**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 3 (Resident #1, Resident #2, and Resident #3) of 5 residents reviewed for accidents and hazards. A) The facility failed to ensure Resident #1 did not leave the facility without supervision and/or staff knowledge as Resident #1 was returned to the facility by a community member on 04/03/2025. B) The facility failed to ensure staff were educated that Resident #2 was a high elopement risk and implement interventions. C) The facility failed to ensure Resident #3's bed was in a low position with a fall mat in place when he fell on [DATE] and sustained a left hip fracture. A & B) These failures resulted in an Immediate Jeopardy (IJ) situation on 04/16/2025. The IJ template was provided on 04/16/2025 at 4:43 PM. C) This failure resulted in an Immediate Jeopardy (IJ) situation on 05/05/2025. The IJ template was provided on 05/05/2025 at 1:17 PM. While the IJs were removed on (A&B) 04/18/2025, and (C) 05/06/2025 the facility remained out of compliance at a scope of pattern and severity level of not actual due to the need to evaluate corrective systems. These failures could place resident at risk of unsafe elopements, falls, injuries, hospitalization, and/or death. Findings include: A) Review of Resident #1 face sheet reflected at [AGE] year-old male admitted on [DATE] and discharged on 04/08/2025 with diagnoses of muscle wasting and atrophy (decrease in size and mass of skeletal muscle tissue leading to a loss of strength and function), difficulty in walking, unsteadiness on feet (difficulty with balance and coordination), other lack of coordination, and unspecified dementia (cognitive decline, impacting memory, thinking and problem-solving skills that are severe enough to impact daily functioning). Review of Resident #1's admission MDS dated [DATE] reflected a BIMS 10 which indicated a moderate cognitive impairment. Review reflected Resident #1 used a walker as a mobility device. Resident #1 required supervision or touching assistance (helper provides verbal cues, touching or steadying) when Resident #1 walked 10 feet - 150 feet. Review of Resident #1's baseline care plan dated 03/04/2025 reflected resident did not have a history of wandering or elopement. Review of Resident #1's admission elopement risk assessment dated [DATE] reflected Resident #1 had a score of five which indicated Resident #1 was at risk of elopement. Further review reflected care plan interventions to apply were routine monitoring of resident. Review of Resident #1's elopement risk assessment dated [DATE] reflected Resident #1 was a high risk for elopement. Review of Resident #1's comprehensive care plan dated 04/04/2025 reflected Resident #1 was a risk for injury related to identified elopement risk and/or exit seeking behavior. Review of map reflected that the gas station was 1.2 miles from the facility and near several businesses and resturants. The residential streets have a speed limit of 30 mph. The highway has a speed limit of 55 mph. During an interview on 04/16/2025 at 1:04 PM, CNA D stated that she worked the shift Resident #1 eloped. CNA D stated her shift was from 6:00 PM to 6:00 AM. CNA D stated Resident #1 went to smoke break at 6:30 PM. CNA D stated when a community member brought Resident #1 back to the facility that was when she found out Resident #1 had been gone. CNA D stated it was around 9:00 PM when Resident #1 was brought back. CNA D stated that Resident #1 was ambulatory, and he usually walked back and forth in the facility or sat in the living room or dining room, but she did not see him on that day (04/03/2025). During an interview on 04/16/2025 at 1:17 PM, CNA C stated he was working when Resident #1 had run off and someone found him at the corner store. CNA C stated he did not remember seeing Resident #1 on his shift. During an interview on 04/16/2025 at 1:26 PM, MA B stated she was already off her shift when Resident #1 returned. MA B stated that apparently the elopement happened right after she left. MA B stated she last saw Resident #1 around 7:30 PM as he was sitting outside with her. MA B stated she was charting and Resident #1 was sitting outside. MA B stated she then clocked out but she stated she did not remember if Resident #1 was sitting outside when she left and stated she was not paying attention. During an interview on 04/16/2025 at 1:37 PM, the DOR stated that Resident #1 was on physical therapy prior to his elopement. The DOR stated that Resident #1 was slow when he walked with a walker. The DOR stated Resident #1 had balance issues and that was the reason he was on service with physical therapy. The DOR stated Resident #1's last therapy