**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the comprehensive care plan described the services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for four (Residents #1, #2, #3, and #5) of nine residents reviewed for Comprehensive Care Plans.Based on interview and record review, the facility failed to ensure the comprehensive care plan described the services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Residents #1. #2. #3 and #5) of nine residents reviewed for Comprehensive Care Plans.1.A. The facility failed to implement and modify interventions to ensure Resident #1 did not experience 7 falls after admitting to the facility on [DATE], and as a result of the last fall on 06/22/2025, sustain a head injury which resulted in the resident's death in the hospital on [DATE]. B. The facility failed to implement and modify interventions to ensure Resident #2 did not experience 5 falls after admitting to the facility on [DATE] with a right hip fracture resulting from a fall at home. C. The facility failed to implement and modify interventions to ensure Resident #3 did not experience 5 falls after admitting to the facility on [DATE]. The facility failed to create , implement and revise care plans to meet the medical , nursing, mental and psychosocial needs identified in the comprehensive assessment related to falls with appropriate and effective interventions . These failures placed residents at risk of serious injury and death. 2.The facility failed to devise and implement any Comprehensive Care Plan goals and/or interventions for Resident #5's documented wandering, exit seeking, and/or elopement behavior on 07/08/2025 to prevent an incident of elopement by Resident #1 on 07/12/2025. The care plan showed no elopement intervention until 07/13/2025. The first non-compliance was identified, and an Immediate Jeopardy (IJ) situation was identified on 07/02/2025. The IJ was removed on 07/16/2025. The facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The second non-compliance was identified, and an Immediate Jeopardy (IJ) Template was presented to facility Administrator and DON on 07/15/2025 at 5:37 PM. The IJ was removed on 07/16/2025. The facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. Findings Included: 1.1. Record review of Resident #1's Face Sheet, dated 06/26/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had diagnoses which included Parkinson's disease (movement disorder of the nervous system that worsens over time), unspecified abnormalities of gait (walking pattern) and mobility, and a history of falls. Record review of Resident #1's admission MDS (tool used to assess health status) Assessment, dated 04/19/2025, reflected moderately impaired cognition with a BIMS (screening tool to assess cognitive status) score of 10. Section J (Health Conditions) reflected Resident #1 had 2 or more falls since admission with no injury. Record review of Resident #1's Comprehensive Care Plan, dated 04/28/2025, reflected the focus resident at risk for falls was initiated on 05/25/2025. Interventions included staff x 1 to assist resident with transfers, ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed, and ensure the resident was wearing appropriate footwear when ambulating or mobilizing in his wheelchair. The care plan did not reflect each fall or a new intervention after each fall. Record review of Resident #1's Fall Risk Assessments, dated 06/12/2025, 06/20/2025, and 06/22/2025, reflected Resident #1 was in the high-risk category for falls. Record review of the facility's incident reports reflected Resident #1 fell on [DATE], 04/11/2025, 04/15/2025, 04/20/2025, 05/25/2025, 06/10/2025, 6/20/2025 which did not result in a serious injury. Resident #1 was sent to the hospital after he fell on [DATE]. Record review of Resident #1's progress notes, dated 06/13/2025, reflected RN C documented This client is somewhat confused. He does not abide by the nurses' instructions about his safety and constantly gets out of the recliner and makes movements that could severely hurt him. He slid out of the recliner at 2145. Once we put him in bed, 30 minutes later, we found him by the door in his chair, naked.We need a baby monitor so that the nurse can see him from the nurse's station. Record review of Resident #1's progress notes, dated 06/20/2025, reflected RN X documented This nurse was called by an Aide that resident was on the floor. Resident was lying next to his recliner and bed. Resident said he was trying to use the bathroom. Resident was lifted off the floor with a Hoyer lift. Resident sustained a skin tear on his right elbow. Site was cleaned and covered with border dressing. Resident assessed and his vital signs were normal. DON, family, and NP were notified. Record review of Resident #1's progress notes, dated 06/22/2025, reflected RN C documented nurse was called to resident room and observed resident on the floor next to the bed, resident is alert and able to response to verbal commands, disorientation also noted, head to toe assessment done at this time, laceration of about 1 cm x 0.5 cm noted right side of the head, extensive bruising from his right shoulder to right lower back, vital signs recorded at this time within normal range, scant amount of blood noted to laceration site, emergency services called, emergency personnels arrive and assessed patient, resident was transported to hospital for further evaluation. Record review of Resident #1's progress notes, dated 06/22/2025, reflected RN C also documented patient fell at 00:51 am, unwitnessed, sustained penetrating injury to his head in the right temporal area. Had an extensive bruise from left shoulder blade diagonally to right waist area. The patient needs close monitoring because he isn't aware of usage of call light. The client is confused, needs one on one or baby monitoring to prevent further falls. Record review of the incident report completed by RN C, dated 06/22/2025, reflected Resident #1 had an unwitnessed fall and was discovered on the floor next to his bed. The incident report reflected Resident #1 stated he tried to get up and fell out of bed. Record review of Resident #1's hospital records, dated 06/23/2025, reflected Resident #1 was admitted to the emergency department on 06/22/2025 at 1:38 AM with a large left subdural hematoma (brain bleed) with a mid-line shift to the right (displacement of the brain away from center line). Resident #1 was not a candidate for surgical repair of the bleed and was placed on palliative care until he passed away in the hospital on [DATE] at 3:30 AM. During a telephone interview on 06/26/2025 at 10:42 AM, CNA D stated Resident #1 tried get up by himself all the time. CNA D stated Resident #1 used a walker and would take himself to the restroom without using the call light and waiting for assistance. She stated when she rounded on her residents, just a few minutes before Resident #1 fell, he was asleep. CNA D stated she was at the nurse's station when she heard someone say help me and found Resident #1 on the floor. CNA D stated she called for RN C to assess the resident and told the resident not to move. She stated Resident #1 told her that he hurt and when CNA D asked where, he said he wasn't sure. She stated RN C assessed Resident#1 and the resident had a laceration on the right side of his head and 2 reddish color marks on his back. She stated Resident #1 was taken to the hospital. During an interview with RN C on 06/26/25 12:54 PM, he stated he was the resident's nurse at the time of the fall on 06/22/2025. He stated CNA D notified him Resident #1 fell and he went to the resident's room and assessed him. RN C stated the resident had a laceration on the right side of his head. He stated he notified the physician and received an order to send Resident #1 to the hospital for evaluation. RN C stated Resident #1 was supposed to use his call light before getting up but did not always do that. During an interview on 06/26/25 at 1:35 PM, the Administrator stated staff notified him Resident #1 was sent to the hospital after a fall. The Administrator stated he called CNA D and RN C to get their statements. He stated he talked to all staff who cared for Resident #1 starting 24 hours before the fall to see if anyone had seen anything out of the normal for Resident #1. He stated staff had not noticed anything different about him. During an interview on 06/26/2025 at 4:18 PM, ADON B stated RN C reported at about midnight he went to Resident #1's room. He stated RN C told him the resident was on the floor next to his bed and had a cut on his head. ADON B stated when RN C asked what happened, Resident #1 stated he thought it was morning and was getting up to get dressed. ADON B stated RN C called 911 because Resident #1 hit his head when he fell, and he was sent to the hospital. ADON B stated Resident #1 had previous falls and therapy had worked with him for balance/gait. He stated the resident used a walker. During an interview on 06/27/25 at 8:55 AM, the Rehab Director stated therapy services were discontinued for Resident #1 on 06/09/2025 and the resident was walker level. She stated the resident fell on the Friday before the incident. She stated Resident #1 needed lots of verbal reminders to walk with someone and not by himself. She stated the resident would use his walker to go to the restroom in his room without calling for assistance. She stated Resident #1 had a walker and wheelchair in his room. She stated the resident had cognition/safety impairment. She stated if Resident #1's knees were bothering him, he would use his wheelchair for longer distances. She stated she had not observed a change in Resident #1's condition prior to his fall. During an interview on 07/02/2025 at 10:26 AM, CNA H stated she worked on different halls and was not working on Resident #1's hall the day he transferred to the hospital. She stated Resident #1 used a walker to go to the bathroom by himself and changed his clothes without assistance. She stated he was not considered a high fall risk. She stated she rounded and checked on Resident #1 and his roommate every two hours. She stated Resident #1 liked to sit in his recliner and watch television. She stated after his wife brought the recliner to the facility; Resident #1 also slept in it. She stated the resident walked to the dining room for breakfast and ate lunch in his room because his wife was visiting with him. She stated the day of the fall she saw Resident #1 in the hall using his walker and another time he was pushing his wheelchair. She stated Resident #1 sat in his wheelchair when he got tired. She stated she did not see any change in mobility or cognition prior to the fall. 2. Record review of Resident #2's Face Sheet, dated 07/02/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had diagnoses which included aftercare following joint replacement surgery, bipolar disorder (extreme mood swings that include emotional highs and lows), COPD (lung condition that makes it difficult to breathe), limitation of activities due to disability, and the need for assistance with personal care. Resident #2 had discharged from the facility. Record review of Resident #2's admission MDS Assessment, dated 05/22/2025, reflected moderately impaired cognition with a BIMS score of 10. Section I (Active Diagnoses) reflected the need for assistance with personal care, limitation of activities due to disability, and unsteadiness on feet. Resident #2 discharged from the facility on 07/02/2025. Record review of Resident #2's Comprehensive Care Plan, dated 04/28/2025, reflected the focus resident at risk for falls was initiated on 05/16/2025. Interventions included staff x 1 to assist resident with transfers, ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed, and ensure the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair. The care plan did not reflect each fall or a new intervention after each fall. Record review of Resident #2's Comprehensive Care Plan, dated 04/28/2025, reflected The resident has an ADL Self Care Performance. Interventions included Bed Mobility: requires staff x1 for assistance. The resident uses a wheelchair. Toilet use: requires staff x1 for assistance. Record review of Resident #2's Fall Risk Assessments, dated 05/24/2025, 06/03/2025, and 06/12/2025, and 06/17/2025 reflected the resident was in the high risk category for falls. Record review of the facility's incident reports reflected Resident #2 had a fall on 05/24/2025, 05/25/2025, 05/27/2025, 6/17/2025, and 06/29/2025. The falls did not result in serious injury. 3. Record review of Resident #3's Face Sheet, dated 07/02/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #3 had diagnoses which included unspecified dementia (decline in mental ability that interferes with daily life) with behavioral disturbances, bipolar disorder, and unsteadiness on feet. Record review of Resident #3's Quarterly MDS Assessment, dated 05/23/2025, reflected severely impaired cognition with a BIMS score of 0. Section C (Cognitive Patterns) reflected the resident demonstrated inattention and disorganized thinking. Section GG (Functional Abilities) reflected Resident #3 required partial/moderate assistance with mobility. Record review of Resident #3's Comprehensive Care Plan, dated 04/28/2025, reflected the focus resident at risk for falls was initiated on 05/05/2025. Interventions included anticipate and meet the resident's needs and ensure the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair. The care plan did not reflect each fall or a new intervention after each fall. Record review of Resident #3's Fall Risk Assessments, dated 05/11/25, 06/24/25, 06/28/25, 06/29/25, and 07/01/25, reflected Resident #3 was in the high-risk category for falls. Record review of the facility's incident reports reflected Resident #3 had a fall on 5/11/2025, 06/08/2025, 06/24/2025, 6/28/2025, 06/29/2025, and 07/01/2025. The falls did not result in serious injury. A follow-up record review of Resident #3's Comprehensive Care Plan reflected additional fall prevention interventions were initiated on 07/01/2025 which included Resident is to wear a soft helmet when out of bed to help prevent fall with major head injury and FREQUENT RESIDENT MONITORING: staff is to ensure that they can visualized residents where about as frequent as possible to help with redirection. An observation on 07/02/2025 at 11:35 AM revealed Resident #3 sitting in the tv room with other residents in the memory care unit. An attempt to interview Resident #3 was unsuccessful because of her cognitive status. Resident #3 was wearing a helmet. During an interview on 07/03/2025 at 11:44 AM, LVN F stated worked in different areas, but was working in the memory care unit today. She stated staff used a lot of redirections with residents in the memory unit. She stated residents wandered and it was important to ensure the space was free of clutter. She stated someone always has to have their eye on the residents. During the interview, LVN F went to assist Resident #3 when she stood up. She stated staff walked with Resident #3 to ensure her safety. During an interview on 07/03/2025 at 11:52 AM, CNA N stated it was important to monitor residents closely especially those who were a high fall risk. She stated Resident #3 liked to get up and walk, but someone had to be with her to be sure she did not fall. She stated Resident #3 was wearing the hat to prevent injury because she had previous falls. Review of the facility's policy Preventive Strategies to Reduce Fall Risk, dated 10/05/2016, reflected The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Review of the facility's policy Falls/Ambulation Difficulty, dated 2003, reflected Risk factors should be assessed upon admission and thereafter as necessary. Risk factors will be identified for all residents. This was determined to be an Immediate Jeopardy (IJ) on 07/02/2025 at 5:21 PM. The Administrator, Director of Nurse, Area Director of Operations and Regional Compliance Nurse were notified. The Director of Nurses, Area Director of Operations, and Regional Compliance Nurse were provided with the IJ template on 07/02/2025 at 5:21 PM and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 07/03/2024 at 1:04 PM. Facility: [Facility Name]Date: 07/02/2025Problem: F689 Accidents and Hazards Plan of Removal Interventions: 1. Resident #1 no longer resides in facility as of 6/22/25. Resident #2 has discharged from the facility and no longer resides in the facility as of 7/2/25. Resident #3 assessed 7/2/25 for fall risk and individual care plan updated to reflect that she is now part of the Falling Stars Program. In addition, new order for a soft-shell helmet to help prevent injury. 2. All residents in the facility were assessed on 7/2/25 for risk of falls or repeat fall residents. Active care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse. 3. We have initiated the NEW Falling Star Program. All residents that have had 5 falls in the last 6 months have Falling Stars Program initiated. This includes notation on the care plan and daily shift acknowledgement that the resident is high risk for falls. Resident #3 is a part of the Falling Star Program Total number of falls in 6 months: 115. 9 residents were identified as high risk for falls due to 5 falls or greater within the last 6 months. 4. The Compliance Nurse in-serviced the Administrator, DON, and ADON 1:1 on the following topics below: This was completed on 7/2/25. All residents whom are identified at high risk of falls will have an active care plan with resident specific interventions with the addition of the falling stars high risk fall program. Upon admission, and as needed, all residents will be assessed for risk of falls. The care plan will reflect findings, interventions based off of each resident's assessment post fall with individualized intervention to prevent serious injury, and monitoring weekly to ensure fall interventions are effective and in place. Upon admission the nurse/designee will be responsible for developing and implementing interventions within the care plan of risk of falls based upon their assessment. Inservice on care plan location and how to access the care plan in PCC (online electronic health record), including how to identify a resident high risk of falls in the Kardex (documentation system used to access and modify resident information). The following in-services were initiated by the DON, ADON, Regional Compliance Nurse : Any staff member not present or in-serviced on 7/2/25, will not be allowed to assume their duties until in-serviced.Licensed Nurses and Therapy Staff:All residents whom are identified at high risk of falls will have an active care plan with resident specific interventions with the addition of the falling stars high risk fall program. Upon admission, and as needed, all residents will be assessed for risk of falls. The care plan will reflect findings, interventions based off of each resident's assessment post fall with individualized intervention to prevent serious injury, and monitoring weekly to ensure fall interventions are effective and in place. Upon admission the nurse/designee will be responsible for developing and implementing interventions within the care plan of risk of falls based upon their assessment. Inservice on care plan location and how to access the care plan in PCC, including how to identify a resident high risk of falls in the Kardex. The following in-services were initiated by the DON, ADON, Regional Compliance Nurse : Any staff member not present or in-serviced on 7/2/25, will not be allowed to assume their duties until in-serviced.Non-Licensed Nursing Staff Inservice on care plan location and how to access the care plan in PCC, including how to identify a resident high risk of falls in the Kardex. All residents whom are at risk of falls will have an active care plan with interventions and monitoring.Monitoring: The DON/ADON/Designee will monitor all incidents and fall risk assessment post fall in daily stand-up meeting for 6 weeks and then PRN to ensure all resident specific interventions are in place with active care plan. The DON/ADON/Designee will monitor admission assessments, daily stand-up meeting for 6 weeks to ensure all resident care plans reflect their risk of falls and resident specific interventions based off current care needs and status. The DON/ADON/Designee will monitor falling star program weekly for 6 weeks and then PRN to ensure resident specific interventions are in place.An ADHOC QAPI was completed on 7/2/25 with medical director and interdisciplinary team to discuss the immediate jeopardy and plan of removal.The medical director was notified of this plan and monitoring on 7/2/25 when IJ was called at 5:21PM.The QAPI committee will review findings and makes changes as needed.