**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each residents environment remained as free from accident hazards as possible for 2 of 27 residents (Resident #12, Resident #28,) and reviewed for accidents. 1. The facility failed to ensure 3 resident rooms (rooms [ROOM NUMBER]) did not have electrical outlets protruding from the wall. 2. The facility failed to ensure 1 resident room (room [ROOM NUMBER]), where Resident #12 resided, did not have an electrical outlet protruding from the wall with exposed wires. Resident #12 had a BIMS score of 03, indicating she had severe cognitive impairment, and she was able to self-ambulate in her wheelchair. This failure could place residents at risk for fires, physical harm, electrocution, pain, mental anguish, emotional distress, and injury. Findings included: Resident #12 Record Review of Resident #12's face sheet dated 12/04/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: unspecified dementia (loss of thinking, remembering, and reasoning interferes with daily life activities), general anxiety disorder (feeling of fear, dread, and uneasiness) and unsteadiness on feet. Record review of Resident #12's comprehensive MDS assessment dated [DATE] revealed a BIMS score of 03 which indicated Resident #12 had severe cognitive impairment. The MDS further revealed Resident #12 used a manual wheelchair and was independent in the ability to wheel at least 150 feet in a corridor or a similar space. Observation on 12/03/24 at 3:19 PM revealed an electrical outlet detached and hanging from the wall in room [ROOM NUMBER] on A side. Access to exposed wires was noted in the back of the electrical outlet. A privacy curtain was observed hanging between the hanging electrical outlet and between the wall. A chair and a card table were noted in place of where a bed would be on A side of room [ROOM NUMBER]. Resident #28 Record Review of Resident #28's face sheet dated 12/09/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: chronic respiratory failure (breathing difficulties), major depressive disorder (mood disorder), and cognitive communication deficit. Record review of Resident #28's comprehensive MDS assessment dated [DATE] revealed a BIMS score of 13 which indicated Resident #28 had intact cognition. The MDS further revealed Resident #28 used a manual wheelchair and required substantial assistance in the ability to wheel at least 150 feet in a corridor or a similar space. Observation on 12/03/24 at 3:39 PM revealed an electrical outlet box hanging from the wall in room [ROOM NUMBER] on A side by the door. Interview on 12/03/24 at 6:42 AM, the ADM stated the Maintenance Supervisor has been out sick for the past 2 days but should be back to work tomorrow. The ADM stated the Maintenance Supervisor was supposed to make rounds weekly on rooms to check for preventative maintenance issues. The ADM stated he will go and check rooms himself daily for any maintenance issues. The ADM stated there is a maintenance work order book on each hall and the staff are to write all of their maintenance concerns in the work order book. Interview on 12/03/24 at 8:48 PM, the ADM stated Resident #12 would be moved to a different room for the night and an electrician would be at the facility in the morning to work on the hanging/protruding electrical outlets. The ADM stated tape would be placed across room [ROOM NUMBER] so no other staff or residents enter the room before the electrician got to the facility. Observation on 12/03/24 at 8:58 PM, Resident #12 was transferred to a room on A-Hall for the night. No concerns noted with transfer of resident. Observation on 12/04/24 at 10:08 AM, an electrician was noted working on the hanging electrical outlet in room [ROOM NUMBER]. The electrician stated there was a possibility for electrical arcing due to the exposed wires on the hanging electrical outlet box. Interview on 12/04/24 at 10:56 AM, the ADM stated there was a maintenance order on 10/31/24 for room [ROOM NUMBER] regarding an electrical outlet and it was in regard to a different outlet. The ADM stated the hanging electrical outlet in room [ROOM NUMBER] on the head wall on A side was missed when the other electrical outlet was removed from her room. Observation on 12/05/24 at 9:02 AM revealed the electrical outlet in room [ROOM NUMBER] attached to the wall and no longer hanging. Observation on 12/05/24 at 1:28 PM revealed the electrical outlet in room [ROOM NUMBER] was firmly attached to the wall. Observation on 12/05/24 at 1:32 PM revealed the electrical outlet in room [ROOM NUMBER] was no longer protruding from the wall. Record review on 12/05/24 at 2:00 PM of the Electronic Medical Record Bulletin on Point Click Care revealed a message to all staff regarding Accident Hazards and Electrical Outlets. Record review of the facility policy and procedure titled Safety Precautions, Electrical with a revised date of 01/11 reflected the following: Policy Statement - Electrical safety precautions have been established for all personnel to follow. Policy Interpretation and Implementation - The following electrical safety precautions have been established for all personnel to follow. These precautions are not all-inclusive. Others may be added or amended as necessary. 5. Report any plug that is broken, bent, loose. 7. Report all worn, cut, frayed, spliced, exposed, or burned power cords. 18. Report any and all unsafe electrical hazards to your supervisor immediately Record review of the facility policy and procedure titled Hazardous Areas, Devices and Equipment with a revised date 07/17 reflected the following: Policy Statement - All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Record review of the facility policy and procedure titled Accidents/Incidents with a revised date of 04/13 reflected the following: Policy Statement - Our facility shall provide a safe and secure environment for staff and residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 14 of 74 residents (Resident #3, #11, #12, #19, #20, #24, #28, #38, #40, #44, #47, #58, #62, and #65) reviewed for call lights. The facility failed to ensure residents were equipped with a fully functioning call light system in room [ROOM NUMBER] and room [ROOM NUMBER]. Resident #11 had a diagnosis of type 2 diabetes and COPD (Chronic obstructive pulmonary disease), both which would require immediate attention if Resident #11 needed oxygen, or his blood sugar fell too low or got too high. Resident #12 had a diagnosis of type e2 diabetes which would require immediate attention if blood sugar were to get too high or too low. There were no frequent rounds being completed. These failures could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. An Immediate Jeopardy was identified on 12/5/24/ The IJ template was provided to the facility Administrator on 12/5/24 at 4:48 PM. While the immediate jeopardy was removed l on 12/6/24 , the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent future concerns. Findings included: Resident #3: Record review of an admission Record dated for Resident #3 shows an [AGE] year-old male with an original admission date of 6/1/2024 and a readmission date of 10/12/2024 with diagnoses of epilepsy (disorder of the brain characterized by repeated seizures), altered mental status, pain, lack of coordination, feeding difficulties, history of pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot), muscle weakness, insomnia (persistent problems falling asleep), depression, acid reflux, lennox-gastaut syndrome (a rare and severe form of epilepsy that starts in early childhood), eosinophilic esophagitis (chronic allergic immune system disease that affects the esophagus), abdominal hernia (any protrusion of intestine or other tissue through a weakness or gap in the abdominal wall), osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bone wears down) (difficulty swallowing), dysphagia, repeated falls. Record review of a Significant Change in Status MDS (Minimum Data Set) assessment dated [DATE] for Resident #3 indicated a BIM (Brief Interview for Mental Status) of 10 meaning Resident #3 had moderate cognitive impairment. Record review of Resident #3's care plan dated 6/5/2024 indicated Resident #3 had ADL self-care performance deficit due to LENNOX-GASTAUT Syndrome, Epilepsy with interventions of encourage resident to use the call for assistance. If the resident is unable to utilize the call light, staff will provide frequent visual