. Nurse roles in a fall Completing and documenting fall risk assessments to identify residents at risk of falling. Monitoring the resident's medical condition for any changes that could affect the resident's fall risk status. Reporting falls to the physician, DON/ADON and Administrator, and obtaining medical orders as needed. Supervising nursing aides and educating patients and their families on fall prevention measures CNA role for a fall: Report to Charge nurse immediately and do not move the resident. Date initiated: 6/5/2026 Date complete:6/9/2025 5 Starting on 6/4/2025, DON will ensure that 1st and 2nd shift CNA's have a gait belt readily available. ADON will be assigned to monitor for 3rd shift on 6/4-5/2025 Will have gait belts readily available for use. This ensures proper preparedness for safe transfer immediately. Administrator will verify gait belts were provided on 6/4/2025 and 6/5/2025 by reviewing the gait belt audit log, daily. Date initiated:6/4/2025 Completed by: 6/5/2025 6. DON and ADON will in-service charge nurses about Admission/ readmission Binder. It will be kept at the nurses' station. DON/ADON, will review this Binder daily, during their assigned shift, to ensure any appointments/ referrals are made according to admission paperwork. All admission paperwork will be uploaded by admitting nurse to Medical Records via front office scanner and logged into the binder log in sheet located in the front of the binder. Weekend staff and PRN will be provided training by DON. This training must be completed before returning to the floor DON and ADON will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep track of competencies/training completed/required. Date initiated 6/3/2025 Date completed: ongoing Monitored in real time on 6/4/2025, LVN B, notified DON, a resident had returned from the hospital with new orders. She uploaded the paperwork to medical records and placed in in the communication binder, at the nurses station. She also logged the information onto the login sheet in the front of said binder. Information included: resident name, date/time, reason for ER/visit or discharge, charge nurse initials, and yes or no boxes for needing appointments or new orders. See exhibit- A readmission paperwork login form. 7. Charge nurses will be in-serviced on reporting incidents such as falls, made by third party vendors, such as Hospice. When report of a fall is received by a third party or family, it is to be reported immediately to the DON/ADON. Weekend staff and PRN will be provided training by DON and ADON. This training must be completed before returning to the floor. DON will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep audit of competencies/training completed/required. Administrator will confirm education provided by interviewing staff on 6/4/2025. Inservice to begin 6/4/2023. Completed by 6/5/2025 Third party vendors will be notified via telephone, by DON/ADON, of referrals recommended, or appointments made. A progress note will be entered into PCC, by the charge nurse, naming who they spoke with, date and time and short description on the nature of the information relayed. 8. Charge nurses will be in-serviced on the Appointments/ Referral Protocol immediately, intermittently, upon hire. Any appointment obtained by a charge nurse, will be reported to DON/ADON as soon as possible, but no later than the end of their shift. DON/ADON will update information pertaining to the resident's appointment in PCC on community board. Weekend staff and PRN will be provided training by DON and ADON. This training must be completed before returning to the floor. DON maintain competency audit and ensure compliance. This training must be completed before returning to the floor. DON/ADON, will visually monitor each member of the nursing staff recite or perform the Appointments/ Referral Protocol starting on 6/4/2025, until 100% of staff have been monitored. Date initiated: 6/2/2025. A master copy of in-services/training/tests table with employee names is being used to audit. This form will be updated and turned into Administrator for review every day. Monitored in real time on 6/4/2025, LVN B, notified DON, a resident had returned from the hospital with new orders and a referral appointment. Initiated 6/4/2025 Completion: ongoing daily 9.Starting today, 6/4/2025, all department heads will conduct Ambassador rounds. The revised form has been provided to all department heads by email. This will identify any incidents or accidents that may have happened and weren't properly reported, documented or identified. These rounds consist of room conditions, meal satisfaction, needs and will address falls, abuse, neglect and feelings of safety. These will be provided to Administrator daily. A manager on duty will be assigned to work 4 hours on Saturday and Sunday, four hours each day. Manager on Duty will be responsible for completing room rounds on all residents, turning form into administrator's mailbox and reporting incidents, accidents, fall or alleged abuse to Administrator immediately via phone. Exhibit E. Administrator will be responsible for monitoring the plan of removal. If it is found the plan is not working or an issue is identified, a meeting amongst department heads will convene immediately to discuss and determine revisions necessary for the safety of the residents and positive outcomes. Monitoring of the POR included the following: Observation on 5/28/25 at 1:23 PM revealed CNA A transferred Resident #2 from a wheelchair to the residents bed. CNA A explained to Resident #2 they were about to perform a transfer. CNA A placed Resident #2's wheelchair next to the bed that was on a level equal to the height of the wheelchair. Wheelchair was observed to be locked. CNA A then placed a gait belt on Resident #2 and counted down with the resident to stand up, Resident #2 was successfully transferred to the bed with no issues. In an interview on 06/07/25 at 3:00 PM the DON stated that in-services had been completed on all nursing staff. Record review of all in-service rosters and written competencies revealed that all nursing staff had received all in-services and written competency tests had been conducted and completed by all nursing staff. Between the dates of 06/05/25 and 06/07/25 6 gait-belt and 2 mechanical lift transfer trainings were observed to be conducted by the DOR and re-demonstrations in front of the DOR by the following staff members: CNA A, LVN B, CNA F, CNA H, CNA M, ADON, LVN Q, LVN R, CNA T, CNA X and LVN Y. Between the dates of 06/05/25 and 06/09/25, during all shifts, twenty-seven nursing staff members out of 39 nursing staff members were asked the following questions: All: -Title/Name/Length of time at the facility? -Did you receive training on transfers? /Did you demonstrate a safe transfer? To whom? -Describe a safe transfer related to showers. -Why are safe transfers important? When would you need a nurse to assess a resident? -Did you take a test for transfers/falls after training? -What is a fall? -Did you learn anything new from your latest in-services/demonstrations? CNA's: -If you see a fall, who do you report it too/What is your role? -When do you use a gait belt? RN's: -What is your role in falls? -Where exactly is the admission/re-admission folder located? What is its purpose? -What methods can you use to report incidents to the ADON/DON? -Why is it important to make sure hospital/specialist/orders are followed/appointments made? -Admissions/re-admissions/falls this shift? ADON, DON, DOR, CNA A, LVN B, LVN E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, LVN P, LVN Q, LVN R, LVN S, CNA T, LVN U, LVN V, CNA W, CNA X, LVN Y and CNA Z representing and interviewed during the 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and the 10:00 PM to 6:00 AM shifts, were able to answer all questions in a satisfactory manner that suggested training had been conducted and understood, written competencies had been conducted and completed, and nursing staff performed transfers in front of the DOR, DON or the ADON. Between the dates of 06/05/25 and 06/09/25 during all shifts, 8 gait-belt transfers and 3 mechanical lifts were observed to be conducted in a safe and competent manner by the following nursing staff CNA A, LVN B, CNA F, CNA K, CNA M, LVN Q, LVN U, CNA W, CNA X, and CNA Z, with Residents #1, #2, #3, #4, #5, #6, #7, and #8. The ADM and the DON were informed the Immediate Jeopardy was removed on 06/09/25 at 4:00 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, and deprivation of goods and services for 1 of 3 residents (Resident #1) reviewed for neglect. 1. The facility failed to provide Resident #1 with services for pain assessments from 02/10/25 to 02/21/25 which resulted in Resident #1 not being diagnosed with a fracture to his left humeral bone for 11 days. 2. The facility staff failed to report a fall to the administrative staff which resulted in Resident #1 not receiving an x-ray from 02/10/25 to 02/21/25. 3. The facility failed to make an appointment for Resident #1 as ordered by a hospital physician to be seen by an orthopedic surgeon from 02/22/25 to 06/07/25. An Immediate Jeopardy (IJ) situation was identified on 06/02/25. While the IJ was removed on 06/09/25, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of deprivation of goods and services. Findings include: Record review of Resident#1's face sheet, dated 05/28/25, reflected a [AGE] year-old male with an initial admission date of 11/27/24. Resident #1 had diagnoses which included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Non-Dominant side (paralysis of the left side of the residents body due to a stroke), Vascular Dementia (Brain damage caused by multiple strokes) and Aphasia (Language disorder caused by brain damage). Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS of 12, which indicated mildly impaired or moderate cognitive impairment. Resident #1 had impairment to one side. Resident #1 required substantial/maximal assistance (help of 1-2 staff members) with showers and sitting to standing and was totally dependent (help of 2 or more staff members) for toileting. Record review of Resident #1's Significant Change MDS, dated [DATE], reflected Resident #1 had a BIMS of 12 which indicated Resident #1 was mildly impaired or had moderate cognitive impairment. Resident #1 was dependent and required the assistance of 2 or more or more helpers for tub/shower transfer, toilet transfer and chair to bed transfer. Resident #1 was listed as Not applicable (due to current injury/illness) for the ability to go up and down a curb and/or up and down one step. Record review of Resident #1's Care Plan, dated 03/06/25, reflected a Focus: The resident has an ADL self-care Performance deficit CVA with left hemiplegia, diabetes with neuropathy(damage to nerves), dementia and muscle weakness. Bed mobility: partial assist of 1-2, Transfers: partial to substantial assist 1-2, Eating: set-up to supervision of 1, Toileting: partial assist of 1-2. Provisions are mad to care as needed. Level of assistance may vary depending on my condition. Goal: The resident will maintain or improve current level of function in bed partial to substantial assist of 1-2 by the next review date. Interventions/Tasks: Provide sponge bath when a full bath or shower cannot be tolerated .Allow sufficient time for ADL tasks .Make sure are comfortable and not slippery. Record review of Resident #1's Active Orders, as of 06/08/25, reflected Resident #1 had 2 active orders for pain medications prior to the left humerus comminuted fracture of 02/10/25 listed as the following: 1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite. 2. Tylenol Oral tablet 325 mg. Give 1 tablet by moth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite. Record review of Resident #1's Active orders, as of 06/08/25, reflected Resident #1 had 4 active orders for pain after the right humorous comminuted fracture of 02/10/25 listed as the following: 1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite. 2. Tylenol Oral tablet 325 mg. Give 1 tablet by mouth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite. 3. Tramadol HCL Oral Tablet 50 mg, Give 50 mg by mouth three times a day for pain. Start Date: 02/10/25, Revision Date: 03/10/25, New orders, give 50 mg by mouth every 8 hours as needed for pain. End Date: Indefinite 4. Hydrocodone-Acetaminophen Oral tablet 5-325 mg, Give 1 tablet by mouth three times a day for pain. Start Date: 03/06/2025. End Date: Indefinite. Record review of Resident #1's weights taken at the facility found reflected Resident #1 weighed 154.4 LBS on 02/07/25. Record review of the facility's PIR, dated 02/25/25, reflected on 02/10/25 CNA A and CNA B stated Resident #1 had a slip in the shower chair while transferring from a shower chair to a wheelchair. Resident #1 stated to the facility that Resident #1 had slipped and hit his shoulder while he was in the shower. Resident #1 did not report the incident to the facility until 02/21/25. The PIR Investigation Summary reflected on 02/10/25 CNA A had taken Resident #1 to the shower room and Resident #1 started to slip out of the shower chair. CNA A then called for LVN B who helped assist the resident immediately by placing their arms (CNA A and LVN B) under Resident #1's arms (while resident was still wet) and pulled Resident #1 back up into the shower chair. LVN B reported Resident #1 did not report any injuries and subsequent skin assessments found no injuries, bruises, or skin integrity issues. Both CNA A and LVN B stated there was no fall or change of plan as they prevented Resident #1 from having a fall. Record review of CNA A's witness statement, included in the PIR, dated 02/24/25, and signed by CNA A, reflected CNA A had assisted the nurse with a transfer in the shower room, shower was given to Resident #1. The nurse assisted with transferring Resident #1 back to the wheelchair from the shower chair. Record review of LVN B's witness statement, included in the PIR, dated 02/24/25, and signed by LVN B, reflected LVN B had assisted CNA A with a transfer of Resident #1 from a wheelchair to a shower chair and then from a shower chair to wheelchair on 02/10/25. She stated Resident #1 had no complaint of pain upon transferring to the wheelchair. Record review of Resident #1's EHR for Resident #1 from 02/04/25 to 2/11/25 found no evidence of a fall being reported, no documentation of skin or pain assessments. No documentation of Resident #1 slipping from a shower chair. Two progress notes related to the incident of 02/10/25 were found (1) denoting a pain medication ordered after LVN E had been informed by Hospice RN D about a fall and need for pain medications, and (2) When the facility first found out about the incident: 1. A Progress Note was found, dated 02/10/25 at 9:17 PM written by LVN E, ordering tramadol HCL Oral tablet 50 mg, give 50 mg by mouth three times a day for pain. 2. A Progress Note, dated 02/21/25 at 9:36 AM by the DON, reflected Resident (#1's) family reported to this nurse, he (Resident #1) still had pain from the fall that happened Monday before last. Skin assessment pain assessment and stat left shoulder x-ray. Notified hospice, family present, notified MD and administrator. Record review of the facility Incident Accident Log found no evidence of Resident #1 having a fall, near fall or injury for the dates of 02/04/25 to 02/21/25. Record review of a document entitled Radiology Report for Resident #1, dated 02/21/25, reflected Left Shoulder X-ray Complete 2 or more views .Significant Findings .Multiple views of the left shoulder show a comminuted fracture (a fracture where the bone breaks into three or more pieces) to the left humeral head/neck (top part of the arm bone). Fracture of the glenoid (where the head of the arm bone connects to the shoulder) is also noted .No soft tissue swelling is seen. Record review of a document titled After Visit Summary, dated 02/22/25, found an order for an appointment to a named Orthopedic Surgeon was to be made as soon as possible. This order was put into place to address the right humorous comminuted fracture after the resident had been admitted to the hospital on [DATE], and discharged from the hospital on [DATE]. Interview on 05/28/25 at 9:45 AM with Resident #1 revealed Resident #1 was able to speak with some difficulty but was able to make his needs known. Resident #1 stated his arm was broken several months ago. He identified the CNA as the facility CNA not his hospice CNA, and he stated it was just CNA A in the shower room with him when the fall occurred. He stated he hit his shoulder when the fall occurred. He stated he went to the hospital but had not been out for any follow-up appointments. Interview on 05/28/25 at 9:58 AM with the Hospice SW C revealed she had been in the building that morning to visit with Resident #1 to discuss care plan options with the resident since he had come under her hospice agency care on 02/04/25. She stated Resident #1 told her he was in pain and he had a fall in the shower room earlier that morning and he indicated his left shoulder where the pain was the worst. Hospice SW C stated she contacted Hospice RN D and reported to her Resident #1 was complaining of 5/10 pain in his left shoulder and Resident #1 told her he had a fall earlier that morning in the shower. Interview on 05/28/25 at 9:58 AM with Hospice RN D revealed Resident #1 reported to her he had a fall in the shower room earlier that day (02/10/25). Hospice RN D stated she did an assessment on Resident #1, and Resident #1 complained of pain in his left shoulder at 5/10 on a pain scale and Resident #1 had no swelling and no redness no bruising. Hospice RN D stated she notified the hospice physician and ordered 50 mg Tramadol three times a day. Hospice RN D stated she informed the facility nurse, LVN E about the new order, fall and pain and another Hospice RN had assessed Resident #1 on 02/13/25 and Resident #1 did not complain of pain that day. Interview on 05/29/25 at 10:58 AM with LVN E revealed she worked on Resident #1's hall on 02/10/25. She stated she remembered speaking with Hospice RN D that day and Hospice RN D told her Resident #1 had complained of 5/10 pain in his left shoulder, he reported to her that he had a fall earlier that day in the shower and she ordered Tramadol 50 mg three times a day for Resident #1. LVN E stated she was a brand-new nurse at the time and assumed LVN B, who had been at the facility much longer, told the DON about the fall in the shower room. LVN E stated she first learned of Resident #1's fracture on 02/23/25 when the DON asked if she knew anything about Resident #1's fracture. Interview on 05/28/25 at 1:58 PM with CNA A, CNA A reported CNA A and LVN B were transferring Resident #1 from a shower chair to a wheelchair in the shower room on 02/10/25. CNA A stated she and LVN B had Resident #1 up from the shower chair and were pivoting him around to sit in the wheelchair and Resident #1 was yelling that he was slipping. CNA A stated Resident #1 did not have a fall. CNA A stated he had started to slip a little out of the shower chair but she and LVN B caught him. She stated he did not complain of pain at any time even after she placed him back into bed. She stated she had not used a gait belt and she was unaware