*Active care planning addresses all acute needs of the resident**All monitoring will be located in the IJ Binder**All residents are at risk for falls, 9 residents identified at high risk for falls**No active restraints within the facility* Observations on 07/03/2025 at 09:20 AM revealed facility staff had placed a yellow star on the name plates of the doors of Resident #3, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 to indicate they were a high fall risk. In a follow-up interview with the DON on 07/03/2025 at 12:32 PM, she stated the facility implemented the falling stars program on 07/02/2025 so everyone would know which residents were a high fall risk. The DON stated staff placed yellow stars on the name plates on high fall risk residents' doors the evening before. She stated the staff received in-service training on 07/02/2025 related to fall risk and prevention. She stated CNAs were in-serviced to ensure they knew how to access resident care information in Kardex. She stated if a resident fell, the resident's nurse should immediately put an intervention in place and include it in the resident's care plan. She stated staff were to increase monitoring and ensure all care planned interventions, such as a fall mat, bed in the lowest position, non-slip pad for wheelchair seat, or helmet were in place for the falling stars or residents at high risk for falls. The DON stated the facility had at risk meetings every week and evaluated residents' care plans and put appropriate interventions in place. She stated staff also discussed any concerns or changes during the interdisciplinary team meetings. The DON stated it was important to ensure residents were assessed as needed and interventions put in place to provide resident centered care and keep the residents safe. In interviews with direct care facility staff on 07/03/2025, between 10:30 AM and 4:10 PM, the DON, ADON A, ADON B, the Rehab Director, the MDS Coordinator, the Physical Therapist, COTA, Hospitality Aide RN C, CNA D, CNA E, LVN F, CNA G, CNA H, Medication Aide I, LVN J , CNA K, Medication Aide L, RN M, CNA N, CNA O, CNA P, RN Q, CNA R, CNA S, CNA T, CNA U, CNA V stated in-service training was provided 07/03/2025 focused on the importance of keeping residents safe in the facility. Staff were reminded to ensure every transfer was safe for the resident. In-service training included to ensure residents wore socks that prevented slipping or had on appropriate fitting shoes. Staff stated high fall risk residents had a yellow star on their name plate on the door and the information was also included in the Kardex. CNAs stated they were responsible for communicating with the nurse if they were going on break or needed to leave the hall briefly. Nursing staff were in-serviced about assessing residents with each fall, putting a new resident specific intervention in place, and ensuring the care plan was updated. Nurses stated they were responsible for communicating with CNAs and ensuring call lights were answered which included the nurse answering call lights when the CNAs were busy with another resident. Timely completion of Elopement Assessments (all assessments;) When a Significant Change in Status documentation and/or re-assessment is required, and Examples of Decline. In interviews with other staff members on 07/03/2025 between 10:30 AM and 4:10 PM, the Maintenance Director, Social Service, Dietary Staff, Dietary Cook, and Housekeeping stated it was important to observe residents around them to ensure residents were safe in their environment and to report any concerns to nursing staff. Staff stated the facility placed yellow stars on the name plates of doors to identify residents who were at high risk for falls. Record review of residents identified as high risk for falls on 07/03/2025 at 10:45 AM revealed compliance with resident specific care plans and inclusion in the facility's falling star program. Record review on 07/03/2025 of In-service, High Fall Risk: Yellow Star, conducted by RCN, reflected all high-risk residents would have a yellow star next to their name on the door and a yellow star on the Kardex. The In-Service included a list of falling star residents. The In-service roster included signatures of direct care staff. Record review on 07/03/2025 of In-service, Fall Risk, Intervention, Prevention, Monitoring, Care Plan Update, conducted by RCN, reflected on admission, and as needed, all residents would be assessed for risk of falls and the care plan would reflect findings, interventions, and monitoring. The In-service included identifying risk factors, reducing environmental hazards, and prevention of unsafe transfers and ambulation. The In-service included evaluating the residents' footwear, daily routine, medications, and social and psychological needs. It also included assessment of resident's gait by physical therapy and/or a nurse. This In-service was provided to all facility staff. The Director of Nurses, Area Director of Operations, and Regional Compliance Nurse were informed the Immediate Jeopardy was removed on 07/03/2025 at 1:04 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 pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 2.Record review of Resident #5's Face Sheet on 07/15/2025 at 11:31 AM revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included Chronic Viral Hepatitis C (viral infection that causes inflammation and damages the liver,) Alcohol Abuse, Dementia (general decline in mental ability,) and bipolar disorder (mental illness that causes a shift in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks.) Record Review of Resident #5's Quarterly Minimum Data Set (MDS) dated [DATE], revealed his cognition was severely impaired with a Brief Interview Mental Status (BIMS) score of 03. He was wheelchair bound. Section E- Behavior E. 0900 Wandering - Presence & Frequency (1) Behavior of this type occurred 1 to 3 days. Record review of Resident #5's Comprehensive Care Plan dated 07/08/2025, revealed no interventions related to wandering and/or elopement prior to the elopement incident on 07/12/2025. Record Review of Resident #5's ELOPEMENT RISK ASSESSMENT V5 dated 07/08/2025. Resident #5 Scored out as a 9, shows him to be low risk for elopement. B. Physical Capability - Self propels wheelchair C. Adjustment to Facility - Understand ad verbalizes acceptance of need for nursing home careD. Cognitive Skills for Daily Decision Making - Modified independence - some difficulty in new situations only E. History - No attempts to leave own residence/facility Record Review of Resident #5's ELOPEMENT RISK ASSESSMENT V5 dated 07/13/2025. Resident #5 Scored out as a 19 shows him to be a high risk for elopement. C. Adjustment to facility - Verbalized anger and frustration re: placement D. Cognitive Skills - Moderately impaired - decisions poor; cues/supervision required. E. History - Previous attempts to leave facility - No attempts to leave facility Record Review of facility's Incident Report for July 2025, dated 07/16/2025, revealed no documentation of Resident #5's wandering, exit seeking, and/or elopement behavior/incident from 07/08/2025.Review of Resident #5's Pre-admission Clinical Documents revealed Treatment Notes from a neurology provider on 04/29/2025 revealed Patient is alert to self only. [Resident #5's RP] reports at that time [Provider] recommended him to be in a care facility. [Resident #5's RP] reports the facility. did not accept him because he was a flight risk. During an interview on 07/16/2025 at 2:15 PM ADON stated she believed Resident #5 was care planned for the Elopement. ADON said she knew Resident #5 had an Elopement Risk Assessment completed previously and thought it had already been care planned. ADON stated that the MDS nurse was responsible for preparing and updating care plans. The ADON indicated the purpose of care plans was to inform direct care staff about resident care needs and preferences. The ADON stated the Care Plan can be reviewed at any time. She added the care plan should be updated and reviewed at least quarterly thereafter, then annually and with significant changes in conditions as defined in the RAI (Resident Assessment Instrument) manual. Additional updates to the care plan may be done as indicated. ADON stated it was the responsibility of the DON, MDS Coordinator to make sure care plans were updated. The ADON confirmed participation in an in-service training that covered topics including abuse, elopement protocols, and internal emergency codes.During a follow up interview on 07/16/2025 at 2:40 PM with SW she stated she has only been there about 3 months. Stated not entirely yet involved in the Care Planning of things still learning all the procedures. SW stated if resident was assessed it should have been in their care plan as an Elopement Risk. SW stated she was not working on the date the Elopement occurred. The SW stated the main focus and purpose of care plans was to inform direct care staff, about resident care needs and preferences. SW stated the care plan can be reviewed at any time. The SW stated the care plan can and should be updated as soon as a change in condition is noted. If not, the care plan should be updated and reviewed at least quarterly thereafter, then annually unless any significant changes occur. The SW stated she did receive an in-service training that covered topics including abuse, elopement protocols, and internal emergency codes.During an interview on 07/16/2025 at 3:35 PM DM stated has been DM for 5 years. DM stated is not involved specifically in care planning, unless there are dietary concerns, then both she and the dietician, become involved with the care plan. The care plan should serve as a guide, which should direct care needs, care choices and care preferences of the resident. DM stated it would have a negative affect if a resident had needs not properly cared planned, in terms of dietary issues from the types of food, how it is prepared and what they can and cannot eat. DM stated she did receive in-service training that covered topics including abuse, elopement protocols, and internal emergency codes.During an interview on 07/16/2025 at 3:53 PM AD stated have been an AD for 3 months. Stated not familiar with too much of the care planning of residents, she has her own type of care plan,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 4 (Residents #1, #2, #3 and #5) of 9 residents reviewed for accidents and hazards. Based on observations, interviews, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 4 (Residents #1, #2, #3 and #5) of 9 residents reviewed for accidents and hazards. 1. A. The facility failed to implement and modify interventions to ensure Resident #1 did not experience 7 falls after admitting to the facility on [DATE], and as a result of the last fall on 06/22/2025, sustain a head injury which resulted in the resident's death in the hospital on [DATE]. B. The facility failed to implement and modify interventions to ensure Resident #2 did not experience 5 falls after admitting to the facility on [DATE] with a right hip fracture resulting from a fall at home. C. The facility failed to implement and modify interventions to ensure Resident #3 did not experience 5 falls after admitting to the facility on [DATE]. 2. A. The facility failed to adequately assess, devise, and implement appropriate interventions to prevent Resident #5's elopement from the facility for approximately 5 minutes on 07/12/2025. The first non-compliance was identified, and an Immediate Jeopardy (IJ) situation was identified on 07/02/2025. The IJ was removed on 07/16/2025. The facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The second non-compliance was identified, and an Immediate Jeopardy (IJ) Template was presented to facility Administrator and DON on 07/15/2025 at 5:37 PM. The IJ was removed on 07/16/2025. The facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The failures could place residents at risk of harm and injuries, hospitalization, and death. Findings include: 1. 1. Record review of Resident #1's Face Sheet, dated 06/26/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had diagnoses which included Parkinson's disease (movement disorder of the nervous system that worsens over time), unspecified abnormalities of gait (walking pattern) and mobility, and a history of falls. Record review of Resident #1's admission MDS (tool used to assess health status) Assessment, dated 04/19/2025, reflected moderately impaired cognition with a BIMS (screening tool to assess cognitive status) score of 10. Section J (Health Conditions) reflected Resident #1 had 2 or more falls since admission with no injury. Record review of Resident #1's Comprehensive Care Plan, dated 04/28/2025, reflected the focus resident at risk for falls was initiated on 05/25/2025. Interventions included staff x 1 to assist resident with transfers, ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed, and ensure the resident was wearing appropriate footwear when ambulating or mobilizing in his wheelchair. The care plan did not reflect each fall or a new intervention after each fall. Record review of Resident #1's Fall Risk Assessments, dated 06/12/2025, 06/20/2025, and 06/22/2025, reflected Resident #1 was in the high-risk category for falls. Record review of the facility's incident reports reflected Resident #1 fell on [DATE], 04/11/2025, 04/15/2025, 04/20/2025, 05/25/2025, 06/10/2025, 6/20/2025 which did not result in a serious injury. Resident #1 was sent to the hospital after he fell on [DATE]. Record review of Resident #1's progress notes, dated 06/13/2025, reflected RN C documented This client is somewhat confused. He does not abide by the nurses' instructions about his safety and constantly gets out of the recliner and makes movements that could severely hurt him. He slid out of the recliner at 2145. Once we put him in bed, 30 minutes later, we found him by the door in his chair, naked.We need a baby monitor so that the nurse can see him from the nurse's station. Record review of Resident #1's progress notes, dated 06/20/2025, reflected RN X documented This nurse was called by an Aide that resident was on the floor. Resident was lying next to his recliner and bed. Resident said he was trying to use the bathroom. Resident was lifted off the floor with a Hoyer lift. Resident sustained a skin tear on his right elbow. Site was cleaned and covered with border dressing. Resident assessed and his vital signs were normal. DON, family, and NP were notified. Record review of Resident #1's progress notes, dated 06/22/2025, reflected RN C documented nurse was called to resident room and observed resident on the floor next to the bed, resident is alert and able to response to verbal commands, disorientation also noted, head to toe assessment done at this time, laceration of about 1 cm x 0.5 cm noted right side of the head, extensive bruising from his right shoulder to right lower back, vital signs recorded at this time within normal range, scant amount of blood noted to laceration site, emergency services called, emergency personnels arrive and assessed patient, resident was transported to hospital for further evaluation. Record review of Resident #1's progress notes, dated 06/22/2025, reflected RN C also documented patient fell at 00:51 am, unwitnessed, sustained penetrating injury to his head in the right temporal area. Had an extensive bruise from left shoulder blade diagonally to right waist area. The patient needs close monitoring because he isn't aware of usage of call light. The client is confused, needs one on one or baby monitoring to prevent further falls. Record review of the incident report completed by RN C, dated 06/22/2025, reflected Resident #1 had an unwitnessed fall and was discovered on the floor next to his bed. The incident report reflected Resident #1 stated he tried to get up and fell out of bed. Record review of Resident #1's hospital records, dated 06/23/2025, reflected Resident #1 was admitted to the emergency department on 06/22/2025 at 1:38 AM with a large left subdural hematoma (brain bleed) with a mid-line shift to the right (displacement of the brain away from center line). Resident #1 was not a candidate for surgical repair of the bleed and was placed on palliative care until he passed away in the hospital on [DATE] at 3:30 AM. During a telephone interview on 06/26/2025 at 10:42 AM, CNA D stated Resident #1 tried get up by himself all the time. CNA D stated Resident #1 used a walker and would take himself to the restroom without using the call light and waiting for assistance. She stated when she rounded on her residents, just a few minutes before Resident #1 fell, he was asleep. CNA D stated she was at the nurse's station when she heard someone say help me and found Resident #1 on the floor. CNA D stated she called for RN C to assess the resident and told the resident not to move. She stated Resident #1 told her that he hurt and when CNA D asked where, he said he wasn't sure. She stated RN C assessed Resident#1 and the resident had a laceration on the right side of his head and 2 reddish color marks on his back. She stated Resident #1 was taken to the hospital. During an interview with RN C on 06/26/25 12:54 PM, he stated he was the resident's nurse at the time of the fall on 06/22/2025. He stated CNA D notified him Resident #1 fell and he went to the resident's room and assessed him. RN C stated the resident had a laceration on the right side of his head. He stated he notified the physician and received an order to send Resident #1 to the hospital for evaluation. RN C stated Resident #1 was supposed to use his call light before getting up but did not always do that. During an interview on 06/26/25 at 1:35 PM, the Administrator stated staff notified him Resident #1 was sent to the hospital after a fall. The Administrator stated he called CNA D and RN C to get their statements. He stated he talked to all staff who cared for Resident #1 starting 24 hours before the fall to see if anyone had seen anything out of the normal for Resident #1. He stated staff had not noticed anything different about him. During an interview on 06/26/2025 at 4:18 PM, ADON B stated RN C reported at about midnight he went to Resident #1's room. He stated RN C told him the resident was on the floor next to his bed and had a cut on his head. ADON B stated when RN C asked what happened, Resident #1 stated he thought it was morning and was getting up to get dressed. ADON B stated RN C called 911 because Resident #1 hit his head when he fell, and he was sent to the hospital. ADON B stated Resident #1 had previous falls and therapy had worked with him for balance/gait. He stated the resident used a walker. During an interview on 06/27/25 at 8:55 AM, the Rehab Director stated therapy services were discontinued for Resident #1 on 06/09/2025 and the resident was walker level. She stated the resident fell on the Friday before the incident. She stated Resident #1 needed lots of verbal reminders to walk with someone and not by himself. She stated the resident would use his walker to go to the restroom in his room without calling for assistance. She stated Resident #1 had a walker and wheelchair in his room. She stated the resident had cognition/safety impairment. She stated if Resident #1's knees were bothering him, he would use his wheelchair for longer distances. She stated she had not observed a change in Resident #1's condition prior to his fall. During an interview on 07/02/2025 at 10:26 AM, CNA H stated she worked on different halls and was not working on Resident #1's hall the day he transferred to the hospital. She stated Resident #1 used a walker to go to the bathroom by himself and changed his clothes without assistance. She stated he was not considered a high fall risk. She stated she rounded and checked on Resident #1 and his roommate every two hours. She stated Resident #1 liked to sit in his recliner and watch television. She stated after his wife brought the recliner to the facility; Resident #1 also slept in it. She stated the resident walked to the dining room for breakfast and ate lunch in his room because his wife was visiting with him. She stated the day of the fall she saw Resident #1 in the hall using his walker and another time he was pushing his wheelchair. She stated Resident #1 sat in his wheelchair when he got tired. She stated she did not see any change in mobility or cognition prior to the fall. 2. Record review of Resident #2's Face Sheet, dated 07/02/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had diagnoses which included aftercare following joint replacement surgery, bipolar disorder (extreme mood swings that include emotional highs and lows), COPD (lung condition that makes it difficult to breathe), limitation of activities due to disability, and the need for assistance with personal care. Resident #2 had discharged from the facility. Record review of Resident #2's admission MDS Assessment, dated 05/22/2025, reflected moderately impaired cognition with a BIMS score of 10. Section I (Active Diagnoses) reflected the need for assistance with personal care, limitation of activities due to disability, and unsteadiness on feet. Resident #2 discharged from the facility on 07/02/2025. Record review of Resident #2's Comprehensive Care Plan, dated 04/28/2025, reflected the focus resident at risk for falls was initiated on 05/16/2025. Interventions included staff x 1 to assist resident with transfers, ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed, and ensure the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair. The care plan did not reflect each fall or a new intervention after each fall. Record review of Resident #2's Comprehensive Care Plan, dated 04/28/2025, reflected The resident has an ADL Self Care Performance. Interventions included Bed Mobility: requires staff x1 for assistance. The resident uses a wheelchair. Toilet use: requires staff x1 for assistance. Record review of Resident #2's Fall Risk Assessments, dated 05/24/2025, 06/03/2025, and 06/12/2025, and 06/17/2025 reflected the resident was in the high risk category for falls. Record review of the facility's incident reports reflected Resident #2 had a fall on 05/24/2025, 05/25/2025, 05/27/2025, 6/17/2025, and 06/29/2025. The falls did not result in serious injury. 