**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 which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for Resident #1. The facility failed to update Resident #1's care plan to reflect she was a two plus person physical assist that resulted in an improper transfer on 07/15/2025. This led to Resident #1's, left shoulder fracture. An immediate jeopardy (IJ) was identified on 07/20/2025. The IJ template was provided to the facility on [DATE] at 10:39 am by the Investigator. While the IJ was removed on 07/21/2025, the facility remained out of compliance at a scope of isolated with a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure placed dependent residents at risk of being injured, bruised, or have fractured limbs. Findings include: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included: Personal history of traumatic brain injury (Primary, Admission), Pain disorder with related psychological factors, Acute pain due to trauma, Pain disorder exclusively related to unsteadiness on feet, Cognitive communication deficit, need for assistance with personal care, other abnormalities of gait and mobility, Idiopathic gout, (a digestive disease-herat-burn) right ankle and foot, Muscle weakness (generalized), Conversion disorder with seizures or convulsions. Record review of Resident # 1's nurses notes, dated 07/15/2025, revealed Nurse A notified Resident # 1 primary Physician of the popping sound. The Dr. ordered a STAT x-ray to the left shoulder and upper arm. Nurse # 1 said she ordered the STAT x-ray with a local X-ray company. The x-ray revealed a left shoulder mild displaced fracture of the proximal humerus (a break in the upper arm bone near the shoulder joint) surgical neck. The Dr. gave orders for the Resident# 1 to be sent out to the hospital for further evaluation and a higher level of care. Resident was sent out by the night nurse. The Hospital x-ray revealed the same proximal humerus fracture. Record review of Resident #1's care plan, effective date 12/06/2024, revealed the resident the Resident requires a Hoyer lift with 2 staff for transfer. Further review revealed resident was at risk for falls related to unsteady gait. Revised on 7/17/2025 Record review of Resident # 1's MDS dated , 06/06/2025, revealed section C0500-BIMS coded as an 11 which indicated moderate cognition impairment. Section G-transfer revealed Resident # 1 depended totally on staff to move to or from between surfaces; bed, chair, wheelchair and standing, with two plus persons' physical assist. Record review of Resident #1's care plan with effective date of 12/6/24 revealed Resident #1 required 1-2 person(s) assist with transfers. Last revised on 5/5/25. During an interview with Nurse A on 07/18/2025 at 11:07 am, she stated she was at the nursing station documenting around shift change when CNA D came and asked her to come with him. Resident # 1 was still sitting in her wheelchair. CNA D said during the transfer, he attempted to pivot Resident #1 back into her bed when he heard a popping sound on Resident # 1's left shoulder, and the Resident was crying. Nurse A stated she did not review the care plan to know how many staff were required currently to assist Resident # 1 during transfers. Nurse A stated she assessed Resident #1 and gave her pain medication. During an interview with CNA D on via telephone on 07/18/2025 at 11:47 am, he stated he walked into Resident # 1's room and remembered she was a 1 person assist from the last time he checked the POC. He stated, he did not check the portion of the POC that would have showed if she was a one or two person assist, so he did not request for assistance. CNA D said, Resident # 1 was begging to be put back into bed. CNA D told the Resident; the mechanical lift was not working because the battery was not charged. CNA D in attempting to pivot Resident #1 back to her bed, he heard a popping sound from the resident's left shoulder. During an interview with Resident #1 on 07/18/2025 at 3:23 pm over the phone, she stated CNA D was trying to put her in bed by himself without using a mechanical lift. She stated CNA D did not tell her that, the mechanical lift was not working because the battery was not charged. Resident #1 said, she asked CNA D; Would you please use the Hoyer Lift, he said no. I can pick you up by myself. Resident #1 said, when CNA D picked her up from under her arms, she heard a popping sound from her left shoulder and started crying. Resident # 1 said when the nurse arrived at her room about 20 minutes later, she told the nurse CNA D picked her up in the wrong way, and her left arm popped. Resident #1 said, the nurse gave her pain medication on that day. Resident # 1 said In the past, it's been two staff helping to transfer me. This one decided not to use the Hoyer lift on Tuesday night.During an interview with the ADON on 07/21/2025 at 10:11 am, she stated updating the care plan to reflect the needs of the residents was the responsibility of all nurse managers, but the MDS coordinator was predominately over the care Plan. The ADON stated she did not know why Resident # 1's care plan was not updated prior to the incident. During an interview with the Administrator on 07/21/2025, at 11:43 am, he stated: I did not realize there was a discrepancy between the care plan and the MDS. During an interview with the Administrator on 07/20/2025 at 1:57 pm, the Administrator stated the MDS, and the Care Plan information should match. He said on the MDS if there is a 7 day look back period for transfer and there are 2 days where the transfer level required a higher level of assistance for the rest for the week, that is what is going to be coded on the MDS. He said the MDS will capture the highest level of assistance, and the care plan will capture the lowest. That is why Resident # 1's care plan and MDS do not match. During an interview with the DON on 07/21/2025, she stated it was the responsibility of the Director of Nursing, Assistant Director of Nursing, wound care nurse and MDS nurses to update care plans. The DON stated it was updated quarterly or when an incident occurred. During an interview via telephone on 07/19/2025 at 11:31 am with the MDS coordinator, she said assessments were done quarterly-every 3 months. She stated if a resident's care changed to hospice care, a new assessment was completed, and the care plan would be updated. The MDS coordinator said, the care plan and MDS should match. The MDS which had what was charted, and the care plan had the same information. The MDS coordinator was not on site. The facility's MDS