if there was a gait belt in the shower room at the time. CNA A stated that Resident #1 was still wet at the time of the transfer. Interview on 05/29/25 at 2:56 PM with LVN B revealed CNA A called her into the shower room to assist with transferring Resident #1 from a shower chair to a wheelchair. She stated Resident #1 was already unclothed and she and CNA A had their arms around Resident #1 to transfer him. She stated the resident was still a little wet and he had a towel around his private area. She stated Resident #1 did not say anything or indicate he was slipping. She stated she did not report anything because there was never any fall. She stated it was possible they could have broken his arm during the transfer but there had been no indication of it, she stated that because nothing happened and there was no indication of pain or discomfort, she did not assess Resident #1. Interview on 05/30/25 at 9:45 AM with the DON revealed she was aware of the need to make an Orthopedic appointment for Resident #1 after he returned from the hospital on [DATE]. She stated the hospice agency was contacted about the need for an appointment at that time but had not addressed the Orthopedic appointment again after that. The DON was unable to explain why the appointment for Resident #1 had never been arranged. The DON was unable to provide any documentation that the hospice agency had been contacted, who was spoken to at the hospice agency or when the conversation may have taken place. Interview on 05/30/25 at 11:09 AM with LVN Q revealed she understood follow-up appointments for residents returning from the hospital were to be handled through the Social Worker or the ADON but because the Social Worker had quit a few weeks ago it was mainly through the ADON. Interview on 05/30/25 at 11:11 AM with the ADON revealed for residents who were on hospice care and returned from the hospital to the facility with orders to have an appointment made the facility should have contacted the hospice agency about the appointment. She stated in the case of Resident #1 she did not see any in any progress notes that the hospice agency for Resident #1 had been contacted about the follow-up order for Resident #1, she stated that in the absence of the SW the ADON or the DON would be responsible for the follow up appointment and notifying the hospice agency. Interview on 05/30/25 at 11:30 AM with the ADM revealed he was not at the facility when this incident occurred. He stated his expectations were that a physical communication sheet should have been filled out showing when, who, what had been communicated to any outside agency. He stated he was not aware of any documentation that showed if Resident #1's orthopedic appointment had been made or if anyone was contacted about the appointment having to be made. Interview on 05/30/25 at 11:48 AM with facility MD, MD stated that it was acute fx, meaning the fracture was recent, around 1-2 weeks, no soft tissue swelling could indicate that there had been enough time for the swelling to have been resolved. Resident #1 might not have been as uncomfortable as someone who did not have paralysis in the affedted arm. Looking back it looks like I was informed about Resident #1 having pain in that arm on the 21st, but I had been informed that the family may have had some idea of a mechanism of injury previous to the 21st of February. I would not expect Resident #1 to have a spontaneous fracture, he did not have diagnosis that would be indicative of that. The two bones could have articulated during a lift. I would say that injury could happen in both a lift or fall scenario. She stated usually the facility will make appointments for residents. Interview on 06/02/25 at 10:26 PM with Hospice SW C revealed her hospice agency had no record of ever being contacted about a referral appointment for Resident #1. She stated she would have been the person who would have been contacted about making an appointment. She stated she had no idea Resident #1 had come back from the hospital with orders to make an appointment to an Orthopedic surgeon. Interview on 06/02/25 at 2:24 PM with the ADM revealed it was ultimately his facility nurses responsibility to make sure all orders from physicians were followed and that his nurses made sure the appointment was made and kept. He stated it was a major concern that a resident returned from the hospital on [DATE] and still had not gone to the appointment that had been ordered. Interview on 06/02/25 at 2:49 PM with the MD revealed she was aware of the referral to Orthopedics for Resident #1, but the hospice agency should have been responsible for making the appointment since they were the ones who had to pay for it. Interview on 06/06/25 at 12:00 PM with the ADON revealed she received and gave training on the new Admissions/Re-admissions binder. She stated the binder was to always be located at the main nursing station next to the permanent computer at the nursing station. She stated if she were to receive re-admission orders on a Sunday, she would have to document the information in the progress note. She stated the new binder was where staff put appointments, informed all parties, family included. Then staff would make the appointment during business hours. After the appointment was made staff would arrange for transportation and then staff would log all of the appointment information in the communication log in the Electronic Health Record to make sure all parties knew the information. She stated all nurses and CNA's had access to the Electronic Health Record communication tab/board. She stated the new binder ensured the resident was receiving all of the services available to them. She stated there had been updates to the Ambassador rounds, staff were more in-depth question on a new form that staff asked the residents assigned to them, she stated an email with all of the new questions was sent to all staff, identified as Ambassadors, and a paper copy was also presented at the morning meeting. Interview on 6/2/25 at 5:59 PM with the DON revealed she defined a fall as anytime a resident stumbled, lost balance or their knees touched the floor. She stated all falls, witnessed or unwitnessed should be reported to the ADON, DON, and the ADM. She stated all orders from a physician, referrals, and appointments should be scheduled, and transportation arranged to get residents to appointments, she stated all appointment/referrals should be documented in the Admission/re-admission binder and in the Electronic Health Record. She stated the family went to her on 02/21/25 because they wanted Resident #1 repositioned, and they told her he had a fall a couple of Mondays ago and he complained his left shoulder hurt. She stated Resident #1 described he had a fall in the shower and his arm hurt. The DON stated that was when she did pain/skin assessments, informed the Administrator and ordered x-rays. Interview on 6/2/25 at 6:08 PM, the ADM stated a fall was defined as anyone who lost balance or for example knees gave out and had to be lowered to the floor, would be a fall. Also, even if they lost balance of gave got and caught themselves and the staff had to assist them in any manner was considered a fall according to the policy/procedure. He stated all physician orders should be carried out by the nursing staff and all appointments made in accordance with those orders, he stated he would monitor the new Admission/re-admission binder to monitor all orders/appointments were followed/made and all corresponding documentation was present. Record review of the facility's policy titled Abuse Investigation and Reporting, dated 2001 and revised July 2017, reflected: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Policy Explanation and Compliance guidelines: The facility will develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. Established policies and procedures to investigate any such allegations; and Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention. Provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. Existing staff will receive annual education through planned and services and as needed. Training topics will include prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators. Reporting process for abuse, neglect exploitation and misappropriation of resident property comma including injuries of unknown sources. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: wandering Preventative abuse, neglect and exploitation the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: Identifying, correcting and intervening in situations in which abuse, neglect, exploitation and or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, license, and certified staff on each shift the sufficient numbers to meet the needs of the residents, and ensure that the staff assigned have knowledge of the individual residence care needs and behavioral symptoms; The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with need and behaviors which might lead to conflict or neglect. Addressing features of physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur. Record review of the facility's policy titled Accidents and Incidents-Investigating and Reporting, dated 2001 and revised July 2017, reflected: Policy Statement. All accidents or incidents involving residents, employees, visitors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Guidelines. 1. The Nurse Supervisor/Charge Nurse and or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . 5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence. Record review on 06/07/25 of the Admission/re-admission Binder documented Resident #11 had been entered into the binder as a new admission. All relevant paperwork for Resident #11 was found in the Admission/re-admission Binder. Subsequent review of the Electronic Health Record documented progress notes with orders for Resident #11. This was determined to be an Immediate Jeopardy (IJ) on 06/02/25 at 8:00 PM. The ADM and the DON were notified. The ADM was provided with the IJ template on 06/02/25 at 8:00 PM. The following Plan of Removal submitted by the facility was accepted on 06/05/25 at 3:00 PM: [The Facility] [address and phone number] FTAG 600- The facility failed to protect Resident # 1 and neglected Resident #1 because CNA A and LVN B failed to report a Slip/Fall on 2/10/2025 during Residents #1 shower which resulting in delay of care and X-rays for Resident #1. Facility will focus on reporting, education on safe transfers, freedom form neglect. 1. DON and ADON will in-service nursing staff on Safe Transfer. Nursing staff will be able to voice concepts of safe transfer to include residents limitations taken into account to determines how many people are required for transfer, where is the transfer taking place, is the resident dried off from a shower, are clothes donned before applying gait belt. Nursing will turn in a written test of knowledge over Safe Transfer and complete a return demonstration for DOR. Weekend staff and PRN will be provided training by DON and ADON and DOR. DON, will visually monitor each member of the nursing staff safely transfer a residents, every shift, starting on 6/4/2025, until 100% of staff have been monitored. Date initiated: 6/2/2025. A master copy of in-services/training/tests table with employee names is being used to audit. This form will be updated and turned into every day. After meeting with the survey team, additional education provided on 6/4/2025. To include place of transfer, resident ability, number of staff required, resident clothed, resident dry. Date completed: 6/9/2025 2. DON and ADON will in-service ALL staff on the definition of a FALL, AWARENESS, REPORTING, INTERVENTION AND PREVENTION. All staff will complete a written test of knowledge to be placed on file immediately. Weekend staff and PRN will be provided training by DON and ADON and DOR. This training must be completed before returning to the floor. ADON, will visually monitor each charge nurse report a fall, every shift, starting on 6/5/2025, until 100% of staff have been monitored. DON will maintain competency audit and update it daily and give to Administrator daily. Date initiated: 6/2/2025 Date completed: 6/5/2025 Upon hire, and quarterly thereafter 3. DON has reviewed all of May admissions and readmissions up to current date to verify there weren't any appointments or referrals needed. No issues identified. An admission/readmission report has been ran, printed and marked with a check mark for reviewed and no issues or a question mark requiring a hospital request for additional records. Date initiated: 6/2/2025 Date completed: ongoing, daily Upon hire, and quarterly thereafter 4 Skills check off will be completed for Nursing staff, in relation to their roles required for a fall, by DON/ADON. Now, Upon hire, and quarterly. Training must be completed before returning to the floor. DON and Administrator will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep track of competencies/training completed/required. Individual interviews will be conducted for all nursing staff by ADON. During the interview the staff member will recite respective response to a fall, according to their position. These interviews will start on 6/5/2025, every shift until 100% of nursing staff have been interviewed. A spread sheet will indicate all staff have been interviewed and will be updated and provided to the Administrator for review daily. Nurse roles in a fall Completing and documenting fall risk assessments to identify residents at risk of falling. Monitoring the resident's medical condition for any changes that could affect the resident's fall risk status. Reporting falls to the physician, DON/ADON and Administrator, and obtaining medical orders as needed. Supervising nursing aides and educating patients and their families on fall prevention measures CNA role for a fall: Report to Charge nurse immediately and do not move the resident. Date initiated: 6/5/2026 Date complete:6/9/2025 5. Starting on 6/4/2025, DON will ensure that 1st and 2nd shift CNA's have a gait belt readily available. ADON will be assigned to monitor for 3rd shift on 6/4-5/2025 Will have gait belts readily available for use. This ensures proper preparedness for safe transfer immediately. Administrator will verify gait belts were provided on 6/4/2025 and 6/5/2025 by reviewing the gait belt audit log, daily. Date initiated:6/4/2025 Completed by: 6/5/2025 6. DON and ADON will in-service charge nurses about Admission/ readmission Binder. It will be kept at the nurses' station. DON/ADON, will review this Binder daily, during their assigned shift, to ensure any appointments/ referrals are made according to admission paperwork. All admission paperwork will be uploaded by admitting nurse to Medical Records via front office scanner and logged into the binder log in sheet located in the front of the binder. Weekend staff and PRN will be provided training by DON. This training must be completed before returning to the floor DON and ADON will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep track of competencies/training completed/required. Date initiated 6/3/2025 Date completed: ongoing Monitored in real time on 6/4/2025, LVN B, notified DON, a resident had returned from the hospital with new orders. She uploaded the paperwork to medical records and placed in in the communication binder, at the nurses station. She also logged the information onto the login sheet in the front of said binder. Information included: resident name, date/time, reason for ER/visit or discharge, charge nurse initials, and yes or no boxes for needing appointments or new orders. See exhibit- A readmission paperwork login form. 7. Charge nurses will be in-serviced on reporting incidents such as falls, made by third party vendors, such as Hospice. When report of a fall is received by a third party or family, it is to be reported immediately to the DON/ADON. Weekend staff and PRN will be provided training by DON and ADON. This training must be completed before returning to the floor. DON will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep audit of competencies/training completed/required. Administrator will confirm education provided by interviewing staff on 6/4/2025. Inservice to begin 6/4/2023. Completed by 6/5/2025 Third party vendors will be notified via telephone, by DON/ADON, of referrals recommended, or appointments made. A progress note will be entered into PCC, by the charge nurse, naming who they spoke with, date and time and short description on the nature of the information relayed. 8. Charge nurses will be in-serviced on the Appointments/ Referral Protocol immediately, intermittently, upon hire. Any appointment obtained by a charge nurse, will be reported to DON/ADON as soon as possible, but no later than the end of their shift. DON/ADON will update information pertaining to the resident's appointment in PCC on community board. Weekend staff and PRN will be provided training by DON and ADON. This training must be completed before returning to the floor. DON maintain competency audit and ensure compliance. This training must be completed before returning to the floor. DON/ADON, will visually monitor each member of the nursing staff recite or perform the Appointments/ Referral Protocol starting on 6/4/2025, until 100% of staff have been monitored. Date initiated: 6/2/2025. A master copy of in-services/training/tests table with employee names is being used to audit. This form will be updated and turned into Administrator for review every day. Monitored in real time on 6/4/2025, LVN B, notified DON, a resident had returned from the hospital with new orders and a referral appointment. Initiated 6/4/2025 Completion: ongoing daily 9.Starting today, 6/4/2025, all department heads will conduct Ambassador rounds. The revised form has been provided to all department heads by email. This will identify any incidents or accidents that may have happened and weren't properly reported, documented or identified. These rounds consist of room conditions, meal satisfaction, needs and will address falls, abuse, neglect and feelings of safety. These will be provided to Administrator daily. A