3. Record review of Resident #3's Face Sheet, dated 07/02/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #3 had diagnoses which included unspecified dementia (decline in mental ability that interferes with daily life) with behavioral disturbances, bipolar disorder, and unsteadiness on feet. Record review of Resident #3's Quarterly MDS Assessment, dated 05/23/2025, reflected severely impaired cognition with a BIMS score of 0. Section C (Cognitive Patterns) reflected the resident demonstrated inattention and disorganized thinking. Section GG (Functional Abilities) reflected Resident #3 required partial/moderate assistance with mobility. Record review of Resident #3's Comprehensive Care Plan, dated 04/28/2025, reflected the focus resident at risk for falls was initiated on 05/05/2025. Interventions included anticipate and meet the resident's needs and ensure the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair. The care plan did not reflect each fall or a new intervention after each fall. Record review of Resident #3's Fall Risk Assessments, dated 05/11/25, 06/24/25, 06/28/25, 06/29/25, and 07/01/25, reflected Resident #3 was in the high-risk category for falls. Record review of the facility's incident reports reflected Resident #3 had a fall on 5/11/2025, 06/08/2025, 06/24/2025, 6/28/2025, 06/29/2025, and 07/01/2025. The falls did not result in serious injury. A follow-up record review of Resident #3's Comprehensive Care Plan reflected additional fall prevention interventions were initiated on 07/01/2025 which included Resident is to wear a soft helmet when out of bed to help prevent fall with major head injury and FREQUENT RESIDENT MONITORING: staff is to ensure that they can visualized residents where about as frequent as possible to help with redirection. An observation on 07/02/2025 at 11:35 AM revealed Resident #3 sitting in the tv room with other residents in the memory care unit. An attempt to interview Resident #3 was unsuccessful because of her cognitive status. Resident #3 was wearing a helmet. During an interview on 07/03/2025 at 11:44 AM, LVN F stated worked in different areas, but was working in the memory care unit today. She stated staff used a lot of redirections with residents in the memory unit. She stated residents wandered and it was important to ensure the space was free of clutter. She stated someone always has to have their eye on the residents. During the interview, LVN F went to assist Resident #3 when she stood up. She stated staff walked with Resident #3 to ensure her safety. During an interview on 07/03/2025 at 11:52 AM, CNA N stated it was important to monitor residents closely especially those who were a high fall risk. She stated Resident #3 liked to get up and walk, but someone had to be with her to be sure she did not fall. She stated Resident #3 was wearing the hat to prevent injury because she had previous falls. Review of the facility's policy Preventive Strategies to Reduce Fall Risk, dated 10/05/2016, reflected The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Review of the facility's policy Falls/Ambulation Difficulty, dated 2003, reflected Risk factors should be assessed upon admission and thereafter as necessary. Risk factors will be identified for all residents. This was determined to be an Immediate Jeopardy (IJ) on 07/02/2025 at 5:21 PM. The Administrator, Director of Nurse, Area Director of Operations and Regional Compliance Nurse were notified. The Director of Nurses, Area Director of Operations, and Regional Compliance Nurse were provided with the IJ template on 07/02/2025 at 5:21 PM and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 07/03/2024 at 1:04 PM. Facility: [Facility Name]Date: 07/02/2025Problem: F689 Accidents and Hazards Plan of Removal Interventions: 1. Resident #1 no longer resides in facility as of 6/22/25. Resident #2 has discharged from the facility and no longer resides in the facility as of 7/2/25. Resident #3 assessed 7/2/25 for fall risk and individual care plan updated to reflect that she is now part of the Falling Stars Program. In addition, new order for a soft-shell helmet to help prevent injury. 2. All residents in the facility were assessed on 7/2/25 for risk of falls or repeat fall residents. Active care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse. 3. We have initiated the NEW Falling Star Program. All residents that have had 5 falls in the last 6 months have Falling Stars Program initiated. This includes notation on the care plan and daily shift acknowledgement that the resident is high risk for falls. Resident #3 is a part of the Falling Star Program Total number of falls in 6 months: 115. 9 residents were identified as high risk for falls due to 5 falls or greater within the last 6 months. 4. The Compliance Nurse in-serviced the Administrator, DON, and ADON 1:1 on the following topics below: This was completed on 7/2/25. All residents whom are identified at high risk of falls will have an active care plan with resident specific interventions with the addition of the falling stars high risk fall program. Upon admission, and as needed, all residents will be assessed for risk of falls. The care plan will reflect findings, interventions based off of each resident's assessment post fall with individualized intervention to prevent serious injury, and monitoring weekly to ensure fall interventions are effective and in place. Upon admission the nurse/designee will be responsible for developing and implementing interventions within the care plan of risk of falls based upon their assessment. Inservice on care plan location and how to access the care plan in PCC (online electronic health record), including how to identify a resident high risk of falls in the Kardex (documentation system used to access and modify resident information). The following in-services were initiated by the DON, ADON, Regional Compliance Nurse : Any staff member not present or in-serviced on 7/2/25, will not be allowed to assume their duties until in-serviced.Licensed Nurses and Therapy Staff:All residents whom are identified at high risk of falls will have an active care plan with resident specific interventions with the addition of the falling stars high risk fall program. Upon admission, and as needed, all residents will be assessed for risk of falls. The care plan will reflect findings, interventions based off of each resident's assessment post fall with individualized intervention to prevent serious injury, and monitoring weekly to ensure fall interventions are effective and in place. Upon admission the nurse/designee will be responsible for developing and implementing interventions within the care plan of risk of falls based upon their assessment. Inservice on care plan location and how to access the care plan in PCC, including how to identify a resident high risk of falls in the Kardex. The following in-services were initiated by the DON, ADON, Regional Compliance Nurse : Any staff member not present or in-serviced on 7/2/25, will not be allowed to assume their duties until in-serviced.Non-Licensed Nursing Staff Inservice on care plan location and how to access the care plan in PCC, including how to identify a resident high risk of falls in the Kardex. All residents whom are at risk of falls will have an active care plan with interventions and monitoring.Monitoring: The DON/ADON/Designee will monitor all incidents and fall risk assessment post fall in daily stand-up meeting for 6 weeks and then PRN to ensure all resident specific interventions are in place with active care plan. The DON/ADON/Designee will monitor admission assessments, daily stand-up meeting for 6 weeks to ensure all resident care plans reflect their risk of falls and resident specific interventions based off current care needs and status. The DON/ADON/Designee will monitor falling star program weekly for 6 weeks and then PRN to ensure resident specific interventions are in place.An ADHOC QAPI was completed on 7/2/25 with medical director and interdisciplinary team to discuss the immediate jeopardy and plan of removal.The medical director was notified of this plan and monitoring on 7/2/25 when IJ was called at 5:21PM.The QAPI committee will review findings and makes changes as needed.*Active care planning addresses all acute needs of the resident**All monitoring will be located in the IJ Binder**All residents are at risk for falls, 9 residents identified at high risk for falls**No active restraints within the facility* Observations on 07/03/2025 at 09:20 AM revealed facility staff had placed a yellow star on the name plates of the doors of Resident #3, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 to indicate they were a high fall risk. In a follow-up interview with the DON on 07/03/2025 at 12:32 PM, she stated the facility implemented the falling stars program on 07/02/2025 so everyone would know which residents were a high fall risk. The DON stated staff placed yellow stars on the name plates on high fall risk residents' doors the evening before. She stated the staff received in-service training on 07/02/2025 related to fall risk and prevention. She stated CNAs were in-serviced to ensure they knew how to access resident care information in Kardex. She stated if a resident fell, the resident's nurse should immediately put an intervention in place and include it in the resident's care plan. She stated staff were to increase monitoring and ensure all care planned interventions, such as a fall mat, bed in the lowest position, non-slip pad for wheelchair seat, or helmet were in place for the falling stars or residents at high risk for falls. The DON stated the facility had at risk meetings every week and evaluated residents' care plans and put appropriate interventions in place. She stated staff also discussed any concerns or changes during the interdisciplinary team meetings. The DON stated it was important to ensure residents were assessed as needed and interventions put in place to provide resident centered care and keep the residents safe. In interviews with direct care facility staff on 07/03/2025, between 10:30 AM and 4:10 PM, the DON, ADON A, ADON B, the Rehab Director, the MDS Coordinator, the Physical Therapist, COTA, Hospitality Aide RN C, CNA D, CNA E, LVN F, CNA G, CNA H, Medication Aide I, LVN J , CNA K, Medication Aide L, RN M, CNA N, CNA O, CNA P, RN Q, CNA R, CNA S, CNA T, CNA U, CNA V stated in-service training was provided 07/03/2025 focused on the importance of keeping residents safe in the facility. Staff were reminded to ensure every transfer was safe for the resident. In-service training included to ensure residents wore socks that prevented slipping or had on appropriate fitting shoes. Staff stated high fall risk residents had a yellow star on their name plate on the door and the information was also included in the Kardex. CNAs stated they were responsible for communicating with the nurse if they were going on break or needed to leave the hall briefly. Nursing staff were in-serviced about assessing residents with each fall, putting a new resident specific intervention in place, and ensuring the care plan was updated. Nurses stated they were responsible for communicating with CNAs and ensuring call lights were answered which included the nurse answering call lights when the CNAs were busy with another resident. Timely completion of Elopement Assessments (all assessments;) When a Significant Change in Status documentation and/or re-assessment is required, and Examples of Decline. In interviews with other staff members on 07/03/2025 between 10:30 AM and 4:10 PM, the Maintenance Director, Social Service, Dietary Staff, Dietary Cook, and Housekeeping stated it was important to observe residents around them to ensure residents were safe in their environment and to report any concerns to nursing staff. Staff stated the facility placed yellow stars on the name plates of doors to identify residents who were at high risk for falls. Record review of residents identified as high risk for falls on 07/03/2025 at 10:45 AM revealed compliance with resident specific care plans and inclusion in the facility's falling star program. Record review on 07/03/2025 of In-service, High Fall Risk: Yellow Star, conducted by RCN, reflected all high-risk residents would have a yellow star next to their name on the door and a yellow star on the Kardex. The In-Service included a list of falling star residents. The In-service roster included signatures of direct care staff. Record review on 07/03/2025 of In-service, Fall Risk, Intervention, Prevention, Monitoring, Care Plan Update, conducted by RCN, reflected on admission, and as needed, all residents would be assessed for risk of falls and the care plan would reflect findings, interventions, and monitoring. The In-service included identifying risk factors, reducing environmental hazards, and prevention of unsafe transfers and ambulation. The In-service included evaluating the residents' footwear, daily routine, medications, and social and psychological needs. It also included assessment of resident's gait by physical therapy and/or a nurse. This In-service was provided to all facility staff. The Director of Nurses, Area Director of Operations, and Regional Compliance Nurse were informed the Immediate Jeopardy was removed on 07/03/2025 at 1:04 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 pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 2. Record review of Resident #5's Face Sheet, dated 07/15/2025 at 11:31 AM revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included Chronic Viral Hepatitis C (viral infection that causes inflammation and damages the liver,) Alcohol Abuse, Dementia (general decline in mental ability,) and bipolar disorder (mental illness that causes a shift in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks.) Record Review of Resident #5's Quarterly Minimum Data Set (MDS) dated [DATE], revealed his cognition was severely impaired with a Brief Interview Mental Status (BIMS) score of 03. He was wheelchair bound. Section E- Behavior E. 0900 Wandering - Presence & Frequency (1) Behavior of this type occurred 1 to 3 days. Record review of Resident #5 Comprehensive Care Plan on 07/15/2025 at 1:24 PM revealed no interventions related to wandering and/or elopement prior to the elopement incident on 07/12/2025. Record review of Resident #5's Elopement Risk Assessment - V5 upon admission dated 07/08/2025 revealed he was at a low risk for elopement with a score of 09. The assessment stated Resident #5: -Self-propels himself in a wheelchair-Understands and verbalizes acceptance of need for nursing home care-Has modified independence related to cognitive skills for daily decision making-No previous attempts to leave his residence/facility-No restlessness or anxiety Record Review of Resident #5's ELOPEMENT RISK ASSESSMENT V5 dated 07/13/2025. Resident #5 was scored as a 19. Indicating at high risk. C. Adjustment to facility - Verbalized anger and frustration re: placement D. Cognitive Skills - Moderately impaired - decisions poor; cues/supervision required. E. History - Previous attempts to leave facility - No attempts to leave facility. Review of Resident #5's Pre-admission Clinical Documents revealed Treatment Notes from a neurology provider on 04/29/2025 revealed: Patient is alert to self only. [Resident #5's RP] reports at that time [Provider] recommended him to be in a care facility. [Resident #5's RP] reports the facility. did not accept him because he was a flight risk. Review of Resident #5's Event Nurses Note by RN C, titled Elopement, dated 07/12/2025 at 9:15 PM revealed Resident #5 was missing at 7:10 PM, and his wheelchair was located at the exit door. At 7:15 PM, Resident #5 was located walking in the parking lot. Attempts to interview RN C on 07/15/2025 at 2:00 PM and 3:07 PM were unsuccessful. In an interview with SW on 07/15/2025 at 1:57 PM, she stated that Resident #5 was very confused as to where he was and why. Resident #5 voiced to her that he wanted to leave on 07/09/2025. SW stated she observed Resident #5 wandering up and down the hallway of the facility and stated he wanted to go home. She stated she reported this to the DON at this time. She stated that Resident #5's wandering behavior was discussed multiple times in morning meeting which served as the facility's interdisciplinary meeting. She did receive an in-service training that covered topics including abuse, elopement protocols, and internal emergency codes. During an interview on 07/16/2025 at 2:45 PM CNA P stated was not present during the recent elopement but had been advised of the incident. CNA P stated does not develop or participate in the care planning of residents, that is a nursing thing. CNA P stated did receive in-service training today, which covered elopement prevention and response, identifying high-risk residents, and the correct reporting process. CNA P stated that now residents who are at high risk for elopement will be identified by using the POC Kardex. In an interview with DON on 07/15/2025 at 12:55 PM, she stated on 07/09/2025, Resident #5 voiced to her that he was confused as to why he was at the facility. She stated he was confused but did not verbalize any desire to leave the facility. She did not recall if his wandering behaviors were discussed in the facility's morning meeting. She did not recall if SW reported to her his wandering behaviors on 07/09/2025. She stated that upon admission, Resident #5 was assessed as a low risk for elopement which did not warrant elopement precautions to be in place at that time. She stated she did not see any information in the Pre-admission Clinical Documents that he was an elopement risk. She stated it was her responsibility to review any pre-admission clinical documents and it was her responsibility to determine if a resident was appropriate for admission clinically. She stated she should have seen the treatment notes that stated he was a flight risk prior to admitting the resident. Additionally, DON stated her expectations were for Resident #5 to have been accurately assessed for elopement upon admission. She stated that accurate assessment and documentation was important. She stated when important information was not reviewed, someone that was high risk for elopement can be admitted inappropriately. Additionally, inaccurate assessment of a resident's elopement risk can result in elopements because relevant interventions will not be in place. She stated policy to discuss elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. During an interview on 07/16/2025 at 3:15 PM CNA T stated has been there for about a year now. CNA T stated was not p

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to ensure resident received adequate monitoring, supervision, and/or assistive devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accidents, hazards, and supervision. On 03/07/2025, the facility failed to identify potential hazards and follow internal systems in place to prevent Resident #1's elopement from the facility approximately two hours and twenty minutes after his admission. He was located approximately two hours later by local law enforcement approximately 1 mile east of the facility. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator on 04/17/2025 at 4:24 PM. The noncompliance began on 03/07/2025 and ended on 03/07/2025. The facility corrected the noncompliance before the investigation began . This failure could place residents at the facility at risk of injury and a decreased quality of life due to the lack of supervision and care that residents need to be safe. Findings Included: Review of Resident #1's Face Sheet, dated 04/17/2025 revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnosis included dementia. Review of Resident #1's Baseline Care Plan, completed after his elopement, dated 03/07/2025 revealed he was and/or had: -At Risk for falls -Impaired cognitive function related to dementia -Required antidepressant and antipsychotic medication -ADL self-care performance deficit -At risk for wandering and had history an elopement at the facility on 03/07/2025 Review of Resident #1's admission MDS, completed after his elopement, dated 03/07/2025 revealed he admitted from a short-term general hospital. No other relevant information was stated. Attempts were made to interview Resident #1 on 04/17/2025 at 10:00 am and 2:00 pm were not successful. In an interview with facility's ADON on 04/17/2025 at 1:00 PM, he revealed he was assisting with Resident #1's admission on [DATE]. He stated that Resident #1 was admitted at approximately 12:00 PM that day and was alert to self and his location but had intermittent confusion. He stated he oriented Resident #1 to his room and then directed the resident to the dining area for lunch. He stated after lunch at approximately 2:20 PM, Resident #1 was seen at the north nurse's station talking to another resident. He stated Resident #1 did not appear to be in any distress at this time, did not voice to him that he wanted to leave, and did not seem confused as to where he was located. When Resident #1 was observed in his room, he was unpacking his belongings into the facility's closet and armoire. The ADON stated at approximately 3:00 PM, Resident #1 could not be located and a code orange [indicating a missing resident] was implemented. Around approximately 5:00 PM local law enforcement reported to the facility Resident #1 was located and was returned to the facility at approximately 5:30 PM. Upon Resident #1's return to the facility, he was thoroughly assessed and appeared the same from admission, was not in any distress , and upon interview he reported to him that a friend gave him a ride to somewhere but could not state any further specifics. The ADON stated he did not state how he exited the facility and was not harmed per assessment. The ADON stated the resident was placed on 1:1 supervision in the secured unit and was transferred to a sister facility by approximately 7:00 PM that evening. He stated it was important to keep residents in the facility for proper monitoring, care, and supervision. In interview with the facility's DON on 04/21/2025 at 1:28 PM, she stated she was not present for this incident, but she stated it was important to keep residents in the facility for proper monitoring, care, and supervision. In interview with the facility Administrator on 04/17/2025 at 1:13 PM, he stated he was not present at the time of the elopement but responded to the event afterwards. He stated it was important to keep residents in the facility for proper monitoring, care, and supervision. The Administrator further stated that he and his leadership team reviewed Resident #1's pre-admission clinical documents and nothing seemed concerning related to wandering and/or elopement. He stated that if he did see any concerning information related to the resident's wandering risk, he would not have