progress note reflected he was slow and took a while to walk 150 feet in the facility. During an interview on 04/16/2025 at 2:00 PM, LVN A stated that her shift started at 2:00 PM on 04/03/2025 and dinner was 5:00 PM. LVN A stated that smoke break was at 6:30 PM and she last saw Resident #1 sitting in the living room at 6:30 PM in the living room watching television. LVN A stated that aides went on break around 7:30 PM. LVN A stated Resident #1 returned to the facility around 9:20 PM - 9:30 PM. LVN A stated that the community member stated they had worked in the facility earlier in the day as a contractor and recognized Resident #1 when he drove by the gas station. LVN A stated that resident had a slow walk with his walker, but felt he was stable when he walked. During an interview on 04/16/2025 at 3:02 PM, the ADON stated she did not know how long Resident #1 was gone because it was not reported to her. The ADON stated Resident #1 was returned to the facility by a community member. The ADON stated that CNAs completed rounds every two hours and nurses should complete rounds every hour or two and this included putting an eye on residents to just check on them. During an interview on 04/16/2025 at 3:10 PM, the ADM stated that Resident #1 was returned to the facility around 9:45 PM or 9:50 PM on 04/03/2025. The ADM stated a few staff members were outside at 7:30 PM and took a break and came in and that was the last time ADM was aware any staff saw Resident #1. The ADM stated aides should round on residents every two hours and nurses should have rounded on the off hour. The ADM stated he expected the nurse to be aware of where residents were as best as possible due to the population of the facility. B) Review of Resident #2 face sheet reflected a [AGE] year-old man admitted on [DATE] with diagnoses of cerebral infarction (type a stroke where brain tissue dies due to lack of blood and oxygen), muscle weakness, other lack of coordination, unsteadiness on feet (difficulty with balance and coordination), aphasia (loss of ability to understand or express speech), and hemiplegia (complete paralysis on one side of body) and hemiparesis (partial weakness on one side of body) following cerebral infarction (stroke) affecting right dominate side. Review of Resident #2 admission MDS dated [DATE] reflected BIMS score of 4 which reflected severe cognitive impairment. Review of Resident #2 elopement risk assessment dated [DATE] reflected Resident #2 was a high risk for elopement and had statements and/or threats to leave the facility. Review of Resident #2 care plan dated 04/04/2025 reflect no information about Resident #2's high risk for elopement and interventions were not included. Review of Resident #2 MD progress note dated 04/11/2025 reflected Resident #2 was restless with anxiety and walked and moved around constantly, risk of elopement on close observation. During an interview on 04/16/2025 at 1:04 PM, CNA D stated that there were not any residents who were considered a high elopement risk. During an interview on 04/16/2025 at 1:17 PM, CNA C stated there were not any residents who were a high elopement risk. During an interview on 04/16/2025 at 1:26 PM, MA B stated there were no other residents that were a high risk of elopement. During an interview on 04/16/2025 at 2:00 PM, LVN A stated there were no other residents who were deemed a high risk for elopement. During an interview on 04/16/2025 at 3:02 PM, ADON stated elopement assessments were completed with all residents and there were a couple who were high risk. During an interview on 04/16/2025 at 3:10 PM, DON and Regional Nurse stated that Resident #2 was the only resident deemed a high risk for elopement. Review of provider investigation report dated 04/04/2025 included statement from LVN A which reflected on 04/03/2025 a community member brought Resident #1 to the nurses station. Resident #1 had his walker and had grass and mud on his pants and shoes. LVN A wrote that Resident #1 was by the gas station down the street from the facility. LVN A's statement reflected that the community member recognized him from the facility. LVN A's statement reflected Resident #1 had a head-to-toe assessment and no injuries were found. Review reflected elopement assessments were conducted with all residents and care plans were to be updated if residents were found a high risk for elopement. In-service dated 04/04/2025 conducted with all staff, reflected all residents wanting to go out on pass and leave the facility needed MD approval, RP approval and any legal entity approval. Residents also needed to sign out with the nurse in the sign-out book and provide who was