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from neglect for two of nine residents (Residents #1 and #2) reviewed for elopement. 1. The facility failed to ensure Resident #1 did not elope from the facility. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility as 2-hour monitoring was not completed properly. Resident #1 had access to the door code for the front door although he had impaired cognitive function or thought processes related to Dementia and lacked safety awareness. Resident #1 eloped from the facility on 05/14/23 and was arrested the same day 3.5 miles away for impeding the progress of a southbound public train. 2. The facility failed to ensure Resident #2 was supervised adequately and did not elope from the facility. Resident #2 was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. Resident #2 suffered a stroke and was hospitalized . An Immediate Jeopardy (IJ) was identified on 5/29/24 at 3:20 PM. The IJ template was provided to the facility on 5/29/24 3:25 PM and signed by the Administrator. While the IJ was removed on 05/31/24 the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. These failures resulted in one arrest due to obstructing traffic and one hospitalization due to being found lying on the ground and had suffered a stroke. Findings included: 1. Review of Resident #1's quarterly MDS assessment, dated 05/02/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epilepsy (abnormal electrical brain activity), muscle weakness, lack of coordination and anxiety (feeling of fear, dread, and uneasiness). The MDS reflected Resident #1 had a BIMS (Brief Interview for Mental Status - is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 10 indicating moderate cognitive impairment, moderately impaired decision-making, required cues/supervision. Under Section P - Restraints and Alarms revealed Resident #1 did not have any physical restraints (wander guard). Resident #1's undated Census Record reflected a discharge date of 05/14/24. Review of Resident #1's care plan revised on 05/08/24 revealed Resident #1 had an ADL self-care performance deficit related to activity intolerance, confusion, impaired balance was addressed. Interventions included encourage the resident to use the call light for assistance, he required extensive assistance x 1 staff for toileting and praise all efforts at self-care. Review of Resident #1's quarterly Elopement Risk Assessments, dated 02/12/24 and 05/12/24, revealed Resident #1 was ambulatory and had no history of wandering. The assessment reflected the Resident #1 was at a low risk for wandering with a score of 2.0 and had no reported episodes of wandering in the past 6 months. Review of Resident #1's progress notes dated 05/14/24 at 10:09 AM, written by LVN J revealed the resident is not in the building, his roommate said, he left at 1:30 AM and he has not come back. Review of Resident #1's progress notes dated 05/14/24 at 11:30 AM, written by SW revealed there were several groups of staff that went out looking for Resident #1 to find him. The groups returned unable to locate him. Review of Resident #1's progress notes dated 05/14/24 at 1:30 PM, written by SW revealed DPD notified the ADM that Resident #1 had been found in [. Jail]. SW called [. Jail] to find him and they were unable to locate him either in jail or in booking. SW then looked up Resident #1 in [. County Jail] and was able to find that Resident #1 had been picked up at 11:01 AM on 05/14/24 due to Obstruction of Highway Passageway. Review of the Provider Investigation Report dated 05/21/24 revealed Resident #1 was last seen on 05/13/24 at 8:30 PM in his room when taking his evening medications. On 05/14/24, CNA L served his breakfast tray at 08:30 AM and Resident #1 could not be found after searching inside the facility. DPD was notified on 05/14/24 of missing resident and was provided with a photo and face sheet. It further stated it was confirmed Resident #1 left the facility without anyone observing him, nor him notifying anyone and Resident #1 had been given the door code by another resident to go outside and smoke off property. Review of Resident #1's Smoking Safety Screen dated 02/01/24 and 05/01/24 revealed due to his diagnosis of dementia, Resident #1 was a supervised smoker. Review of in-service training dated 05/14/24, after Resident #1's elopement, revealed training related to the procedure to follow when a resident was missing. The in-service did not address elopement prevention, ensuring wander-guard transmitters were routinely tested/checked to ensure they were functioning properly or training to ensure staff were able to demonstrate competency in monitoring and checking wander-guard transmitters. Review of DTP Police Report dated 05/14/24 revealed Resident #1 was arrested on Tuesday, 05/14/24 at approximately 08:30 AM . impeding the progress of a southbound [Company] train. Interview with a family member of Resident #1 on 05/23/24 at 9:45 AM, she stated the SW called her on 05/14/24 and informed her Resident #1 was missing. Resident #1's family member stated she had not spoken to, nor visited Resident #1 since November 2023. Resident #1's family member stated they have not found Resident #1, and the SW stopped communicating with her. Interview with the ADM on 05/23/24 at 10:30 AM, she stated due to Resident #1 not being exit-seeking, he did not wear a wander-guard transmitter. The ADM stated during their morning meeting on 5/14, it was reported by LVN J they were unable to locate Resident #1 inside the facility. The ADM stated LVN J informed her CNA L delivered Resident #1's breakfast tray to his room and then took residents out to smoke at 8:30 AM, but Resident #1 did not partake in neither. The ADM stated a report was filed with the DPD and a couple of hours later she was informed by DPD that Resident #1 was no longer considered missing as he had been arrested. Interview with the DON on 05/23/24 at 10:40 AM, she stated Resident #1 had not experienced a medical decline. The DON stated she believed Resident #1 had the door code because the only way you can get out without sounding the alarm, you would have to enter the door code. The DON stated Resident #1 had Dementia, but you would not know it by talking to him or looking at him. Interview with Resident #3 (Resident #1's roommate) on 05/23/24 at 12:00 PM, he stated Resident #1 did not tell him he was leaving. Resident #3 stated he woke up around 01:00 AM and Resident #1 was not in his bed. Resident #3 stated Resident #1 never mentioned he wanted to leave. Resident #3 stated all Resident #1 did was smoke and visit other residents. Resident #3 stated Resident #1 never showed any signs that he was leaving or that he did not like it here. Interview with Resident #4 (Resident #1's friend) on 05/23/24 at 12:20 PM, he stated Resident #1 would follow him outside and he may have seen him enter the door code to get out. Resident #4 denied intentionally providing the door code to Resident #1. Interview with DET A on 5/23/24 at 01:35 PM, he stated it was believed Resident #1 was arrested in [City] , but then it was determined he had been arrested by the DTP. DET A stated when he was assigned to locate Resident #1, he was not missing as he had already been arrested. DET A stated when he located Resident #1 in jail, his case was closed as Resident #1 was no longer considered a missing person. Interview with the MD on 5/23/24 at 01:50 PM, he stated he was made aware that Resident #1 eloped, and the police picked him up. The MD stated Resident #1 had never eloped before and did not exhibit any exit-seeking behaviors. The MD stated he had not been made aware that there were any concerns for Resident #1 smoking on his own. The MD stated Resident #1 had not had any change in conditions. The MD stated Resident #1 ambulated independently. Interview with LVN H on 5/23/24 at 02:35 PM, she stated she worked on Monday, 5/13 from 2:00 PM until 10:00 PM. LVN H stated she administered Resident #1's medication before the regular smoke break at 8PM. LVN H stated she saw Resident #1 return to his room after he finished smoking. LVN H stated she never saw Resident #1 come out of his room before she ended her shift at 09:50 PM. LVN H stated Resident #1 was his normal self and had not had a change in condition. LVN H stated they are not supposed to give the door code to any residents. LVN H stated the door codes are now changed once a month. LVN H stated you must make sure the door was fully closed and locked and not allow any residents to exit behind you. LVN H stated the Residents that previously had the door code, had to be assessed by the SW. LVN H stated if a resident passed the Mental Mini-Assessment, they were allowed to sign themselves in and out. LVN H stated if you were unable to locate a resident, you must notify the ADM. LVN H stated then the ADM would instruct management to drive around the neighborhood and if they still could not find the resident, they would notify the police. LVN H stated if the resident was found, they would complete an assessment, an incident report and notify the doctor and the family. LVN H stated if the doctor gave an Order for a wander guard, they would place a wander guard on the resident. LVN H stated Resident #1 was not a wanderer. Interview with CNA K on 5/23/24 at 02:50 PM, he stated he saw Resident #1 the day prior on Monday (5/13). CNA K stated there were no concerns CNA K stated Resident #1 walked throughout the facility independently and went outside to smoke. CNA K stated the next morning on 5/14/24, he did not see Resident #1 up and walking around prior to taking his breakfast tray to his room. CNA K stated when he arrived at Resident #1's room around 07:50 AM, Resident #1 was not in his room. CNA K stated he told CNA L that Resident #1 was not in his room, and CNA L said to leave his breakfast tray because Resident #1 was probably outside smoking. CNA K stated he told LVN J that Resident #1 was not in his room, and LVN J said he may be smoking. CNA K stated around 9:00 AM, it was discovered Resident #1 had not come out to smoke, and they started searching for him inside and outside the facility. CNA K stated you were supposed to check on residents every 2 hours but now it was every 1 hour. CNA K stated when you complete the checks, you must chart in PCC any care provided. CNA K stated if you are just laying eyes on a Resident, you do not have to enter anything in PCC. CNA K stated you must now check residents off on the Rounding List only after physically laying eyes on them. CNA K stated he has never known for a resident to go missing. CNA K stated previously residents that were authorized to enter and exit with the door code, had the freedom to go as they please if they signed in and out. CNA K stated the door code was now changed once a month and only employees are allowed the code. CNA K stated whenever an employee enters or exits the facility, they must make sure the door was closed and locked so no resident follows them out. Interview on 05/23/24 at 03:05 PM, the ADON stated Resident #1 was quiet and kept to himself. The ADON stated Resident #1 was usually alert and oriented. The ADON stated on Monday (5/13), Resident #1 tried to go out front to smoke by himself when the ADM was entering the building and she explained to Resident #1 that he must sign out first. The ADON stated Resident #1 complied and then went out and returned, and everything was fine. The ADON stated the next morning on 05/14/24, LVN J stated Resident #1 was not in his room or the common areas. The ADON stated the ADM had Management driving throughout the community searching for Resident #1. The ADON stated the ADM called DPD and Resident #1 was located in jail. The ADON stated Resident #1 had been arrested for obstructing traffic. The ADON stated each Resident must complete a Mini Mental Exam and depending on their score determines if they are allowed to sign themselves in and out, smoke unsupervised, or leave the facility without a family member. The ADON stated she does not know if anything could have been done differently because Resident #1 was not a wanderer, and he caught the facility off guard. The ADON stated they are making sure any resident that leaves the facility signs out and informs the nurse. The ADON stated the aides and nurses now completes rounds every hour. The ADON stated Resident #1 could have been hit by a vehicle, ended up in the hospital, or even killed. Interview with the ADM on 05/23/24 at 03:25 PM, she stated they have completed re-assessments on all residents to make sure the assessments were accurate. The ADM stated all residents that were already exit-seeking had a doctor's order to wear a wander guard. The ADM stated the SW had recently reassessed the residents that are allowed to sign themselves out. The ADM stated they completed in-services on 05/14/24 on rounding with each other and not by themselves. The ADM stated now nurses must print out the Midnight Census Report, give the report to the DON and text the ADM the headcount at midnight. The ADM stated they spoke with all the residents that are allowed to sign themselves out and informed them they must notify staff and make sure they sign in and out. The ADM stated they are having another in-service tomorrow on 05/24/24 on the same items. During an observation on 05/24/24 at 10:30 AM, Surveyor observed several Residents across from the entrance sitting in the dining area waiting to play bingo. The residents all denied being provided or knowing the door code to exit the facility. Interview with the SW on 05/24/24 at 11:00 AM, she stated Resident #1 did not have any change of conditions leading up to the elopement. The SW stated she drove throughout the neighborhood and could not locate Resident #1. The SW stated she looked Resident #1 up on the DPD website and confirmed that Resident #1 had been arrested for obstructing a highway passageway. The SW stated Resident #1 was not exit-seeking and did not wear a wander guard. The SW stated on 5/22/24 at 10:21 AM, Resident #1's daughter called her to get an update because she could not get through to the jail. The SW stated she looked Resident #1 up again on the DPD's website and it showed Resident #1 had been released the day prior on 5/21. The SW stated she drove downtown, around the jail and where the homeless people congregate and did not see Resident #1. The SW stated Resident #1's friend, Resident #4 most likely gave Resident #1 the door code. The SW stated Resident #4 was allowed to sign himself in and out and exit the facility using the door code. The SW stated Resident #1 was not allowed the door code due to his dementia diagnosis. The SW stated Resident #4 did not admit to giving Resident #1 the door code but suggested Resident #1 may have witnessed him entering it, or he may have given it to Resident #1 to enter. Interview with LVN J on 05/24/24 at 01:20 PM, she stated she arrived to work late on 05/14/24. She stated while completing her rounds on 05/14/24 around 08:00 AM, she did not see anyone in Resident #1's room. LVN J stated this was around the time Resident #1 goes to smoke. LVN J stated after she completed her rounds, she went to receive the shift change report from the night nurse, LVN I. LVN J stated she went back to Resident #1's room to give him his medication, but he was not back. LVN J stated she checked the bathroom, and no one was in there. LVN J stated she went ahead and asked Resident #3 (roommate), and he responded, Resident #1 went out last night and he never came back. LVN J stated she asked CNA L if she had seen Resident #1 and she responded she had not seen him. LVN J stated she went to check his usual places, his friends' rooms and the smoking area and he was not there. LVN J stated she checked if Resident #1 signed himself out, but his name was not in the binder. LVN J stated she then requested all the CNAs to check every room, but Resident #1 could not be found. LVN J stated she then reported the information to the ADM. LVN J explained the old process for completing rounds was you would go to each room but did not have to sign anything. LVN J stated the new process has changed to hourly checks and if you arrive to a room and if the resident was not there you must look for them immediately. LVN J stated staff must now complete 15-minute door checks and someone would be stationed at the front desk 24-hours day. LVN J stated if someone were at risk for elopement you must complete an elopement assessment and the results would tell you if the resident was at risk. LVN J stated she would then inform the ADM, DON, and the ADON. LVN J explained the process for wander guards are each day on every shift, you must check to see if it was working. LVN J stated if the wander guard was not working properly, you must report it to the MD, the ADM, and the DON. LVN J stated if the wander guard were working properly, the light would be red, and it makes a continuous sound if a resident gets too close to the door. LVN J stated the alarm would have to be physically turned off at the nursing station. LVN J stated she was trained by the DON to take residents with wander guards to the front door to ensure the equipment was working properly. LVN J stated residents are not allowed to have the door code and staff must open the door for them to enter and exit the facility. LVN J stated she received a new door code, and the door code would now be changed monthly. LVN J stated Resident #1 could have been harmed, hit by a car, or even killed. Interview with CNA L on 05/24/24 at 01:40 PM, she stated when she arrived to work 05/14/24 at 6:00 AM, she completed her rounds noticed Resident #1 was not in his room and his bed was made. CNA L stated when the breakfast trays arrived on the floor at approximately 8:30 AM, and CNA K took Resident #1 his breakfast tray, he was still not in his room. CNA L stated LVN J asked her if Resident #1 was in his room when she completed her rounds and she stated, No. CNA L stated her, and CNA K searched the inside and outside of the facility and did not see Resident #1. CNA L stated the process for completing rounds did not have a checklist at the time. CNA L stated you would inform the nurse if there were any concerns. CNA L stated now there was a checklist. CNA L stated if a resident was not in their room, they must search all rooms and they cannot wait and assume the resident was smoking. CNA L stated now CNAs complete rounds every odd hour and Nurses complete rounds every even numbered hour. CNA L stated since the elopement, if any resident signs themselves out to smoke and if the resident was not back within 15 minutes, staff must check on them. CNA L stated she had two residents on her hall that wears a wander guard, and she must make sure the wander guard was working by observing the light taking the resident to the door to sound the alarm. CNA L stated she must then sign the wander guard binder at the front desk. CNA L stated there was a sign-out binder for residents to sign out and staff must walk the resident to the door. CNA L stated staff was not allowed to share the door code with anyone. CNA L stated she was unsure how the residents previously received access to the door code. CNA L stated prior to this incident, Resident #1 had never tried to elope. Surveyor attempted to interview CNA M on 05/24/24 at 02:00 PM, Surveyor left a voicemail and sent a text requesting a callback. Record review of a Witness Statement dated 05/15/24 by CNA M revealed, I clocked in and walked his halls at 10:00 PM. Resident #1 was in his room. At approximately 11:00 PM, Resident #1 received ice. At midnight, Resident #1 was in his room. At 2:00 AM, another round was completed, and Resident #1 was in his room. During his last round at 4:00 AM, he assumed Resident #1 was asleep and did not disturb him nor his roommate. Surveyor attempted to interview LVN I on 05/24/24 at 02:15 PM. Surveyor left a voicemail and sent a text requesting a callback. Record review of a Witness Statement dated 05/15/24 sent in by LVN I revealed, I went to Resident #1's room early morning on 05/14/24 to administer medications to his roommate, Resident #3. I noticed Resident #1's bed was unmade, and Resident #3 was sitting in his wheelchair asleep in front of the television. There was light on in the restroom, the water was running, and the restroom door was closed all the way. I allowed Resident #1 to have privacy in the restroom. I left the main door unlocked per the roommate's request then moved on to the next room to continue passing medications. 