admitted Resident #1 because the secured unit at the facility was female-only. He stated that the resident was not present at the facility long enough for his staff to complete all the admission assessments required. He stated his expectations were for the admission assessments to be completed within four hours of admission. He stated that Resident #1 eloped from the facility within two hours and twenty minutes of his admission. The administrator stated that the post-elopement interventions for Resident #1 included: -Physician and responsible party notification -Head-to-toe assessment completed and no injuries noted -Trauma-informed assessment completed and no trauma noted -Elopement risk assessments were immediately reviewed for all residents at the facility -Exit doors reviewed and inspected to be in working order -All resident care plans reviewed for high-risk for elopement residents -In-services to staff related to the incident were provided -A sign was placed at the skilled nursing entrance instructing families to ensure residents do not exit building -A hinged transparent cover on top of the green exit button was installed so someone with cognitive limitations would have a harder time locating it to prevent future elopements -Upon his return to the facility, Resident #1 was placed in the secured unit under 1:1 supervision prior to his transfer to a co-ed secured unit at a sister facility later that evening. In observation on 04/17/2025 at 1:00 PM with facility's ADON, facility exit doors were tested and inspected to be in working order, a sign located on the skilled nursing entrance that stated to ensure residents do not exit the building was observed, and a hinged, transparent cover was observed on top of the green exit button by the facility's entrance and exit doorway. Record review of facility's elopement drill, Internal Disaster Drill Form, dated 03/07/2025 at 3:00 PM provided by the facility's ADO revealed signatures from staff from all disciplines, departments, and shifts revealed Real Event, Missing Resident, police department was involved, and the duration of the drill was 2 hours. The narrative was listed as [Police Department] notified to assist in finding missing resident . Found approximately 5:00 PM. Record review of facility's In-service Trainings, Identifying at Risk Residents and Assessments, Elopement Policy and Procedure, One on one door monitoring, and Abuse and Neglect, dated 03/07/2025 provided by the facility's ADO revealed multiple signatures from staff from multiple disciplines, departments, and shifts covered. Education provided included: Identifying at Risk Residents and Assessments -Elopement risk assessment protocol -Assessments are for people that score above a 10 on elopement assessments -Staff are to be familiar with the resident's care needs and risk for wandering and elopement -Clinical staff are responsible to ensure assessments are completed and safety measures are in place and implemented Elopement Policy and Procedure -Every effort will be made to prevent elopement while maintaining the least restrictive environment for residents at risk or elopement -Clinical staff are required to assess residents for elopement risk and ensure safety measures are in place and implemented -Code Orange Procedures and delegation of roles, tasks -How to identify the cause of wandering -Intervention strategies that include: reducing discomfort, labeling residents room clearly, maintain a resident's routine, schedule ambulation and toileting, and reducing excess stimulation One on one door monitoring -Staff are required to monitor of and document on resident at all times until monitoring is discontinued Abuse and Neglect -Definition of abuse, neglect, exploitation, misappropriation of property, mistreatment, and involuntary seclusion -Procedure for reporting any abuse, neglect, exploitation, misappropriation of property, mistreatment, and involuntary seclusion to the abuse coordinator -Leadership is required to conduct a comprehensive investigation for all allegations abuse, neglect, exploitation, misappropriation of property, mistreatment, and involuntary seclusion In interview with multiple staff over multiple disciplines, departments, and shifts included Administrator, ADO, CC, DON, ADON, SW, AD, [NAME] I, [NAME] J, [NAME] K, DA L, HSK M, HSK N, HSK O, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, and LVN B between 04/17/2025 and 04/21/2025 between 9:00 AM - 5:00 PM, they stated information related to their discipline that included how elopement risk assessment protocol relates to their job role, clinical staff were able to report that a resident is considered high risk when they score above a 10 on an elopement assessment, staff are required to be familiar with the resident's care needs and risk for wandering and elopement, clinical staff are responsible to ensure assessments are completed and safety measures are in place and implemented, that every effort will be made to prevent elopement while maintaining the least restrictive environment for residents at risk or elopement, clinical staff are required to assess residents for elopement risk and ensure safety measures are in place and implemented, reported information related to Code Orange and delegation of roles, how to identify the and causes/triggers of wandering, and intervention strategies that include: reducing discomfort, labeling residents room clearly, maintain a resident's routine, schedule ambulation and toileting, and reducing excess stimulation. Additionally, relevant staff reported they are required to monitor and document on resident at all times after an elopement or wandering behaviors are exhibited until monitoring is discontinued. Finally, staff were able to report the definition of abuse, neglect, exploitation, misappropriation of property, mistreatment, and involuntary seclusion, the procedure for reporting any abuse, neglect, exploitation, misappropriation of property, mistreatment, and involuntary seclusion to the abuse coordinator, and that leadership is required to conduct a comprehensive investigation for all allegations abuse, neglect, exploitation, misappropriation of property, mistreatment, and involuntary seclusion. Staff confirmed an elopement drill was conducted on 03/07/2025 and that Resident #1 was transferred to a secured unit the same day of the incident. In review of facility policy, Elopement Prevention, dated 01/2023 revealed Every effort will be made to prevent elopement while maintaining the least restrictive environment for residents at risk or elopement . 1. The Elopement Risk Assessment will be completed upon admission . the assessment tool should be completed, and interventions implemented as indicated. The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, upon new exit seeking behavior, and upon change of condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative where there was a significant change in the resident's physical, mental, or psychosocial status and when there was a need to alter treatment significantly for one of two (Resident #99) post operative surgical residents reviewed for notification of changes related to post operative care. The facility failed to notify Resident #99's attending physician or surgeon after changes to her surgical incision site were repeatedly observed resulting a subsequent infection that required hospitalization and surgical intervention. An Immediate Jeopardy (IJ) situation was identified on 11/08/2024 at 12:35 PM. The IJ was removed on 11/27/2024 at 3:15 PM the facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of a delay in medical intervention, decline in health, serious injury, harm, impairment or death. Findings include: Record review of Resident #99's face sheet, dated 11/07/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #99 had relevant diagnoses which included metabolic encephalopathy (alteration in consciousness caused by diffuse or global brain dysfunction from impaired cerebral metabolism,) subluxation of lumbar vertebra (misalignment of spine,) wedge compression fracture of thoracic vertebrae (one or more back bones collapse,) protein-calorie malnutrition, anxiety (persistent nervousness, anxiety, and/or restlessness) and major depressive disorder (persistent low mood.) Record review of Resident #99's MDS dated [DATE], reflected she was cognitively intact with a BIMS score of 15. She required a wheelchair for mobility and required substantial/maximal assistance with toileting and shower/baths which included transfers. Record review of Resident #99's Baseline Care Plan dated 09/26/2024 at 2:30 PM revealed no evidence of surgical site assessment, treatment, or care documentation. Record review of Resident #99's Comprehensive Care Plan was not available for review due to the resident's short-term stay at the facility. Record review of Resident #99's Physician Orders reflected her attending physician as Dr N, Admit to Skilled Services Under The Care of [Dr N] effective 09/20/2024. No orders stated monitoring of surgical site and/or treatment and care from Dr N were observed. Record review of Resident #99's Physician Orders from Dr L stated Clean surgical site on lower back with normal saline, pat dry and apply dry dressing one time a day for wound care start date 10/05/2024. An order to monitor surgical site stated, Monitor surgical site for infection one time a day for wound care start date 10/05/2024. Record review of Resident #99's Physician Orders on 11/27/2024 at 9:30 AM revealed no evidence of physician orders for monitoring of surgical site and/or treatment and care for Resident #99's surgical incision site for the month of September. Record review of Resident #99's Discharge Instructions, from [Hospital] prior to Resident #99's admission at [Facility,] dated 09/20/2024, reflected Resident #99 had back and pelvis surgery on 09/15/2024. Procedures/Surgeries . L4-L5 Laminectomy, L3 to Pelvis Posterior Instrumentation Fusion . Notify PCP of these signs and symptoms . increased redness, increased swelling, increased tenderness/pain . bleeding . pus-like discharge .Dispo: SNF on discharge. S/p L3-S2 instrumentation with pelvic fixation and L4-L5 laminectomy Record review of Resident #99's Progress Notes, dated 10/04/2024, completed by the facility's Treatment Nurse reflected, Noticed resident surgical site was draining, wound DR was informed to see her next visit to the facility, but she stated she cannot see resident unless the surgeon request for her to see patient because patient is still under the care of the surgeon for 3 months. Order to clean surgical site with normal saline and apply dry dressing and order to monitor the surgical site are both in place. Record review of Provider Notes authored by NP L with an encounter date 10/07/2024, reflected Patient lethargic today, she awakens to tactile stimuli and drifts off quickly. Nurse reports surgeon appointment tomorrow Record review of the document reflected no evidence of surgical site observation, assessment, and/or intervention. Record review of Resident #99's Weekly Skin Assessment - V 5 history reflected four assessments on 09/30/2024, two on 10/07/2024, and 10/08/2024 completed by facility's Treatment Nurse. No evidence of Resident #99's incision site was documented by any staff member nor the facility's Treatment Nurse. An additional record review of Resident #99's on 11/27/2024 of Weekly Skin Assessment - V 5 revealed no evidence of Resident #99's incision site documentation by any staff member nor the facility's Treatment Nurse. Record review of Resident #99's Progress Notes, with a look-back period between 10/04/2024 - 10/08/2024, reflected no documentation related to a completed assessment or notification to a provider of Resident #99's incision site drainage nor any other surgical concerns. An additional record review of Resident #99 on 11/27/2024 of Progress Notes, with a look-back period between 10/04/2024 - 10/08/2024, reflected no documentation related to a completed assessment or notification to a provider of Resident #99's incision site drainage nor any other surgical concerns. In interview with the facility's Wound Physician, Dr L, on 11/06/2024 at 7:16 AM, she stated she never saw or treated Resident #99 as a patient. She stated she never intended to see her at the facility as she did not see post operative neurological or orthopedic patients unless specifically requested by the surgeon. She stated she directed the Treatment Nurse to report her concerns to Resident #99's surgeon. She stated the appropriate monitoring and timely reporting of any surgical site concerns to Resident #99's surgeon was important for infection control purposes. Interview attempts with Resident #99's Surgeon, Dr B, on 11/07/2024 at 11:11 AM and 11/08/2024 at 11:32 AM were unsuccessful. In interview with CNA G on 11/08/2024 at 8:32 AM, she stated she recalled observing and immediately reporting to Treatment Nurse that Resident #99's dressing on her back was soiled with drainage, but she did not recall the specific date this occurred. In interview with the Treatment Nurse on 11/07/2024 at 2:08 PM, she stated CNA G reported Resident #99's surgical incision site on her back was draining on 10/04/2024. She stated she called the facility's wound care doctor, Dr L, for advice but stated Dr L was not Resident #99's provider at this time. She stated Dr L gave her a verbal order to change Resident #99's dressing, to monitor incision site for infection, and to notify her surgeon immediately for further instruction. The Treatment nurse stated she delegated Resident #99's nurse for that day, RN K, to notify the surgeon the incision site had drainage. In follow-up interview with facility's Treatment Nurse on 11/27/2024 at 11:50 AM, she stated she did not notify Resident #99's physician of a change in condition because she delegated that to RN K. She stated she did not document an incision site assessment because there was no physician order that came with [Resident #99's] incision when [Resident #99] was admitted . She stated she did not document any skin assessments of Resident #99's incision site because physician orders dictate her assessment documentation and treatment requirements. In interview with RN K on 11/07/2024 at 12:29 PM, he stated he did not recall any significant events of 10/04/2024 nor the facility's Treatment Nurse asking him to notify Resident #99's surgeon that day. He stated he was not sure if he was allowed to call Resident #99's surgeon directly. RN K referred to his cell phone and stated he was Resident #99 nurse on 10/04/2024, 10/06/2024, 10/07/2024 and 10/08/2024. He stated he did not notice any incision site changes on Resident #99 until just prior to the end of his shift on 10/07/2024. He stated he observed a little bit of pink drainage and the incision looked open on 10/07/2024. He stated he reported to Dr N that I think we need labs on this lady [Resident #99,] but he did not report to Dr N any concerns related to her incision site. He stated he did not report his observations to Resident #99's surgeon either. He stated it slipped his mind and he got busy and did not document it. He stated it was important to report any changes to a resident's surgical incision to a provider because it's an infection risk, a lot of things can happen . which can lead to sepsis. He stated he told the night shift nurse, LVN J, to watch out for this lady, but did not recall if he reported to her about Resident #99's incision site changes. In interview with LVN J on 11/07/2024 at 2:20 PM, she stated she did not recall any specifics as it's been a long time. She stated as far as she knew, when she took care of Resident #99 her incision site was intact during night shift. She stated it was important to report any changes in status of the resident to the doctor immediately for the safety of the resident. In interview with LVN Y on 11/07/2024 at 1:09 PM, she stated her first day of employment at the facility was 10/03/2024. She stated she worked with RN K under his supervision in orientation on 10/06/2024. She stated on 10/06/2024 she stated she observed Resident #99's incision dehisced (to come apart) and observed serosanguinous drainage (thin, watery, pink discharge containing serous fluid and blood) on Resident #99's back incision dressing. LVN Y stated she showed RN K the soiled dressing and reported her observation to him. She stated she did not notify any physicians. She stated she did not recall if any doctors were notified that day and she was on orientation and assumed [RN K] reported it to the doctor. In a follow up interview with RN K on 11/07/2024 at 2:50 PM, he stated he trained LVN Y on 10/06/2024. He stated he did not recall observing Resident #99's incision site that day but he should have. He stated LVN Y did show him Resident #99's soiled dressing with light drainage present, but he did not conduct any follow up assessments on Resident #99's incision site and could not specify why. He stated he should have because LVN Y was his trainee, and that it was his responsibility to assess Resident #99's incision site because something negative can occur. RN K stated he should have notified Resident #99's surgeon but stated he did not and could not specify why. In interview with Resident #99's attending doctor, Dr N, she stated she was not informed of any incision site physician orders, incision site changes, or concerns. She stated her expectations were, at a minimum, for the facility staff to notify her of any resident condition changes so follow up with the surgeon could be facilitated. She stated this was important for infection purposes, especially surgical cases. In interview with Dr N's Nurse Practitioner, NP L, on 11/08/2024 at 8:12 AM, she stated he was not informed of any incision site changes or concerns. She stated she saw Resident #99 at the facility on 10/07/2024 but was not informed of any incision site changes or concerns and did not assess the incision site. She stated if I had known, I would have taken a look at it [incision site] and assessed as it was important for infection purposes. She stated she expected the facility to ultimately report any incision site changes to the surgeon for further advisement. In interview with Resident #99's family member on 11/05/2024 at 11:33 AM and 11/07/2024 at 1:34 PM, he stated Resident #99 had to go back into the hospital for another surgery after her admission at [Facility.] He stated he believed the incision came apart on 10/06/2024. He further stated on 10/07/2024 I noticed her acting strange, like the infection had returned. On 10/08/2024, Resident #99 had a follow up appointment with her surgeon where it was found the infection had indeed returned and she was re-admitted to the hospital where she had to have another surgery to clean out their [the facility's] mistake. He stated Resident #99 has experienced a lot of pain and suffering due to the facility's negligence. In a follow up interview with Resident #99's family member on 11/13/2024 at 9:11 AM, he stated Resident #99's current condition was she has pretty much [gone] out of her mind, she stays very confused, and she does not know where she is and is still having [cognitive] problems. He stated he was hopeful that her course of Intravenous (IV) antibiotics would help her get back to normal but it hasn't happened yet . Attempts to interview Resident #99 on 11/08/2024 at 2:00 PM and 11/13/2024 9:11 AM were unsuccessful due to her cognitive limitations. In interview with DON on 11/08/2024 at 9:14 AM, she stated it was her expectation for Resident #99's surgeon to be called immediately if there were any incision site changes. She stated this was not done and it was a failure on the facility's part. The DON stated no documentation was able to be provided to reflect that any provider of Resident #99 was notified about her incision site changes. She stated prompt notification to a provider about a decline in condition and/or incision site changes was important for infection control purposes. In interview with the Administrator on 11/08/2024 at 11:35 AM, he stated his expectations were for the nurse to have reported it [incision site changes] to the doctor. He stated it was important for facility nursing staff to notify the doctor of any changes a resident may have to prevent any decline. In interview with the facility's ADO on 11/08/2024 at 12:35 PM, she stated she did not expect the surgeon to be called by facility per their [facility] policy. She provided the State Surveyor with facility policy, Notifying the physician of Change in Status and stated facility nurses see incisions as wounds and she felt the facility notified the appropriate provider [Dr L.] She further stated it was then Dr L's responsibility to follow up with the surgeon and not the facility staff. Record review of the facility's staffing schedule, provided by the DON, via email on 11/07/2024 reflected: RN K worked day shift on 10/04/2024, 10/06/2024, 10/07/2024, and 10/08/2024. LVN J worked night shift 10/06/2024 and 10/07/2024. LVN Y worked day shift and was in orientation 10/05/2024 and 10/06/2024. On 10/06/2024, RN K oriented LVN Y on day shift. The following documents reviewed state Resident #99's status and condition immediately after her admission at [Facility] and after her 10/08/2024 surgical appointment that necessitated her subsequent re-admission to [Hospital] on 10/08/2024: Record review of Resident #99's Discharge Summary dated 10/30/2024, from Resident #99's hospital admission after her admission at [Facility] revealed Discharge diagnosis . lumbar incisional wound dehiscence with possible infection . Hospital course . recent L4/L5 laminectomy and L3 to pelvis posterior instrumentation done 09/15/2024 and discharged to SNF. She presented to outpatient neurosurgery clinic from SNF for evaluation of lower back wound with discharge. She was seen at outpatient clinic and sent to ER from neurosurgery clinic for evaluation of lumbar wound dehiscence and yellow-colored drainage . continue wound vac . intraoperative culture results and UTI culture results, both growing E. coli (bacteria) . ID recommend to continue 6 week of antibiotics, Rocephin 2 g daily through a PICC line, right upper extremity PICC line in place . Followed by plastic surgery . Procedures: 1. Excisional debridement of skin, subcutaneous tissue, muscle and bone, lumbar wound 120 square cm. 2. Drainage of deep lumbar abscess. 