taking the resident out, the resident's name, where they were going, time they left, when they would return, a phone number and information that failure to comply would result in the facility finding alternative placement. In-service dated 04/03/2025 reflected in-service was completed with staff on wandering and elopement. Review of facility policy with revision dated 2001 and titled Wandering and Elopements' reflected the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review reflected if resident was identified as risk for elopement care plan will include strategies to maintain safety. C) Review of Resident #3 reflected a [AGE] year-old man re-admitted on [DATE] with diagnoses of need for assistance with personal care (need for assistance with care such as bathing, dressing or eating), dysphagia (difficulty swallowing), unspecified fractures of shaft of right femur (break in main part of the right thigh bone), history of falling, unsteadiness on feet (difficulty with balance and coordination), other lack of coordination. Review of Resident #3 quarterly MDS dated [DATE] reflected BIMS of 10 which indicated moderate cognitive impairment. Review reflected Resident #3 was dependent for most ADLs (bathing, toileting, upper/lower body dressing and personal hygiene). Resident #3 was substantial/maximum assistance (helper does more than half the effort) for toilet, chair/bed-to chair transfers. Review of Resident #3 care plan dated 02/21/2024 reflected Resident #3 was a risk for falls due to history of falls. Review reflected increased staff supervision with intensity based on resident need. Care plan did not include to keep resident's bed in low position or to ensure fall mat was at bedside. Review of Resident #3 physician orders in Matrix with a start date of 02/21/2024 reflected mat on floor at beside every shift with no discontinue date. Review of Resident #3 physician orders in PCC with a start date of 04/10/2025 reflected fall mat on floor at bedside every shift for fall precautions. Further review reflected order with a start date of 04/17/2025 for low bed with fall mat while in bed for fall safety every shift. Review of incident report dated 04/02/2025 completed by LVN E, reflected CNA called LVN E to Resident #3's room. Resident #3 was noted on floor near door with wheelchair at side without complaints of pain. Further review reflected bed not in low position and fall mat not on floor. Review of admission summary dated [DATE] reflected Resident had diagnoses of intertrochanteric fracture left femur (left hip fracture). Review of Resident #3's discharge information dated 04/04/2025 reflected resident had a hip fracture treated with ORIF (where pieces of fractured bones are surgically aligned and held in place with implants like screws, plates or rods). Observation 04/17/2025 at 10:26 AM, revealed CNA G lowered Resident #3's bed to the lowest position via manual crank at the foot of the bed, under the footboard. Observation revealed control Resident #3 had access to adjust the head and foot of the bed and Resident #3 would have been unable to raise the height of the bed on his own. During an interview on 04/17/2025 at 10:12 AM, LVN E stated that she was on shift the morning of Resident #3's fall. She stated she received a call from a CNA that Resident #3 had fallen. She stated she believed the CNA was CNA F that called her. LVN E stated that Resident #3 was on his left hip and tried to move himself. LVN E stated CNA F called her between 6:00 AM and 6:15 AM and she had not yet done her morning rounds as she was counting medications. LVN E stated interventions to prevent falls for Resident #3 were to have his bed in low position and a fall mat at bedside. LVN E stated that Resident #3's bed was not in low position, and he did not have fall mat. LVN E described the height of the bed as where an aide would have raised it to change a resident. LVN E stated that Resident #3 had no complaints of pain, but due to the height of the bed, his age and prior fall she suggested sending him out to the ER and MD agreed. During an interview on 04/17/2025 at 10:19 AM, CNA F stated she had just started her shift at 6:00 AM and heard Resident #3 yelled out. CNA F stated she saw Resident #3 on the floor and she called for the nurse. CNA F stated Resident #3 would raise his bed up and down on his own. CNA F stated she did not see a floor mat in his room that day. CNA F stated she did not usually work with CNA F but went to assist because she heard him yell. During an interview on 04/17/2025 at 10:26 AM, CNA G stated she usually worked with Resident #3. She stated his fall interventions included to put a mat on the