policy revised on 05/05 2023 revealed: -Complete a comprehensive significant assessment as soon as needed to provide appropriate care to the individual. -A significant correction is completed when the MDS or care plan does not suit Residents' needs.On 07/20/2025 at 10:39 am., an Immediate Jeopardy was identified. The Administrator was provided with the IJ template on 07/20/2025 at 10:39 am and Plan of Removal (POR) was requested at that time. The POR summited by the Administrator was accepted on 07/20/2025 at 10:17 am. The POR revealed: Immediate Jeopardy, Plan of Removal 07/21/2025 at 11:34 am.F656 Develop/Implement Comprehensive Care Plan The facility failed to develop and implement a comprehensive person-centered care plan for Resident#1, which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs.Identified resident is being transferred using 2-person mechanical lift transfer per updated resident's plan of care. Resident #1's care plan and care profile were updated to reflect 2-person mechanical lift transfer on 7/17/25 by the Director of Nursing/Designee. Investigator observed Resident #1 during a transfer with 2 staff. The facility record reviewed by the Investigator revealed, Certified Nursing Assistant D no longer employed at facility. Last day of employment was 7/17/25 due to violation of rules and policies. Mechanical lifts in the facility were examined for proper functioning and operation including batteries on 7/18/25 at 12:15 pm by the Maintenance Director/designee. Facility record reviewed by the Investigator revealed, Licensed nurses and certified nurse aides were re-educated by Rehab Director/Designee by 7/18/25 on the following: Identifying changes to resident's activities of daily living assistance required and reporting to nurse/nurse management to update the plan of care. Accessing point of care profile of the resident to confirm assistance needed for activities of daily living Facility records reviewed by the Investigator revealed Licensed Nurses and certified Nurse aides had 2-person competency checks completed by the director of Nursing/Designee by 7/19/25. Nursing Staff not receiving the education or completing the competency by 7/19/25 will receive prior to their next scheduled shift. The Administrator, Director of Nursing and Nurse Assessment Coordinators were reeducated by the Clinical Consultant on comprehensive person-centered care plans including that the care plan and MDS should reflect the residents current transfer status on 7/20/25. Change in status needs will be discussed three times a week during nurse aide meeting. The Director of Nursing/Designee during this meeting will review the identified resident's profile and care plan to validate changes in assistance have been updated. Completed MDS will be reviewed in clinical morning meeting to validate current transfer status is reflected in the care plan and care profile Monday - Friday by the Director of Nursing/Designee. The Director of Nursing/Designee will randomly observe 3 certified nursing assistants performing transfers three times weekly to validate transfers are following the residents' plan of care. Resident's will be reviewed quarterly following the MDS schedule and as needed with changes of condition daily during the clinical meeting review to validate current transfer status matches the care plan and care profile by the Director of Nursing/Designee. The administrator will validate reviews in clinical morning meeting and review transfer observations to validate appropriate actions are taken to safeguard the residents. This was verbalized during a morning meeting. The Administrator stated the medical director was notified of the immediate jeopardy on 7/20/2025 by the administrator.An Ad Hoc (A meeting called to address specific quality issues) Quality Assurance Performance Improvement meeting was held on 7/20/2025 regarding the contents of this plan. Monitoring of the Plan of Removal included: Following acceptance of the facility's plan of removal, the facility was monitored from 07/20/2025 at 10:39 am to 07/21/2025 at 11:34 am. The Investigator confirmed the facility implemented their plan of removal sufficiently from 07/20/2025 to 07/21/2025. Record review, Resident #1's care plan was updated to reflect 2 persons transfer with a mechanical lift on 07/17/2025 by the DON. CNA D was terminated on 07/17/2025 due to violation of rules and policies. Record review of facility's records revealed, nurses and certified nurse assistants were re-educated on:-Identifying changes to Residents'' activities of daily living assistance requirements and reporting to nursing management to update care plan.-Nurses and CNAs to identify point of care profile of the residents to confirm assistance is needed. Nursing staff had competency checks from 07/18/2025 to 07/19/2025 with signatures. Record Review of facility's record revealed: Change in status will be discussed 3 times a week during Nurse Aides meetings. The DON/designee during these meetings will review the identified Residents' profile and care plan to validate changes in assistance have been updated. Interview with the facility Administrator on 07/21/2025 at 11:43 am, revealed the care plan was updated to reflect Resident # 1's current assistance needs. The Administrator, Regional Clinical Consultant, DON, ADON and the Medical Director, were informed the Immediate Jeopardy was removed on 07/21/2025 at 11:34 am. 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 jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received supervision and assistive devices to prevent accident for Resident #1. On 07/15/2025, CNA D transferred Resident #1 unassisted using a stand and pivot method instead of a mechanical lift (a device used to aid in the transfer and movement of individuals especially those with mobility limitation) device as required by her care plan dated 12/06/2024. During the transfer there was audible pop from Resident #1's left shoulder. Resident #1 had pain and sustained a fracture. An immediate jeopardy (IJ) was identified on 07/18/2025. The IJ template was provided to the facility on [DATE] at 05:34 pm. While the IJ was removed on 07/20/2025, the facility remained out of compliance at a scope of isolated with a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure placed dependent residents at risk of experiencing pain, injuries, bruises, and fractures from possible accidents which could result in a diminished quality of life and hospitalization. Findings include: Record review of Resident #1's face sheet