3. Application of a drug-eluting antibiotics beads deep in lumbar wound over lumbosacral area. 4. Application of VAC dressing, negative pressure dressing lumbar wound 80 square cm . Long-term wound VAC . Acute UTI . Anemia; uncertain etiology. May be related to postop blood loss versus infection . transfuse 1 PRBC 10/20 . Follow up with [ID Doctor] in 2-3 weeks after discharge. Patient will likely need oral suppressive antibiotic after finishing the IV as she does have infected hardware . wound vac in place on low back . Continue wound vac with MWF changes . Record review from Resident #99's hospital admission after her admission at [Facility,] titled [Hospital] Brief Operative Report, dated 10/22/2024, reflected Pre-operative diagnosis . Lumbar Spine Dehiscence . Name of Procedure: 1. Excisional debridement of skin, subcutaneous tissue, and bone of the lumbar spine 2. Placement of deep antibiotic beads 3. Placement of negative pressure wound vac . Findings: 1. Open lumbar spine wound 2. Necrotic tissue wound bed . Assessment/Plan . Plastic surgery was consulted for wound closure. Record review from Resident #99's hospital admission after her admission at [Facility,] titled [Hospital] Hospitalist Progress Note, dated 10/28/2024 revealed status post I&D by neurology on 10/09. Disposition . patient will need rehab secondary to multiple needs starting from deconditioning wound vac to IV antibiotics. Personally messaged plastic surgery . Record review from Resident #99's hospital admission after her admission at [Facility,] titled [Hospital] Wound Progress Note, dated 10/29/2024 revealed Wound Diagnosis: S/p excisional debridement of lumbar wound . location low back, midline . type open surgical or dehisce . drain wound vac/neg pressure . dressing drainage amount copious . serosanguineous . length/width/depth 8.8 x 3.5 x 5.9 cm . percent necrotic tissue 5%. Facility policy review: Record review of the facility policy, Notifying the Physician of Change in Status, dated 03/11/2013, reflected The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention . 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record . 3 . The nurse is responsible . for responding to a change in condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. 4 . The nurse will document all attempts to contact the physician in the resident's clinical record . Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve. Review of facility policy, Skin Integrity Management, undated/provided by the facility's CCD via email on 11/08/2024 at 3:27 PM did not specifically address surgical/incisional site care. In interview with facility's CCD via email at 11/27/2024 at 10:35 AM revealed the facility did not have a policy specific to surgical care, incision site care, or quality of care. This was determined to be an Immediate Jeopardy (IJ) on 11/08/2024 at 12:35 PM. The Administrator, Director of Nursing, Area Director of Operations, and Clinical Compliance Director were notified. The Administrator, DON, ADO, and the CCD as provided with the IJ template on 11/08/2024 at 12:35 PM and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 11/27/2024 at 3:15 PM. [Facility] 11/8/2024 [rev. 11/27/2024] Plan of Removal F580 Notify Change of Condition Interventions: 100% skin sweep of all residents completed on 11/8/24 by the DON, ADON, and Charge Nurses. All residents with wounds including surgical wounds were assessed on 11/8/24 by the DON for potential decline in wound status. No acute changes noted. The Administrator and DON were in-serviced 1:1 on the following by the Regional Compliance Nurse on 11/8/24. Notification of Change in Condition Policy- Reporting changes in condition involving wounds to the physician, nurse practitioner, or surgeon - i.e., new wound or decline of a current wound. If the change in condition involves a surgical wound, the surgeon will also be notified immediately for any additional orders. If a LVN or RN Charge Nurse does not assess or notify the physician timely, the DON or Administrator will be notified. -All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site, as of 11/27/24. DON/designee to monitor weekly for compliance. -All surgical wounds/incisions changes or decline in condition will be reported to the surgeon of the incision site and attending physician. This will start 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee to ensure surgeon contact information is available in resident's EMR upon admission, starting 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds, as of 11/27/24. DON/designee to monitor weekly for compliance. Abuse and Neglect Policy to include failure to assess a wound and/or notify a physician for a change in condition on a wound including surgical wounds, could be considered neglect. The DON or Designee will review the clinical dashboard daily for any documentation that notes a change in condition in wounds including surgical wounds. The DON or Designee will ensure that the wound was assess and notification to the Attending MD as well as the Surgeon was completed timely. This will begin 11/8/24 and continue indefinitely. -All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site, as of 11/27/24. DON/designee to monitor weekly for compliance. -All surgical wounds/incisions changes or decline in condition will be reported to the surgeon of the incision site and attending physician. This will start 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee to ensure surgeon contact information is available in resident's EMR upon admission, starting 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds, as of 11/27/24. DON/designee to monitor weekly for compliance. The medical director was notified of the immediate jeopardy situation on 11/8/24 by the Administrator. An ADHOC QAPI meeting was completed on 11/8/24 to include the IDT team and Medical Director. The following in-services were initiated by the DON, ADON and regional nurse on 11/8/24. Any staff member not present or in-serviced on 11/8/24, will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation prior to taking an assignment. All agency staff will in serviced prior to their scheduled shift. All Charge Nurses: -Notification of Change in Condition Policy- Reporting changes in condition involving wounds to the physician, nurse practitioner, or surgeon - i.e. new wound or decline of a current wound. If the change in condition involves a surgical wound, the surgeon will also be notified immediately for any additional orders. If a LVN or RN Charge Nurse does not assess or notify the physician timely, the DON or Administrator will be notified. -All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site, as of 11/27/24. DON/designee to monitor weekly for compliance. -All surgical wounds/incisions changes or decline in condition will be reported to the surgeon of the incision site and attending physician. This will start 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee to ensure surgeon contact information is available in resident's EMR upon admission, starting 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds, as of 11/27/24. DON/designee to monitor weekly for compliance. Abuse and Neglect Policy to include failure to assess a wound and/or notify a physician for a change in condition on a wound including surgical wounds, could be considered neglect. Non-licensed nursing staff -Abuse and Neglect Policy- failure report a change a change in condition on a resident such as a new or worsening wound, could be considered neglect. -Notification of Change in Condition Policy- Reporting negative changes in condition involving wounds to the charge nurse immediately. Changes include a soiled dressing, foul odor, redness, or complaints of pain to the wound. If the charge nurse is not available, the DON or ADON will be notified. Monitoring of the POR Included the following: Record review of the facility's Skin Sweep Documentation on 11/08/2024 at 4:58 PM reflected no other post operative residents at the facility. In interview with facility's CCD on 11/08/2024 at 1:00 PM she stated there were no post-operative surgical residents currently at the facility. In follow-up interview with facility's CCD on 11/27/2024 at 11:40 AM she stated there were no post-operative surgical residents currently at the facility. Record review on 11/08/2024 of facility's AD HOC QUAPI meeting minutes and sign in sheet, titled OFF CYCLE (AD HOC) QA MEETING DOCUMENT, content included facility failures related to physician notification, assessment, and abuse/and or neglect. Facility CCD, DON, Administrator, Medical Director, and ADO signatures were included. Record review on 11/08/2024 of In-service, Notification of Change in Condition, conducted by CCD, included facility definition, purpose, process for provider notification as it related to all surgical wounds/incisions changes or decline in condition are required to be reported to the surgeon and attending physician by utilizing the facility sanctioned communication documents. Facility Administrator and DON's signatures were included. Record review on 11/08/2024 of In-service, Notifying the Physician of Change in Status, conducted by the Administrator and the DON, included facility definition, purpose, process for provider notification as it related to all surgical wounds/incisions changes or decline in condition are required to be reported to the surgeon and attending physician by utilizing the facility sanctioned communication documents. Multiple staff RN and LVN signatures were included. Record review on 11/08/2024 of In-service, Abuse and Neglect, conducted by CCD, included facility definition of abuse/neglect, identification of abuse/neglect, and facility specific policy, protocol, and procedure for reporting abuse/neglect at the facility. Facility Administrator and DON's signatures were included. Record review on 11/08/2024 of In-service, Abuse and Neglect, conducted by DON, included facility definition of abuse/neglect, identification of abuse/neglect, and facility specific policy, protocol, and procedure for reporting abuse/neglect at the facility. Multiple staff signatures included department leadership, rehabilitation department, nurses, nursing aides, social services, dietary department, housekeeping, and the maintenance department. In interview with facility's CCD via email on 12/06/2024 at 12:32 PM, she clarified that the facility's Abuse and Neglect policy was not revised; but the facility in-serviced on the current policy. This includes a clarification that neglect could include failure to notify would be considered neglectful. Record review on 11/27/2024 of In-service titled, SBAR, conducted by CCD, included the SBAR definition, purpose, process, relevant examples, and specific procedure as it related to all surgical wounds/incisions changes or decline in condition to be reported to the surgeon and attending physician by utilizing the facility's SBAR document. Facility Administrator and DON's signatures were included. Record review on 11/27/2024 of In-service titled, SBAR for Surgical Incisions, conducted by DON, included the SBAR definition, purpose, process, relevant examples, and specific procedure as it related to all surgical wounds/incisions changes or decline in condition to be reported to the surgeon and attending physician by utilizing the facility's SBAR document. Multiple facility nursing staff signatures were included. In interview with the facility Administrator and DON on 11/08/2024 at 6:10 PM and 6:02 PM respectively, they stated the clinical dashboard was reviewed for compliance as per the POR. In follow up interview with the Administrator and DON on 11/27/2024 at 1:50 PM, they stated the clinical dashboard was reviewed for compliance which included action items added by the facility on 11/27/2024 per the POR. In interview with the facility Administrator on 11/08/2024 at 6:10 PM, he stated failure to report a change a change in condition to the resident's nurse could be considered neglect. Immediate notification to a provider for any resident change in condition was important. He sufficiently explained what would constitute a change in condition and the signs and symptoms his staff should be monitoring for infection. He further stated what and where his staff should be documenting any change in condition in the electronic medical record (EMR) and the other parties that should be notified in addition to the provider. He sufficiently defined abuse, neglect, and/or exploitation and the expectations of his staff to report any observed, reported, or suspected abuse, neglect, and/or exploitation to him immediately. In follow up interview with facility's Administrator on 11/27/2024 at 2:30 PM he stated facility's DON, or a designee were responsible for daily monitoring of new surgical incision resident orders and will present this information to leadership during the daily stand-up meeting to ensure treatment orders are in place and admission assessments included surgical incision sites. He stated the DON was responsible to ensure resident surgical contact information was updated in resident EMRs upon admission and was responsible for monitoring weekly for compliance. He stated he will ensure the DON will complete weekly audits to ensure that all surgical wounds were to monitored daily by nurses, any changes or decline were reported to attending physician and surgeon of incision site, to ensure all surgical wounds have treatment orders upon admission, all surgical wounds/incisions changes or decline in condition were reported to the surgeon and attending physician, and all skin assessments upon admission reflect any surgical incisions a resident may have. He stated the DON will complete an audit weekly to ensure charge nurses included surgical incision sites on baseline care plans upon admission and the DON included any updates in

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #99) of two residents reviewed for quality of care. 1. The facility failed to ensure physician orders for treatment, care, and monitoring of Resident #99's surgical site incision was obtained upon admission resulting a subsequent infection that required hospitalization and surgical intervention. 2. The facility failed to complete and document any skin/incision/wound assessments of Resident #99's surgical incision site resulting a subsequent infection that required hospitalization and surgical intervention. 3. The facility failed to develop a baseline care plan that addressed Resident #99's surgical care needs. An Immediate Jeopardy (IJ) situation was identified on 11/08/2024 at 12:35 PM. The IJ was removed on 11/27/2024 at 3:15 PM the facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed Resident #99 at risk of not receiving timely medical intervention as needed and ordered by the physician, of not having their health condition monitored timely for changes in condition, which resulted in a delay in medical intervention and decline in health for Resident #99. As a result of these failures, Resident #99 was re-admitted to the hospital on [DATE] and required further treatment, surgeries, IV antibiotics, and medical devices. Findings include: Record review of Resident #99's Face Sheet, dated 11/07/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #99 had relevant diagnoses which included metabolic encephalopathy (alteration in consciousness caused by diffuse or global brain dysfunction from impaired cerebral metabolism,) subluxation of lumbar vertebra (misalignment of spine,) wedge compression fracture of thoracic vertebrae (one or more back bones collapse,) protein-calorie malnutrition, anxiety (persistent nervousness, anxiety, and/or restlessness) and major depressive disorder (persistent low mood.) Record review of Resident #99's MDS dated [DATE], reflected she was cognitively intact with a BIMS score of 15. She required a wheelchair for mobility and required substantial/maximal assistance with toileting and shower/baths which included transfers. Record review of Resident #99's Baseline Care Plan dated 09/26/2024 at 2:30 PM revealed no evidence of surgical site assessment, treatment, or care documentation. Record review of Resident #99's Comprehensive Care Plan was not available for review due to the resident's short-term stay at the facility. Record review of Resident #99's Physician Orders reflected her attending physician as Dr N, Admit to Skilled Services Under The Care of [Dr N] effective 09/20/2024. No orders stated monitoring of surgical site and/or treatment and care from Dr N were observed. Record review of Resident #99's Physician Orders from Dr L stated Clean surgical site on lower back with normal saline, pat dry and apply dry dressing one time a day for wound care start date 10/05/2024. An order to monitor surgical site stated, Monitor surgical site for infection one time a day for wound care start date 10/05/2024. Record review of Resident #99's Physician Orders on 11/27/2024 at 9:30 AM revealed no evidence of physician orders for monitoring of surgical site and/or treatment and care for Resident #99's surgical incision site for the month of September. Record review of Resident #99's Discharge Instructions, from [Hospital] prior to Resident #99's admission at [Facility,] dated 09/20/2024, reflected Resident #99 had back and pelvis surgery on 09/15/2024. Procedures/Surgeries . L4-L5 Laminectomy, L3 to Pelvis Posterior Instrumentation Fusion . Notify PCP of these signs and symptoms . increased redness, increased swelling, increased tenderness/pain . bleeding . pus-like discharge .Dispo: SNF on discharge. S/p L3-S2 instrumentation with pelvic fixation and L4-L5 laminectomy Record review of Resident #99's Progress Notes, dated 10/04/2024, completed by the facility's Treatment Nurse stated she reported Resident #99's incision site drainage to Dr L, Noticed resident surgical site was draining, wound DR was informed to see her next visit to the facility, but she stated she cannot see resident unless the surgeon request for her to see patient because patient is still under the care of the surgeon for 3 months. Order to clean surgical site with normal saline and apply dry dressing and order to monitor the surgical site are both in place. Record review of Provider Notes authored by Dr N's Nurse Practitioner, NP L with an encounter date 10/07/2024, reflected Patient lethargic today, she awakens to tactile stimuli and drifts off quickly. Nurse reports surgeon appointment tomorrow Record review of the document reflected no evidence of surgical site observation, assessment, and/or intervention. Record review of Resident #99's Weekly Skin Assessment - V 5 history reflected four assessments on 09/30/2024, two on 10/07/2024, and 10/08/2024 completed by facility's Treatment Nurse. No evidence of Resident #99's incision site was documented by any staff member nor the facility's Treatment Nurse. An additional record review of Resident #99's on 11/27/2024 of Weekly Skin Assessment - V 5 revealed no evidence of Resident #99's incision site documentation by any staff member nor the facility's Treatment Nurse. Record review of Resident #99's Progress Notes, with a look-back period between 10/04/2024 - 10/08/2024, reflected no documentation related to a completed assessment or notification to a provider of Resident #99's incision site drainage nor any other surgical concerns. An additional record review of Resident #99 on 11/27/2024 of Progress Notes, with a look-back period between 10/04/2024 - 10/08/2024, reflected no documentation related to a completed assessment or notification to a provider of Resident #99's incision site drainage nor any other surgical concerns. In interview with the facility's Wound Physician, Dr L, on 11/06/2024 at 7:16 AM, she stated she never saw or treated Resident #99 as a patient. She stated she never intended to see her at the facility as she did not see post operative neurological or orthopedic patients unless specifically requested by the surgeon. She stated she directed the Treatment Nurse to report her concerns to Resident #99's surgeon. She stated the appropriate monitoring and timely reporting of any surgical site concerns to Resident #99's surgeon was important for infection control purposes. Interview attempts with Resident #99's Surgeon, Dr B, on 11/07/2024 at 11:11 AM and 11/08/2024 at 11:32 AM were unsuccessful. In interview with CNA G on 11/08/2024 at 8:32 AM, she stated she recalled observing and immediately reporting to Treatment Nurse that Resident #99's dressing on her back was soiled with drainage, but she did not recall the specific date this occurred. In interview with the Treatment Nurse on 11/07/2024 at 2:08 PM, she stated CNA G reported Resident #99's surgical incision site on her back was draining on 10/04/2024. She stated she called the facility's wound care doctor, Dr L, for advice but stated Dr L was not Resident #99's provider at this time. She stated Dr L gave her a verbal order to change Resident #99's dressing, to monitor incision site for infection, and to notify her surgeon immediately for further instruction. The Treatment nurse stated she delegated Resident #99's nurse for that day, RN K, to notify the surgeon the incision site had drainage. In follow-up interview with facility's Treatment Nurse on 11/27/2024 at 11:50 AM, she stated she did not notify Resident #99's physician of a change in condition because she delegated that to RN K. She stated she did not document an incision site assessment because there was no physician order that came with [Resident #99's] incision when [Resident #99] was admitted . She stated she