2. Review of Resident #2's admission MDS assessment dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was moderately impaired, and he had hallucinations. He did not have wandering behaviors. His diagnoses included heart failure, diabetes, and Non-Alzheimer's Dementia, hemiplegia, and multiple sclerosis. Review of Resident #2's Order Summary Report for May 2024 reflected: -04/24/24 Resident is wearing a wander guard device to the left ankle every shift for elopement. -04/24/24 To ensure that wander guard is functioning correctly, every shift take resident to front door to ensure that alarm sounds. If alarm does not sound, please alert Administrator as soon as possible every shift for elopement. Review of Resident #2's Care Plans reflected: -05/24/24 Resident is an elopement risk/wanderer related to dementia. Resident has a wander guard on his left ankle. Facility interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering. Provide structured activities. Wander alert on left ankle. Monitor function and skin integrity every shift. Review of Resident #2's Progress Notes reflected: -05/21/24 5:46 PM Resident noted packing his clothing and stating, I'm leaving I'm going home. Writer attempted to redirect resident. Unable to redirect resident. Writer called family; resident calmed down after speaking with family. - LVN A -05/22/24 2:30 PM Type: Behavior Note Resident insisted on leaving out the front door, despite receptionist attempts to redirect. Writer went outside and eventually was able to redirect resident to come back inside. Resident stated he wanted to go home. Called the wife and she said she was on the way. Resident appearing less agitated. - DON -05/22/24 5:09 PM SW spoke with resident about wanting to leave today. Resident was very agitated, upset, angry, and verbally making threats towards people. Resident verbalized that he was upset over his cigarettes and not seeing his family. SW took resident outside to smoke and talk. Resident became very agitated again and began to pace and not listen to redirection. Resident would partially deescalate and then allow himself to amp up once again. Resident Mrs. [NAME] is aware of his behaviors and actions. SW sent referral to two facilities. - SW -05/22/24 10:34 PM At approximately 7:27 PM alarm to the front door was sounding. Staff answered the alarm to discover resident was outside trying to leave the facility. Resident was stopped by staff and redirected back inside of facility. Resident placed on every 15-minute checks. - LVN A -05/23/24 9:15 AM Resident continues this morning to attempt leaving. Redirecting this behavior is getting more difficult. - DON -05/23/24 11:09 AM Late Entry Resident being sent to hospital for evaluation. Arranging transportation. - DON -05/23/24 12:12 PM Resident noted with his belongings packed at the front door mentioning that he was leaving and didn't want to stay in this F** place no more, called the wife who is also the POA to talk to his and encourage him to wait for the social worker to get him another home, resident got very agitated and angry, threatening to leave any way notified the NP who gave an order to send resident to hospital, notified the wife transport arrived to pick up resident he refused to leave without all his belongings, cigarettes, bible, urinal he carried everything with him into the van, wife on the phone trying to convince him not to go with belongings resident was very adamant. Resident transported to hospital, Dr notified and DON aware. - ADON -05/23/24 3:06 PM Resident returned from hospital at approximately 1:27 PM with no paperwork. Resident was alert, responsive, calm, and cooperative at that time. Resident ambulating with walker ab lib in hallways. Displays no distress. Denies any pain/discomfort. - LVN A -05/23/24 10:24 PM The resident had a psych consult today with NP. New orders received to discontinue risperidone (used to treat schizophrenia) 2 and 3 mg and start risperidone 5 mg at bedtime, Depakote DR (anti-seizure medication and treats bipolar disorder) 250mg twice daily, change venlafaxine (anti-depressant) to every morning and a Valproic acid level and CBC 7 days after starting Depakote. - LVN A -05/25/24 3:01 PM Late Entry Resident forced himself out through the front door. Writer and another nurse ADON followed him and tried to redirect him, but resident did not want to listen or take directions. Resident was agitated and aggressive stating that he was going home. The ADON called resident's wife via video. Wife talked with the resident and asked him to come back into building. Wife told him that she will come to visit him today. Resident then came into the building. Resident redirected to his room. - LVN B -05/26/24 2:02 PM Resident followed another resident through the front door and forced himself outside. Writer tried to redirect resident and bring him back to the building, but resident refused and aggressively pushed the doors and got out. Writer then walked with the resident. Resident stated that he was going home, and he wanted to go buy cigarettes. Writer told resident that he had some cigarettes in the box. Resident then stated that he needed to sit down for few minutes. Writer stayed with resident outside for about 20 minutes. Resident then decided to come back into the building. Resident walked to his room and laid down on his bed. - LVN B -05/26/24 5:20 PM, Writer asked the other staff member if they had seen the resident. CNA on duty stated that they were outside in the smoke area with other residents, and he came back with other residents after the smoke break. Resident's walker noted at the dining hall, but resident is not there. Immediately all staff members alerted and started looking for the resident. All rooms searched but resident was not found. Administrator notified. Staff members went outside and searched around the building as some drove within the streets around, but resident was not found. Police notified and wife also called and notified. Staff members extended to search for the resident within the neighborhood, but resident was not found. Police arrived and were given description of the resident and gave the claim number. Police stated that if we find him before they do, we call them. - LVN B Review of Resident #2's Ambulance Record, dated 05/26/24, reflected: Dispatch notified: 7:31 PM On scene: 7:36 PM Resident transferred: 8:10 PM Patient was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. EMS arrived and transfer station staff were pouring water on him in an attempt to cool him off. EMS transported patient to the hospital. Review of Resident #2's Hospital Records, dated 05/26/24 8:30 PM, reflected: Chief Complaint: slurred speech, extremity weakness, fall, unable to respond to questioning. Temperature 98.9 degrees Fahrenheit. Final Diagnosis: Stroke Review of website: timeanddate.com on 05/29/24 reflected the following temperatures: [NAME] TX temperature: 5/26/24 4:53 PM 97 degrees 5/26/24 6:53 PM 97 degrees Dallas TX temperature: 5/26/24 4:53 PM 97 degrees 5/26/24 6:53 PM 98 degrees Observation of Resident #2 on 05/25/25 at 1:20 PM, revealed the resident was wearing a wander-guard transmitter on the left lower extremity and the presence of the LED light indicated it was functional. Observation of Resident #2 on 05/25/24 at 03:15 PM, revealed the DM sitting one-on-one with Resident #2 in the facility's lobby with his wander-guard transmitter still visible on the left lower extremity and the presence of the LED light indicated it was functional. An interview on 05/25/24 at 01:00 PM, with the MTD he stated he adjusted the front door to make the door close faster and changed the door code. The MTD stated the front door was monitored by the wander-guard system. The MTD stated normally, [Company] instructed him over the phone how to change the door code, but this time, he had [Company] come to the facility and [Company] installed a button under the receptionist's desk in order to open the door remotely and provided him a manual on how to change the door code himself. The MTD stated there had not been any concerns and everything was working properly. The MTD stated he monitored the doors as needed to ensure they are closing properly. The MTD stated he completed door checks three times a day and completed Tail Logs for documentation purposes. The MTD stated he had never been aware of any residents being in possession of the door code. On 05/25/24 at 01:20 PM, Surveyor observed the five residents identified for placement of a Wander Guard. Surveyor observed the five residents in their rooms with their Wander Guard placed according to their individual Care Plans and Orders. Surveyor also conducted testing with the ADON at the front door to ensure the Wander Guards were functioning properly. An interview on 05/25/24 at 02:15 PM, with the DM, he stated he drove around looking for Resident #1 when he was reported missing. The DM stated he was in-serviced on not giving the door code out or allowing residents to follow anyone outside. The DM stated the door codes were changed and a remote access button was installed under the receptionist's desk. An interview on 05/25/24 at 02:30 PM, with HR, she stated she was in-serviced on making sure all residents know they must be buzzed in and out. HR stated no residents nor visitors should have access to the door code. HR stated the approved residents must sign in and out of the facility and let staff know they are leaving. HR stated the MTD changed the door codes last on Thursday, 05/23/24. HR stated when she ends her shift at 5:00 PM and over the weekend, various staff members would cover the front door. An interview on 05/25/24 at 02:45 PM, HK O stated she was in-serviced on being more concerned when entering and exiting the front door. HK O stated she was informed the door code would be changed once a month. HK O stated she was informed to keep an eye on the residents that wear a Wander Guard. Interviews were conducted with facility staff across multiple shifts on 05/23/24, 05/24/24, and 05/25/24. Staff interviewed were LVN H, LVN J, CNA L, CNA K, CNA F, CNA G, CNA C, HK O, LVN B, LVN J and MA A. Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on obtaining orders when a resident was assessed and determined to require a wander guard to ensure the wander guard monitoring populated into the TARS. They stated they had been in-serviced on checking to ensure the wander guard was functional every shift by observing that the light was

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement written policies and procedures that prohibited and prevented abuse and neglect for two of nine residents (Resident #1 and Resident#2) reviewed for elopement. 1. The facility failed to follow the policy and procedure for neglect which allowed Resident #1 to elope from the facility. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility as 2-hour monitoring was not completed properly. Resident #1 had access to the door code for the front door although he had impaired cognitive function or thought processes related to Dementia and lacked safety awareness. Resident #1 eloped from the facility on 05/14/23 and was arrested the same day 3.5 miles away for impeding the progress of a southbound public train. 2. The facility failed to follow the policy and procedure for neglect which allowed Resident #2 to elope from the facility. The facility failed to ensure Resident #2 was supervised adequately and did not elope from the facility. Resident #2 was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. Resident #2 suffered a stroke and was hospitalized . An Immediate Jeopardy (IJ) was identified on 5/29/24 at 3:20 PM. The IJ template was provided to the facility on 5/29/24 3:25 PM and signed by the Administrator. While the IJ was removed on 05/31/24 the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. These failures resulted in the failure to follow the policy for neglect as well as hospitalization with stroke. Findings included: Review of facility's policy Abuse and Neglect Clinical Protocol, revised March 2018, reflected: Neglect .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. 1. Review of Resident #1's quarterly MDS assessment, dated 05/02/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epilepsy (abnormal electrical brain activity), muscle weakness, lack of coordination and anxiety (feeling of fear, dread, and uneasiness). The MDS reflected Resident #1 had a BIMS (Brief Interview for Mental Status - is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 10 indicating moderate cognitive impairment, moderately impaired decision-making, required cues/supervision. Under Section P - Restraints and Alarms revealed Resident #1 did not have any physical restraints (wander guard). Resident #1's undated Census Record reflected a discharge date of 05/14/24. Review of Resident #1's care plan revised on 05/08/24 revealed Resident #1 had an ADL self-care performance deficit related to activity intolerance, confusion, impaired balance was addressed. Interventions included encourage the resident to use the call light for assistance, he required extensive assistance x 1 staff for toileting and praise all efforts at self-care. Review of Resident #1's quarterly Elopement Risk Assessments, dated 02/12/24 and 05/12/24, revealed Resident #1 was ambulatory and had no history of wandering. The assessment reflected the Resident #1 was at a low risk for wandering with a score of 2.0 and had no reported episodes of wandering in the past 6 months. Review of Resident #1's progress notes dated 05/14/24 at 10:09 AM, written by LVN J revealed the resident is not in the building, his roommate said, he left at 1:30 AM and he has not come back. Review of Resident #1's progress notes dated 05/14/24 at 11:30 AM, written by SW revealed there were several groups of staff that went out looking for Resident #1 to find him. The groups returned unable to locate him. Review of Resident #1's progress notes dated 05/14/24 at 1:30 PM, written by SW revealed DPD notified the ADM that Resident #1 had been found in [. Jail]. SW called [. Jail] to find him and they were unable to locate him either in jail or in booking. SW then looked up Resident #1 in [. County Jail] and was able to find that Resident #1 had been picked up at 11:01 AM on 05/14/24 due to Obstruction of Highway Passageway. Review of the Provider Investigation Report dated 05/21/24 revealed Resident #1 was last seen on 05/13/24 at 8:30 PM in his room when taking his evening medications. On 05/14/24, CNA L served his breakfast tray at 08:30 AM and Resident #1 could not be found after searching inside the facility. DPD was notified on 05/14/24 of missing resident and was provided with a photo and face sheet. It further stated it was confirmed Resident #1 left the facility without anyone observing him, nor him notifying anyone and Resident #1 had been given the door code by another resident to go outside and smoke off property. Review of Resident #1's Smoking Safety Screen dated 02/01/24 and 05/01/24 revealed due to his diagnosis of dementia, Resident #1 was a supervised smoker. Review of in-service training dated 05/14/24, after Resident #1's elopement, revealed training related to the procedure to follow when a resident was missing. The in-service did not address elopement prevention, ensuring wander-guard transmitters were routinely tested/checked to ensure they were functioning properly or training to ensure staff were able to demonstrate competency in monitoring and checking wander-guard transmitters. Review of DTP Police Report dated 05/14/24 revealed Resident #1 was arrested on Tuesday, 05/14/24 at approximately 08:30 AM . impeding the progress of a southbound [Company] train. Interview with a family member of Resident #1 on 05/23/24 at 9:45 AM, she stated the SW called her on 05/14/24 and informed her Resident #1 was missing. Resident #1's family member stated she had not spoken to, nor visited Resident #1 since November 2023. Resident #1's family member stated they have not found Resident #1, and the SW stopped communicating with her. Interview with the ADM on 05/23/24 at 10:30 AM, she stated due to Resident #1 not being exit-seeking, he did not wear a wander-guard transmitter. The ADM stated during their morning meeting on 5/14, it was reported by LVN J they were unable to locate Resident #1 inside the facility. The ADM stated LVN J informed her CNA L delivered Resident #1's breakfast tray to his room and then took residents out to smoke at 8:30 AM, but Resident #1 did not partake in neither. The ADM stated a report was filed with the DPD and a couple of hours later she was informed by DPD that Resident #1 was no longer considered missing as he had been arrested. Interview with the DON on 05/23/24 at 10:40 AM, she stated Resident #1 had not experienced a medical decline. The DON stated she believed Resident #1 had the door code because the only way you can get out without sounding the alarm, you would have to enter the door code. The DON stated Resident #1 had Dementia, but you would not know it by talking to him or looking at him. Interview with Resident #3 (Resident #1's roommate) on 05/23/24 at 12:00 PM, he stated Resident #1 did not tell him he was leaving. Resident #3 stated he woke up around 01:00 AM and Resident #1 was not in his bed. Resident #3 stated Resident #1 never mentioned he wanted to leave. Resident #3 stated all Resident #1 did was smoke and visit other residents. Resident #3 stated Resident #1 never showed any signs that he was leaving or that he did not like it here. Interview with Resident #4 (Resident #1's friend) on 05/23/24 at 12:20 PM, he stated Resident #1 would follow him outside and he may have seen him enter the door code to get out. Resident #4 denied intentionally providing the door code to Resident #1. Interview with DET A on 5/23/24 at 01:35 PM, he stated it was believed Resident #1 was arrested in [City] , but then it was determined he had been arrested by the DTP. DET A stated when he was assigned to locate Resident #1, he was not missing as he had already been arrested. DET A stated when he located Resident #1 in jail, his case was closed as Resident #1 was no longer considered a missing person. Interview with the MD on 5/23/24 at 01:50 PM, he stated he was made aware that Resident #1 eloped, and the police picked him up. The MD stated Resident #1 had never eloped before and did not exhibit any exit-seeking behaviors. The MD stated he had not been made aware that there were any concerns for Resident #1 smoking on his own. The MD stated Resident #1 had not had any change in conditions. The MD stated Resident #1 ambulated independently. Interview with LVN H on 5/23/24 at 02:35 PM, she stated she worked on Monday, 5/13 from 2:00 PM until 10:00 PM. LVN H stated she administered Resident #1's medication before the regular smoke break at 8PM. LVN H stated she saw Resident #1 return to his room after he finished smoking. LVN H stated she never saw Resident #1 come out of his room before she ended her shift at 09:50 PM. LVN H stated Resident #1 was his normal self and had not had a change in condition. LVN H stated they are not supposed to give the door code to any