checks. Record review of Resident #3's care plan dated 6/5/2024 indicated Resident #3 had risk for falling due to co-morbid. conditions and impaired mobility with the interventions of call light is within reach and encourage me to use it for assistance as needed. Record review of Resident #3's care plan date revised on 10/3/2024 indicated Resident #3 had risk for Alteration in musculoskeletal status due to contusion of lower back with the interventions of anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Resident #11: Record review of an admission Record dated for Resident #11 shows an [AGE] year-old male with an original admission date of 6/12/2008 and a readmission date of 3/1/2024 with diagnoses of muscle weakness, unsteadiness on feet, hypokalemia, elevated white blood count, age-related physical disability, schizoaffective disorder, neuroleptic induced parkinsonism, type 2 diabetes, major depressive disorder, hypothyroidism, anxiety disorder, hyperlipidemia, paranoid schizophrenia, high blood pressure, chronic obstructive pulmonary disease, benign prostatic hyperplasia. Record review of a Significant Change in Status MDS (Minimum Data Set) assessment dated [DATE] for Resident #11 indicated a BIMS (Brief Interview for Mental Status) of 14 meaning Resident #11 had minimum cognitive impairment. Record review of Resident #11's care plan dated 6/5/2024 indicated Resident #11 had is at moderate is risk for falls due to Psychotropic use, Antidepressant use, and Antianxiety use with the interventions of call light is within reach and encourage him to use it for assistance as needed. Resident #11 needs prompt response to all requests for assistance. Record review of Resident #11's blood sugar for the dates between 4/9/2024 through 12/19/2024, revealed: 12/11/2024 at 19:58 with blood sugar of 78 mg/dl 11/24/2024 at 16:51 with blood sugar of 77 mg/dl 11/23/2024 at 20:37 with blood sugar of 77 mg/dl 11/14/2024 at 20:55 with blood sugar of 76 mg/dl 11/14/2024 at 20:30 with blood sugar of 76 mg/dl 11/08/2024 at 21:31 with blood sugar of 79 mg/dl 11/07/2024 at 10:15 with blood sugar of 68 mg/dl 11/05/2024 at 20:55 with blood sugar of 79 mg/dl 11/03/2024 at 16:46 with blood sugar of 75 mg/dl 11/02/2024 at 16:36 with blood sugar of 79 mg/dl 10/22/2024 at 20:26 with blood sugar of 72 mg/dl 10/16/2024 at 20:56 with blood sugar of 76 mg/dl 10/13/2024 at 21:22 with blood sugar of 77 mg/dl 10/12/2024 at 20:49 with blood sugar of 72 mg/dl 10/11/2024 at 11:31 with blood sugar of 79 mg/dl 10/10/2024 at 10:56 with blood sugar of 66 mg/dl 9/28/2024 at 19:45 with blood sugar of 75 mg/dl 9/15/2024 at 19:34 with blood sugar of 65 mg/dl 9/10/2024 at 20:55 with blood sugar of 74 mg/dl 8/30/2024 at 10:07 with blood sugar of 76 mg/dl 8/3/2024 at 19:21 with blood sugar of 77 mg/dl 7/15/2024 at 20:20 with blood sugar of 74 mg/dl 7/10/2024 at 11:51 with blood sugar of 73 mg/dl 7/09/2024 at 11:33 with blood sugar of 71 mg/dl 7/08/2024 at 11:08 with blood sugar of 76 mg/dl 6/29/2024 at 10:18 with blood sugar of 75 mg/dl 6/21/2024 at 21:18 with blood sugar of 75 mg/dl 6/14/2024 at 11:30 with blood sugar of 67 mg/dl 6/3/2024 at 13:10 with blood sugar of 79 mg/dl 6/1/2024 at 20:01 with blood sugar of 75 mg/dl 5/30/2024 at 16:41 with blood sugar of 67 mg/dl 5/27/2024 at 11:47 with blood sugar of 79 mg/dl 5/25/2024 at 20:23 with blood sugar of 77 mg/dl 5/24/2024 at 11:33 with blood sugar of 79 mg/dl 5/18/2024 at 15:09 with blood sugar of 73 mg/dl 5/18/2024 at 10:50 with blood sugar of 61 mg/dl 5/17/2024 at 10:28 with blood sugar of 76 mg/dl 5/10/2024 at 11:14 with blood sugar of 73 mg/dl 5/2/2024 at 11:24 with blood sugar of 69 mg/dl 5/1/2024 at 19:37 with blood sugar of 68 mg/dl 5/1/2024 at 11:33 with blood sugar of 79 mg/dl 4/26/2024 at 11:10 with blood sugar of 57 mg/dl 4/24/2024 at 10:23 with blood sugar of 57 mg/dl 4/21/2024 at 11:26 with blood sugar of 59 mg/dl 4/19/2024 at 10:35 with blood sugar of 59 mg/dl 4/13/2024 at 16:44 with blood sugar of 73 mg/dl 4/11/2024 at 19:51 with blood sugar of 76 mg/dl 4/9/2024 at 11:25 with blood sugar of 58 mg/dl Record review of Resident #11's Progress Note dated 07/10/2024 stated: Spoke to FNP this morning about changing Resident #11's sliding scale insulin to start at 200. He bottoms out if we give any insulin below that. Received order to discontinue all sliding scale insulin. Record review of Resident #11's Progress Note dated 03/05/2024 stated: This nurse notified, NP regarding this resident having fluctuating blood glucose levels, with no insulin orders or SSI orders in place. This nurse notified Nurse practitioner, insulin and SSI was discontinued in hospital. New order placed; Start back on SSI, with Novolin R 100 units/ML and monitor, per NP, DON, and ADON, notified. Resident #12: Record review of an admission Record dated for Resident #12 shows a [AGE] year-old female with an admission date of 8/5/2022 with diagnoses of dementia, anxiety, unsteadiness on feet, urinary tract infection, schizoaffective disorder, pain, feeding difficulties, muscle weakness, cognitive communication deficit, age-related disability, type 2 diabetes, hyperlipidemia, high blood pressure, A-Fib, arthritis. Record review of an Annual MDS (Minimum Data Set) assessment dated [DATE] for Resident #12 indicated a BIMS (Brief Interview for Mental Status) of 3 meaning Resident #12 had severe cognitive impairment. Record review of Resident #12's care plan dated 6/5/2024 indicated Resident #12 had is at moderate is risk for falls. due co-morbid conditions and impaired mobility with interventions of call light is within reach and encourage me to use it for assistance as needed. Resident #19: Record review of an admission Record dated for Resident #19 shows an [AGE] year-old female with an admission date of 5/1/2023 with diagnoses of Alzheimer's disease, unsteadiness on feet, anxiety, atrial flutter, paroxysmal tachycardia, chronic obstructive pulmonary disease, psychotic disorder, hyperlipidemia, major depression, neuromuscular dysfunction, feeding difficulties, aphasia, abnormalities of gait and mobility, muscle weakness, lack of coordination, cognitive communication deficit, pain in joint, history of falling. Record review of an Annual MDS (Minimum Data Set) assessment dated [DATE] for Resident #19 indicated a BIMs (Brief Interview for Mental Status) of 3 meaning Resident #19 had severe cognitive impairment. Record review of Resident #19's care plan dated 6/5/2024 indicated Resident #19 had oxygen Therapy due to COPD O2 @ 2-3 Liters Per Minute via NC PRN to keep sats at 90% with interventions of provide reassurance and allay anxiety: Have an agreed-on method for the resident to call for assistance (e.g., call light, bell). Stay with the resident during episodes of respiratory distress. Record review of Resident #19's care plan dated 12/5/2024 indicated Resident #19 had a handbell to use as an auditory alarm with the interventions of do frequent checks to ensure needs are met, ensure handbell is within reach and resident is aware of where the handbell is, ensure staff is aware of the handbell. Record review of Resident #19's care plan dated 5/15/2024 indicated Resident #19 had a risk for falls due to impaired mobility, cognition, and history of falls with interventions of call light is within reach and encourage resident to use it for assistance as needed. Resident needs prompt response to all requests for assistance. If resident is unable to utilize the call light staff will provide frequent visual checks. Record review of Resident #19's O2 SAT Summary between dates of 1/28/2022-10/5/2023, revealed that Resident #19 ran consistently low between 95-90 throughout the entire summary. Resident #20: Record review of an admission Record dated for Resident #20 shows an [AGE] year-old female with an admission date of 12/11/2023 with diagnoses of dementia, hypothyroidism, hyperlipidemia, hearing loss, chronic kidney disease, atherosclerotic kidney disease, aortic valve stenosis, acid reflux, atopic dermatitis, osteoporosis, chronic kidney disease, stress incontinence, edema, proteinuria, history of falling. Record review of a Quarterly MDS (Minimum Data Set) assessment dated [DATE] for Resident #20 indicated a BIMS (Brief Interview for Mental Status) of 00 meaning Resident #20 was unable to recall information. Record review of Resident #20's care plan dated 12/12/2023 indicated Resident #20 had a risk for falling due to my co-morbid conditions and