revealed, a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included: Personal history of traumatic brain injury (Primary, Admission), Pain disorder with related psychological factors, Acute pain due to trauma, Pain disorder exclusively related to unsteadiness on feet, Cognitive communication deficit, Need for assistance with personal care, other abnormalities of gait and mobility, Idiopathic gout (A digestive disease-heart burn), right ankle and foot, Muscle weakness (generalized), Conversion disorder with seizures or convulsions (Violent , uncontrollable shaking of the body). Record review of Resident # 1's MDS dated , 06/06/2025, revealed section C0500-BIMS codes as an 11 which indicated moderate cognition impairment. Section G-transfer revealed Resident # 1 depended totally on staff to move to or from between surfaces; bed, chair, wheelchair and standing, with two plus persons' physical assist. Record review of Resident #1's care plan, dated 12/06/2024, revealed the Resident required a mechanical lift with 2 staff for transfer. Further review revealed resident was at risk for falls related to unsteady gait. Record review of Resident # 1's nurses notes, dated 07/15/2025, revealed Nurse A notified Resident # 1 primary Physician of the popping sound. The Dr. ordered a STAT x-ray to the left shoulder and upper arm. Nurse # 1 said she ordered the STAT x-ray with a local X-ray company. The x-ray revealed a left shoulder mild displaced fracture of the proximal humerus (a break in the upper arm bone near the shoulder joint) surgical neck. Nurse A stated, the Dr. gave orders for Resident# 1 to be sent out to the hospital for further evaluation and a higher level of care. Resident was sent out by the night nurse. The Hospital x-ray revealed the same proximal humerus fracture. Observation of the mechanical lift storage room on 07/18/2025, at 10:25 am revealed there were three mechanical lifts and a battery charging unit that could hold three mechanical lift batteries. Two of the mechanical lifts had fully charged batteries while the third battery was on the battery charging unit. During an interview with Nurse A on 07/18/2025 at 11:07 am , said, she was at the nursing station documenting around shift change when CNA D came and asked her to come with him. Resident # 1 was still sitting in her wheelchair. CNA D said during the transfer, he attempted to pivot Resident #1 back into her bed when he heard a popping sound on Resident # 1's left shoulder, and the Resident was crying. Nurse A stated she did not review the care plan to know how many staff were required currently to assist Resident # 1 during transfers. Nurse A stated she assessed Resident #1 and gave her pain medication. During an interview with CNA D via telephone on 07/18/2025 at 11:47 am, he stated he walked into Resident # 1's room and remembered Resident #1 was a 1 person assist from the last time he looked at the POC. He did not check the portion of the POC on the day of the incident that would have showed if she was a one or two person assist, so he did not request for assistance. CNA D said, Resident # 1 was begging to be put back into bed. CNA D told the resident the mechanical lift was not working because the battery was not charged. CNA D in attempting to pivot Resident #1 back to bed, he heard a popping sound from Resident #1's left shoulder. During an interview with Resident #1 on 07/18/2025 at 3:23 pm over the phone, she stated CNA D was trying to put her in bed by himself without using a mechanical lift. She stated CNA D did not tell her that, the Mechanical lift was not working because the battery was not charged. Resident #1 said, she asked CNA D, Would you please use the mechanical Lift, he said, no. I can pick you up by myself. Resident #1 said, when CNA D picked her up from under her arms, she heard a popping sound from her left shoulder and started crying. Resident # 1 said when the nurse arrived at her room about 20 minutes later, she told the nurse CNA D picked her up in the wrong way, and her left arm popped. Resident #1 said, the nurse gave her pain medication on that day. Resident # 1 said; In the past, it's been two staff helping to transfer me. This one decided not to use the mechanical lift on Tuesday night. During an interview with the DON on 07/18/2925 at 12:49 pm, she said transfers were covered during orientation, which include the use of gait belt and mechanical lift. The DON stated inappropriate transfers, could cause injury, bruising, skin tears, a fall, a fracture, dislocation and abrasions. The DON stated, delayed treatment could cause further injury or harm to the resident. The DON stated she was notified of Resident # 1's incident. The DON stated, the CNAs had a profile on the computer where they documented and saw what assistance was needed by the residents. During an interview with the Administrator on 07/18/2025 at 2:37 pm, he stated CNA D disclosed what happened to the DON. The Administrator stated CNA D was terminated on 07/17/2025 for completing an improper transfer with Resident #1. The Administrator stated an inappropriate transfer, could lead to injuries of the Resident or the staff. He said it was inappropriate transfer that led to Resident # 1's left shoulder fracture. Fracture. During an interview with the Maintenance Director on 07/18/2025 at 3:05 pm, he stated staff told him the mechanical lift battery charger was not working. He stated he got a new battery, and it started working. He stated that was roughly about 3 months ago. Record review of facility's residents' rights policy revised on 06/09 2023 revealed: The facility must provide equal access to quality care regardless of diagnosis, and severity of condition. A record review of the facility's mechanical lift policy, revised on 05/05/2023, revealed: Mechanical lifts may be used for enhanced safety of patients, residents in situations including but not limited to:-Lifting from the floor-Bed to chair-Lateral transfer-Toileting and bathing-Repositioning.