did not document any skin assessments of Resident #99's incision site because physician orders dictate her assessment documentation and treatment requirements. In interview with RN K on 11/07/2024 at 12:29 PM, he stated he did not recall any significant events of 10/04/2024 nor the facility's Treatment Nurse asking him to notify Resident #99's surgeon that day. He stated he was not sure if he was allowed to call Resident #99's surgeon directly. RN K referred to his cell phone and stated he was Resident #99 nurse on 10/04/2024, 10/06/2024, 10/07/2024 and 10/08/2024. He stated he did not notice any incision site changes on Resident #99 until just prior to the end of his shift on 10/07/2024. He stated he observed a little bit of pink drainage and the incision looked open on 10/07/2024. He stated he reported to Dr N that I think we need labs on this lady [Resident #99,] but he did not report to Dr N any concerns related to her incision site. He stated he did not report his observations to Resident #99's surgeon either. He stated it slipped his mind and he got busy and did not document it. He stated it was important to report any changes to a resident's surgical incision to a provider because it's an infection risk, a lot of things can happen . which can lead to sepsis. He stated he told the night shift nurse, LVN J, to watch out for this lady, but did not recall if he reported to her about Resident #99's incision site changes. In interview with LVN J on 11/07/2024 at 2:20 PM, she stated she did not recall any specifics as it's been a long time. She stated as far as she knew, when she took care of Resident #99 her incision site was intact during night shift. She stated it was important to report any changes in status of the resident to the doctor immediately for the safety of the resident. In interview with LVN Y on 11/07/2024 at 1:09 PM, she stated her first day of employment at the facility was 10/03/2024. She stated she worked with RN K under his supervision in orientation on 10/06/2024. She stated on 10/06/2024 she stated she observed Resident #99's incision dehisced (to come apart) and observed serosanguinous drainage (thin, watery, pink discharge containing serous fluid and blood) on Resident #99's back incision dressing. LVN Y stated she showed RN K the soiled dressing and reported her observation to him. She stated she did not notify any physicians. She stated she did not recall if any doctors were notified that day and she was on orientation and assumed [RN K] reported it to the doctor. In a follow up interview with RN K on 11/07/2024 at 2:50 PM, he stated he trained LVN Y on 10/06/2024. He stated he did not recall observing Resident #99's incision site that day but he should have. He stated LVN Y did show him Resident #99's soiled dressing with light drainage present, but he did not conduct any follow up assessments on Resident #99's incision site and could not specify why. He stated he should have because LVN Y was his trainee, and that it was his responsibility to assess Resident #99's incision site because something negative can occur. RN K stated he should have notified Resident #99's surgeon but stated he did not and could not specify why. In interview with Resident #99's attending doctor, Dr N, she stated she was not informed of any incision site physician orders, incision site changes, or concerns. She stated her expectations were, at a minimum, for the facility staff to notify her of any resident condition changes so follow up with the surgeon could be facilitated. She stated this was important for infection purposes, especially surgical cases. In interview with Dr N's Nurse Practitioner, NP L, on 11/08/2024 at 8:12 AM, she stated he was not informed of any incision site changes or concerns. She stated she saw Resident #99 at the facility on 10/07/2024 but was not informed of any incision site changes or concerns and did not assess the incision site. She stated if I had known, I would have taken a look at it [incision site] and assessed as it was important for infection purposes. She stated she expected the facility to ultimately report any incision site changes to the surgeon for further advisement. In interview with Resident #99's family member on 11/05/2024 at 11:33 AM and 11/07/2024 at 1:34 PM, he stated Resident #99 had to go back into the hospital for another surgery after her admission at [Facility.] He stated he believed the incision came apart on 10/06/2024. He further stated on 10/07/2024 I noticed her acting strange, like the infection had returned. On 10/08/2024, Resident #99 had a follow up appointment with her surgeon where it was found the infection had indeed returned and she was re-admitted to the hospital where she had to have another surgery to clean out their [the facility's] mistake. He stated Resident #99 has experienced a lot of pain and suffering due to the facility's negligence. In a follow up interview with Resident #99's family member on 11/13/2024 at 9:11 AM, he stated Resident #99's current condition was she has pretty much [gone] out of her mind, she stays very confused, and she does not know where she is and is still having [cognitive] problems. He stated he was hopeful that her course of Intravenous (IV) antibiotics would help her get back to normal but it hasn't happened yet . Attempts to interview Resident #99 on 11/08/2024 at 2:00 PM and 11/13/2024 9:11 AM were unsuccessful due to her cognitive limitations. In interview with DON on 11/08/2024 at 9:14 AM, she stated it was her expectation for Resident #99's surgeon to be called immediately if there were any incision site changes. She stated this was not done and it was a failure on the facility's part. The DON stated no documentation was able to be provided to reflect that any provider of Resident #99 was notified about her incision site changes. She stated prompt notification to a provider about a decline in condition and/or incision site changes was important for infection control purposes. In interview with the Administrator on 11/08/2024 at 11:35 AM, he stated his expectations were for the nurse to have reported it [incision site changes] to the doctor. He stated it was important for facility nursing staff to notify the doctor of any changes a resident may have to prevent any decline. In interview with the facility's ADO on 11/08/2024 at 12:35 PM, she stated she did not expect the surgeon to be called by facility per their [facility] policy. She provided the State Surveyor with facility policy, Notifying the physician of Change in Status and stated facility nurses see incisions as wounds and she felt the facility notified the appropriate provider [Dr L.] She further stated it was then Dr L's responsibility to follow up with the surgeon and not the facility staff. Record review of the facility's staffing schedule, provided by the DON, via email on 11/07/2024 reflected: RN K worked day shift on 10/04/2024, 10/06/2024, 10/07/2024, and 10/08/2024. LVN J worked night shift 10/06/2024 and 10/07/2024. LVN Y worked day shift and was in orientation 10/05/2024 and 10/06/2024. On 10/06/2024, RN K oriented LVN Y on day shift. The following documents reviewed state Resident #99's status and condition immediately after her admission at [Facility] and after her 10/08/2024 surgical appointment that necessitated her subsequent re-admission to [Hospital] on 10/08/2024: Record review of Resident #99's Discharge Summary dated 10/30/2024, from Resident #99's hospital admission after her admission at [Facility] revealed Discharge diagnosis . lumbar incisional wound dehiscence with possible infection . Hospital course . recent L4/L5 laminectomy and L3 to pelvis posterior instrumentation done 09/15/2024 and discharged to SNF. She presented to outpatient neurosurgery clinic from SNF for evaluation of lower back wound with discharge. She was seen at outpatient clinic and sent to ER from neurosurgery clinic for evaluation of lumbar wound dehiscence and yellow-colored drainage . continue wound vac . intraoperative culture results and UTI culture results, both growing E. coli (bacteria) . ID recommend to continue 6 week of antibiotics, Rocephin 2 g daily through a PICC line, right upper extremity PICC line in place . Followed by plastic surgery . Procedures: 1. Excisional debridement of skin, subcutaneous tissue, muscle and bone, lumbar wound 120 square cm. 2. Drainage of deep lumbar abscess. 3. Application of a drug-eluting antibiotics beads deep in lumbar wound over lumbosacral area. 4. Application of VAC dressing, negative pressure dressing lumbar wound 80 square cm . Long-term wound VAC . Acute UTI . Anemia; uncertain etiology. May be related to postop blood loss versus infection . transfuse 1 PRBC 10/20 . Follow up with [ID Doctor] in 2-3 weeks after discharge. Patient will likely need oral suppressive antibiotic after finishing the IV as she does have infected hardware . wound vac in place on low back . Continue wound vac with MWF changes . Record review from Resident #99's hospital admission after her admission at [Facility,] titled [Hospital] Brief Operative Report, dated 10/22/2024, reflected Pre-operative diagnosis . Lumbar Spine Dehiscence . Name of Procedure: 1. Excisional debridement of skin, subcutaneous tissue, and bone of the lumbar spine 2. Placement of deep antibiotic beads 3. Placement of negative pressure wound vac . Findings: 1. Open lumbar spine wound 2. Necrotic tissue wound bed . Assessment/Plan . Plastic surgery was consulted for wound closure. Record review from Resident #99's hospital admission after her admission at [Facility,] titled [Hospital] Hospitalist Progress Note, dated 10/28/2024 revealed status post I&D by neurology on 10/09. Disposition . patient will need rehab secondary to multiple needs starting from deconditioning wound vac to IV antibiotics. Personally messaged plastic surgery . Record review from Resident #99's hospital admission after her admission at [Facility,] titled [Hospital] Wound Progress Note, dated 10/29/2024 revealed Wound Diagnosis: S/p excisional debridement of lumbar wound . location low back, midline . type open surgical or dehisce . drain wound vac/neg pressure . dressing drainage amount copious . serosanguineous . length/width/depth 8.8 x 3.5 x 5.9 cm . percent necrotic tissue 5%. Facility policy review: Record review of the facility policy, Notifying the Physician of Change in Status, dated 03/11/2013, reflected The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention . 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record . 3 . The nurse is responsible . for responding to a change in condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. 4 . The nurse will document all attempts to contact the physician in the resident's clinical record . Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve. Review of facility policy, Skin Integrity Management, undated, provided by the facility's CCD via email on 11/08/2024 at 3:27 PM did not specifically address surgical/incisional site care. In interview with facility's CCD via email at 11/27/2024 at 10:35 AM revealed the facility did not have a policy specific to surgical care, incision site care, or quality of care. Review of facility policy, Base Line Care Plans, undated provided by facility CCD via email on 11/27/2024 at 11:51 AM revealed Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission . The baseline care plan will . Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- Initial goals based on admission orders, physician orders . The baseline care plan will reflect the resident's stated goals and objectives and include interventions that address his or her current needs. It will be based on the admission orders, information about the resident available from the transferring provider, and discussion with the resident and resident representative, if applicable. Because the baseline care plan documents the interim approaches for meeting the resident's immediate needs, professional standards of quality care would dictate that it must also reflect changes to approaches, as necessary, resulting from significant changes in condition or needs, occurring prior to development of the comprehensive care plan. Facility staff will implement the interventions to assist the resident to achieve care plan goals and objectives . This was determined to be an Immediate Jeopardy (IJ) on 11/08/2024 at 12:35 PM. The Administrator, Director of Nursing, Area Director of Operations, and Clinical Compliance Director were notified. The Administrator, DON, ADO, and the CCD as provided with the IJ template on 11/08/2024 at 12:35 PM and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 11/27/2024 at 3:15 PM. [Facility] 11/8/2024 [rev. 11/27/2024] Plan of Removal F684 Quality of Care Interventions: 100% skin sweep of all residents completed on 11/8/24 by the DON, ADON, and Charge Nurses. All residents with wounds including surgical wounds were assessed on 11/8/24 by the DON for potential decline in wound status. No acute changes noted. The Administrator and DON were in-serviced 1:1 on the following by the Regional Compliance Nurse on 11/8/24. Notification of Change in Condition Policy- Reporting changes in condition involving wounds to the physician, nurse practitioner, or surgeon - i.e., new wound or decline of a current wound. If the change in condition involves a surgical wound, the surgeon will also be notified immediately for any additional orders. If a LVN or RN Charge Nurse does not assess or notify the physician timely, the DON or Administrator will be notified. -All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site, as of 11/27/24. DON/designee to monitor weekly for compliance. -All surgical wounds have treatment orders, upon admission, as of 11/27/24. DON/designee to monitor weekly for compliance. -All skin assessments, upon admission and weekly reflect any surgical incision, as of 11/27/24. DON/designee to monitor initial skin assessments weekly for compliance. -DON/designee to monitor new surgical incision resident orders during daily stand up to ensure treatment orders are in place and admission assessment includes surgical incisions, starting 11/27/24. -DON/designee to ensure surgeon contact information is available in resident's EMR upon admission, starting 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds, as of 11/27/24. DON/designee to monitor weekly for compliance. Abuse and Neglect Policy to include failure to assess a wound and/or notify a physician for a change in condition on a wound including surgical wounds, could be considered neglect. The DON or Designee will review the clinical dashboard daily for any documentation that notes a change in condition in wounds including surgical wounds. The DON or Designee will ensure that the wound was assess and notification to the Attending MD as well as the Surgeon was completed timely. This will begin 11/8/24 and continue indefinitely. -All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site, as of 11/27/24. DON/designee to monitor weekly for compliance. -All surgical wounds have treatment orders, upon admission, as of 11/27/24. DON/designee to monitor weekly for compliance. -All skin assessments, upon admission and weekly reflect any surgical incision, as of 11/27/24. DON/designee to monitor initial skin assessments weekly for compliance. -DON/designee to monitor new surgical incision resident orders during daily stand up to ensure treatment orders are in place and admission assessment includes surgical incisions, starting 11/27/24. -DON/designee to ensure surgeon contact information is available in resident's EMR upon admission, starting 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds, as of 11/27/24. DON/designee to monitor weekly for compliance. The medical director was notified of the immediate jeopardy situation on 11/8/24 by the Administrator. An ADHOC QAPI meeting was completed on 11/8/24 to include the IDT team and Medical Director. The following in-services were initiated by the DON, ADON and regional nurse on 11/8/24. Any staff member not present or in-serviced on 11/8/24, will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation prior to taking an assignment. All agency staff will in serviced prior to their scheduled shift. All Charge Nurses: -All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site, as of 11/27/24. DON/designee to monitor weekly for compliance. -All surgical wounds have treatment orders, upon admission, as of 11/27/24. DON/designee to monitor weekly for compliance. -All skin assessments, upon admission and weekly reflect any surgical incision, as of 11/27/24. DON/designee to monitor initial skin assessments weekly for compliance. -The Charge nurse or designee will include surgical incision sites on the baseline care plan upon admission, as of 11/27/24. Charge nurse or designee will update the baseline care plan for changes in surgical incision site, as of 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee to monitor new surgical incision resident orders during daily stand up to ensure treatment orders are in place and admission assessment includes surgical incisions, starting 11/27/24. -DON/designee to ensure surgeon contact information is available in resident's EMR upon admission, starting 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds, as of 11/27/24. DON/designee to monitor weekly for compliance. Abuse and Neglect Policy to include failure to assess a wound and/or notify a physician for a change in condition on a wound including surgical wounds, could be considered neglect. Non-licensed nursing staff -Abuse and Neglect Policy- failure report a change a change in condition on a resident such as a new or worsening wound, could be considered neglect. -Notification of Change in Condition Policy- Reporting negative changes in condition involving wounds to the charge nurse immediately. Changes include a soiled dressing, foul odor, redness, or complaints of pain to the wound. If the charge nurse is not available, the DON or ADON will be notified. Monitoring of the POR Included the following: Record review of the facility's Skin Sweep Documentation on 11/08/2024 at 4:58 PM reflected no other post operative residents at the facility. Record review of 5 recent admissions at [Facility] on 11/27/2024 at approximately 3:00 PM revealed compliance with admission physician orders, baseline care plans, skin assessments, and clinical dashboard information. Record review on 11/08/2024 of facility's AD HOC QUAPI meeting minutes and sign in sheet, titled OFF CYCLE (AD HOC) QA MEETING DOCUMENT, content included facility failures related to physician notification, assessment, and abuse/and or neglect. Facility CCD, DON, Administrator, Medical Director, and ADO signatures were included. Record review on 11/08/2024 of In-service, Notification of Change in Condition, conducted by CCD, included facility definition, purpose, process for provider notification as it related to all surgical wounds/incisions changes or decline in condition are required to be reported to the surgeon and attending physician by utilizing the facility sanctioned communication documents. Facility Administrator and DON's signatures were included. Record review on 11/08/2024 of In-service, Notifying the Physician of Change in Status, conducted by the Administrator and the DON, included facility definition, purpose, process for provider notification as it related to all surgical wounds/incisions changes or decline in condition are required to be reported to the surgeon and attending physician by utilizing the facility sanctioned communication documents. Multiple staff RN and LVN signatures were included. Record review on 11/08/2024 of In-service, Abuse and Neglect, conducted by CCD, included facility definition of abuse/neglect, identification of abuse/neglect, and facility specific policy, protocol, and procedure for reporting abuse/neglect at the facility. Facility Administrator and DON's signatures were included. Record review on 11/08/2024 of In-service, Abuse and Neglect, conducted by DON, included facility definition of abuse/neglect, identification of abuse/neglect, and facility specific policy, protocol, and procedure for reporting abuse/neglect at the facility. Multiple staff signatures included department leadership, rehabilitation department, nurses, nursing aides, social services, dietary department, housekeeping, and the maintenance department. Record review on 11/27/2024 of In-service titled, SBAR, conducted by CCD, included the SBAR definition, purpose, process, relevant examples, and specific procedure as it related to all surgical wounds/incisions changes or decline in condition to be reported to the surgeon and attending physician by utilizing the facility's SBAR document. Facility Administrator and DON's signatures were included. Record review on 11/27/2024 of In-service titled, SBAR for Surgical Incisions, conducted by DON, included the SBAR definition, purpose, process, relevant examples, and specific procedure as it related to all surgical wounds/incisions changes or decline in condition to be reported to the surgeon and attending physician by utilizing the facility's SBAR document. Multiple facility nursing staff signatures were included. In interview with the facility Administrator and DON on 11/08/2024 at 6:10 PM and 6:02 PM respectively, they stated the clinical dashboard was reviewed for compliance as per the POR. In follow up interview with the Administ[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan to include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for each resident for (Resident #1, Resident #2, Resident #3) 3 of 6 residents reviewed for Comprehensive Care Plans. The facility failed to ensure Resident #1, Resident #2, and Resident #3 had comprehensive care plans to reflect their high elopement risk. Consequently, the facility failed to properly supervise Resident #1, a psychiatrically affected and assessed as high risk for elopement resident, from elopement on [DATE]. Resident #1 eloped via an