impaired mobility. Resident #24: Record review of an admission Record dated for Resident #24 shows an [AGE] year-old male with an admission date of 4/17/2023 with diagnoses of cellulitis, pain, gastrostomy, muscle wasting, supraventricular tachycardia, seizures, allergic dermatitis, high blood pressure, anoxic brain damage, seborrheic dermatitis, high blood pressure, fasciculation, pain in joint, iron deficient anemia, moderate protein calorie malnutrition, anxiety, quadriplegia, acid reflux, constipation, contracture of right and left hand, muscle spasm, dysphagia, flatulence, aphasia, convulsions, traumatic brain injury. Record review of a Quarterly MDS (Minimum Data Set) assessment dated [DATE] for Resident #24 indicated a BIMs (Brief Interview for Mental Status) was left blank and incomplete. Record review of Resident #24's care plan date revised on 9/22/2019 indicated Resident #24 had a has a communication problem due to Head Injury, Weak or absent voice with the allegations of call light in reach. Record review of Resident #24's care plan date revised on 11/15/2024 indicated Resident #24 had a high risk for falls due to balance problems, poor trunk control, no purposeful movement, secondary to traumatic brain injury. Resident #28: Record review of an admission Record dated for Resident #28 shows an [AGE] year-old female with an admission date of 11/23/2023 with diagnoses of chronic respiratory failure, major depression, cognitive communication deficit, pain in joint, muscle weakness, feeding difficulties, tinea cruris, candidiasis of vulva, anemia, hypothyroidism, type 2 diabetes, iron deficiency, morbid obesity, hyperlipidemia, insomnia, chronic pain syndrome, peripheral neuropathy, high blood pressure, diverticulosis, gout, plantar fascial fibromatosis, acute kidney failure, urge incontinence, post-menopausal bleeding, dizziness, injury of muscle and tendon of rotator cuff, urinary tract infection, dependence on supplemental oxygen. Record review of a Quarterly MDS (Minimum Data Set) assessment dated [DATE] for Resident #28 indicated a BIMS (Brief Interview for Mental Status) of 13 meaning Resident #28 had mild cognitive impairment. Record review of Resident #28's care plan dated 12/12/2023 indicated Resident #28 had a risk for falling due to co-morbid.conditions and impaired mobility with the allegations of call light is within reach and encourage me to use it for assistance as needed. Resident #38: Record review of an admission Record dated for Resident #38 shows an [AGE] year-old female with an admission date of 12/10/20203 and an original admission date of 11/9/2023 with diagnoses of stroke, major depression, high blood pressure, type 2 diabetes, hyperlipidemia, chronic kidney disease, sciatica, hemiplegia & hemiparesis, pain, muscle weakness, lack of coordination, feeding difficulties, age-related physical disability. Record review of a Quarterly MDS (Minimum Data Set) assessment dated [DATE] for Resident #38 indicated a BIMS (Brief Interview for Mental Status) of 12 meaning Resident #38 had mild cognitive impairment. Record review of Resident #38's care plan dated 11/10/2024 indicated Resident #38 had a risk for risk for falling d/t my co-morbid conditions and impaired mobility with interventions of call light is within reach and encourage me to use it for assistance as needed. Resident #40: Record review of an admission Record dated for Resident #40 shows an [AGE] year-old female with an admission date of 7/22/2019 with diagnoses of psychotic disturbance, wheezing, tachypnea, abscess of bursa, unspecified falls, drug induced dyskinesia, torsion dystonia, major depression, Huntington's disease, urinary incontinence, muscle weakness, dysphagia, abnormalities of gait and mobilities, lack of coordination, cognitive communication deficit. Record review of an Annual MDS (Minimum Data Set) assessment dated [DATE] for Resident #40 indicated a BIMS (Brief Interview for Mental Status) of 9 meaning Resident #40 had mild cognitive impairment. Record review of Resident #40's care plan dated 6/15/2022 indicated Resident #40 had behaviors such as physically and verbally aggressive when offered the services with interventions of ensure call light is in reach at all times. Record review of Resident #40's care plan date revised on 11/15/2024 indicated Resident #40 had a risk for falling due to my co-morbid conditions and impaired mobility with interventions of call light is within reach and encourage me to use it for assistance as needed. Record review of Resident #40's care plan dated on 12/5/2024 indicated Resident #40 had a bell in place of a call light. Resident #44: Record review of an admission Record dated for Resident #44 shows an [AGE] year-old female with an admission date of 9/3/2024 with an initial admission date of 12/2/2022 with diagnoses of stroke, shortness of breath, anemia, hyperlipidemia, melena, chronic kidney disease, dementia, schizoaffective disorder, edema, dysphagia, unsteadiness on feet, iron deficiency anemia, acid reflux, dermatitis, abnormalities of gait and mobility, weakness, malaise, high blood pressure, aphasia, dysarthria, chronic embolism, pain in joint, muscle weakness, feeding difficulties, lack of coordination, reduced mobility. Record review of an Annual MDS (Minimum Data Set) assessment dated [DATE] for Resident #44 indicated a BIMS (Brief Interview for Mental Status) of 12 meaning Resident #44 had mild cognitive impairment. Record review of Resident #44's care plan dated 6/15/2022 indicated Resident #44 had a risk for falling due to my co-morbid conditions and impaired mobility with the interventions of call light is within reach and encourage me to use it for assistance as needed. Record review of Resident #44's care plan dated 10/2/2023 indicated Resident #44 had an actual fall with no injury with the interventions of all light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Record review of Resident #44's care plan dated 12/5/2024 indicated Resident #44 had a handbell to use as an auditory alarm. Record review of Resident #44's care plan dated 12/7/2022 indicated Resident #44 had an ADL self-care performance deficit r/t cerebral infarction with interventions of encourage Resident #44 to use the call for assistance. If the resident is unable to utilize the call light, staff will provide frequent visual checks. Record review of Resident #44's care plan dated 12/7/2022 indicated Resident #44 is at moderate risk for falls due to impaired mobility with interventions of Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Resident #47: Record review of an admission Record dated for Resident #47 shows an [AGE] year-old female with an admission date of 11/4/2024 with diagnoses of fracture of sacrum, pain in joint, muscle weakness, urinary tract infection, nausea with vomiting, hypo-osmolality, major depression, anxiety, high blood pressure, atherosclerotic heart disease, pulmonary hypertension, emphysema, respiratory failure, sacrococcygeal disorders, acute kidney failure. Record review of an admission MDS (Minimum Data Set) assessment dated [DATE] for Resident #47 indicated a BIMS (Brief Interview for Mental Status) of 10 meaning Resident #47 had moderate cognitive impairment. Record review of Resident #47's care plan dated 4/20/2023 dated on 11/11/2024 indicated Resident #47 was at risk for falls. Interventions included to place Resident #47's call light within reach and encourage to use it for assistance as needed. Resident #58: Record review of an admission Record dated for Resident #58 shows an [AGE] year-old female with an admission date of 12/25/2023 with an original admission date of 6/26/2023 with diagnoses of Alzheimer's disease, history of UTI's, restlessness and agitation, intertrochanter fracture of left femur, anxiety, insomnia, unsteadiness on feet, unspecified fall, pain in joint, muscle weakness, lack of coordination, cognitive communication deficit, feeding difficulties, hypothyroidism, dementia, glaucoma, high blood pressure, acid reflux, osteoporosis. Record review of an Significant Change in Status MDS (Minimum Data Set) assessment dated [DATE] for Resident #58 indicated a BIMS (Brief Interview for Mental Status) of 3 meaning Resident #58 had severe cognitive impairment. Record review of Resident #58's care plan dated 4/20/2023 date revised on 10/28/2024 indicated Resident #58 was high at risk for falls due to confusion. Interventions included to place Resident #58's