-Sitting or lying-to stand Prior to initiating the use of a mechanical lift for a patient or resident: Determine how many caregivers are necessary to safely lift the patient or Resident. In most cases and for safety, a minimum of 2 caregivers is recommended. Evaluate the resident's medical stability. On 07/18/2025 at 05:34 pm., an Immediate Jeopardy was identified. The Administrator was provided with the IJ template on 07/18/2025 at 05:34 pm, and a Plan of Removal (POR) was requested at that time. The POR summited by the Administrator was accepted on 07/19/2025 at 07: 29 am. The POR revealed: Crimson Heights Health and Wellness, Immediate Jeopardy, Plan of Removal, 07/20/2025 at 09:37 am.F689 Free of Accident Hazards/Supervision/Devices. The facility failed to safely transfer Resident #1 when CNA D performed a two person transfer alone using a stand and pivot method instead of a full Hoyer lift when resident persistently asked to be put in bed. Identified resident is being transferred using 2-person Hoyer transfer per updated resident's plan of care. Resident #1's care plan and care profile were updated to reflect 2 person Hoyer transfer on 7/17/25 by the Director of Nursing/Designee. Certified Nursing Assistant D no longer employed at facility. Last day of employment was 7/17/25 due to violation of rules and policies. An audit was completed by the Director of Nursing/designee validating residents transfer status, including residents that require 2 person Hoyer lift with current orders, profiles, and care plans by 7/19/25. No discrepancies identified. Mechanical lifts in the facility were examined for proper functioning and operation including batteries on 7/18/25 at 12:15 pm by the Maintenance Director/designee. Licensed nurses and certified nurse aides were re-educated by Rehab Director/Designee on 7/18/25 on the following: Identifying changes to resident's activities of daily living assistance required and reporting to nurse/nurse management to update the plan of care. Accessing point of care profile of the resident to confirm assistance needed for activities of daily living Licensed Nurses and certified nurse aides will have 2-person competency checks completed by the Director of Nursing/Designee by 7/19/25. This was verified by the investigator. Nursing Staff not receiving the education or completing the competency by 7/19/25 will receive prior to their next scheduled shift. The Director of Nursing/Designee will randomly observe 3 certified nursing assistants performing transfers three times weekly to validate transfers are following the Resident's plan of care. This was verified by the investigator. Residents' will be reviewed quarterly following the MDS schedule and as needed with changes of condition daily during the clinical meeting review to validate accurate transfer status is included in the care plan and care by the Director of Nursing/Designee. New admissions and re-admissions will be reviewed daily in clinical morning meeting to validate transfer status included in the care plan and care profile is accurate. The weekend supervisor will validate care plans and care profile accuracy of transfer status on the weekend. There were no new admissions for the Investigator to observe. The Administrator will validate reviews in clinical morning meeting and review transfer observations to validate appropriate actions are taken to safeguard the residents. The Administrator verbalized this statement to the Investigator The medical director was notified of the immediate jeopardy on 7/18/2025 by the administrator.An Ad Hoc (A meeting called to address a specific issue) Quality Assurance Performance Improvement meeting was held on 7/18/2025 regarding the contents of this plan. Monitoring of the plan of removal included: Following acceptance of the facility's plan of removal, the facility was monitored from 07/18/2025 from 05:34 pm to 07/20/2025 at 09: 37 am. The Investigator confirmed the facility implemented their plan of removal sufficiently from 7/17/2025 to 07/20/2025 to remove IJ by: Record review of the facility completed reeducation from 07/17/2025 to 07/19/2025 on all-certified nurse assistants, completed by the ADON. The perpetrator, CNA D was terminated on 07/17/2025 due to violation of rules and policies. Resident # 1's care plan was updated to reflect 2-person mechanical lift transfer. Nurses and certified nurse assistants had two competency checks from 07/18/2025 to 07/19/2025 Observation of two CNAs on 07/18/2025 at 10:04 am, revealed they completed successful mechanical lift transfers from bed to wheelchair and wheelchair to bed. Observation of the storage room on 07/18/2025 at 10: 25 am revealed 3 mechanical lifts, and 2 of them had a fully charged battery. The third mechanical lift's battery was in the battery charging station. Observation on 07/18/2025 at 12:15 am, revealed all mechanical lift devices in the facility were examined for proper functioning and operation, including batteries and 07/18/2025 by Maintenance Director. Interviews were conducted with CNAs and nurses from 07/18/2025 at 10:04 am to 07/19/2025 at 10:57 pm ; CNA A,CNA C,CNA E, LVN A, CNA F, CNA F, LVN B, CNA G, LVN C, CNA H, CNA B, LVN D, RN A, CNA I, and CNA J, revealed they were reeducated on the use of mechanical lift and gait belt. The Administrator, DON, ADON, and Regional Clinical Consultant, Medical Director were informed, the Immediate Jeopardy was removed on 07/20/2025 at 09:37 am. 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 jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Residents #1) reviewed for adequate supervision. The facility failed to provide Resident #1 with adequate supervision and monitoring related to his wandering behaviors which resulted in an elopement to an apartment complex by EMS. Resident #1 was absent from the facility for approximately 7 hours before he was noticed by staff that he was missing. This failure could affect residents who and place them at risk for physical harm and or pain. An Immediate Jeopardy (IJ) was identified on 3/28/2024. The IJ template was provided to the Administrator and DON on 3/28/2024 at 5:12 PM While the IJ was removed on 3/29/2024 at 1:45 PM, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated, due to the facility's need evaluate the effectiveness of the corrective systems. These failures could place residents at risk for possible serious injuries, harm and death to residents who require supervision. Findings include: Record review of Resident #1's face sheet, dated 3/27/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Dementia (loss of cognitive functioning - thinking, remembering, and reasoning), abnormalities of gait and mobility, cognitive communication deficit. Record review of Resident #1's H/P dated 3/31/2023 revealed the following in part: .He (Resident #1) ran away from the home .and family member is afraid that he (Resident #1) will escape. Record review of Resident #1's care plan dated 10/4/2023 revealed the following in part: Problem - Exhibits risk factors for elopement risk. Goal - will not have any episodes of elopement over the next 90 days. Approach - 1. Assess resident for increased confusion, s/s of possible elopement as needed. 