floor and to have his bed in the lowest position. CNA G stated Resident #3 raised his own bed and had a control to raise it. CNA G stated she did not think Resident #3 had a bed that lowered all the way to the ground. During an interview on 04/17/2025 at 11:45 AM, the DON stated Resident #3 was found on the floor at shift change. The DON stated that Resident #3 was sent to the ER for evaluation and stated he should have a low bed and fall as those were interventions prior to the fall on 04/02/2025. The DON stated it was discussed with the nurse that Resident #3 was a fall risk and to have his bed in a low position and fall mat in place because of his history of falls. The DON stated it was discussed verbally with the nurses and CNAs. The DON stated that the facility is going through a change in HER systems. She stated that with the old system she would have looked at the incident report for Resident #3. The DON stated with the new system it looked like she and the ADM reviewed it. The DON stated that she wanted to discuss with MD if Resident #3 had osteopenia because the level he fell from should not have resulted in a hip fracture. The DON stated it was reported to her that Resident #3's bed was in a low position, but she did not recall who reported that to her. The DON stated she did not review the incident report and stated I did not know how to. The DON stated she was not aware the incident report reflected that Resident #3's bed was not in a low position and that he did not have a fall mat in place at the time of his fall. A phone interview was attempted with the MD on 04/16/2025 at 4:13 PM and 04/17/2025 at 12:06 PM, but the phone call was not returned. During an interview on 05/05/2025 at 2:58 PM, CNA F stated that Resident #3 was near the door and stated that he screamed and that his wheelchair was tipped over on the floor. CNA F stated Resident #3 had fallen out of bed and it looked like he crawled to the door in his room. CNA F stated that Resident #3 was usually helped up by the 6:00 AM - 2:00 PM shift and he was not up when she got to the facility at 6:00 AM for her shift. During an interview on 05/05/2025 at 2:59 PM, LVN E stated that when CNA F called her to Resident #3's room he was near his doorway with his hands maybe a foot from his doorway. CNA F stated that the 6:00 am - 2:00 pm shift got Resident #3 up for the day. LVN E stated that it looked that Resident #3 had crawled from where his bed way. LVN E stated it was obvious based Resident #3 crawled and fell out of bed. LVN E stated Resident #3 head was toward the door of the room and he leaned on his right side. LVN E stated that Resident #3's was folded up and on it's side tipped over. Review of facility policy titled Falls and Fall Risk, Managing with revision date of March 2018 reflected, based on previous evaluations and current data, the staff with identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize the complications from falling. Review reflected environmental fall risk factors included incorrect bed height or width. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls. Review of facility policy with revision date of July 2017 and titled Safety and Supervision of Residents reflected our facility strives to make the environment free from accident hazards as possible. Resident safety and supervisions and assistance to prevent accidents are facility-wide priorities. Review reflected interventions to reduce accident risks and hazards included ensuring interventions were implemented and documenting interventions. A&B) The ADM, ADON and regional nurse were notified on 04/16/2025 at 4:54 PM, that an IJ had been identified. An IJ template was provided, and a POR was requested. C)The ADM, and regional nurse were notified on 05/05/2025 at 1:17 PM, than an IJ had been identified. An IJ template was provided, and a POR was requested. A&B) The following POR was approved on 04/18/2025 at 9:59 AM and indicated: [Facility] IJ Plan of Removal F689 4/16/25 Resident #1 was discharged to a secured facility on 4/8/25. All entrances to the facility have been key- pad locked as of 4/4/25 and residents are not allowed out of the facility without an assigned staff member being with them. There is currently one (1) resident who is high risk for elopement and on 4/16/25 at 5:30 PM he was placed on 1:1 monitoring until secure placement is located for him. The facility has sent information to three (3) other facilities and placement has not yet been secured. On 4/4/25, all resident elopement assessments were completed, and one (1) resident was identified as high risk as identified below. On 4/16/25, the identified high risk residents care