call light within reach and encourage to use it for assistance as needed. Record review of Resident #58's care plan date revised on 7/7/2023 indicated Resident #58 had a cognitive communication deficit due to Alzheimer's with the interventions of Call light in reach. Resident #62: Record review of an admission Record dated for Resident #62 shows an [AGE] year-old female with an admission date of 6/13/2024 with diagnoses of urinary tract infection, bipolar disorder, anxiety, hypokalemia, dementia, diverticulitis, irritable bowel syndrome, pain in joint, muscle weakness, unsteadiness on feet, lack of coordination, cognitive communication deficit, feeding difficulties, hypothyroidism, hyperlipidemia, depression, insomnia, hearing loss, high blood pressure, atherosclerosis of aorta, diarrhea, fracture of sacrum, left ilium, left pubis, falls. Record review of a Significant Change in Status MDS (Minimum Data Set) assessment dated [DATE] for Resident #62 indicated a BIMS (Brief Interview for Mental Status) of 3 meaning Resident #62 had severe cognitive impairment. Record review of Resident #62's care plan date revised on 9/2/2024 indicated Resident #62 was at risk for falls. Interventions included to place Resident #62's call light within reach and encourage to use it for assistance as needed. Record review of Resident #62's care plan date revised on 11/14/2024 indicated Resident #62 had a witnessed actual fall with NO INJURIES ON 11/13 with interventions of call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Record review of Resident #62's care plan date revised on 12/5/2024 indicated Resident #62 had a handbell to use as an auditory alarm with the interventions of ensure handbell is within reach and resident is aware of where the handbell is. Resident #65: Record review of an admission Record dated for Resident #65 shows an [AGE] year-old female with an admission date of 9/30/2024 with diagnoses of atherosclerosis of coronary artery bypass, pain, muscle weakness, unsteadiness on feet, lack of coordination, candidiasis, hyperthyroidism, type 2 diabetes, hyperlipidemia, depression, high blood pressure, angina pectoris, acid reflux, gout, syncope and collapse, history of falling, presence of cardiac pacemaker, essential tremor, heart failure, stroke, acute kidney failure. Record review of an admission MDS (Minimum Data Set) assessment dated [DATE] for Resident #65 indicated a BIMS (Brief Interview for Mental Status) of 10 meaning Resident #62 had moderate cognitive impairment. Record review of Resident #65's care plan date revised on 10/8/2024 indicated Resident #65 was at risk for falls due to gait problems. Interventions included to place Resident #65's call light within reach and encourage to use it for assistance as needed. Record review of Resident #65's care plan date revised on 10/9/2024 indicated Resident #65 had an alteration in musculoskeletal status due to other specified disorders of bone density and structure with interventions of anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. During an interview with Resident #44 on 12/3/2024 at 11:10 AM. Resident #44 stated that when the call light is used that Resident #44 is not helped a lot of the time. Resident #44 stated that the call light was used on 12/12/2024 to get assistance with a glass of water and no one ever came to help. Resident #44 stated that she had fallen back to sleep without any water. During an interview with Resident #28 on 12/3/2024 at 11:35 AM. Resident #28 stated that it takes the staff a long time to answer the lights and sometimes they do not answer at all. Resident #28 stated that there are times that she is left wet for a while until someone comes to help. Resident #28 stated that it makes her feel like her needs are not important. During night observations and interview on 12/4/2024 at 10:37 PM, Observed room for Resident #44 was on outside of her door but was no sound was triggered at the nurse's station. Resident #44 stated that it takes a long time for staff to answer the call lights. During an interview with LVN C on 12/4/2024 at 10:52 PM. LVN C stated that the call lights had been messed up for a while. LVN C stated that the staff has to make sure to complete rounds because some of the rooms do not trigger a light or a sound. LVN C stated that maintenance had been notified a long time ago and it continues to not be fixed. During an interview with CNA B on 12/4/2024 at 11:01 PM. CNA B stated that the call lights do not work correctly. CNA B stated that on some of the resident's rooms if you trigger the call light in one room it will also trigger in another room. CNA B stated that most of the time it is hard to get to the resident's needs if she does not know that the call light is being triggered. During an interview with LVN E on 12/5/2024 at 10:00 AM. LVN E stated that when she pushes the call light in room [ROOM NUMBER], it also triggers the light in room [ROOM NUMBER] at the same time. LVN E stated that when she pushes the call light in room [ROOM NUMBER], it also triggers the light in room [ROOM NUMBER]. LVN E stated that the call light in room [ROOM NUMBER] only lights up outside of the room but does not trigger a sound at the nurse's station. LVN E showed Surveyor that all these call lights were not working properly. LVN E stated that the call lights had been not working for about 4 to 6 months. LVN E stated that maintenance requests had been completed. Interview with MA B on 12/5/2024 at 11:18 AM. MA B stated that the call lights had not worked for about 4 to 5 months. MA B stated that it is hard to tell who needs help. MA B stated that the staff has to make more frequent rounds. MA B stated that a resident could get hurt if the staff is not aware that the resident needs help and they try to help themselves. During an observation of expanded sample for call lights on 12/5/2024 beginning at 1:48 PM revealed: During observations it was learned that no other method for the residents to alert the staff. Call lights that had a light but not sounding at the nurse's station: room [ROOM NUMBER] A&B, 103 A&B, 125 A, 131 A, 141 A&B, 146 A Rooms with no call light: room [ROOM NUMBER] had no call light. It had the call light cord plugged in and hanging down and at the end of the cord had frayed wired with no call light button attached. Rooms with lights being triggered in other rooms at the same time: In room [ROOM NUMBER] the call light is triggered and also triggers the light in room [ROOM NUMBER] at the same time. In room [ROOM NUMBER] if the call light is triggered it also triggers the light in 109. Call Light that does not work: room [ROOM NUMBER] some of the time the light will work and some of the time the light would not work. During an interview with Resident #11 on 12/5/2024 at 2:38 PM. Resident #11 stated that sometimes the call light works and sometimes it does not. Resident #11 stated that the call light does not work right and sometimes he is not able to get the help that he needs because the call light is not working. Resident #11 stated that it had been not working for about six months. Resident #11 stated that he never knows when it is working and when it is not. Resident #11 stated that the only way to tell that the call light is not working is no one shows up to help. Resident #11 stated that he had diabetes and had issues with his blood sugars falling or at times it will get too high and those times help is needed. Resident #11 stated that help is also needed for brief changes. Resident #11 stated that if no one comes to help he just has to suffer through it. Resident #11 stated that there are times where help is really needed. Resident #11 stated that one time Resident #11's blood sugar had fallen severely low and used the call light but noticed it had been a long time and no one came to help. Resident #11 stated that when Resident #11 started feeling ill because of the drop he yelled out for help and then someone came to help. Resident #11 stated that what would happen if no one had come in to help. Resident #11 stated that he feared that he was going to die that day. During an observation of Resident #11 call light on 12/5/2024 at 3:01 PM showed the call light plugged into port B that did not work. The call light did not light up outside the door and it did not sound at the nurse's station. During an interview with the Administrator on 12/09/2024 at 11:00 AM. The Administrator stated that he was assuming that the maintenance was taking care of the call light situation. The Administrator stated that the Maintenance guy had missed some work due to illness. The Administrator stated that he was not sure how long the call light situation had occurred. The Administrator stated that the negative outcome for the call light not fully functioning is the resident would not be able to get their needs met. Record review of a facility policy titled, Call System, Resident, dated September 2022 stated: Policy Heading: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member of a centralized workstation. Policy Interpretation and Implementation: 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 2. Call system communication may be audible or visual. The system may be wired or wireless. 