2. Convey an attitude of acceptance toward the resident. 3. Document about situation and complete elopement risk assessment with any increase in s/s of possible elopement risk, report such episodes to physician as needed. Record review of Resident #1's care plan dated 3/21/2024 revealed the following in part: Problem start date: 3/21/2024 - Resident #1 experienced an elopement r/t Dementia and confusion. Long Term Goal Target Date 6/21/2024 -Resident will not have any unaddressed episodes of elopement over the next 90 days. Approach: 1. Assess resident for increased confusion, s/s of possible elopement as needed. 2. Document about situation and complete elopement risk assessment with any increase in s/s of possible elopement risk, report such episodes to the physician as needed. 3. Elopement assessment completed. 4. Medication review. 5. Social service to review, refer out to secure unit as necessary. Problem - Exhibits risk factors for elopement risk. Goal - will not have any episodes of elopement over the next 90 days. Approach - 1. Assess resident for increased confusion, s/s of possible elopement as needed. 2. Convey an attitude of acceptance toward the resident. 3. Document about situation and complete elopement risk assessment with any increase in s/s of possible elopement risk, report such episodes to physician as needed. Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS of 06, which indicated severe cognitive impairment. Section GG 120 - indicated Resident #1 used a walker (not accurate it was a cane). Section GG 170 - Mobility - Resident #1 is independent to walk 150 feet once standing the ability to walk at least 150 feet in a corridor or similar space. Wandering was not indicated for the lookback period for this MDS. Record review of Resident #1's progress notes dated 6/30/2023 - 3/20/2024 revealed the following: Elopement - 3/20/24 - found at hospital emergency room. Exit seeking - 1/29/24, 1/23/24,10/3/23, 6/30/23. Wandering - 1/28/24, 2/13/24, 3/5/24, 8/20/23 Record review of Resident #1's admission Elopement Assessment dated 4/25/2023 revealed the following in part: Is the patient confused? Answer: Yes Does the patient/resident have a history of wandering? Answer: Yes Is the patient/resident ambulatory/propels self? Answer: Yes Does the patient/resident have a diagnosis that requires supervision? Answer: Yes Decision: Proceed or Do not proceed. There is no answer or intervention documented. Record review of Resident #1's progress note, dated 3/20/2024 at 7:10 PM (late entry 3/22/2024 at 4:14 AM) by RN A revealed the following in part . Resident observed not to be in facility he was located on a neighboring property (nearby local hospita) by staff and returned to facility . Record review of Resident 1's progress note, dated 3/20/2024 at 10:30 PM (late entry 3/22/2024 at 2:49 AM) by RN B revealed the following in part . On arrival to facility, patient (Resident #1) was not able to be located by staff, whom reported the concern .Nurse supervisor (RN B) made contact with ER staff at name hospital, patient was confirmed to haven admitted .returned to facility at approximately 9:30 PM . Record review of EMS run sheet dated 3/20/24 revealed Resident #1 was seen at 2:44 PM at an apartment complex (.4 miles away from facility) and transported to a nearby hospital. Resident #1 was transferred to the hospital's care at 2:59 PM. Record review of Resident #1's MAR dated 3/20/2024 revealed the following: Resident #1 was not administered Donepezil 10mg tablet (prescribed for dementia) at 7:00 PM on 3/20/2024. Reason: Not administered - Resident Unavailable. Resident #1 was not administered Namenda 10mg tablet (prescribed for dementia) 7:00 PM on 3/20/2024. Reason: Not administered - Resident Unavailable. Interview on 3/27/2024 at 1:25 PM with DON, said she was notified approximately at 9:05 PM on 3/20/2027 when Resident #1 was not able to be located by RN B. The DON said staff should make rounds at least every 2 hours to ensure residents are present and if care is needed. The DON said all staff are responsible and should ensure residents are supervised and monitored. The DON said there is not a specific training or protocol that staff are trained on to confirm residents are present in the facility. Interview on 3/27/2024 at 2:15 PM ADON A said she worked on the day Resident #1 eloped from the facility. ADON A said she worked from approximately 9:00 AM to 9:00 PM. ADON A said she was normally in the office working and did not recall seeing Resident #1. She said Resident #1 wandered around the building daily. ADON A said the facility addressed his wandering by generally redirecting him (Resident #1). She said she was not able to give an exact time for when to round, but it should have been done every 1-2 hours. ADON A said staff should be mindful of Resident #1 because he wandered, which made him an elopement risk. ADON A said she was informed Resident #1 was missing when RN B arrived for his shift at approximately 7:45 PM. ADON A said she called Resident #'s family member to see if he was out on pass. ADON A said she received training on the elopement protocol, but there was no specific guidance regarding the frequency of resident being monitored during a shift. She said there was not a specific protocol on how staff members are monitored to ensure residents receive adequate supervision every two hours. ADON A said staff who worked directly with Resident #1 should have ensured he was present during their shift and if he was not seen, a Charge Nurse or ADON should have been notified. Interview on 3/27/2024 at 3:04 PM, RN B said he arrived at work at approximately 8:00 PM. He said he was told immediately by RN A that Resident #1 was missing. He said after they searched, he went to a nearby hospital to see if Resident #1 was there. He said he found the resident in the ER and brought him back, by car to the facility at approximately 9:05 PM. He said Resident #1 was not able to verbalize where he had been. He said Resident #1 had wandered out to the parking lot and was brought back in with no incident . He said it was not documented because the resident was easily redirected. He said Resident #1 would stand by exit doors. He said there was not an intervention to prevent Resident #1 from standing at the doors, but he would redirect Resident #1 when he wandered. Interview on 3/27/2024 at 3:23 PM, CNA A said she was assigned to Resident #1 for the 2:00 PM - 10:00 PM shift on the day Resident #1 eloped. CNA A said