unknown route and was located by Law Enforcement approximately 4.9 miles away from the facility. An IJ was identified on [DATE] at 4:14 PM. The IJ template was provided to the facility on [DATE] at 4:32 PM. While the IJ was removed on [DATE] at 12:45 PM, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because all staff had not been trained at the time of exit [DATE] at 6:00 PM. This failure could place residents at risk for comprehensive care plans that do not meet the resident's customized supervison needs, which could lead to an elopement from the facility which could result in serious injury and/or death. Findings included: Review of Resident #1's Face Sheet dated [DATE] revealed he was a [AGE] year-old male re-admitted to the facility on [DATE] from an acute care hospital for rehabilitation. Relevant diagnoses included schizoaffective disorder bipolar type (psychotic symptoms, such as hallucinations or delusions, as well as symptoms of a mood disorder - either bipolar type (episodes of mania and sometimes depression), depression (mood disorder) unsteadiness on feet, unspecified lack of coordination, cognitive communication deficit, altered mental status, suicidal ideations, auditory hallucinations (hearing things that are not real,) and elevated white blood cell count (infection.) Record review of Resident #1's Elopement Risk Assessment, dated [DATE] revealed he was a high elopement risk. Resident #1's Elopement Risk Assessment reflected: .7. Elopement Screen .A score of 5 or greater = HIGH RISK for Wandering/Elopement Potential .5. Based on admission information and/or responsible party information has the resident ever eloped before or does the resident have a habit of wandering or pacing? A) Yes [score 5.] Review of Resident #1's MDS, dated [DATE], revealed he was cognitively intact with a BIMS score of 15. Resident #1 required supervision of one staff to physically assist him to walk in room, and supervision of setup help only to walk in corridor, locomotion on unit, locomotion off unit. He did not require any assistive devices for ambulation and was scored as steady at all times when moving from seated to standing position, walking, turning around and facing the opposite direction when walking, moving on and off toilet, and surface-to-surface transfers. Review of Resident #1's Comprehensive Care Plan, dated [DATE], revealed he was at risk for falls, required assistance with ADLs, was on antidepressant, antianxiety, and hypnotic medications that required monitoring for effectiveness and/or negative outcomes. No evidence of elopement risk or precautions were indicated in Resident #1's care plan. Record Review of Resident #1's EHR on [DATE] revealed there was not an assessment or an evaluation to determine Residnet #1 ability to to independently and safety sign out of the facility on temporary leave by himself. Review of Resident #2's Face Sheet on [DATE] at 3:39 PM revealed she was a [AGE] year-old female admitted to the facility on [DATE] from an assisted living facility. Relevant diagnoses included dementia, visual loss, unsteadiness on feet, lack of coordination, disorientation, fatigue, and need for continuous supervision. Record review of Resident #2's most recent Elopement Risk Assessment, dated [DATE] revealed she was a high elopement risk due to C. Adjustment to Facility . Statement and/or threats to leave facility . 4. Confused expressions related to tasks to complete . D. Cognitive Skills for Daily Decision Making . 4. Moderately impaired - decisions poor, cues/supervision required. Review of Resident #2's Comprehensive Care Plan, dated [DATE], revealed she was at risk for falls, required assistance with ADLs, had impaired cognitive function, confusion, or memory problems, with an intervention that included to Report any new or worsening confusion to the nurse. No evidence of elopement risk or precautions were indicated in Resident #2s care plan. Review of Resident #3's Face Sheet on [DATE] at 3:45 PM revealed he was an [AGE] year-old male admitted to the facility on [DATE] from an acute care hospital. Relevant diagnoses included encephalopathy (damage or disease that affects the brain,) cerebral ischemia (impaired blood flow to the brain that results in injury,) dementia, difficulty walking, unsteadiness on feet, lack of coordination, hemiplegia and hemiparesis (muscle weakness on one side of the body) following cerebrovascular (related to blood flow to the brain) disease affecting right dominant side and need for assistance with personal care. Record review of Resident #3's most recent Elopement Risk Assessment, dated [DATE] revealed he was a high elopement risk due to B. Physical Capability . 1. Physical Capability 3. Self propels wheelchair . C. Adjustment to Facility . Statement and/or threats to leave facility . 4. Confused expressions related to tasks to complete . D. Cognitive Skills for Daily Decision Making . 4. Moderately impaired - decisions poor, cues/supervision required. Review of Resident #3's Comprehensive Care Plan, dated [DATE], revealed he was very impulsive and was a high fall risk, and required close monitoring to prevent serious injury related to falls. He required assistance with ADLs, was on an antipsychotic and anticoagulant medications that required monitoring for effectiveness and/or negative outcomes. Resident #3 had a history of behaviors that included agitation or anxiety and required special assistance and care when experiencing an episode. His care plan revealed no evidence of elopement risk or precautions prior to surveyor's entry into the facility. In an interview with the Administrator on [DATE] at 10:31 AM, he stated that Resident #1 had a BIMS score of 15 and was very high functioning. Administrator stated the facility was aware of Resident #1's elopement risk and they had provided him a room away from any exit doors, and in a high traffic area close to the nurse's station to enable enhanced monitoring. Administrator also stated that he personally had provided education to Resident #1 about the option of signing himself out of the facility if he wanted to temporarily leave the facility for whatever reason. He stated Resident #1 was admitted to the facility for rehabilitation, and MHMR and the facility's SW were working together to find him a group home upon discharge. He stated that his facility does not offer a secured unit nor a Wanderguard[TM] type device (WanderGuard system relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts your caregivers) but Resident #1 would not have been appropriate for that level of securement due to his cognitive function. He acknowledged that Resident #1's Care Plan should have included his elopement risk, but he did not feel it contributed to Resident #1's elopement. He stated the SW spoke with Resident #1 the morning of [DATE] around 9:00 AM to discuss discharge planning. The Administrator stated that around 1:20 PM, he was informed by staff they could not locate Resident #1. The facility was searched, and local law enforcement was contacted. The Administrator stated that during his investigation, Resident #4 stated she spoke with Resident #1 between 9:00 AM -10:30 AM that morning. The Administrator further stated that the charge nurse on duty, LVN S, reported seeing Resident #1 around 10:40 AM. He stated local Law Enforcement located the resident around 5:30 PM approximately 4.9 miles south near a lake eating cheese fries and drinking tea. He stated the Law Enforcement Officers reported to him that Resident #1 did not look in distress. Furthermore, he was going to be transported to a nearby psychiatric acute care facility per the Resident #1's request and would not be coming back to the facility. Administrator stated he reported this information to the physician. The Administrator further stated that Resident #1's family member was contacted to gather additional information about Resident #1's whereabouts. Resident #1's family member reported to the Administrator that she had access to his bank records and that Resident #1 made a withdrawal of cash from a bank approximately 1 mile away at 9:20 AM the morning of [DATE]. The Administrator stated he was not exactly sure how Resident #1 eloped, and the facility did not have cameras to review. The Administrator did not provide documention of the education for Resident #1 for temporary leave. Attempts to interview Resident #1 were made on [DATE] at 10:13 AM and [DATE] at 1:00 PM, but the phone line was disconnected. In an interview with the SW on [DATE] at 10:31 AM he stated he was aware of Resident #1's previous elopement attempt, wandering behavior, and episodes of impulsivity. He stated that while Resident #1 exhibited wandering behaviors as evidenced by pacing the halls, he did not have any exit seeking behaviors since his admission on the skilled unit. He stated Resident #1 had completed his rehabilitation at the facility and he had had found a group home that was willing to accept Resident #1. He stated that he went the morning of [DATE] around 8:30 AM to update Resident #1 to discuss the information. He recalled that the resident was not thrilled about going to a group home, and stated Resident #1 reported to him that he wanted to live independently. The SW further stated that Resident #1 told him that he wanted to go to the bank, grocery store, and go to an acute care psychiatric facility. The SW stated he told Resident #1 that the facility could arrange transport for him, and that Resident #1 going to an acute care psychiatric facility was a last resort. He stated he educated the resident on how a group home was a least restrictive option. The SW stated Resident #1 did not seem upset and did not give him the impression he was going to elope. He stated Resident #1 acknowledged that the facility would arrange transportation for him and was in agreeance with the current discharge plan. Furthermore, he stated that elopement risk assessments and interventions were a nursing component and he thought it would have fallen under the MDS nurse's scope of practice and responsibility. In an interview with Resident #4 on [DATE] at 9:00 AM, she stated that Resident #1 was really nice and that they had spoken previously on multiple occasions. She remembered seeing and speaking with Resident #1 after breakfast at approximately 9:00 AM on the day he eloped ([DATE].) She recalled that they spoke about what they had for breakfast, and that he stated to her that he did not like his breakfast that morning. She denied any knowledge of Resident #1 reporting to her any intent or plan to elope from the facility. Attempts to interview LVN S were made [DATE] at 11:25 AM and 2:30 PM. In interview with Resident #1's Guardian on [DATE] at 9:32 AM, he stated he was his guardian, but his guardianship expired on [DATE] and was not his guardian at the time of the elopement. He stated he remained in contact with Resident #1 and considered him a friend. He stated that he was contacted by Resident #1 the day of the elopement, not certain of the time, and told him he was on foot walking to [Acute Care Psychiatric Hospital.] He stated that Resident #1 told him that he met a gentlemen that looked homeless and gave him money, then proceeded walking south towards where [Acute Care Psychiatric Hospital] was located. He stated Resident #1 had a history of taking long walks and reported that information to Law Enforcement when they contacted him between 10-12:00 PM the day of the elopement. In an interview with Resident #1's Family Member, on [DATE] at 9:45 AM she stated she was a co-signer on his bank account, and she kept a close eye to ensure his balance stayed where it needed to be. She stated she was not his responsible party and did not expect to be notified of his discharge, so she assumed that he was being discharged from the facility that day ([DATE]) and dismissed the withdrawal as initially concerning. She stated a few hours later she received a call from a nurse at the facility and later Law Enforcement stating that he was missing. She reported that Resident #1 made a withdrawal from [Bank] which was about 1 mile away from the facility around 9:00 AM that morning. She further stated she called the bank, as the bank staff were familiar with Resident #1 and reported to her that they recalled seeing him that morning, and that he made a withdrawal. In an interview with the MDS nurse on [DATE] at 5:42 PM, she stated it was her responsibility to complete resident MDS's and ensure resident care plans were updated to reflect their specific care needs and risks. She stated that Resident #1 did trigger for a high risk for elopement but stated in her opinion, Resident #1 was not an elopement risk and would not have included that in his care plan. Additionally, she did not provide a statement as to why Resident #2 and Resident #3 did not have their elopement risk care planned. She stated the facility policy dictated to put the risk with relevant interventions on the care plan but stated, it depends on the resident. She stated that the Elopement Assessment was just a tool' and triggers to give a possible risk but did not necessarily mean they were an elopement risk. She stated if someone was a true elopement risk, their care plan should reflect that as the nurses and the interdisciplinary care team looked at it during their morning meeting each day to ensure each resident's care needs were addressed. In an interview with the DON on [DATE] at 2:48 PM, she stated it was her first week employed at the facility and she was not involved in the elopement nor the investigation surrounding the elopement. She stated her expectation was for any elopement assessment scored as high risk should be entered into the care plan along with relevant interventions. She stated it was traditionally the MDS nurse's responsibility to ensure resident care plans were customized and comprehensive to address resident care needs. She further stated that was important so resident care needs could be reviewed every day in morning meeting, where they work from resident care plans. She stated if resident care plans were not updated for a high risk for elopement residents, an elopement could occur. In interview with the Administrator on [DATE] at 4:16 PM, he stated it was the MDS nurse's responsibility to ensure resident care plans were updated to reflect resident care needs. It was the former DON's responsibility to ensure the MDS nurse was completing that role. He stated if resident care plans were not updated for high risk for elopement residents, an elopement could occur. Review on [DATE] at 12:00 PM of the weather the day of the elopement revealed a high of 95 and a low of 71 degrees Fahrenheit. < https://www.accuweather.com/en/us/[NAME]/76201/august-weather/331112> Review of the facility policy, Elopement Prevention, revised [DATE] revealed Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission . The assessment tool should be completed and interventions implemented as indicated . 4. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. 5. Interventions into elopement episodes will be entered onto the resident's care plan and medical record. An IJ was identified on [DATE] at 4:14 PM. The IJ template was provided to the facility on [DATE] at 4:32 PM. While the IJ was removed on [DATE] at 12:45 PM, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because all staff had not been trained at the time of exit [DATE] at 6:00 PM. The POR went as follows: Facility: [ Facility name] Date: [DATE] PLAN OF REMOVAL FOR Missing Resident Problem: F656 Care Plans Action Taken: Resident #1 eloped from facility on [DATE] approximately between 11:45 AM and 1:20 PM. The resident's care plan was not updated to reflect risk of elopement during length of stay. Facility failed to identify resident as elopement risk and implement care plan with monitoring and interventions. Regional Compliance, Administrator, DON, ADON A, and ADON B initiated care plan updates to reflect elopement scores as of [DATE]. Starting [DATE] and ongoing In-services: An in-service regarding the company care plan policy labeled Baseline care plan and comprehensive care plan was initiated as of [DATE] by Regional Compliance, DON, ADON A, and ADON B. All direct-care staff to be in-serviced prior to start of shift [DATE] and on-going. Policies to discuss baseline care plan initiation within 48 hours of admission, Comprehensive care plan updated with resident specific items to include elopement risk if applicable, changes of condition and quarterly review. Regional Compliance Nurse in-serviced Administrator and DON on care plan policies and procedures Baseline care plan and comprehensive care plan on [DATE]. Policies to discuss baseline care plan initiation within 48 hours of admission, Comprehensive care plan updated with resident specific items to include elopement risk if applicable, changes of condition and quarterly review. Regional Compliance in-serviced Administrator and DON on elopement care plan updates on [DATE]. Policy to discuss elopement risk care plan updates on admission, quarterly and as needed for change in condition. Monitoring: The Administrator and DON will monitor for compliance and ensure all staff have been in-serviced on [DATE] and ongoing. A printed roster of all staff who have been trained will be maintained by the DON and Administrator. Start Date on [DATE] and ongoing. The DON, ADON A, and ADON will monitor all care plans daily for new admissions, quarterly and for any change in condition to ensure resident care plans reflect the risk for elopements. Monitoring weekly x 6 weeks. Start Date [DATE]. Findings will reviewed in the monthly QAPI meeting by the IDT for 3 months. Involvement of Medical Director The Medical Director was notified of immediate jeopardy on [DATE]. Interviews were conducted with facility staff across multiple shifts on [DATE] between 12:45 PM and 4:00 PM. Staff interviewed were CNA C, CNA D, CNA E, CNA F, CMA G, CNA H, CNA I, LVN K, Medical Records, Admissions Director, Housekeeping L, Housekeeping M, Laundry, LVN S, LVN N, ADON A, and ADON B. Record review conducted on [DATE] at 4:00 PM revealed Resident #1, Resident #2, and Resident #3 care plan had updates to reflect elopement risk scores. Review of the facility's Care Planning - Elopement Response and Prevention in-service dated, [DATE], revealed 42 of staff from direct care staff positions signed off on the in-service. The in-service covered facility policy, protocol, and procedure related to baseline and comprehensive care planning; In-service was facilitated by DON. Review of facility's Elopement Risk Assessment on Admit and Quarterly and Change of Condition, in-service dated [DATE], revealed 26 of staff from nursing and nurse aides signed off on the in-service. The in-service covered facility policy, protocol, and procedure related to elopement response; In-service was facilitated by DON. Review of facility's Elopement, Care Plans, in-service dated [DATE] revealed Administrator and DON signed off on the in-service. The in-service covered facility policy, protocol, and procedure related to baseline and comprehensive care planning; In-service was facilitated by Regional Compliance. Review of facility's Elopement Response and Prevention and Specific Response, in-service dated [DATE] revealed 121 of staff from all departments signed off on the in-service. The in-service covered general policies, protocols, and procedures as well as specific residents at the facility that were at risk for elopement and was facilitated by DON. Review of facility monitoring tool, Monitoring, with start date [DATE], revealed DON/ADON/Designee to ask 5 staff members weekly if they have noticed any residents attempting to elope or leave facility, what would their actions be? Was their response appropriate? Monitoring continues weekly times 6 weeks. Further review of monitoring tool revealed the sheet indicated monitoring for Maintenance Director to check all exit doors for proper alarming and functioning daily. The Care Plan monitoring tool revealed Don/ADON/Designee will monitor all care plans daily for new admissions, quarterly and for any change in condition to ensure resident care plans reflect the risk for elopement. Monitoring weekly x 6 weeks . Elopement risk assessment monitoring included DON/Administrator to monitor Elopement Risk Assessments in PCC (Point Click Care.) Were elopement risk assessments completed timely upon admission and quarterly? Monitoring continues weekly times 6 weeks. In interview with Administrator on [DATE] at 4:30 PM, he stated his management company was transitioning to a new company, and that they would be placing an experienced MDS nurse in the near future. He stated he was confident with a new MDS nurse coupled with new corporate support, this issue would be remedied. He stated he will be responsible for ensuring the monitoring for compliance will be completed by DON and he would ensure all staff have been in-serviced on [DATE] and ongoing. In interview with DON on [DATE] at 4:45 PM, she stated she would ensure that she and the ADONs at the facility will monitor all care plans daily for new admissions, quarterly and for any change in condition to ensure resident care plans reflect the risk for elopements. She stated she would monitor weekly and continue to monitor for 6 weeks. Interviews with facility staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. Relevant staff were in-serviced regarding completing elopement evaluations and/or the identification of and/or monitoring for exit seeking behaviors. Additionally, relevant staff verbalized understanding of facility policies to discuss baseline care plan initiation within 48 hours of admission, comprehensive care plan updated with resident specific items to include elopement risk if applicable, and changes of condition and quarterly review. An IJ was identified on [DATE] at 4:14 PM. The IJ template was provided to the facility on [DATE] at 4:32 PM. While the IJ was removed on [DATE] at 12:45 PM, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because all staff had not been trained at the time of exit [DATE] at 6:00 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure residents received adequate monitoring and supervision to prevent elopement of (Resident #1) 1 of 6 residents reviewed for accidents, hazards, and supervision. The facility failed to adequately supervise Resident #1 who was assessed as high risk for elopement. This risk was not included on his comprehensive care plan. Consequently, on [DATE] Resident #1 eloped from an unknown route and was located by Law Enforcement approximately 4.9 miles away from the facility. An IJ was identified on [DATE] at 4:14 PM. The IJ template was provided to the facility on [DATE] at 4:32 PM. While the IJ was removed on [DATE] at 12:45 PM, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained at the time of exit [DATE] at 6:00 PM. This failure could place residents requiring supervision at risk for serious injury and death. Findings included: Review of Resident #1's Face Sheet dated [DATE] revealed he was a [AGE] year-old male re-admitted to the facility on [DATE] from an acute care hospital for rehabilitation. Relevant diagnoses included schizoaffective disorder bipolar type (psychotic symptoms, such as hallucinations or delusions, as well as symptoms of a mood disorder - either bipolar type (episodes of mania and sometimes depression), depression (mood disorder,) unsteadiness on feet, unspecified lack of coordination, cognitive communication deficit, altered mental status, suicidal ideations, auditory hallucinations (hearing things that are not real,) and elevated white blood cell count (infection.) Record review of Resident #1's Elopement Risk Assessment, dated [DATE] revealed he was a high elopement risk. Resident #1's Elopement Risk Assessment revealed: .7. Elopement Screen . A score of 5 or greater = HIGH RISK for Wandering/Elopement Potential . 