3. The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional. 4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communications that is usable for the resident is provided and documented in the care plan. 5. The resident call system is routinely maintained and tested by the maintenance department. 6. Calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately. 7. Call light response times are reviewed as part of the QAPI program. Record review of facility maintenance log dates from 09/20/2024-10/11/2024 stated: 1. 9/20/2024: 126 B- (Description or issue) call light does not work, (Completion Date) stated: repaired 9/23/2024. 2. 9/20/2024: 141 B- (Description or issue) call light does not sound, (Completion Date) stated: Do not know what to do about this. 3. 10/10/2024: 134 B- (Description or issue) call light needs to be fixed, (Completion Date) stated: needs new call card. Record review of Resident Council Minutes dated September 09/03/2024, 10/1/2024, and 11/4/2024 all stated: Night Aides not doing their 2-hour rounds. This failure was determined to be an Immediate Jeopardy on 12/05/2024 at 4:48 p.m The Administrator was notified. The Administrator was provided with the IJ template on 12/05/2024 at 4:48 PM. The following Plan of Removal submitted by the facility was accepted on 12/06/2024 at 9:18 AM: Plan of [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent elopement for 1 of 7 residents who wandered (Resident #60). The facility further failed to ensure that the resident environment remained as free of accident hazards on 2 of 2 Halls (Hall1/Central and Hall2), in that: 1). The facility failed to adequately supervise Resident #60 to prevent him from eloping from the facility on 8/18/22 and 9/03/22. The facility failed to develop and implement interventions to prevent elopement after multiple verbalizations by Resident #60 of wanting to leave the facility which resulted in him eloping. 2) The facility failed to store chemicals in a safe manner and were left accessible to residents in common areas on 2 of 2 Halls (Hall 1/Central and Hall 2). An immediate jeopardy (IJ) was identified on 9/28/22 at 5:25 PM. While the IJ was removed, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy and a scope of pattern. These failures related to adequate supervision could place residents at risk for wandering into unsafe environments outside of the facility and sustaining serious injury, harm, impairment or death. Failures related to chemical storage could place residents at risk for chemical injuries. The findings include: 1) Resident #60 Record review of the face sheet and Order Summary Report for male Resident #60 dated 9/15/22 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnosis of Hypothyroidism, Unspecified, Major Depressive Disorder, Recurrent, Unspecified, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Muscle Weakness (Generalized), Cognitive Communication Deficit, Unsteadiness on Feet, Major Depressive Disorder, Recurrent Severe Without Psychotic Features, and Anxiety Disorder Due to Known Physiological Condition. Record review of the admission MDS assessment for Resident #60 dated 8/19/22 revealed that the resident had a BIMS score of 4 , indicating he was cognitively impaired. Further record review of the MDS revealed the resident had a behavior of rejecting care. This behavior occurred every one to three days. The resident was also documented as wandering and this behavior occurred daily. It was further documented that the residents wandering did not place the resident at significant risk of getting to a potentially dangerous place, such as stairs, outside of the facility. Record review of the current undated care plan for Resident #60 revealed that there was a Focus titled, The resident is an elopement risk r/t dementia. ***Patient has a (electronic monitoring device) *** *(Electronic monitoring device) checks 3 times each shift. *Staff will round to lay eyes on patient every 1 to 2 hours and as needed. Patient eloped on 08/18/2022* WAS FOUND SAFE AND RETURNED TO BUILDING Date Initiated: 08/10/2022 Revision on: 08/19/2022. The documented Goal for this Focus was documented as follows, The resident's safety will be maintained through the review date. Date Initiated: 08/10/2022 Revision on: 09/07/2022. Target Date: 11/30/2022. o The resident will not leave facility unattended through the review date. Date Initiated: 08/10/2022 Revision on: 09/07/2022 Target Date: 11/30/2022. The Approach for this Focus was documented as, o Assess for fall risk. Date Initiated: 08/10/2022 o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 08/10/2022 . Record review of the Elopement Risk Assessment for Resident #60 conducted on 8/09/22 by LVN D revealed that the resident made statements and or threats to leave the facility and made frequent request to go home. It also documented that the resident had confused expressions related to tasks to complete. It further documented that the resident verbalized anger and frustration related to his placement. The document stated that the resident had restless behavior such as wandering. Additional information listed on the form revealed that the resident did not recognize stoplights and signs, did not know precautions when crossing streets and did not know the location of his current residence. It was further documented that the resident does not recognize all needs but some. Related to physical capacity it documented that the resident ambulates independently or with device. Cognitive skills for daily decision-making were listed as modified independence - some difficulty in new situation only. Record review of the Progress Notes (8/10/22 thru 9/03/22) for Resident #60 revealed: -On 8/18/22 at 4:45 PM the resident could not be found in the facility. He was found and returned to the facility at 6:37 PM. The nurse on duty was LVN C (agency). The police were called, and facility staff searched for the resident in the facility and surrounding areas. Family and department heads were informed. On his return it was determined he had no injury and an electronic monitoring device was placed on the resident on his return. -On 8/28/22 the resident removed his electronic monitoring device and staff placed another one on his ankle. -On 8/30/22 the resident's wife discovered his electronic monitoring device amongst the resident's possessions and staff placed another one on the resident's right wrist. -On 9/3/22 at 9:15 AM Resident #60 could not be found in the facility again. He was found by family at 11:43 AM and returned to the facility at 12:00 PM. The LVN on duty was LVN D (agency). The police were called, and facility staff searched for the resident in the facility and surrounding areas. Family and department heads were informed. The resident had no injuries. -On 9/03/22, 12:00 PM - Upon entrance to facility, door alarm sounded d/t resident being noted to have electronic monitoring device on wrist. How resident got out of facility with electronic monitoring device on is TBD ADON requested Q 30 min checks for a couple areas then hrly (hourly) until further notice . The resident was discharged from the facility on 9/03/22. Record review of the Incident-by-Incident Type list for the facility dated 9/13/22 revealed that there was one resident listed as having an elopement incident. The date range for the list was 3/13/22 to 9/13/22. Resident #60 was not listed on this document as eloping from the facility. Record review of the MAR/TAR for Resident #60 for August 2022 revealed that the facility started ordered electronic monitoring device checks on 8/11/22 on the night shift. The electronic monitoring device was checked Q shift. On 