she did not see Resident #1 at the beginning of her shift and assumed he was in another part of the building with family member. She said he normally wandered around the building. She said she was told by nursing staff to redirect Resident #1 if she saw him wandering. She said she was not aware of his care-plan interventions related to elopement risk. CNA A said she was not able to do shift change with CNA B due to her being late to work. CNA A said approximately at 4:30 PM, when she was passing meal trays, she asked at the nurse's station if anyone had seen Resident #1. She said she did not receive an answer and could not remember the staff that were around the nurse station. She said she did not alert staff at that time that she had not seen Resident #1. She said she continued with her work duties. She said between 7:30 PM and 8:00 PM she picked up the meal trays and saw that Resident #1's tray was in his room untouched. CNA A said CNA C said she had not seen Resident #1 during the shift either. CNA A said she looked with RN A in another area of the building and did not find him. She said she should have ensured the resident was present in the building when she was not able to locate him throughout her shift. She said she is supposed to round every 2 hours but during her rounds she did not see Resident #1. Interview on 3/27/2024 at 3:58 PM, CNA C said she worked the 2:00 PM - 10:00 PM shift when Resident #1 eloped. She said she was not assigned to Resident #1 and had not seen him during her shift. She said she was supposed to round every two hours for the residents she was assigned. She said she does not document if a resident was present, she would visually verify a resident is present. She said after dinner, approximately 6:30 PM, she was asked by CNA A if she had seen Resident #1 and she told her she had not. CNA C said she looked for Resident #1 with CNA A after dinner in other areas of the building and did not see him. She said she returned to her duties for her assigned residents for the rest of the shift. Interview on 3/27/2024 at 4:16 PM, RN A said she worked the 6:00 PM to 6:00 AM shift when Resident #1 eloped. She said arrived approximately 6:15 PM. She said she started medication administration and Resident #1 was not in his room and she remember his dinner tray in the rooms. She said she saw his cane as well and assumed Resident #1 was in the bathroom. She said she did not check the bathroom or verify if Resident #1 was present. She said she continued with the medication pass. She said she was alerted by CNA A that Resident #1 was not able to be located. She said all staff looked for the resident for maybe 30 minutes. She said she informed RN B that Resident #1 was not able to be located. She said she notified RN B at the start of his shift, approximately at 7:45 PM, that Resident #1 could not be located. RN A said we monitored residents by rounding and checking on them. RN A said we don't have a check off to document a resident is in the building, but she said there was a sign out sheet for residents out on pass. She said she did not check that sheet. She said residents with elopement risk do not have a specific monitoring schedule. Interview on 3/28/2024 at 11:20 AM, LVN A said had worked with Resident #1 before but not on the day he eloped. LVN A said Resident #1 would wander around the building, go into resident rooms, and go towards the exit doors at the end of the hallways. She said she would redirect Resident #1 when he was at the exit doors. She said there was not a protocol related to accounting for a resident visually or if a resident was in the building. She said they round every 2 hours but did not explain what is done if the resident is not seen every 2 hours. She said she thought one of Resident #1's interventions were frequent monitoring but was not sure. Interview on 3/28/2024 at 12:20 PM, ADON B said it was common knowledge that a CNA would have learned in there CNA training to round every 2 hours and visually see residents to ensure they are supervised or monitored. ADON B said Resident #1 wandered the building and staff were instructed to redirect him. She said residents should be monitored to make sure they are in their rooms or the building but there was no specific documentation related to that. ADON B said she was not able explain why staff would not question where Resident #1 was during an 8-hour shift. Interview on 3/28/2024 at 2:20 PM, CNA B said she worked that 6:00 AM - 2:00 PM shift when Resident #1 eloped. She said she assisted Resident #1 up that morning and helped him to breakfast. She said it was normal for Resident #1 to wander around the building constantly. She said she had been trained to redirect Resident #1 when he wandered. She said she saw the resident eat lunch with his spouse approximately 11:30 AM - 12:00 PM. CNA B said she last saw Resident #1 approximately 1:45 PM, near the nurses' station watching TV on the skilled hall before she went to lunch. She said she did not return to that side of the building because she went to work on the long-term side for another shift. She said previously Resident #1 would attempt to the exit the long-term care exit doors when visitor would enter or exit the building. CNA B said she was instructed to redirect him. She said the DON, ADON or Charge Nurse were responsible and ensured CNAs supervised and monitored residents. Interview on 3/28/2024 at 3:22 PM, Administrator said the staff supervised and monitored residents by rounding. He said an example would be when staff completed medication administration. Administrator said Resident #1 would be monitored throughout the halls as he wandered. He said there was no specific training or policy to ensure resident was present in the building throughout the shift. He said he expected staff to round every 2 hours to monitor resident. He said he was informed approximately after 8:00 PM that Resident #1 was unable to be located. Administrator said he interviewed the staff that worked 2:00 PM - 10:00 PM. He said they reported on the day Resident #1 eloped and they did not find it weird or report the resident was missing because he wandered a lot and they thought he may have been with his on pass. Administrator said there was no sign in and out sheet for residents on pass . He said he did not know how staff tracked residents out on pass. Administrator said the CNA's and Nurses were responsible for ensuring residents were supervised during the shift. Administrator said it was the CNA's and Nurses responsibility to ensure the residents are present