residents. LVN H stated the door codes are now changed once a month. LVN H stated you must make sure the door was fully closed and locked and not allow any residents to exit behind you. LVN H stated the Residents that previously had the door code, had to be assessed by the SW. LVN H stated if a resident passed the Mental Mini-Assessment, they were allowed to sign themselves in and out. LVN H stated if you were unable to locate a resident, you must notify the ADM. LVN H stated then the ADM would instruct management to drive around the neighborhood and if they still could not find the resident, they would notify the police. LVN H stated if the resident was found, they would complete an assessment, an incident report and notify the doctor and the family. LVN H stated if the doctor gave an Order for a wander guard, they would place a wander guard on the resident. LVN H stated Resident #1 was not a wanderer. Interview with CNA K on 5/23/24 at 02:50 PM, he stated he saw Resident #1 the day prior on Monday (5/13). CNA K stated there were no concerns CNA K stated Resident #1 walked throughout the facility independently and went outside to smoke. CNA K stated the next morning on 5/14/24, he did not see Resident #1 up and walking around prior to taking his breakfast tray to his room. CNA K stated when he arrived at Resident #1's room around 07:50 AM, Resident #1 was not in his room. CNA K stated he told CNA L that Resident #1 was not in his room, and CNA L said to leave his breakfast tray because Resident #1 was probably outside smoking. CNA K stated he told LVN J that Resident #1 was not in his room, and LVN J said he may be smoking. CNA K stated around 9:00 AM, it was discovered Resident #1 had not come out to smoke, and they started searching for him inside and outside the facility. CNA K stated you were supposed to check on residents every 2 hours but now it was every 1 hour. CNA K stated when you complete the checks, you must chart in PCC any care provided. CNA K stated if you are just laying eyes on a Resident, you do not have to enter anything in PCC. CNA K stated you must now check residents off on the Rounding List only after physically laying eyes on them. CNA K stated he has never known for a resident to go missing. CNA K stated previously residents that were authorized to enter and exit with the door code, had the freedom to go as they please if they signed in and out. CNA K stated the door code was now changed once a month and only employees are allowed the code. CNA K stated whenever an employee enters or exits the facility, they must make sure the door was closed and locked so no resident follows them out. Interview on 05/23/24 at 03:05 PM, the ADON stated Resident #1 was quiet and kept to himself. The ADON stated Resident #1 was usually alert and oriented. The ADON stated on Monday (5/13), Resident #1 tried to go out front to smoke by himself when the ADM was entering the building and she explained to Resident #1 that he must sign out first. The ADON stated Resident #1 complied and then went out and returned, and everything was fine. The ADON stated the next morning on 05/14/24, LVN J stated Resident #1 was not in his room or the common areas. The ADON stated the ADM had Management driving throughout the community searching for Resident #1. The ADON stated the ADM called DPD and Resident #1 was located in jail. The ADON stated Resident #1 had been arrested for obstructing traffic. The ADON stated each Resident must complete a Mini Mental Exam and depending on their score determines if they are allowed to sign themselves in and out, smoke unsupervised, or leave the facility without a family member. The ADON stated she does not know if anything could have been done differently because Resident #1 was not a wanderer, and he caught the facility off guard. The ADON stated they are making sure any resident that leaves the facility signs out and informs the nurse. The ADON stated the aides and nurses now completes rounds every hour. The ADON stated Resident #1 could have been hit by a vehicle, ended up in the hospital, or even killed. Interview with the ADM on 05/23/24 at 03:25 PM, she stated they have completed re-assessments on all residents to make sure the assessments were accurate. The ADM stated all residents that were already exit-seeking had a doctor's order to wear a wander guard. The ADM stated the SW had recently reassessed the residents that are allowed to sign themselves out. The ADM stated they completed in-services on 05/14/24 on rounding with each other and not by themselves. The ADM stated now nurses must print out the Midnight Census Report, give the report to the DON and text the ADM the headcount at midnight. The ADM stated they spoke with all the residents that are allowed to sign themselves out and informed them they must notify staff and make sure they sign in and out. The ADM stated they are having another in-service tomorrow on 05/24/24 on the same items. During an observation on 05/24/24 at 10:30 AM, Surveyor observed several Residents across from the entrance sitting in the dining area waiting to play bingo. The residents all denied being provided or knowing the door code to exit the facility. Interview with the SW on 05/24/24 at 11:00 AM, she stated Resident #1 did not have any change of conditions leading up to the elopement. The SW stated she drove throughout the neighborhood and could not locate Resident #1. The SW stated she looked Resident #1 up on the DPD website and confirmed that Resident #1 had been arrested for obstructing a highway passageway. The SW stated Resident #1 was not exit-seeking and did not wear a wander guard. The SW stated on 5/22/24 at 10:21 AM, Resident #1's daughter called her to get an update because she could not get through to the jail. The SW stated she looked Resident #1 up again on the DPD's website and it showed Resident #1 had been released the day prior on 5/21. The SW stated she drove downtown, around the jail and where the homeless people congregate and did not see Resident #1. The SW stated Resident #1's friend, Resident #4 most likely gave Resident #1 the door code. The SW stated Resident #4 was allowed to sign himself in and out and exit the facility using the door code. The SW stated Resident #1 was not allowed the door code due to his dementia diagnosis. The SW stated Resident #4 did not admit to giving Resident #1 the door code but suggested Resident #1 may have witnessed him entering it, or he may have given it to Resident #1 to enter. Interview with LVN J on 05/24/24 at 01:20 PM, she stated she arrived to work late on 05/14/24. She stated while completing her rounds on 05/14/24 around 08:00 AM, she did not see anyone in Resident #1's room. LVN J stated this was around the time Resident #1 goes to smoke. LVN J stated after she completed her rounds, she went to receive the shift change report from the night nurse, LVN I. LVN J stated she went back to Resident #1's room to give him his medication, but he was not back. LVN J stated she checked the bathroom, and no one was in there. LVN J stated she went ahead and asked Resident #3 (roommate), and he responded, Resident #1 went out last night and he never came back. LVN J stated she asked CNA L if she had seen Resident #1 and she responded she had not seen him. LVN J stated she went to check his usual places, his friends' rooms and the smoking area and he was not there. LVN J stated she checked if Resident #1 signed himself out, but his name was not in the binder. LVN J stated she then requested all the CNAs to check every room, but Resident #1 could not be found. LVN J stated she then reported the information to the ADM. LVN J explained the old process for completing rounds was you would go to each room but did not have to sign anything. LVN J stated the new process has changed to hourly checks and if you arrive to a room and if the resident was not there you must look for them immediately. LVN J stated staff must now complete 15-minute door checks and someone would be stationed at the front desk 24-hours day. LVN J stated if someone were at risk for elopement you must complete an elopement assessment and the results would tell you if the resident was at risk. LVN J stated she would then inform the ADM, DON, and the ADON. LVN J explained the process for wander guards are each day on every shift, you must check to see if it was working. LVN J stated if the wander guard was not working properly, you must report it to the MD, the ADM, and the DON. LVN J stated if the wander guard were working properly, the light would be red, and it makes a continuous sound if a resident gets too close to the door. LVN J stated the alarm would have to be physically turned off at the nursing station. LVN J stated she was trained by the DON to take residents with wander guards to the front door to ensure the equipment was working properly. LVN J stated residents are not allowed to have the door code and staff must open the door for them to enter and exit the facility. LVN J stated she received a new door code, and the door code would now be changed monthly. LVN J stated Resident #1 could have been harmed, hit by a car, or even killed. Interview with CNA L on 05/24/24 at 01:40 PM, she stated when she arrived to work 05/14/24 at 6:00 AM, she completed her rounds noticed Resident #1 was not in his room and his bed was made. CNA L stated when the breakfast trays arrived on the floor at approximately 8:30 AM, and CNA K took Resident #1 his breakfast tray, he was still not in his room. CNA L stated LVN J asked her if Resident #1 was in his room when she completed her rounds and she stated, No. CNA L stated her, and CNA K searched the inside and outside of the facility and did not see Resident #1. CNA L stated the process for completing rounds did not have a checklist at the time. CNA L stated you would inform the nurse if there were any concerns. CNA L stated now there was a checklist. CNA L stated if a resident was not in their room, they must search all rooms and they cannot wait and assume the resident was smoking. CNA L stated now CNAs complete rounds every odd hour and Nurses complete rounds every even numbered hour. CNA L stated since the elopement, if any resident signs themselves out to smoke and if the resident was not back within 15 minutes, staff must check on them. CNA L stated she had two residents on her hall that wears a wander guard, and she must make sure the wander guard was working by observing the light taking the resident to the door to sound the alarm. CNA L stated she must then sign the wander guard binder at the front desk. CNA L stated there was a sign-out binder for residents to sign out and staff must walk the resident to the door. CNA L stated staff was not allowed to share the door code with anyone. CNA L stated she was unsure how the residents previously received access to the door code. CNA L stated prior to this incident, Resident #1 had never tried to elope. Surveyor attempted to interview CNA M on 05/24/24 at 02:00 PM, Surveyor left a voicemail and sent a text requesting a callback. Record review of a Witness Statement dated 05/15/24 by CNA M revealed, I clocked in and walked his halls at 10:00 PM. Resident #1 was in his room. At approximately 11:00 PM, Resident #1 received ice. At midnight, Resident #1 was in his room. At 2:00 AM, another round was completed, and Resident #1 was in his room. During his last round at 4:00 AM, he assumed Resident #1 was asleep and did not disturb him nor his roommate. Surveyor attempted to interview LVN I on 05/24/24 at 02:15 PM. Surveyor left a voicemail and sent a text requesting a callback. Record review of a Witness Statement dated 05/15/24 sent in by LVN I revealed, I went to Resident #1's room early morning on 05/14/24 to administer medications to his roommate, Resident #3. I noticed Resident #1's bed was unmade, and Resident #3 was sitting in his wheelchair asleep in front of the television. There was light on in the restroom, the water was running, and the restroom door was closed all the way. I allowed Resident #1 to have privacy in the restroom. I left the main door unlocked per the roommate's request then moved on to the next room to continue passing medications. 2. Review of Resident #2's admission MDS assessment dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was moderately impaired, and he had hallucinations. He did not have wandering behaviors. His diagnoses included heart failure, diabetes, and Non-Alzheimer's Dementia, hemiplegia, and multiple sclerosis. Review of Resident #2's Order Summary Report for May 2024 reflected: 04/24/24 Resident is wearing a wander guard device to the left ankle every shift for elopement. 04/24/24 To ensure that wander guard is functioning correctly, every shift take resident to front door to ensure that alarm sounds. If alarm does not sound, please alert Administrator as soon as possible every shift for elopement. Review of Resident #2's Care Plans reflected: 05/24/24 Resident is an elopement risk/wanderer related to dementia. Resident has a wander guard on his left ankle. Facility interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering. Provide structured activities. Wander alert on left ankle. Monitor function and skin integrity every shift. Review of Resident #2's Progress Notes reflected: 05/21/24 5:46 PM Resident noted packing his clothing and stating, I'm leaving I'm going home. Writer attempted to redirect resident. Unable to redirect resident. Writer called family; resident calmed down after speaking with family. - LVN A 05/22/24 2:30 PM Type: Behavior Note Resident insisted on leaving out the front door, despite receptionist attempts to redirect. Writer went outside and eventually was able to redirect resident to come back inside. Resident stated he wanted to go home. Called the wife and she said she was on the way. Resident appearing less agitated. - DON 05/22/24 5:09 PM SW spoke with resident about wanting to leave today. Resident was very agitated, upset, angry, and verbally making threats towards people. Resident verbalized that he was upset over his cigarettes and not seeing his family. SW took resident outside to smoke and talk. Resident became very agitated again and began to pace and not listen to redirection. Resident would partially deescalate and then allow himself to amp up once again. Resident Mrs. [NAME] is aware of his behaviors and actions. SW sent referral to two facilities. - SW 05/22/24 10:34 PM At approximately 7:27 PM alarm to the front door was sounding. Staff answered the alarm to discover resident was outside trying to leave the facility. Resident was stopped by staff and redirected back inside of facility. Resident placed on every 15-minute checks. - LVN A 05/23/24 9:15 AM Resident continues this morning to attempt leaving. Redirecting this behavior is getting more difficult. - DON 05/23/24 11:09 AM Late Entry Resident being sent to hospital for evaluation. Arranging transportation. - DON 05/23/24 12:12 PM Resident noted with his belongings packed at the front door mentioning that he was leaving and didn't want to stay in this F** place no more, called the wife who is also the POA to talk to his and encourage him to wait for the social worker to get him another home, resident got very agitated and angry, threatening to leave any way notified the NP who gave an order to send resident to hospital, notified the wife transport arrived to pick up resident he refused to leave without all his belongings, cigarettes, bible, urinal he carried everything with him into the van, wife on the phone trying to convince him not to go with belongings resident was very adamant. Resident transported to hospital, Dr notified and DON aware. - ADON 05/23/24 3:06 PM Resident returned from hospital at approximately 1:27 PM with no paperwork. Resident was alert, responsive, calm, and cooperative at that time. Resident ambulating with walker ab lib in hallways. Displays no distress. Denies any pain/discomfort. - LVN A 05/23/24 10:24 PM The resident had a psych consult today with NP. New orders received to discontinue risperidone (used to treat schizophrenia) 2 and 3 mg and start risperidone 5 mg at bedtime, Depakote DR (anti-seizure medication and treats bipolar disorder) 250mg twice daily, change venlafaxine (anti-depressant) to every morning and a Valproic acid level and CBC 7 days after starting Depakote. - LVN A 05/25/24 3:01 PM Late Entry Resident forced himself out through the front door. Writer and another nurse ADON followed him and tried to redirect him, but resident did not want to listen or take directions. Resident was agitated and aggressive stating that he was going home. The ADON called resident's wife via video. Wife talked with the resident and asked him to come back into building. Wife told him that she will come to visit him today. Resident then came into the building. Resident redirected to his room. - LVN B 05/26/24 2:02 PM Resident followed another resident through the front door and forced himself outside. Writer tried to redirect resident and bring him back to the building, but resident refused and aggressively pushed the doors and got out. Writer then walked with the resident. Resident stated that he was going home, and he wanted to go buy cigarettes. Writer told resident that he had some cigarettes in the box. Resident then stated that he needed to sit down for few minutes. Writer stayed with resident outside for about 20 minutes. Resident then decided to come back into the building. Resident walked to his room and laid down on his bed. - LVN B 05/26/24 5:20 PM Writer asked the other staff member if they had seen the resident. CNA on duty stated that they were outside the smoke area with other residents, and he came back with other residents after the smoke break. Resident's walker noted at the dining hall, but resident is not there. Immediately all staff members alerted and started looking for the resident. All rooms searched but resident was not found. Administrator notified. Staff members went outside and searched around the building as some drove within the streets around, but resident was not found. Police notified and wife also called and notified. Staff members extended to search for the resident within the neighborhood, but resident was not found. Police arrived and were given description of the resident and gave the claim number. Police stated that if we find him before they do, we call them. - LVN B Review of Resident #2's Ambulance Record, dated 05/26/24, reflected: Dispatch notified: 7:31 PM On scene: 7:36 PM Resident transferred: 8:10 PM Patient was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. EMS arrived and transfer station staff were pouring water on him in an attempt to cool him off. EMS transported patient to the hospital. Review of Resident #2's Hospital Records, dated 05/26/24 8:30 PM, reflected: Chief Complaint: slurred speech, extremity weakness, fall, unable to respond to questioning. Temperature 98.9 degrees Fahrenheit. Final Diagnosis: Stroke Review of website: timeanddate.com on 05/29/24 reflected the following temperatures: [NAME] TX temperature: 5/26/24 4:53 PM 97 degrees 5/26/24 6:53 PM 97 degrees Dallas TX temperature: 5/26/24 4:53 PM 97 degrees 5/26/24 6:53 PM 98 degrees An interview on 05/28/24 at 2:00 PM with a family member of Resident #2 revealed