8/17/22 there was no documentation that the electronic monitoring device was checked on the dayshift. On 8/18/22 it was documented that the resident had his electronic monitoring device on during the day and night shift. On 8/19/22 at 4:00 PM the residents electronic monitoring device monitoring order changed from Q shift to Q4 hours. Further documentation on the TAR revealed that on 8/25/22 there was no documentation that the electronic monitoring device had been checked at (4:00 AM). The resident's electronic monitoring device was documented as being off him on the following dates and times: 8/28/22 at (8:00 PM) 8/30/22 at (4:00 PM and 8:00PM) 8/31/22 at (12:00 AM and 8:00 AM) On 8/31/22 there was no documentation of the electronic monitoring device being checked at (4:00 AM). Record review of the September 2022 MAR/TAR for Resident #60 revealed an order for electronic monitoring device checks Q4 hours. There was no documentation on 9/1/22 at (4:00 PM) that the electronic monitoring device was checked. Further record review of this MAR/TAR for Resident #60 revealed that the electronic monitoring device documentation for his right ankle and left wrist on 9/2/22 ( 8:00 AM and 12:00 PM) was documented as Other and to see the nurses notes for an explanation. The resident was documented as having the electronic monitoring device on starting 9/02/22 at (4:00 PM) through (12:00 PM) on 9/3/22. The electronic monitoring device checks on 9/03/22 revealed that the resident had his electronic monitoring device on for the 8:00 AM and 12:00 PM checks. Record review of the Progress Notes for Resident #60 revealed no documentation as to why there was no on or off electronic monitoring device documentation on 9/2/22 at (8:00 AM) and (12:00 PM). On 9/16/22 at 10:11 AM, an interview and record review was conducted with LVN C (agency) regarding Resident #60's wandering and eloping from the facility. He stated the resident was a wanderer but could converse and state his needs. He added that he would hang around at the exit door near room [ROOM NUMBER]. He was definitely a wanderer. Regarding the day the resident eloped, he stated, on 8/18/22 it was a normal day. Dinner was served. LVN C was in the dining room helping out. Staff report to him at approximately 4:45 PM that they could not find the resident. LVN C searched every room, outside and surrounding areas including businesses. He also called local hospital ERs. Family and law enforcement were called, and the resident was located by police at 82nd street and returned at approximately 6:50 PM. Upon the resident's return, he was assessed, and an electronic monitoring device was placed on him. He further stated the resident had a history of asking for scissors to cut off his electronic monitoring device. The LVN stated he was on duty the next day and monitored him closely. He added he double checked him every hour or two for his whereabouts. There were no other interventions to prevent him from eloping. The LVN stated he was told by staff the resident would remove his electronic monitoring device and ask for scissors to cut it off. He added that the resident never asked him for scissors. LVN C was then asked about their procedures related to electronic monitoring devices. He stated he visually checked the electronic monitoring devices and documented it in the MAR. He added that if a resident wanders to the front of the facility, the electronic monitoring device alarms. He added staff used harder zip type ties to keep the electronic monitoring device on once they knew he could take it off. LVN C then checked the electronic incident documentation system to see if an incident report had been developed for the elopements on 8/18/22 and 9/03/22 and found none. LVN C also stated that he contacted the Administrator, DON and ADON about the 8/18/22 elopement but did not contact the physician. He added that it was not OK not to inform the physician. Regarding the missing incident reports, he stated if there is no documentation it is not done. He further stated he was not sure if the facility had an elopement protocol and did not know what the facility elopement protocol was. He stated, I'm just agency. He also added that there was no documentation of his monitoring of the resident every one or two hours. He stated that his monitoring documentation was only in the nurses' notes . On 9/16/22 at 11:14 AM, an interview was conducted with the DON. Regarding Resident #60 she stated he was tall, had dementia, confusion, was a wanderer and was admitted from a secure facility . Regarding wandering intervention for the resident, she stated after the first elopement they increased electronic monitoring device checks and checked the room daily. Staff checked every shift and more often. The second time he eloped, staff implemented checks every 2 hours. She added, the last time he eloped, he still had his electronic monitoring device on. Staff did not know if someone let him out. She was unsure how far he was from the facility the first time he eloped. The second time he eloped he was found outside a new restaurant on 82nd street. Regarding their elopement protocol, she stated nurses are to check each room. Some staff checked the parameters. Within an hour we called the police. Regarding any orientation provided to agency nurses prior to assuming duties in the facility, she stated, staff conduct a quick one. Staff familiarize them with the charting system. Contact information is given to them for the DON and ADON. Regarding residents, agency staff know what to do. They are informed of resident tendencies. On 9/16/22 at 11:29 AM, an interview was conducted with the Administrator. Regarding elopement protocols, she stated, if residents are not found they look in-house. The administrator is informed, and the administrator informs staff by group text and the department heads look for the resident. She stated the second elopement was handled this same way. Regarding Resident #60 she stated, he was a dementia resident admitted from a secure nursing home. He did not do any wandering there. He was here two weeks and then was found outside. He was gone about 45 minutes . He was not exit seeking. She added that after meals his dementia tells him to go to work. Staff knew to monitor him after meals. He thought he was trying to get to work when he was found at a restaurant on 82nd and Quaker Avenue (Approximately 0.6 miles from the facility). He was found quickly. She believed, the first time he was found on 76th and Salem Avenue (approximately 0.3 miles from the facility). She further stated, both times he was gone an hour or less . The second time was on a Saturday. On 9/16/22 at 11:54 AM, an interview was conducted with the Maintenance Supervisor regarding the electronic monitoring device system. He stated there are two doors with the electronic monitoring device system; the front and the dining room that are exits are alarmed. He added he checks the doors weekly on Mondays. During the generator test it deactivates the electronic monitoring device system and the test lasts 30 minutes . He further stated to test the electronic monitoring devices, he uses an electronic monitoring device and goes to the door to check if it alarms. He also stated that he has a resident, with a monitoring device, go by the door and see if it locks. Regarding Resident #60, he stated the resident got out two times. The first time, staff say he cut off the electronic monitoring device. The second time only thing he could think of was the resident went out with a visitor. He added he did not know if anyone heard the electronic monitoring device alarm go off, but staff should have. Record review of the facility documentation on Door Alarm checks revealed that weekly checks were made. Between 8/01/22 and 9/12/22 all door alarms were documented as passing and had no issues (8/01/22, 8/08/22, 8/15/22, 8/23/22, 8/29/22, 9/05/22 and 9/12/22). On 9/16/22 at 12:45 PM, an interview was conducted with the ADON regarding Resident #60's elopement. Regarding why the incidents happened, she stated, some family may have let him out. He may have been gone out before staff saw him. It's hit and miss who's around the exit door. LVN D told her she did not hear an alarm. Agency staff was at station one. She added that the first elopement he said he was going to work. It was something all staff knew. These were suggestions of what he was thinking. She stated they