plan was formulated. Any resident care plans requiring updates was done at this time. On 4/16/25, the administrator in-serviced department heads and100% of facility staff were in-serviced on interventions for the identified high risk resident including 1:1 monitoring, updated care plan indicating 1:1, and Kardex update so that CNAs can be alerted. Also included in this in-service was notifying the administrator of any resident exhibiting high risk behavior or scoring high risk (score over 10) on an elopement assessment so that interventions can be identified and staff informed. Staff not available in person were contacted by phone and verbally in-serviced. Staff are informed that the administrator/designee will notify staff through the above measures and through an in-service if any other resident is deemed high risk for elopement. PRN, agency staff, and new hires will be educated on this process as they are assigned to work by the administrator, DON, or an administrative staff member. Initial comprehension of understanding was done by the administrator on 4/17/25, by questioning staff regarding training. The administrator/designee will interview staff two times (2) a week for one (1) month on their understanding and retention of education given to them on elopement and where to find information on residents at high risk for elopement. The Regional Nurse will monitor new admission elopement assessments for high risk residents, weekly, for one month and randomly thereafter to validate that interventions are in place and communication is in the EMR system. The administrator will document this on an audit form. On 4/16/25, the regional nurse in-serviced the administrator and the director of nursing on reviewing any new admission elopement assessments within twenty-four hours of admission to identify a resident scoring ten (10) or more. Included in this in-service is ensuring that any new staff are educated to the interventions of a resident deemed high-risk for elopement. Initial comprehension of education with the administrator and the DON was completed on 4/17/25, with questioning on understanding of the training by the regional nurse consultant. The regional nurse will document compliance using an audit form. On 4/16/25 at 6:00 PM a Ad.Hoc QAPI meeting was completed with the IDT and the medical director to discuss this plan of removal. C)The follow POR was approved on 05/06/2025 at 3:15 PM and indicated the following: IJ Plan of Removal F689 5/5/25 On 5/5/25, an abbreviated survey was re-opened at facility. On 5/5/25, the surveyor provided an immediate jeopardy (IJ) template notification that the regulatory services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure Resident #1s bed was in the lowest position and had fall mat in place when he fell on 4/2/25 and fractured his left hip. Resident #1s fall care plan interventions and Point of Care Kardex were reviewed and updated to reflect the resident's current condition. On 5/5/25, the Regional Nurse Consultant/ADON, reviewed the facility fall assessment report to identify residents at risk of falls and to validate that current interventions are in place on the resident care plan and Point of Care Kardex. The RNC and the ADON reviewed all facility residents to validate that their fall interventions were care planned and that the Point of Care Kardex was updated to list the fall interventions. This audit was documented utilizing the PCC Fall Assessment score report. Twelve (12) additional residents were identified as at risk for falls. Each had a care plan developed with interventions added to their POC Kardex. On 5/5/25, the RNC/administrator educated 100% of facility staff regarding where to find the information for fall interventions. Staff not receiving the initial education will receive if before starting their next assigned shift. Nurses were instructed to review the care plan, and CNAs were instructed to review the Point of Care Kardex. 100% of the interdisciplinary team (IDT) were given a list of resident fall interventions by the RNC, to refer to while making rounds on their regularly assigned residents before the morning stand-up meeting and reporting any concerns during that meeting. The IDT manager on duty will make rounds on the weekend to identify and immediately resolve concerns with fall interventions. The administrator verified the initial Comprehension of staff training by questioning staff and documenting it on an audit form. The administrator and the RNC will document these tasks on a facility created audit form for record keeping purposes. The RNC will review falls weekly, for one (1) month to ensure that the care plan is