facility staff told her the resident was trying to leave the facility prior to his elopement. She said facility staff did not say he was on any enhanced monitoring. The family member said Resident #2 had tried to leave the previous facility he was in also. She said Resident #2 moved to the current facility because the facility had the wander guard system. The facility called her on 05/26/24 between 5:30 PM and 6:00 PM to tell her the resident had eloped. On 05/27/24 a person from the hospital called her and said the resident had been found and was in the hospital. An interview on 05/28/24 at 12:15 PM with the DON revealed she did not know how Resident #2 had eloped from the facility on 05/26/24. She said the resident was on 15-minute checks and provided a document showing 15-minute checks were completed and signed by staff. The DON said the resident kept attempting to get out of the facility and he was placed on a wander guard. She said the way the door worked was that if it was pressed on it would beep with the wander guard and then open. She said the resident was admitted on [DATE]. She said the facility staff noticed he was missing and began searching for the resident on 05/26/24. The DON said the resident was found in a gas station restroom and was taken to the hospital. The DON said the resident would not be returning to the facility. The DON said she had been working at the facility since 02/26/24. An interview on 05/28/24 at 12:40 PM with the Administrator revealed she said Resident #2 kept trying to get out and the staff were keeping him in sight. The Administrator said the resident forced himself out earlier when visitors were coming in and he was holding the door even though the alarm sounded, and staff had to tell him in to coming back again. The Administrator said Resident #2 was on 15-minute checks. Record review of the Resident Behavior Monitoring Log for Resident #2, dated 05-22-24 to 5-26-24 and provided by the DON, reflected 15-minute checks were documented and each entry was signed. The form showed LVN B's initials were signed for each entry on 05/26/24 from 6:00 AM to 5:45 PM. An interview on 05/29/24 at 9:45 AM with LVN B revealed he last saw Resident #2 on 04/26/24 at 4:00 PM when he went out to smoke. His initials were on the 15-minute checks provided by the DON. He said he went back to passing medications and noticed the resident's walker was in the front area next to the kitchen. LVN B said he did not perform 15-minute monitoring checks and also did not sign a form saying that he did. He said the resident was on hourly checks. He said he was the charge nurse, and the other staff were also not performing 15-minute checks on the resident. An interview on 05/29/24 at 11:06 AM with CNA C revealed she worked on 05/26/24 and last saw Resident #2 after smoke break between 4:00 PM and 4:30 PM. She said she was not checking on the resident every 15 minutes. She said she checked on the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents receives adequate supervision and assistance devices to prevent accidents for two of nine residents (Resident #1 and Resident #2) reviewed for elopement. 1. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility. Resident #1 had access to the door code for the front door although he had impaired cognitive function or thought processes related to Dementia and lacked safety awareness. Resident #1 eloped from the facility on 05/14/23 and was arrested the same day 3.5 miles away for impeding the progress of a southbound public train. 2. The facility failed to ensure Resident #2 was supervised adequately and did not elope from the facility. Resident #2 was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. Resident #2 suffered a stroke and was hospitalized . An Immediate Jeopardy (IJ) was identified on 5/29/24 at 3:20 PM. The IJ template was provided to the facility on 5/29/24 3:25 PM and signed by the Administrator. While the IJ was removed on 05/31/24 the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. These failures resulted in one arrest due to obstructing traffic and one hospitalization due to being found lying on the ground and had suffered a stroke. Findings included: 1. Review of Resident #1's quarterly MDS assessment, dated 05/02/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epilepsy (abnormal electrical brain activity), muscle weakness, lack of coordination and anxiety (feeling of fear, dread, and uneasiness). The MDS reflected Resident #1 had a BIMS (Brief Interview for Mental Status - is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 10 indicating moderate cognitive impairment, moderately impaired decision-making, required cues/supervision. Under Section P - Restraints and Alarms revealed Resident #1 did not have any physical restraints (wander guard). Resident #1's undated Census Record reflected a discharge date of 05/14/24. Review of Resident #1's care plan revised on 05/08/24 revealed Resident #1 had an ADL (activities of daily living) self-care performance deficit related to activity intolerance, confusion, impaired balance was addressed. Interventions included encourage the resident to use the call light for assistance, he required extensive assistance x 1 staff for toileting and praise all efforts at self-care. Review of Resident #1's quarterly Elopement Risk Assessments, dated 02/12/24 and 05/12/24, revealed Resident #1 was ambulatory and had no history of wandering. The assessment reflected the Resident #1 was at a low risk for wandering with a score of 2.0 and had no reported episodes of wandering in the past 6 months. Review of Resident #1's progress notes dated 05/14/24 at 10:09 AM written by LVN J revealed the resident is not in the building, his roommate said, he left at 1:30 AM and he has not come back. Review of Resident #1's progress notes dated 05/14/24 at 11:30 AM written by SW revealed there were several groups of staff that went out looking for Resident #1 to find him. The groups returned unable to locate him. Review of Resident #1's progress notes dated 05/14/24 at 1:30 PM written by SW revealed DPD notified the ADM that Resident #1 had been found in [. Jail]. SW called [. Jail] to find him and they were unable to locate him either in jail or in booking. SW then looked up Resident #1 in [. County Jail] and was able to find that Resident #1 had been picked up at 11:01 AM on 05/14/24 due to Obstruction of Highway Passageway. Review of the Provider Investigation Report dated 05/21/24 revealed Resident #1 was last seen on 05/13/24 at 8:30 PM in his room when taking his evening medications. On 05/14/24, CNA L served his breakfast tray at 08:30 AM and Resident #1 could not be found after searching inside the facility. DPD was notified on 05/14/24 of missing resident and was provided with a photo and face sheet. It further stated it was confirmed Resident #1 left the facility without anyone observing him, nor him notifying anyone and Resident #1 had been given the door code by another resident to go outside and smoke off property. Review of Resident #1's Smoking Safety Screen dated 02/01/24 and 05/01/24 revealed due to his diagnosis of dementia, Resident #1 was a supervised smoker. Review of in-service training dated 05/14/24, after Resident #1's elopement, revealed training related to the procedure to follow when a resident was missing. The in-service did not address elopement prevention, ensuring wander-guard transmitters were routinely tested/checked to ensure they were functioning properly or training to ensure staff were able to demonstrate competency in monitoring and checking wander-guard transmitters. Review of DTP Police Report dated 05/14/24 revealed Resident #1 was arrested on Tuesday, 05/14/24 at approximately 08:30 AM . impeding the progress of a southbound [Company] train. Interview with a family member of Resident #1 on 05/23/24 at 9:45 AM she stated the SW called her on 05/14/24 and informed her Resident #1 was missing. Resident #1's family member stated she had not spoken to, nor visited Resident #1 since November 2023. Resident #1's family member stated they had not found Resident #1, and the SW stopped communicating with her. Interview with the ADM on 05/23/24 at 10:30 AM she stated due to Resident #1 not being exit-seeking, he did not wear a wander-guard transmitter. The ADM stated during their morning meeting on 5/14, it was reported by LVN J they were unable to locate Resident #1 inside the facility. The ADM stated LVN J informed her CNA L delivered Resident #1's breakfast tray to his room and then took residents out to smoke at 8:30 AM, but Resident #1 did not partake in neither. The ADM stated a report was filed with the DPD and a couple of hours later she was informed by DPD that Resident #1 was no longer considered missing as he had been arrested. Interview with the DON on 05/23/24 at 10:40 AM she stated Resident #1 had not experienced a medical decline. The DON stated she believed Resident #1 had the door code because the only way you can get out without sounding the alarm, you would have to enter the door code. The DON stated Resident #1 had Dementia, but you would not know it by talking to him or looking at him. Interview with Resident #3 (Resident #1's roommate) on 05/23/24 at 12:00 PM, he stated Resident #1 did not tell him he was leaving. Resident #3 stated he awakened around 01:00 AM and Resident #1 was not in his bed. Resident #3 stated Resident #1 never mentioned he wanted to leave. Resident #3 stated all Resident #1 did was smoked and visited other residents. Resident #3 stated Resident #1 never showed any signs that he wanted to leave or that he did not like it here. Interview with Resident #4 (Resident #1's friend) on 05/23/24 at 12:20 PM, he stated Resident #1 followed him outside and on occasion might had seen him enter the door code to get out. Resident #4 denied intentionally providing the door code to Resident #1. Interview with DET A on 5/23/24 at 01:35 PM, he stated it appeared Resident #1 had been arrested in Waxahachie, but later confirmed he had been arrested by the [Agency] Police. DET A stated when he started his search for Resident #1, he was not deemed missing as he had already been arrested. DET A stated his case was closed as Resident #1 was no longer considered a missing person. Interview with the MD on 5/23/24 at 01:50 PM, he stated he was notified by the facility on 05/14/24 that Resident #1 eloped, and the police picked him up. The MD stated Resident #1 had never eloped before and did not exhibit any exit-seeking behaviors. The MD stated Resident #1 had not had any change in conditions. The MD stated Resident #1 ambulated independently. Interview with LVN H on 5/23/24 at 02:35 PM, she stated she worked on Monday, 5/13 from 2:00 PM until 10:00 PM. LVN H stated she administered Resident #1's medication before the regular smoke break at 8:00 PM. LVN H stated she saw Resident #1 return to his room after he finished smoking. LVN H stated she never saw Resident #1 come out of his room before she ended her shift at 09:50 PM. LVN H stated Resident #1 was his normal self and had not had a change in condition. LVN H stated staff was not supposed to give the door code to any residents. LVN H stated now the door codes would be changed monthly by the MTD. LVN H stated you had to make sure the door closed and locked and not allow any residents to exit behind you. LVN H stated the Residents that previously had the door code, had to be assessed by the SW. LVN H stated if a Resident passed the Mental Mini-Assessment, they were allowed to sign themselves in and out. LVN H stated if you were unable to locate a resident, you would notify the ADM. LVN H stated then the ADM would instruct management to drive around the neighborhood and if they still could not find the resident, the police would be notified. LVN H stated if the resident were found, they would complete an assessment, an incident report and notify the doctor and the family. LVN H stated if the doctor gave an Order for a wander guard, they would place a wander guard on the resident. LVN H stated Resident #1 was not a wanderer. Interview with CNA K on 5/23/24 at 02:50 PM, he stated he saw Resident #1 the day prior on Monday (5/13). CNA K stated there were no concerns. CNA K stated Resident #1 walked throughout the facility independently and went outside to smoke. CNA K stated the next morning on 5/14/24, he had not seen Resident #1 up and walking around when he delivered his breakfast tray to his room. CNA K stated when he arrived at Resident #1's room approximately 07:50 AM, Resident #1 was not in his room. CNA K stated he told CNA L that Resident #1 was not in his room, and CNA L said to leave his breakfast tray because Resident #1 had probably gone outside to smoke. CNA K stated he then told LVN J that Resident #1 was not in his room, and LVN J said he probably had gone outside to smoke too. CNA K stated approximately 9:00 AM, Resident #1 had not come out to smoke, and they started searching for him inside and outside the facility. CNA K stated you were supposed to check on residents every 2 hours, but it had now been changed to every one hour. CNA K stated when you completed the checks, you had to chart in PCC any care provided. CNA K stated if you just laid eyes on a Resident only, you do not have to enter anything in PCC. CNA K stated you must now check residents off on the Rounding List, but only after physically laying eyes on them. CNA K stated he had never known for a resident to go missing. CNA K stated previously residents authorized to enter and exit with the door code, had the freedom to go as they pleased if they signed in and out. CNA K stated the MTD changed the door code, and it would now be changed monthly and only employees are allowed the code. CNA K stated whenever an employee enters or exits the facility, they must make sure the door was closed to prevent any resident from following them out. Interview on 05/23/24 at 03:05 PM, the ADON stated Resident #1 was quiet and kept to himself. The ADON stated Resident #1 was usually alert and oriented. The ADON stated on the morning of 05/14/24, LVN J stated Resident #1 was not in his room or the common areas. The ADON stated the Management drove throughout the community searching for Resident #1. The ADON stated the ADM called DPD and Resident #1 was located in jail. The ADON stated Resident #1 had been arrested for obstructing traffic. The ADON stated each Resident must complete a Mini Mental Exam and depending on their score determines if they are allowed to sign themselves in and out, smoke unsupervised, or leave the facility without a family member. The ADON stated she did not know if anything could have been done differently because Resident #1 was not a wanderer, and he caught the facility off guard. The ADON stated any resident that leaves the facility must sign out and inform the nurse. The ADON stated aides and nurses completes rounds every hour. The ADON stated Resident #1 could had been hit by a vehicle, ended up in the hospital, or even killed. Interview with the ADM on 05/23/24 at 03:25 PM, she stated they had completed re-assessments on all residents to ensure the assessments were accurate. The ADM stated all exit-seeking residents had a doctor's order to wear a wander guard. The ADM stated the SW reassessed the residents that are allowed to sign themselves out. The ADM stated the DON completed in-services with staff on 05/14/24 on rounding with each other and not by themselves. The ADM stated now nurses had to print out the Midnight Census Report, give the report to the DON and text the ADM the headcount at midnight. The ADM stated they spoke with all residents approved to sign themselves out and informed them they must notify staff and make sure they sign in and out. The ADM stated they would have another in-service tomorrow on 05/24/24 to discuss the same items. During an observation on 05/24/24 at 10:30 AM, Surveyor observed several Residents across from the entrance sitting in the dining area waiting to play bingo. The residents all denied being provided or knowing the door code to exit the facility. Interview with the SW on 05/24/24 at 11:00 AM, she stated Resident #1 did not have any change of conditions leading up to the elopement. The SW stated she drove throughout the neighborhood and could not locate Resident #1. The SW stated she searched for Resident #1 on the DPD website and confirmed that Resident #1 had been arrested for obstructing a highway passageway. The SW stated Resident #1 was not exit-seeking and did not wear a wander guard. The SW stated on 5/22/24 at 10:21 AM, Resident #1's daughter called her to get an update because she could not get through to the jail. The SW stated she looked Resident #1 up again on the DPD's website and it showed Resident #1 had been released the day prior on 5/21. The SW stated she drove downtown, around the jail and where the homeless people congregate and did not see Resident #1. The SW stated Resident #4 was allowed to sign himself in and out and exit the facility using the door code. The SW stated Resident #1 was not allowed the door code due to his dementia diagnosis. The SW stated Resident #4 did not admit to giving Resident #1 the door code but suggested Resident #1 may have witnessed him entering it, or he may have given it to Resident #1 to enter. Interview with LVN J on 05/24/24 at 01:20 PM, she stated she arrived to work late on 05/14/24. She stated while completing her rounds on 05/14/24 around 08:00 AM, she did not see anyone in Resident #1's room. LVN J stated this was around the time Resident #1 goes to smoke. LVN J stated after she completed her rounds, she went to receive the shift change report from the night nurse, LVN I. LVN J stated she went back to Resident #1's room to give him his medication, but he was not back. LVN J stated she checked the bathroom, and no one was in there. LVN J stated she went ahead and asked Resident #3 (roommate), and he responded, Resident #1 went out last night and he never came back. LVN J stated she asked CNA L if she had seen Resident #1 and she responded she had not seen him. LVN J stated she went to check his usual places, his friends' rooms and the smoking area and he was not there. LVN J stated she checked if Resident #1 signed himself out, but his name was not in the binder. LVN J stated she then requested all the CNAs to check every room, but Resident #1 was not found. LVN J stated she then reported the information to the ADM. LVN J explained the old process for completing rounds was you would go to each room but did not have to sign anything. LVN J stated the new process had changed to hourly checks and if you arrive to a room and if the resident was not there you must look for them immediately. LVN J stated staff must now complete 15-minute door checks and someone would be stationed at the front desk 24-hours day. LVN J stated if someone were at risk for elopement you must complete an elopement assessment and the results would confirm if the resident was at risk. LVN J stated she would then inform the ADM, DON, and the ADON. LVN J explained the process for wander guards are each day on every shift, you must check to see if the wander guard was working. LVN J stated if the wander guard was not working properly, you must report it to the MD, the ADM, and