in the building and they should have rounded to monitor residents location. Interview on 3/28/2023 at 4:03 PM, ADON B said she was not sure who was responsible and reviewed the sign-in and out sheet for residents out on pass. She said she was not sure if staff reviewed the sign in and out sheet to verify if Resident #1 was out on pass. Observation on 3/28/2024 at 5:20 PM revealed, the main street to the facility had moderate traffic with fast moving vehicles. The main street had 3 unhoused citizens asking for money. The main street (four lanes) to the facility had posted speed limits of 35 mile per hour. The apartment complex that Resident #1 was seen at by EMS was .4 miles away from the facility. Record review of facility out of facility/on pass Sign in and out Sheet for residents dated March 2024 revealed two names on the form and it did not have Resident #1 on it. In an interview 3/28/2024 at 3:22PM, Administrator said the facility did not have a policy on supervision or how residents were monitored by staff throughout a shift . Record review of facility job description for Certified Nursing Assistant dated 6/27/2008 (Rev. 11/2016) revealed the following in part: To provide routine daily nursing care and services that support the care delivered to patients/residents residing in the facility in accordance with the established nursing care policy and procedures as directed by the supervisor . 3. Safety concerns are identified, and appropriate actions are taken to assure a patient [sic] safety. 4. Reports to the nursing supervisor any observations and pertinent information related to the care of the patient/resident. 20. Communication A. Reports all changes in a patients/residents condition as soon as possible to the nursing supervisor (LPN/LVN/RN) Standard Responsibilities: 5. C. Compliance with all regulatory requirements. Record review of facility job description for Registered Nurse dated 5/2/2005 (Rev. 11/2016) revealed the following in part: To plan and deliver nursing care to patients/residents requiring long-term and/or rehabilitative care. 1. Works using the guidelines established by the Nurse Practice Act, facility Policies and Procedures, and sound nursing judgement. 17. General Patient/Resident Care B. Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided. E. Safety concerns are identified, and appropriate actions are taken to maintain and assure patient safety . Record review of facility Elopement policy dated (Complete revision 11/1/2017) revealed the following in part: To safely and timely redirect patient/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. The facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/resident. This was determined to be an Immediate Jeopardy (IJ) on 3/28/2024. The Administrator and DON were notified. The Administrator was provide with the IJ template on 3/28/2024 at 5:12 PM. A plan of removal was requested. The following Plan of Removal was submitted by the facility and was accepted on 3/29/2024 at 9:14 AM. Date:3/28/24 F689 The facility failed to provide adequate supervision for Resident #1. Immediate action: Identified resident no longer resides at facility. Resident discharged home with on 3/25/24. 1:1 education provided to CNA A. CNA B, and RN A by the Director of Nursing on 3/29/24 on resident care and the elopement policy which included checking for residents needs approximately every 2 hours, validating during shift change resident's location, and notifying their supervisor immediately if a resident is not accounted for additional direction. Elopement assessments completed in the past 90 days on current residents in the facility will be reviewed by nursing managers for accuracy on 3/28/24. Any not completed in past 90 days or found to be inaccurate will be completed by the Director of Nursing on 3/28/24. None were identified as inaccurate. Identified residents at risk will be reviewed using the Elopement Risk Assessment for interventions on 3/28/24, by the Director of Nursing and any issues identified were corrected at the time of discovery. Care plans were updated to reflect the interventions by the Nurse Assessment Coordinator on 3/28/24. 10 residents identified as an elopement risk had their care plan updated. Facility Doors were validated to be in proper working order by Maintenance Director on 3/28/24. Facilities Plan to ensure compliance quickly Licensed Nurses will be reeducated on Accidents and Incidents, the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified, which may include every 6 hour documentation to validate the resident's location. Nursing Staff will be reeducated on resident care and the elopement policy that includes o Checking for residents needs approximately every 2 hours o Validating during shift change resident's location o Notifications to Charge Nurse or Director of Nursing as indicated when a resident is not located This reeducation will be completed by the Director of Nursing/Designee on 3/28/24. Any member of the target audience not receiving this reeducation by 3/28/24 will receive prior to their next scheduled shift. This will be presented in New Hire Orientation. An elopement drill will be completed on 3/29/24 that includes: o The Administrator will notify the Charge Nurse, Director of Nursing and Social Service Designee that a resident is missing. The Director of Nursing/designee will announce Code [NAME] to signal the Elopement Drill Procedure o The Director of Nursing/designee will organize an immediate and thorough search of the center and surrounding grounds. The entire search process will be completed within 30 minutes o If the search fails to locate the missing resident in the allotted time, the Administrator/designee will place a mock telephone call to the appropriate community agencies, resident's legal representative and attending physician. Staff will provide the mock police with all the physical identifying information o The Search will continue if resident not located to include 2 staff members searching the surrounding streets by care for a 2 mile radius o When the volunteer resident is located the Charge Nurse will complete a head to toe assessment. The Social Services Designee will assess the resident for emotional distress. The Director of Nursing will notify the appropriate community agencies, attending physician and the resident's legal representative. o The facility's Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrences o When the missing resident is found, an announcement will be made, Code [NAME] all clear. The Medical Director was notified of the Immediate Jeopardy on 3/28/24 Ad Hoc Quality Assurance and Performance Improvement Meeting was held on 3/28/24 to discuss contents of this plan. Monitoring of the POR included: Identified resident no longer resides at facility. Resident discharged home with spouse on 3/25/24. 