5. Based on admission information and/or responsible party information has the resident ever eloped before or does the resident have a habit of wandering or pacing? A) Yes [score 5.] Review of Resident #1's MDS, dated [DATE], revealed he was cognitively intact with a BIMS score of 15. Resident #1 required supervision of one staff to physically assist him to walk in room, and supervision of setup help only to walk in corridor, locomotion on unit, locomotion off unit. He did not require any assistive devices for ambulation and was scored as steady at all times when moving from seated to standing position, walking, turning around and facing the opposite direction when walking, moving on and off toilet, and surface-to-surface transfers. Review of Resident #1's Comprehensive Care Plan, dated [DATE], revealed he was at risk for falls, required assistance with ADLs, was on antidepressant, antianxiety, and hypnotic medications that required monitoring for effectiveness and/or negative outcomes. No evidence of elopement risk or precautions were indicated in Resident #1's care plan. Record review of Resident #1's EHR on [DATE] revealed there was not an assessment or an evaluation to determine Residnet #1 ability to to independently and safety sign out of the facility on temporary leave by himself. In an interview with the Administrator on [DATE] at 10:31 AM, he stated that Resident #1 had a BIMS score of 15 and was very high functioning. Administrator stated the facility was aware of Resident #1's elopement risk and they had provided him a room away from any exit doors, and in a high traffic area close to the nurse's station to enable enhanced monitoring. Administrator also stated that he personally had provided education to Resident #1 about the option of signing himself out of the facility if he wanted to temporarily leave the facility for whatever reason. He stated Resident #1 was admitted to the facility for rehabilitation, and MHMR and the facility's SW were working together to find him a group home upon discharge. He stated that his facility does not offer a secured unit nor a Wanderguard[TM] type device (WanderGuard system relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts your caregivers) but Resident #1 would not have been appropriate for that level of securement due to his cognitive function. He acknowledged that Resident #1's Care Plan should have included his elopement risk, but he did not feel it contributed to Resident #1's elopement. He stated the SW spoke with Resident #1 the morning of [DATE] around 9:00 AM to discuss discharge planning. The Administrator stated that around 1:20 PM, he was informed by staff they could not locate Resident #1. The facility was searched, and local law enforcement was contacted. The Administrator stated that during his investigation, Resident #4 stated she spoke with Resident #1 between 9:00 AM -10:30 AM that morning. The Administrator further stated that the charge nurse on duty, LVN S, reported seeing Resident #1 around 10:40 AM. He stated local Law Enforcement located the resident around 5:30 PM approximately 4.9 miles south near a lake eating cheese fries and drinking tea. He stated the Law Enforcement Officers reported to him that Resident #1 did not look in distress. Furthermore, he was going to be transported to a nearby psychiatric acute care facility per the Resident #1's request and would not be coming back to the facility. Administrator stated he reported this information to the physician. The Administrator further stated that Resident #1's family member was contacted to gather additional information about Resident #1's whereabouts. Resident #1's family member reported to the Administrator that she had access to his bank records and that Resident #1 made a withdrawal of cash from a bank approximately 1 mile away at 9:20 AM the morning of [DATE]. The Administrator stated he was not exactly sure how Resident #1 eloped, and the facility did not have cameras to review. The Administrator did not provide documention of the education for Resident #1 for temporary leave. Attempts to interview Resident #1 were made on [DATE] at 10:13 AM and [DATE] at 1:00 PM, but the phone line was disconnected. In an interview with the SW on [DATE] at 10:31 AM he stated he was aware of Resident #1's previous elopement attempt, wandering behavior, and episodes of impulsivity. He stated that while Resident #1 exhibited wandering behaviors as evidenced by pacing the halls, he did not have any exit seeking behaviors since his admission on the skilled unit. He stated Resident #1 had completed his rehabilitation at the facility and he had had found a group home that was willing to accept Resident #1. He stated that he went the morning of [DATE] around 8:30 AM to update Resident #1 to discuss the information. He recalled that the resident was not thrilled about going to a group home, and stated Resident #1 reported to him that he wanted to live independently. The SW further stated that Resident #1 told him that he wanted to go to the bank, grocery store, and go to an acute care psychiatric facility. The SW stated he told Resident #1 that the facility could arrange transport for him, and that Resident #1 going to an acute care psychiatric facility was a last resort. He stated he educated the resident on how a group home was a least restrictive option. The SW stated Resident #1 did not seem upset and did not give him the impression he was going to elope. He stated Resident #1 acknowledged that the facility would arrange transportation for him and was in agreeance with the current discharge plan. Furthermore, he stated that elopement risk assessments and interventions were a nursing component and he thought it would have fallen under the MDS nurse's scope of practice and responsibility. Attempts to interview LVN S were made [DATE] at 11:25 AM and 2:30 PM. In interview with Resident #1's Guardian on [DATE] at 9:32 AM, he stated he was his guardian, but his guardianship expired on [DATE] and was not his guardian at the time of the elopement. He stated he remained in contact with Resident #1 and considered him a friend. He stated that he was contacted by Resident #1 the day of the elopement, not certain of the time, and told him he was on foot walking to [Acute Care Psychiatric Hospital.] He stated that Resident #1 told him that he met a gentlemen that looked homeless and gave him money, then proceeded walking south towards where [Acute Care Psychiatric Hospital] was located. He stated Resident #1 had a history of taking long walks and reported that information to Law Enforcement when they contacted him between 10-12:00 PM the day of the elopement. In an interview with Resident #1's Family Member, on [DATE] at 9:45 AM she stated she was a co-signer on his bank account, and she kept a close eye to ensure his balance stayed where it needed to be. She stated she was not his responsible party and did not expect to be notified of his discharge, so she assumed that he was being discharged from the facility that day ([DATE]) and dismissed the withdrawal as initially concerning. She stated a few hours later she received a call from a nurse at the facility and later Law Enforcement stating that he was missing. She reported that Resident #1 made a withdrawal from [Bank] which was about 1 mile away from the facility around 9:00 AM that morning. She further stated she called the bank, as the bank staff were familiar with Resident #1 and reported to her that they recalled seeing him that morning, and that he made a withdrawal. In interview with MDS nurse on [DATE] at 5:42 PM, she stated it was her responsibility to complete resident MDS's and ensure resident care plans were updated to reflect their specific care needs and risks. She stated that Resident #1 did trigger for a high risk for elopement but stated in her opinion, Resident #1 was not an elopement risk and would not have included that in his care plan. Additionally, she did not provide a statement as to why Resident #2 and Resident #3 did not have their elopement risk care planned. She stated that facility policy dictated to put the risk with relevant interventions on the care plan but stated, it depends on the resident. She stated that the Elopement Assessment was just a tool' and triggers to give a possible risk but does not necessarily mean they are an elopement risk. She stated if someone was a true elopement risk, their care plan should reflect that as the nurses and the interdisciplinary care team looked at it during their morning meeting each day to ensure each resident's care needs were addressed. In interview with DON on [DATE] at 2:48 PM, she stated it was her first week employed at the facility and was not involved in the elopement nor the investigation surrounding the elopement. She stated her expectation was for any elopement assessment scored as high risk should be entered into the care plan along with relevant interventions. She stated it was traditionally the MDS nurse's responsibility to ensure resident care plans were customized and comprehensive to address resident care needs. She further stated this was important so resident care needs can be reviewed every day in morning meeting, where they work from resident care plans. She stated if resident care plans were not updated for a high risk for elopement residents, an elopement could occur. In interview with Administrator on [DATE] at 4:16 PM, he stated it was the MDS nurse's responsibility to ensure resident care plans were updated to reflect resident care needs. It was the former DON's responsibility to ensure the MDS nurse was completing this role. He stated if resident care plans were not updated for high risk for elopement residents, an elopement could occur. Review on [DATE] at 12:00 PM of the weather the day of the elopement revealed a high of 95 and a low of 71 degrees Fahrenheit. < https://www.accuweather.com/en/us/[NAME]/76201/august-weather/331112> Review of facility policy, Elopement Prevention, rev. [DATE] revealed Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission . The assessment tool should be completed and interventions implemented as indicated . 4. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. 5. Interventions into elopement episodes will be entered onto the resident's care plan and medical record. An IJ was identified on [DATE] at 4:14 PM. The IJ template was provided to the facility on [DATE] at 4:32 PM. While the IJ was removed on [DATE] at 12:45 PM, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained at the time of exit [DATE] at 6:00 PM. Facility: [Facility] Date: [DATE] PLAN OF REMOVAL FOR Missing Resident Problem: F689 Accident and Hazards Action Taken As of [DATE] Resident #1 eloped on the facility on [DATE] approximately between 11:45 AM and 1:20 PM. When located by [City] Police at approximately 5:30 PM, the resident transported and admitted to a behavioral hospital related to his schizophrenic diagnosis. The Facility failed to identify resident as elopement risk and implement care plan with monitoring and interventions. Elopement Risk Assessments were updated on [DATE] for all residents in the facility by the DON, ADON A, and ADON B, and the facility's Treatment Nurse. There were 7 residents identified for elopement risks. The Charge Nurse on shift will be responsible for completing elopement risk assessments on all resident admissions, quarterly assessments, and all residents with each change of condition related to increased risk elopement. Start Date [DATE] and ongoing. Elopement Risk Assessments for all new admissions, quarterly assessments, and all residents with change of condition related to increased elopement risk assessment will be reviewed and monitored by the Administrator and DON weekly. Starting [DATE] and ongoing. Regional Compliance, Administrator, DON, ADON A, and ADON B initiated care plan updates to reflect elopement risk scores for 7 residents, including [NAME] alerts for residents at risk as of [DATE]. Starting [DATE] and ongoing. DON, ADON A, and ADON B will monitor by asking 5 staff per week if they noticed any resident attempting to elope or leave facility what would their actions be? Monitoring weekly x 6 weeks. Start Date [DATE]. All exit doors in the facility were checked by Regional Compliance and Administrator for proper alarm and functioning. No issues were identified. Completed [DATE]. Moving forward, the Maintenance Director, Maintenance X, and Maintenance Y will check all exit doors daily. Start Date [DATE] and ongoing. Administrator will review monitoring tool weekly for compliance. Start Date [DATE]. DON, ADON A, and ADON B will monitor all new and updated elopement risk assessments daily to identify any residents at risk for elopements. Monitoring weekly x 6 weeks. Start Date [DATE]. In-services: Regional Compliance Nurse in-serviced DON and Administrator on elopement policy and procedure on [DATE]. Policy to discuss elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. Regional Compliance in-serviced DON and Administrator on the elopement risk assessments to be completed on admission, quarterly, and as needed for changes in condition on [DATE]. Policy to discuss elopement risk assessment of residents, assessment to be completed on all new admissions, quarterly, and change of condition related to elopement risk on all residents. An in-service regarding resident elopement facility protocols were initiated as of [DATE] by the Administrator and DON for all facility staff. All staff not present will be in-serviced prior to performing work duties. All staff will be in-serviced on [DATE] and on-going, prior to start of their shift. All Charge Nurses were in-serviced by DON that all residents must have elopement risk assessment completed upon admission, quarterly, and as needed for changes of condition. All nurses not present will be in-serviced prior to performing work duties. Start Date - [DATE]. All staff will be in-serviced prior to the start of their shift. Policy to discuss elopement risk assessment of residents, assessment to be completed on all new admissions, quarterly, and change of condition related to elopement risk on all residents. DON, ADON A, and ADON B will monitor all new and updated elopement risk assessments daily to identify any residents at risk for elopements. Monitoring weekly x 6 weeks. Start Date [DATE]. All direct care staff were in-serviced by DON, ADON A, and ADON B on current residents at risk for elopement, monitoring, and appropriate interventions. DON, ADON A, and ADON B will monitor by asking 5 staff per week if they noticed any resident attempting to elope or leave facility what would their actions be? Monitoring weekly x 6 weeks. Start Date [DATE]. Monitoring: The Administrator and DON will monitor for compliance and ensure all staff have been in-serviced on [DATE] and ongoing. A printed roster of all staff who have been trained will be maintained by the DON and Administrator. Start Date on [DATE] and ongoing by the following: Moving forward, the Maintenance Director, Maintenance X, and Maintenance Y will check all exit doors daily. Start Date [DATE] and ongoing. Administrator will review monitoring tool weekly for compliance. Start Date [DATE] DON, ADON A, and ADON B will monitor all new and updated elopement risk assessments daily to identify any residents at risk for elopements. Monitoring weekly x 6 weeks. Start Date [DATE]. DON, ADON A, and ADON B will monitor by asking 5 staff per week if they noticed any resident attempting to elope or leave facility what would their actions be? Monitoring weekly x 6 weeks. Start Date [DATE]. Findings will reviewed in the monthly QAPI meeting by the IDT for 3 months. Involvement of Medical Director The Medical Director was notified of immediate jeopardy on [DATE]. Interviews were conducted with facility staff across multiple shifts on [DATE] between 12:45 PM and 4:00 PM. Staff interviewed were CNA C, CNA D, CNA E, CNA F, CMA G, CNA H, CNA I, LVN K, Medical Records, Admissions Director, Housekeeping L, Housekeeping M, Laundry, LVN S, LVN N, ADON A, and ADON B. Record review conducted on [DATE] at 4:00 PM revealed Resident #1, Resident #2, and Resident #3 care plan had updates to reflect elopement risk scores. Review of the facility's Care Planning - Elopement Response and Prevention in-service dated, [DATE], revealed 42 of staff from direct care staff positions signed off on the in-service. The in-service covered facility policy, protocol, and procedure related to baseline and comprehensive care planning; In-service was facilitated by DON. Review of facility's Elopement Risk Assessment on Admit and Quarterly and Change of Condition, in-service dated [DATE], revealed 26 of staff from nursing and nurse aides signed off on the in-service. The in-service covered facility policy, protocol, and procedure related to elopement response; In-service was facilitated by DON. Review of facility's Elopement, Care Plans, in-service dated [DATE] revealed Administrator and DON signed off on the in-service. The in-service covered facility policy, protocol, and procedure related to baseline and comprehensive care planning; In-service was facilitated by Regional Compliance. Review of facility's Elopement Response and Prevention and Specific Response, in-service dated [DATE] revealed 121 of staff from all departments signed off on the in-service. The in-service covered general policies, protocols, and procedures as well as specific residents at the facility that were at risk for elopement and was facilitated by DON. Interviews with facility staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. Relevant staff were in-serviced regarding completing elopement evaluations and/or the identification of and/or monitoring for exit seeking behaviors. Additionally, relevant staff verbalized understanding of facility policies to discuss baseline care plan initiation within 48 hours of admission, comprehensive care plan updated with resident specific items to include elopement risk if applicable, and changes of condition and quarterly review. Review of facility monitoring tool, Monitoring, with start date [DATE], revealed DON/ADON/Designee to ask 5 staff members weekly if they have noticed any residents attempting to elope or leave facility, what would their actions be? Was their response appropriate? Monitoring continues weekly times 6 weeks. Further review of monitoring tool revealed the sheet indicated monitoring for Maintenance Director to check all exit doors for proper alarming and functioning daily. The Care Plan monitoring tool revealed Don/ADON/Designee will monitor all care plans daily for new admissions, quarterly and for any change in condition to ensure resident care plans reflect the risk for elopement. Monitoring weekly x 6 weeks . Elopement risk assessment monitoring included DON/Administrator to monitor Elopement Risk Assessments in PCC [Point Click Care]. Were elopement risk assessments completed timely upon admission and quarterly? Monitoring continues weekly times 6 weeks. In interview with Administrator on [DATE] at 4:30 PM, he stated his management company was transitioning to a new company, and that they would be placing an experienced MDS nurse in the near future. He stated he was confident with a new MDS nurse coupled with new corporate support, this issue would be remedied. He stated he will be responsible for ensuring the monitoring for compliance will be completed by DON and he would ensure all staff have been in-serviced on [DATE] and ongoing. In interview with DON on [DATE] at 4:45 PM, she stated she would ensure that she and the ADONs at the facility will monitor all care plans daily for new admissions, quarterly and for any change in condition to ensure resident care plans reflect the risk for elopements. She stated she would monitor weekly and continue to monitor for 6 weeks. An IJ was identified on [DATE] at 4:14 PM. The IJ template was provided to the facility on [DATE] at 4:32 PM. While the IJ was removed on [DATE] at 12:45 PM, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained at the time of exit [DATE] at 6:00 PM.