the DON. LVN J stated if the wander guard were working properly, the light would be red, and it makes a continuous sound if a resident gets too close to the door. LVN J stated the alarm would have to be physically turned off at the nursing station. LVN J stated she was trained by the DON to take residents with wander guards to the front door to ensure the equipment was working properly. LVN J stated residents are not allowed to have the door code and staff must open the door for them to enter and exit the facility. LVN J stated she received a new door code, and the door code would now be changed monthly. LVN J stated Resident #1 could have been harmed, hit by a car, or even killed. Interview with CNA L on 05/24/24 at 01:40 PM, she stated when she arrived to work 05/14/24 at 6:00 AM, she completed her rounds noticed Resident #1 was not in his room and his bed was made. CNA L stated when the breakfast trays arrived on the floor at approximately 8:30 AM, CNA K took Resident #1 his breakfast tray, and he was still not in his room. CNA L stated LVN J asked her if Resident #1 were in his room when she completed her rounds and she stated, No. CNA L stated her, and CNA K searched the inside and outside of the facility and could not located Resident #1. CNA L stated the process for completing rounds did not have a checklist at the time. CNA L stated you would inform the nurse if there were any concerns. CNA L stated now there was a checklist. CNA L stated if a resident was not in their room, they must search all rooms and they cannot wait and assume the resident was smoking. CNA L stated now CNAs complete rounds every odd hour and Nurses complete rounds every even numbered hour. CNA L stated since the elopement, if any resident signs themselves out to smoke and if the resident was not back within 15 minutes, staff must check on them. CNA L stated she had two residents on her hall that wears a wander guard, and she must check the wander guard by observing the light taking and take the resident to the door to sound the alarm. CNA L stated she must then sign the wander guard binder at the front desk. CNA L stated there was a sign-out binder for residents to sign out and staff must escort the resident to the door. CNA L stated staff was not allowed to share the door code with anyone. CNA L stated she was unsure how the residents previously received access to the door code. CNA L stated prior to this incident, Resident #1 had never tried to elope. Surveyor attempted to interview CNA M on 05/24/24 at 02:00 PM. Surveyor left a voicemail and sent a text requesting a callback. Record Review of a Witness Statement dated 05/15/24 by CNA M revealed, I clocked in and walked my halls at 10:00 PM. Resident #1 was in his room. At approximately 11:00 PM, Resident #1 received ice. At midnight, Resident #1 was in his room. At 2:00 AM, another round was completed, and Resident #1 was in his room. During my last round at 4:00 AM, I assumed Resident #1 was asleep and did not disturb him nor his roommate. Surveyor attempted to interview LVN I on 05/24/24 at 02:15 PM. Surveyor left a voicemail and sent a text requesting a callback. Record Review of a Witness Statement dated 05/15/24 sent in by LVN I revealed, I went to Resident #1's room early morning on 05/14/24 to administer medications to his roommate, Resident #3. I noticed Resident #1's bed was unmade, and Resident #3 was sitting in his wheelchair asleep in front of the television. There was light on in the restroom, the water was running, and the restroom door was closed all the way. I allowed Resident #1 to have privacy in the restroom. I left the main door unlocked per the roommate's request then moved on to the next room to continue passing medications. 2. Review of Resident #2's admission MDS assessment dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was moderately impaired, and he had hallucinations. He did not have wandering behaviors. His diagnoses included heart failure, diabetes, and Non-Alzheimer's Dementia, hemiplegia, and multiple sclerosis. Review of Resident #2's Order Summary Report for May 2024 reflected: 04/24/24 Resident is wearing a wander guard device to the left ankle every shift for elopement. 04/24/24 To ensure that wander guard is functioning correctly, every shift take resident to front door to ensure that alarm sounds. If alarm does not sound, please alert Administrator as soon as possible every shift for elopement. Review of Resident #2's Care Plans reflected: 05/24/24 Resident is an elopement risk/wanderer related to dementia. Resident has a wander guard on his left ankle. Facility interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering. Provide structured activities. Wander alert on left ankle. Monitor function and skin integrity every shift. Review of Resident #2's Elopement Assessment, dated 05/22/24 revealed the resident was ambulatory, had a history of wandering, and diagnosis of dementia/cognitive impairment. The assessment reflected the resident was at a high risk for wandering with a score of 13.0. Review of Resident #2's Progress Notes reflected: 05/21/24 5:46 PM Resident noted packing his clothing and stating, I'm leaving I'm going home. Writer attempted to redirect resident. Unable to redirect resident. Writer called family; resident calmed down after speaking with family. - LVN A 05/22/24 2:30 PM Type: Behavior Note Resident insisted on leaving out the front door, despite receptionist attempts to redirect. Writer went outside and eventually was able to redirect resident to come back inside. Resident stated he wanted to go home. Called the wife and she said she was on the way. Resident appearing less agitated. - DON 05/22/24 5:09 PM SW spoke with resident about wanting to leave today. Resident was very agitated, upset, angry, and verbally making threats towards people. Resident verbalized that he was upset over his cigarettes and not seeing his family. SW took resident outside to smoke and talk. Resident became very agitated again and began to pace and not listen to redirection. Resident would partially deescalate and then allow himself to amp up once again. Resident Mrs. [NAME] is aware of his behaviors and actions. SW sent referral to two facilities. - SW 05/22/24 10:34 PM At approximately 7:27 PM alarm to the front door was sounding. Staff answered the alarm to discover resident was outside trying to leave the facility. Resident was stopped by staff and redirected back inside of facility. Resident placed on every 15-minute checks. - LVN A 05/23/24 9:15 AM Resident continues this morning to attempt leaving. Redirecting this behavior is getting more difficult. - DON 05/23/24 11:09 AM Late Entry Resident being sent to hospital for evaluation. Arranging transportation. - DON 05/23/24 12:12 PM Resident noted with his belongings packed at the front door mentioning that he was leaving and didn't want to stay in this F** place no more, called the wife who is also the POA to talk to his and encourage him to wait for the social worker to get him another home, resident got very agitated and angry, threatening to leave any way notified the NP who gave an order to send resident to hospital, notified the wife transport arrived to pick up resident he refused to leave without all his belongings, cigarettes, bible, urinal he carried everything with him into the van, wife on the phone trying to convince him not to go with belongings resident was very adamant. Resident transported to hospital, Dr notified and DON aware. - ADON 05/23/24 3:06 PM Resident returned from hospital at approximately 1:27 PM with no paperwork. Resident was alert, responsive, calm, and cooperative at that time. Resident ambulating with walker ab lib in hallways. Displays no distress. Denies any pain/discomfort. - LVN A 05/23/24 10:24 PM The resident had a psych consult today with NP. New orders received to discontinue risperidone (used to treat schizophrenia) 2 and 3 mg and start risperidone 5 mg at bedtime, Depakote DR (anti-seizure medication and treats bipolar disorder) 250mg twice daily, change venlafaxine (anti-depressant) to every morning and a Valproic acid level and CBC 7 days after starting Depakote. - LVN A 05/25/24 3:01 PM Late Entry Resident forced himself out through the front door. Writer and another nurse ADON followed him and tried to redirect him, but resident did not want to listen or take directions. Resident was agitated and aggressive stating that he was going home. The ADON called resident's wife via video. Wife talked with the resident and asked him to come back into building. Wife told him that she will come to visit him today. Resident then came into the building. Resident redirected to his room. - LVN B 05/26/24 2:02 PM Resident followed another resident through the front door and forced himself outside. Writer tried to redirect resident and bring him back to the building, but resident refused and aggressively pushed the doors and got out. Writer then walked with the resident. Resident stated that he was going home, and he wanted to go buy cigarettes. Writer told resident that he had some cigarettes in the box. Resident then stated that he needed to sit down for few minutes. Writer stayed with resident outside for about 20 minutes. Resident then decided to come back into the building. Resident walked to his room and laid down on his bed. - LVN B 05/26/24 5:20 PM Writer asked the other staff member if they had seen the resident. CNA on duty stated that they were outside the smoke area with other residents, and he came back with other residents after the smoke break. Resident's walker noted at the dining hall, but resident is not there. Immediately all staff members alerted and started looking for the resident. All rooms searched but resident was not found. Administrator notified. Staff members went outside and searched around the building as some drove within the streets around, but resident was not found. Police notified and wife also called and notified. Staff members extended to search for the resident within the neighborhood, but resident was not found. Police arrived and were given description of the resident and gave the claim number. Police stated that if we find him before they do, we call them. - LVN B Review of Resident #2's Ambulance Record, dated 05/26/24, reflected: Dispatch notified: 7:31 PM On scene: 7:36 PM Resident transferred: 8:10 PM Patient was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. EMS arrived and transfer station staff were pouring water on him in an attempt to cool him off. EMS transported patient to the hospital. Review of Resident #2's Hospital Records, dated 05/26/24 8:30 PM, reflected: Chief Complaint: slurred speech, extremity weakness, fall, unable to respond to questioning. Temperature 98.9 degrees Fahrenheit. Final Diagnosis: Stroke Review of website: timeanddate.com on 05/29/24 reflected the following temperatures: [NAME] TX temperature: 5/26/24 4:53 PM 97 degrees 5/26/24 6:53 PM 97 degrees Dallas TX temperature: 5/26/24 4:53 PM 97 degrees 5/26/24 6:53 PM 98 degrees Observation of Resident #2 on 05/25/25 at 1:20 PM revealed the resident was wearing a wander-guard transmitter on the left lower extremity and the presence of the LED light indicated it was functional. Observation of Resident #2 on 05/25/24 at 03:15 pm revealed the DM sitting one-on-one with Resident #2 in the facility's lobby with his wander-guard transmitter still visible on the left lower extremity and the presence of the LED light indicated it was functional. An interview on 05/25/24 at 01:00 PM with the MTD he stated he adjusted the front door to make the door close faster and changed the door code. The MTD stated the front door was monitored by the wander-guard system. The MTD stated normally, [Company] instructed him over the phone how to change the door code, but this time, he had [Company] come to the facility and [Company] installed a button under the receptionist's desk in order to open the door remotely and provided him a manual on how to change the door code himself. The MTD stated there had not been any concerns and everything was working properly. The MTD stated he monitored the doors as needed to ensure they are closing properly. The MTD stated he completed door checks three times a day and completed Tail Logs for documentation purposes. The MTD stated he had never been aware of any residents being in possession of the door code. On 05/25/24 at 01:20 PM, Surveyor observed the five residents identified for placement of a Wander Guard. Surveyor observed the five residents in their rooms with their Wander Guard placed according to their individual Care Plans and Orders. Surveyor also conducted testing with the ADON at the front door to ensure the Wander Guards were functioning properly. An interview on 05/25/24 at 02:15 PM, with the DM, he stated he drove around looking for Resident #1 when he was reported missing. The DM stated he was in-serviced on not giving the door code out or allowing residents to follow anyone outside. The DM stated the door codes were changed and a remote access button was installed under the receptionist's desk. An interview on 05/25/24 at 02:30 PM, with HR, she stated she was in-serviced on making sure all residents know they must be buzzed in and out. HR stated no residents nor visitors should have access to the door code. HR stated the approved residents must sign in and out of the facility and let staff know they are leaving. HR stated the MTD changed the door codes last on Thursday, 05/23/24. HR stated when she ends her shift at 5:00 PM and over the weekend, various staff members would cover the front door. An interview on 05/25/24 at 02:45 PM, HK O stated she was in-serviced on being more concerned when entering and exiting the front door. HK O stated she was informed the door code would be changed once a month. HK O stated she was informed to keep an eye on the residents that wear a Wander Guard. Interviews were conducted with facility staff across multiple shifts on 05/23/24, 05/24/24, and 05/25/24. Staff interviewed were LVN H, LVN J, CNA L, CNA K, CNA F, CNA G, CNA C, HK O, LVN B, LVN J and MA A. Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on obtaining orders when a resident was assessed and determined to require a wander guard to ensure the wander guard monitoring populated into the TARS. They stated they had been in-serviced on checking to ensure the wander guard was functional every shift by observing that the light was visible and taking residents to the front door to ensure the alarm sounded. Staff verbalized the wander guard could only be monitored and checked at the front door and they stated if they saw a resident with a wander guard, they would en[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent elopements for three (Residents #1 #2 and #3) of six residents reviewed for elopements. 1. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility unsupervised. Resident #1 had severe cognitive impairment, wandering behavior, and lacked safety awareness. Resident #1 eloped from the facility on 04/03/23 and was found by facility staff two blocks away. 2. The facility failed to routinely monitor wander-guard transmitters to ensure they were functional for Residents #1, #2 and #3. 3. The facility failed to ensure staff were trained and able to demonstrate competency in monitoring and checking wander-guard transmitters. An Immediate Jeopardy was identified on 04/19/23 at 3:50 p.m. While the Immediate Jeopardy was removed on 04/20/23, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for injury and/or death from elopement-related harm, including vehicular accidents, falls, missing medications, and extreme weather exposure. Findings included: 1. Review of Resident #1's admission MDS assessment, dated 03/21/23, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included dementia, muscle weakness, lack of coordination and cardiac pacemaker. The MDS reflected he had a BIMS (Brief Interview for Mental Status- is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 5 indicating severe cognitive impairment, symptoms of delirium to include continuous inattention that did not fluctuate and disorganized thinking. He had an unsteady gait, and impaired vision. Resident #1's undated admission Record reflected a discharge date of 04/06/23. Review of Resident #1's care plan revised on 03/15/23 revealed the resident's risk for elopement, wandering and impaired safety awareness was addressed. Interventions included an alert that the resident had a wander-guard to the right ankle, offering pleasant diversions, structured activities, and food. The care plan did not address testing, checking, or monitoring the wander-guard transmitter to ensure it was functional. Review of Resident #1's Elopement Risk Assessment, dated 03/14/23, revealed the resident was ambulatory, had a history of wandering, and diagnosis of dementia/cognitive impairment. The assessment reflected the resident was at a high risk for wandering. Review of Resident #1's progress notes dated 03/31/23 revealed the resident was alert and confused. The notes reflected Continued exit seeking noted wandering, easily redirected to join in on activities and other things. Review of Resident #1's MARS/TARS (Medication Administration Records/Treatment Administration Records) dated 03/2023 revealed no evidence of wander-guard monitoring/checks since his admission [DATE] and his elopement on 04/03/23. Review of Resident #1's physician orders dated from 03/2023 to 04/2023 revealed no orders related to the wander guard to include monitoring the wander guard to ensure it was functional. Review of the Provider Investigation Report dated 04/05/23 revealed Resident #1 was observed at a service station two blocks from the facility by CNA C who recognized the resident by his gait. CNA C took the resident back to the facility at approximately midnight where he was assessed by LVN B without injuries and placed on every 15-minute checks. The investigation report reflected Resident #1 was last seen by the evening nurse, LVN D at 11:21 p.m. sitting in the dining room. The investigation report further reflected the resident's wander-guard was in place and working properly. Review of in-service training dated 04/04/23, after Resident #1's elopement, revealed training related to the procedure to follow when a resident was missing. The in-service did not address elopement prevention, ensuring wander-guard transmitters were routinely tested/checked to ensure they were functioning properly or training to ensure staff were able to demonstrate competency in monitoring and checking wander-guard transmitters. Interview with the Administrator on 04/18/23 at 9:53 a.m. she stated Resident #1 wore a wander-guard transmitter but when the resident eloped from the facility on 04/03/23 no staff reported hearing the alarm. The Administrator stated the wander-guard system that monitored the front door of the facility was tested weekly to ensure it was functional and individual wander-guard transmitters worn by residents were routinely tested, but she was not sure how often or where the testing was documented. Interview with maintenance on 04/18/23 at 10:25 a.m. he stated there were magnetic (Mag) locks on all exit doors to include the front door that was also monitored by a wander-guard system. He stated