1:1 education provided to CNA A. CNA B, and RN A by the DON on 3/29/24 on resident care and the elopement policy which included checking for residents needs approximately every 2 hours, validating during shift change resident's location, and notifying their supervisor immediately if a resident is not accounted for additional direction. Elopement assessments completed in the past 90 days on current residents in the facility will be reviewed by nursing managers for accuracy on 3/28/24. Any not completed in past 90 days or found to be inaccurate will be completed by the DON on 3/28/24. None were identified as inaccurate. Identified residents at risk will be reviewed using the Elopement Risk Assessment for interventions on 3/28/24, by the Director of Nursing and any issues identified were corrected at the time of discovery. Care plans were updated to reflect the interventions by the Nurse Assessment Coordinator on 3/28/24. 10 residents identified as an elopement risk had their care plan updated. Facility Doors were validated to be in proper working order by Maintenance Director on 3/28/24. Facilities Plan to ensure compliance quickly Licensed Nurses will be reeducated on Accidents and Incidents, the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified, which may include every 6-hour documentation to validate the resident's location. Nursing Staff will be reeducated on resident care and the elopement policy that includes. o Checking for residents needs approximately every 2 hours. o Validating during shift change resident's location. o Notifications to Charge Nurse or Director of Nursing as indicated when a resident is not located. This reeducation will be completed by the Director of Nursing/Designee on 3/28/24. Any member of the target audience not receiving this reeducation by 3/28/24 will receive prior to their next scheduled shift. This will be presented in New Hire Orientation. An elopement drill will be completed on 3/29/24 that includes: o The Administrator will notify the Charge Nurse, Director of Nursing and Social Service Designee that a resident is missing. The Director of Nursing/designee will announce Code [NAME] to signal the Elopement Drill Procedure o The Director of Nursing/designee will organize an immediate and thorough search of the center and surrounding grounds. The entire search process will be completed within 30 minutes o If the search fails to locate the missing resident in the allotted time, the Administrator/designee will place a mock telephone call to the appropriate community agencies, resident's legal representative and attending physician. Staff will provide the mock police with all the physical identifying information. o The search will continue if resident not located to include 2 staff members searching the surrounding streets by care for a 2 mile radius o When the volunteer resident is located the Charge Nurse will complete a head to toe assessment. The Social Services Designee will assess the resident for emotional distress. The Director of Nursing will notify the appropriate community agencies, attending physician and the resident's legal representative. o The facility's Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrences. o When the missing resident is found, an announcement will be made, Code [NAME] all clear. The Medical Director was notified of the Immediate Jeopardy on 3/28/24. Ad Hoc Quality Assurance and Performance Improvement Meeting was held on 3/28/24 to discuss contents of this plan. 9:30am-Record review of the listed residents Elopement risk seemed to be current and accurate. 10:15am-Record review of Inservice Title: Resident Monitoring/Incident/Accidents/Elopement. The Inservice was developed by DON on 03/27/24. o Round q 2 hours during general rounds, attention to those at risk for wandering/elopement. o Charge nurse does q 6-hour location verification in the record. o Check for location of at-risk residents during change of shift rounds. o Notify Charge Nurse/ADON or DON if resident is not located during this process o Nurse performs Elopement assessment, if identified as an elopement risk, the resident profile is updated, the MDS team will care plan with interventions. ADON/DON is notified. o NOTIFY DON/ADMINISTRATOR IMMEDIATELY IF A RESIDENT IS NOT LOCATED ON INITIAL SEARCH. 10:47am-The following staff were interviewed regarding In-Service Resident Monitoring/Incident/Accidents/Elopement. Staff were able to answer questions in a satisfactory manner and did not raise any concerns. 10:50am-Interview conducted with LVN D. 10:55am-Interview conducted with Restorative aide A. 11:00am Interview conducted with CNA D. 11:06am-Interview conducted with LVN B. 11:11am-interview conducted with ADON A. 11:15am-Interview conducted with LVN C. 11:20am-Interview conducted with CNA E. 11:24am-Interview conducted with Med Aide A. 11:30am-Interview conducted with CNA F. 11:36am-Interview conducted with CNA G. 11:45am-Interview conducted with LVN D. 11:50am-Interview conducted with CNA H. 12:00pm-Observations of staff and resident's interactions during lunch and on hallways did not raise any concerns and residents were being appropriately supervised. Residents were dressed appropriately none of the residents appeared to be in distress. Also while rounding observations were made of exit doors and all doors appeared to be secure and were fitted with an alarm in case of anyone exiting the door. 12:30pm-Record review of facility documentation from Maintenance Director dated 03/28/24 indicated that all exit doors were checked on 03/27/24 and were in working order. 1:00pm-Record review of document tilted Elopement Drill indicated that an Elopement Drill was conducted on 3/28/24 with 16 staff and RN B conducted the drill. 1:10pm-Attempted to call RN B for interview but was unable to reach him. 1:15pm-Interview with DON revealed that she wrote the Inservice and that she in-serviced staff on Service Resident Monitoring/Incident/Accidents/Elopement.] An Immediate Jeopardy (IJ) was identified on 3/28/2024. The IJ template was provided to the Administrator and DON on 3/28/2024 at 5:12 PM While the IJ was removed on 3/29/2024 , the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated, due to the facility's need evaluate the effectiveness of the corrective systems.