ensured residents do not elope outside of the facility by conducting hourly checks , frequent checks. She added if staff hear the alarm, they go straight to the door. She further stated there were no documentation of the (hourly) checks. She added, staff make sure they make rounds. She stated, everyone is responsible to ensure that residents do not elope from the facility. She added, she expected that staff are in the building working and others are out searching for any eloped residents. She stated that if residents were not appropriately monitored and eloped, others could elope from the facility. She also stated that there was no paper documentation of the monitoring that they conducted on Resident #60. On 9/16/22 at 2:40 PM, an interview was conducted with the Administrator. Regarding Resident #60 elopements she stated, the staff did not think he would leave prior to the first elopement . She added that staff were supposed to monitor the resident after dinner . She also stated that someone may have let him out. She stated caregivers, charge nurse, nursing and administrator were responsible for ensuring that residents do not elope from the facility. She added she expected staff to provide a better monitoring system to prevent elopements. She further stated she made it clear to staff and they should have taken Resident #60 to his room after his meals. She was asked how an elopement could affect residents. She responded by stating that the facility makes sure residents are in a safe environment, experiencing no harm. On 9/16/22 at 3:06 PM, an interview was conducted with agency LVN E (agency). She stated she worked in the facility approximately three times a month. She stated that she was not oriented by the facility regarding missing residents and the elopement protocol prior to working in the facility. She stated that she had been oriented at other facilities. She stated if residents elope from the facility they could be in danger, run over, or multiple things happen to them. On 9/19/22 at 7:50 PM an interview was conducted with LVN D (agency at the time of elopement). She stated Resident #60, was a roamer and walked all day and night. He was super confused. Sometimes he would layer his clothes wearing seven or eight shirts at a time. All day he would say he was going somewhere. She stated she was not told specifically to take the resident back to his room after meals, but felt it was a given fact. Regarding the 9/03/22 elopement, she stated, it was an hour and a half after breakfast . She had been looking for him for him for something and then discovered he was missing. She added staff started checking and he was not found. Staff did not hear an alarm; no one did. She stated, if the door is held, it should have alarmed. She added that she did not know what exit he may have gotten out of. She stated she did not develop an incident report but documented the incident in the nurse's notes. She stated the incident occurred on her second day at work and she called the family, ADON and DON. She added that family brought the resident back and she assessed him. She was asked what could result from an elopement of a resident. She stated if residents were to elope from the facility they could be hit by a car and be led to do things they should not do. She added that the resident talked well and presented himself well if you were not aware he had dementia . She stated that she had not call the doctor about the incident. She stated when she started working in the facility, nothing special was told to her about Resident #60, but she was made aware that he removed his electronic monitoring device. She added that she placed it back on him a couple of times and that he would pull real hard and could pull it off. During an interview conducted on 09/29/2022 at 9:42 AM with the Administrator , she said she did not recall if they had reviewed camera footage once she was notified the facility had been searched, they started searching outside. She said she was out of town during Resident #60's second elopement. She said it was her understanding that both elopements were through the front door of the facility. She was not sure if an alarm went off, she was told Resident #60 was out on the porch outside of the facility, seen by another visitor, then later found at a restaurant. She said the first time Resident #60 eloped; he was found about a block from his house, which she said was in the area of the facility, talking to the neighbors who called the police while they were at the facility with the Administrator. She further stated the electronic monitoring device alarm on the door goes off until the keypad code is entered by staff. Observation made on 09/28/2022 at 8:16 AM showed a camera to be in the lobby facing the entrance to the facility. Observation made on 09/28/2022 at 8:45 AM showed a camera facing the first nurses' desk nearest the entrance to the facility (Hall1). Observation on 09/28/2022 at 8:47 AM showed a camera facing the facility's dining hall and back door entrance. Observation made on 09/28/2022 at 8:48 AM showed a camera facing the break room. Observation made on 09/28/2022 at 8:50 AM showed a camera facing the south side door at the end of the east hall (Hall 2). Observation made on 09/28/2022 at 8:35 AM showed a camera to be facing the north side door at the end of the east hall (Hall 2). During an interview conducted on 09/28/2022 at 8:59 AM with the Administrator, she said all the cameras were working. She said the monitors were in the central supply room in the beauty shop. During an observation and interview on 9/28/22 at 9:58 AM with the Maintenance Supervisor, he was asked if it would be possible to check camera footage from specific dates. He was not sure if the cameras saved footage. Observation of the central supply closet inside the beauty salon room with the Maintenance Supervisor revealed a monitor could be seen with several viewing panels for all cameras showing no footage being taken currently on any camera as indicated by a blank black screen. Using the search feature found on the monitor, the Maintenance Supervisor typed in the dates in question (08/18/2022, 09/03/2022) and no footage was found. Observation of the cameras in the Dietary Manager's office showed live footage from only the temperature-scanning camera located in the lobby could be seen. He was unable to show footage of the dates in question (08/18/2022, 09/03/2022). During an interview conducted on 09/28/2022 at 9:28 AM with the DON. When asked about the cameras and whether they had ever reviewed camera footage after Resident #60's elopements. She said she did not know how to access them and has never reviewed camera footage. During an interview conducted on 09/28/2022 at 10:33 AM, the Maintenance Supervisor stated he had spoken with the facility's IT (Information Technology) department and was told the cameras send footage to the Administrator's computer with storage only for the last 30 days. He said the Administrator did not know that though, and he was going to her office next to see if it was set up on her computer. Based on the time frames of stored footage, he was asked to provide footage from 09/03/2022 for the hours leading up to Resident #60's noted absence from the facility at 9:15 AM. During an interview conducted on 09/28/2022 at 11:36 AM with the Administrator, she said they had made progress on finding camera footage from 09/03/2022 and said: they are looking at it right now. During an interview conducted on 09/28/2022 at 11:37 AM, the ADON was asked if they had found the footage from 09/03/2022 pertaining to Resident #60 and the elopement from 09/03/2022. She said they were still looking. Observation made on 09/28/2022 at 11:37 AM showed staff members in the Business Office Manager's office looking at camera footage on the computer. During an interview conducted on 09/29/2022 at 10:39 AM with the Business Office Manager concerning footage that she and the ADON had reviewed the previous day, she said they were not able to see any footage of the resident exiting the building. She said they had reviewed footage from all the cameras in the facility yesterday, and that not all doors exiting the facility had a camera facing them that adequately captured the view of the door. On 9/28/22 at 9:10 AM, an interview was conducted LVN A. Regarding Resident #60 she stated, she remembered him. Staff were told to basically watch him and keep an