all exit doors except the front door could be opened after pushing on the door bar for 15 seconds causing an alarm to sound that had to be silenced by staff. The front door required a code to enter and exit and the wander-guard system would cause an alarm to sound when a resident wearing a transmitter was close to the door and staff would have to silence the alarm. He stated he checked all exit door alarms weekly to include the wander-guard system on the front door and there had been no problems with the alarms functioning. He further stated he was not aware of Resident #1's elopement. Interview with ADON on 04/18/23 at 2:05 p.m. she stated she checked the function of Resident #1's wander-guard transmitter on 04/04/23 the day after the resident eloped. She stated it was the same transmitter he had always worn, and when she took the resident to the front door, the alarm sounded, and the red indicator light was blinking on the transmitter indicating it was functional. Interview with LVN A on 04/18/23 at 3:59 p.m. she stated she worked on an as needed basis and she checked resident's wander-guard transmitters every shift by taking them to either the front door or the exit door at the end of Hall 100. She stated she did not recall receiving any training or instruction on the wander-guard system and did not know all of the residents who wore a wander-guard to include the residents she was assigned to. She stated she would have to check the TARS to determine who the residents were that had physician orders in reference to checking the wander-guard transmitter. Interview with the ADON on 04/18/23 at 4:20 p.m. she stated an order for wander-guard checks had to be put into the resident's EHR (Electronic Health Record) for the checks to populate onto the TAR so that nursing staff would be aware to perform and document the checks. She stated putting the order in must have been missed for Resident #1. The ADON confirmed the wander-guard system could only be monitored and/or checked at the front door of the facility. Interview with LVN B on 04/18/23 at 4:32 p.m. she stated she was the night nurse on duty on 04/03/23 when she saw CNA C bring Resident #1 back into the facility. LVN B stated she had been making rounds and was not aware Resident #1 was out of the facility. LVN B stated Resident #1 was wearing a wander-guard transmitter when he returned, but she did not know if it was working because she did not check it but placed the resident on every 15-minute checks. LVN B stated she was aware Resident #1 wore a wander-guard transmitter but had never checked it at the front door as residents were usually in bed during her shift. She usually checked the light on the resident's transmitters to ensure they were functioning. Resident #1's transmitter appeared dead when she checked it on the night he eloped as there was no visible light. LVN B further stated she notified the Administrator that there was no light on the resident's transmitter and was told arrangements would be made to get the resident another one. LVN B was unable to recall if she had received training on the wander-guard system and stated she might not have fully understood during orientation. She stated she never documented any checks of Resident #1's wander-guard transmitter and never noticed there were no orders on the TAR to check the transmitter. She stated, We just missed that part. Interview on 04/18/23 at 4:46 p.m. with LVN D he stated he was the evening nurse on 04/03/23 the day Resident #1 eloped. He stated when he clocked out sometime after 11:00 p.m. he saw Resident #1 ambulating in the hallway. He stated Resident #1 did not use a wander-guard and therefore he had performed no wander-guard checks for the resident. LVN D stated he checked residents with wander-guard transmitters by pressing the button on the transmitter to ensure the light flashed green to ensure it was functioning. Interview on 04/18/23at 6:19 p.m. CNA C stated on the morning of 04/04/23 at approximately 12:00 midnight or 12:30 a.m. she just happened to be at a service station located two blocks from the facility when she recognized Resident #1 walking by. She stated she asked the resident where he was going, and he told her he didn't know. CNA C stated she recalled the resident was wearing a wander-guard transmitter on his ankle and when she put the code in the front door of the facility and entered with the resident the alarm sounded. She further stated she did not check for or recall seeing a light on the wander-guard transmitter. Interview with the Administrator on 04/19/23 at 9:41 a.m. she stated she was not aware Resident #1's wander-guard was not being monitored/checked to ensure it was functional. She stated the ADON was responsible for monitoring physician orders, MARS, and TARS to ensure nothing was missed and there was no missing documentation. She confirmed the wander-guard system monitored the front door only. Interview with Staff E on 04/19/23 at 10:15 a.m. she stated she was the central supply staff and was responsible for activating the Accutech wander-guard Tags/transmitters before they were placed on residents. She stated after activated the transmitter had a constant red light indicating it was functional. Prior to 04/18/23 she had not been provided any training or instruction related to checking or testing the transmitter after it was placed on a resident. Staff E stated she would provide the user manual for the Accutech Tag/transmitter. Review of the undated user manual for the Accutech Tag/transmitter section 1-1 revealed the function of the system was to alert facility staff of the possible egress of a monitored resident. The system could be utilized for special care residents suffering from wandering with tendencies of leaving the facility. Section 2-4 of the manual reflected the Tag/transmitter operated by an internal battery and over the course of normal operation would lose battery power and would need to be replaced as the battery was not replaceable. Recommendations were that the Tag/transmitter be tested on a weekly basis. Interview with ADON on 04/19/23 at 1:44 p.m. she stated when there was no DON, she was responsible for checking MARS/TARS and physician orders. She stated, I can only do what I can being one person, sometimes things get missed. She stated the best practice was for nurses to make rounds to ensure all residents were accounted for. Observation on 04/19/23 at 2:00 p.m. with the Administrator to test the sound level of the wander-guard system on the front door. The alarm sounded loudly near the front door but further away from the front door the sound of the alarm decreased and was barely audible at the nurse's station. Interviews on 04/19/23 at 2:12 p.m. with three nursing staff (CNA C, LVN F and LVN G) who were sitting at the nurse's station when the alarm was tested on [DATE] at 2:00 p.m. They all stated they were able to hear the alarm if they listened intently and it would be helpful if the alarm was louder. Interview on 04/20/23 at 11:10 a.m. LVN F stated she was aware Resident #1 wore a wander-guard transmitter, but she had never checked it to ensure it was functioning. She stated there were no orders for checking the wander-guard on the resident's TAR. She stated she was not aware that all residents who wore a wander-guard had to be checked at the front door or that they needed an order. She further states she had received no training prior to training received on 04/18/23. 2. Review of Resident #2's admission MDS assessment dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease. The MDS assessment reflected she had a BIMS of 4 indicating severe cognitive impairment, an unsteady gait, and symptoms of delirium, to include continuous inattention that did not fluctuate. Review of Resident #2's care plan revised on 02/20/23 revealed the resident's risk for elopement, wandering behavior and that the resident wore a wander-guard was addressed. Interventions included offering pleasant diversions, structured activities, and food. The care plan did not address testing, checking, or monitoring the wander-guard transmitter to ensure it was functional until the revision dated 04/19/23 which reflected, Nurse will monitor wander guard to make sure its functioning properly every shift. Review of Resident #2's Elopement Assessment, dated 02/15/23 revealed the resident was ambulatory, had a history of wandering, and diagnosis of dementia/cognitive impairment. The assessment reflected the resident was at a high risk for wandering. Observation of Resident #2 on 04/18/23 at 4:15 p.m. revealed the resident was wearing a wander-guard transmitter on the left lower extremity and the presence of the LED light indicated it was functional. Review of a list provided by the Administrator on 04/20/23 revealed Resident #2's wander-guard transmitter was placed on 01/17/23. Review of MARS/TARS dated from 01/2023 to 04/2023 reflected there was no evidence of monitoring or checking the wander-guard transmitter to ensure it was functional prior to 04/18/23. Review of Resident #2's physician order dated 04/18/23 revealed, Monitor wander-guard to left lower extremity. Review of the resident's clinical records revealed no orders or monitoring the function of the wander-guard prior to 04/18/23. 3. Review of Resident #3's quarterly MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included vascular dementia. The MDS assessment reflected he had a BIMS of 6 indicating severe cognitive impairment, he used a wheelchair for mobility and required extensive assistance of one person for dressing and personal hygiene. Review of Resident #3's care plan revised on 04/19/23 revealed Check wander guard on leg. Check for any pressure problems and assure he has it on lower leg/ankle. Review of Resident #3's Elopement Assessment, dated 03/30/23 revealed the resident was ambulatory, had no history of wandering, and diagnosis of dementia/cognitive impairment. The assessment reflected the resident was at risk for wandering. Observation on 04/18/23 at 4:18 p.m. revealed Resident #3 was wearing a wander-guard transmitter on the right lower extremity and the presence of the LED light indicated it was functional. Review of a list provided by the Administrator on 04/20/23 revealed Resident #3's wander-guard transmitter was placed on 12/28/22. Review of MARS/TARS dated from 12/2022 to 04/2023 revealed there was no evidence of any monitoring or checking of the wander-guard transmitter to ensure it was functional prior to 04/18/23. Review of Resident #3's physician order dated 04/18/23 revealed Monitor wander-guard to the right lower leg for functioning. Review of the resident's clinical records revealed no orders or monitoring the function of the wander-guard prior to 04/18/23. Observations on 04/18/23 from 4:03 p.m. to 4:18 p.m. with the ADON and LVN A revealed five residents were wearing wander-guard transmitters and the presence of LED lights for four of the residents indicated they were functional. One resident became aggressive and declined to allow a full observation or test of his wander guard transmitter. Review of a list of residents with wander-guard transmitters provided by the Administrator on 04/18/23 revealed Resident #2 and Resident #3 were not listed as having wander-guard transmitters. Interview with Administrator on 04/20/23 at 9:56 a.m. she confirmed there were no orders to monitor Resident #2's and Resident #3's wander-guard transmitters prior to 04/18/23. She stated she was not sure if the monitoring was listed on the TARS or if staff had been monitoring the transmitters to ensure they were functional. Interview on 04/20/23 at 11:55 a.m. the Administrator stated when nurses placed wander-guard transmitters on residents they should have an order in the EHR so that the monitoring would populate on the TAR. She stated she did not know the wander-guards for Residents #2 and #3 were not being monitored to ensure they were functional. Interview on 04/20/23 at 11:10 a.m. LVN F stated she was aware of Residents #2 and #3 having wander-guard transmitters, but she had never checked them to ensure they were functioning. She stated there were no orders and checking them was not listed on the TARS. She stated she was not aware that all residents who wore a wander-guard had to be checked at the front door or that they needed an order. She further stated she had received no training prior to the training received on 04/18/23. Interview on 04/22/23 at 1:15 p.m. the Administrator stated her expectations were for nursing staff caring for residents with wander guards to ensure the wander guard was checked every shift to ensure it was operational and the resident was safe. She stated if wander guards were not checked to ensure they were functional a resident could get out of the facility and be harmed while outside. She stated it was important for staff to be trained on the wander guard system and know what residents used a wander guard so they could watch out for residents who could elope. Review of the facility's P/P entitled Wandering, Unsafe Resident revised August 2014 revealed in part: 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. Review of the facility's P/P entitled Elopements revised December 2007 revealed the procedure for searching for and reporting a missing resident was included. Page three of the P/P addressed staff training for residents exhibiting wandering behavior to include education on the various alarm systems utilized for wandering residents. The P/P reflected Our facility uses the Accutech Alarm Tags which are activated by our Nursing Department. The flashing led red light shows the wandering tag is active. Confirmation of the active unit can be determined by presenting the tag within a few feet of the installed Mag Lock system which is located at the front door (only) as well as mini security alarms that will sound upon opening. They can only be de-activated by entering the proper code in the keypad 11* and resetting the mini security alarm. An Immediate Jeopardy was identified on 04/19/23 at 3:50 p.m. and the Administrator was informed of IJ in the area of accidents/supervision and the IJ template was provided via email at 3:59 p.m. The Plan of Removal was accepted on 04/20/23 at 1:26 p.m. and reflected: Plan of Removal [Facility Name] 04- 19-2023 The Facility failed to provide evidence of any wander-guard checks to ensure the wander guard bracelet or system was functional and in good working order for the Identified Resident #l 's admission date of (3/14/2023), which resulted in an elopement. Identified Resident #2 and Resident #3 did not elope but were wearing wander-guards and were not included on the Facility wander guard. Removal Plan: l) Identified resident no longer resides in the facility. 2) Residents listed (see attached) are at risk for elopement and have the potential to be effected (sic) by the alleged deficient practice. On 04/19/2023 none of the 5 residents are currently exit seeking. The ADON verified wander guard orders to include: placement and functionality 04-19-2023 on the TAR. Care Plans have been completed on residents being at risk for elopement by 04-19-2023. 3) Administrator will re-educated facility staff starting 04-18-2023 and completing by 04-19-2023: Licensed nurses will verify and document that wander guards are properly placed on resident's arms or legs and properly functioning, each shift by taking the resident, who is wearing the wander guard unit, to the front door to hear the alarm sound. Licensed nurses will be re-educated on if a resident develops new onset of exit seeking behaviors, an elopement assessment will be initiated and Care Plans will be updated to reflect the new behavior. If a resident is deemed appropriate for wander guard but refuses to wear the wander guard, DON will be notified, and this resident will be placed on one-to-one monitoring pending possible discharge. Facility Staff will complete a post test on the above education to validate the understanding of the facility procedure. The employee roster will be used to validate compliance for every staff member trained. The Maintenance Director will check every door in the facility and make sure they are operational and alarms are sounding appropriately by 04/19/23. Total Fire and Safety will be on site 04/20/23 to ensure speaker volume of the alarm that sounds when the wander guard system is amplified. Prior to the Administrator training the ADON, the VP (Vice President) of Operations will conduct a train the trainer education with the Administrator and she will then, in turn, conduct a train the trainer in-service with the ADON on how to accurately use the Accutech wander guard device to ensure the wander guards are working properly by 04/19/23. Once the ADON performs a correct return demonstration, she will train all licensed nurses on the proper procedure for Accutech to ensure the doors and alarms are operational. This training will begin on 04/19/23 and will continue with each nurse prior to their next scheduled shift. 4) The Administrator and ADON will observe a minimum of 3 nurses each week for 1 month to conduct return demonstration to validate the understanding and proper checking of placement and functionality of the wander guard. The Medical Director was notified on 04/19/23 of the Immediate Jeopardy. The VP of Operations will monitor the tasks of the Administrator and ADON, once weekly, for a minimum of 1 month. Plan of removal monitorng: Review of in-service training logs and competency tests dated 04/18/23 and 04/19/23 revealed education included checking wander guards, completing assessments to determine the resident's risk for wandering and determining if a wander guard unit was needed. Obtaining and placing an order into the EHR for the use and monitoring of the wander guard unit. Documenting in the MAR/TAR to confirm the wander guard unit was being checked every shift. Ensuring the red light was flashing on the wander guard unit and performing a double check to confirm the wander guard unit was active by taking the resident to the front door. Observing residents on the wander guard list and responding immediately to any alarms. Interviews were conducted with facility staff across multiple shifts on 04/20/23 from 2:48 p.m. to 4:10 p.m. and on 04/22/23 from 11:40 a.m. to 12:06 p.m. Staff interviewed were LVN D, LVN F, LVN G, LVN H, LVN I, CNA J, CNA K, CNA L, CNA M, Housekeepers N, Housekeeper O, Dietary Aide P and [NAME] Q. Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on obtaining orders when a resident was assessed and determined to require a wander guard to ensure the wander guard monitoring populated to the TARS. Checking to ensure the wander guard was functional every shift buy observing that the light was visible and taking residents to the front door to ensure the alarm sounded. Staff verbalized the wander guard could only be monitored/checked at the front door and they stated if they saw a resident with a wander guard, they would ensure there were orders and monitoring in the clinical record. All were aware to notify the ADON or Administrator for any concerns with the wander guard system. The Administrator was notified on 02/17/22 at 4:15 p.m. that the Immediate Jeopardy was removed. However, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.