eye on him; Every 30 minutes. She had to check his wander guard four times a day because he would take it off. His roommate was Resident #40. Their room was near the nurse's station. Regarding Resident #60's electronic monitoring device removal, she stated she did not know what he cut it off with. She never witnessed the removal. Staff placed a type of zip tie on it to keep it on. The band looked like it was cut when she saw it. She thought he may have got a butter knife to cut it off. She stated she never checked the resident for a knife and she only kind of looked around his room for an item that could have been used to cut it off. She added, he could get aggressive. She stated Resident #60 mostly watched TV. It seemed lunchtime he might get up. Regarding training about elopements and wandering residents she stated, she had not had any since being in the facility, which was approximately 2 months. She stated she learned from other facilities to keep an eye on them. The other places (facilities) staff saw them and where they were. Regarding any documentation of the 30-minute checks that she conducted on wandering residents, she stated she recently started documenting the checks and added that her weak point in nursing was documentation. She further stated, she could not recall staff asking her to document the one- or two-hour checks on Resident #60's whereabouts. Regarding any interventions told to her after the 8/18/22 elopement, she stated, she was told to make sure to keep an eye on him; her and the CNAs. He was always dressed and ready to go. He mainly stayed in his room. She further stated she never had anything to write on the nurse communication sheets about Resident #60. She stated the nurse communication sheets were placed in the box and then given to the ADON. Record review of the Nurse Communication Sheets for 8/18/22 and 9/03/22 - 9/04/22 revealed no documentation related to Resident #60. On 9/28/22 at 9:45 AM LVN A was interviewed and stated, sometimes Resident #60 ate in his room and she tried to be in the dining room to feed her residents during meals. She added, because he was an elopement risk, she kept her eyes on him. She further stated that no one had told her that Resident #60 needed to be taken to his room after meals. On 9/28/22 at 9:53 AM an interview was conducted with CNA I. She stated staff did one-hour checks on Resident #60 and documented it on their POC (CNA electronic resident documentation kiosk). Staff just checked that he had not wandered off and that his electronic monitoring device was on. He was known to take it off. She stated she never figured out how he got it off. He would tear it off. He was strong. Regarding the 8/18/22 elopement, she stated she was the one that noticed he was gone. Staff searched inside and outside. Staff would see him wandering. He walked with Resident #40. She noticed she had not seen him at her hourly check . It was at supper, and she had not seen him. After he returned, staff was instructed to conduct 30-minute checks. They changed where his wander guard was applied. She added, there was no documentation of the 30-minute checks, it was just every day and it continued. She stated, she received training regarding wandering residents and elopement weeks or months ago. She further stated staff were told Resident #60 should go back to his room after meals by LVN A. On 9/28/22 at 10:40 AM, an interview was conducted with the DON. Regarding interventions implemented after the elopement on 8/18/22, she stated, electronic monitoring devices were checked frequently, and redirection using activities. The nurse was to report abnormal behaviors. The nurse also made rounds. Staff were rounding different hours for the electronic monitoring devices. On 8/19/22 they checked the wander guard three times and then later every four hours. Regarding interventions for the resident removing his electronic monitoring device, she stated, place a new one on and provide education to the resident which was not very effective. Staff changed the positions of the electronic monitoring device. Staff made sure the electronic monitoring devices was comfortable. The main intervention was rounding every four hours. She stated that she would check him when she saw him. The Resident spent a lot of time in common areas. Regarding how he got the electronic monitoring devices off, she stated there was nothing in his room to remove it. Staff thought he was just pulling it off. The resident made comments about scissors. Staff checked everywhere they could for something he used to take the electronic monitoring devices off. The DON stated she thought it was irritating to him and he pulled it off. Regarding if staff had been instructed to take the resident to his room after meals, she stated, she instructed staff to conduct more rounding. She further stated she did not instruct staff to take Resident #60 back to his room after meals. Regarding in-services or training provided for wandering residents and elopements, she stated, staff were provided verbal education. She added more attention was given to station two since Resident #60 resided there. She stated she talked to LVN D, who was the charge nurse. LVN A and agency staff. She added she started the verbal education when the electronic monitoring device was placed on him. Regarding the screening process to determine if referred residents were appropriate for admission, she stated, they reviewed the referrals with a whole team. If there were unresolved issues with the referral, the DON was responsible for addressing the issues. She stated that she did not see Resident #60 prior to admission. She added that the referrals for admission for Resident #60 were received by the Administrator. The DON stated she ensured the nurses were competent in their skills in caring for residents that wandered by the DON and ADON talking to them. She added staff do rounds and check on the residents. Regarding what type of plan was in place for wanderers, she stated, the facility has electronic monitoring devices and an electronic monitoring device system. It locks the door. Staff check doors weekly. Staff try to provide activities for wanderers. Regarding any type of in-services provided on wanderers and elopement since admitting residents with those issues, she stated, staff were provided a lot of verbal instruction. The most recent documented in-service was 6/16/22. She stated, she did not think the facility was secure enough for Resident #60. She added that the facility was secure to a certain extent. On 9/28/22 at 11:24 AM an interview was conducted with the DON regarding why there was no incident report done for Resident #60's two elopements. She stated, no incident report was done since staff found him within two hours. She stated she was told that by the Administrator. During an interview conducted on 9/28/2022 at 1:47 PM with the DON , she was asked if notification to Resident #60's physician regarding his elopement had been made. She said that notification to the resident's physician would be documented in a progress note in the EMR (Electronic Medication Record). She said she would verify with the ADON as well and ask if there is anywhere else that would be documented. This documentation was never provided. During an observation and interview on 9/28/22 at 11:28 AM, CNA I demonstrated where the resident monitoring documentation was located in the POC system for CNAs. The dates range checked was 8/19/22 through 9/03/22. There was no documentation in this system of hourly monitoring checks. At this time CNA I stated, she guessed their instructions to monitor were just verbal. Staff were verbally told to do it. She confirmed that there was no documentation on any of those days that one hour or 30 minutes or any resident checks were conducted for Resident #60. The only documentation that she found was on 9/02/22. There was a note that stated, walk with supervision. On 9/28/22 at 11:45 AM an interview was conducted with the Administrator. Regarding monitoring documentation, she stated, staff would not be documenting unless he was one-on-one supervision or mandated. She stated, It was just known, especially after meals, that he wandered. There was nothing written. Regarding any viewing of the cameras footage for Resident #60's elopements. She stated, they cannot find anything on camera so far. Regarding in-services offered on wanderers and elopement, she [TRUNCATED]