updated with a new intervention and that those interventions, if applicable, are carried over to the Point of Care Kardex. Any concerns will be corrected immediately and re-education given to the management team. This will be documented on an audit flow sheet. Education understanding will be completed three (3) times a week for one (1) month by the administrator by questioning the facility staff about where they can find the fall intervention information. The RNC will complete education understanding with the management IDT by questioning them two (2) times a week for one (1) month regarding IDT rounds and identifying problems with fall interventions specifically. This will be documented on an audit flow sheet. On 5/5/25, an Ad.Hoc QAPI meeting was held with the medical director and the IDT to discuss this plan of removal. A&B) Monitoring for the POR occurred on 04/17/2025 and 04/18/2025 as followed: Observation on 04/17/2025 at 10:05 AM, revealed door was secured and required a code from staff to answer or exit. Observations conducted between 04/17/2025 and 04/18/2025 reflected ongoing 1:1 oversight with Resident #2 and staff. Review of Ad.Hoc QAPI sign-in sheet dated 04/16/2025 reflected meeting completed. Review of Resident #2's care plan reflected he was a high elopement risk and interventions included 1:1 oversight. Review of in-service dated 04/16/2025 by regional nurse completed with ADM, and DON reviewed within 24 hours of admission, elopement assessment must be reviewed by nursing administration for any resident deemed high risk for elopement and communication with staff. New employees with receive the training on high risk residents and where to find the information, interventions and communication. Review of in-service dated 04/16/2025 completed with all staff reflected Resident #2 was a high risk for elopement and was currently on 1:1. In-service included any resident who had the potential to elope must be reported to the ADM immediately for interventions to be implemented. Information regarding elopement could be found on Kardex on PCC and in the resident's care plan. Resident deems high risk will have a care plan formulated, added to Kardex in PCC and verbal communication with front line staff. Review of in-service dated 04/16/2025 completed with nurses reflected any resident who scored a 10 or high on elopement assessment or exhibits any elopement possibilities must be communicated to the ADM and DON immediately and interventions will be put in place and communicated to staff. Review of Audit Log dated 04/18/2025 reflected six employees were tested for retention over in-service and elopement. During interviews conducted between 04/17/2025 and 04/18/2025, 4 LVNs, 4 CNAs, 1 HSK ADON, DON, ADM and regional nurse, revealed that Resident #2 is the only resident currently a high risk for elopement and he currently is on 1:1. Staff interviewed stated they can determine who was a high elopement risk by looking at the resident's Kardex or in PCC. Nurses interviewed stated that any resident who scored a 10 or high and was deemed a high elopement risk on the elopement assessment would notified the DON and ADM immediately. Staff stated that any changes in behavior or increase in wandering should be notified to the charge nurse and then the DON and ADM immediately. During interviews conducted on 04/18/2025, regional nurse, DON and ADM stated that any new admission will be reviewed by regional nurse within 24 hours. They stated nurses have been in-serviced to notify the DON and ADM immediately of any residents who scored high-risk for elopement. The care plan should also be updated and this included their baseline care plan. Resident #2 was currently 1:1. They stated education will be on going and staff will be tested for retention. C)Monitoring for POR occurred on 05/06/2025 as followed: Review of 12 residents identified as at risk for falls indicated fall evaluation was completed and care plans included that the residents were a fall risk and interventions for each resident. Review of in-service sign-in sheet dated 05/05/2025 at 05/06/2025 reflected subject of fall interventions completed with staff on shift and prior to the start of their next shift. Information reviewed included staff is to ensure residents are safe by ensuring their fall interventions are always in place. Nurses can find residents fall interventions on their care plan as well as the resident Kardex in PCC. CNAs can find fall interventions on the resident point of care Kardex in PCC. Staff should round at the start of their shift and at least every two hours to ensure listed fall interventions are in place. In-service included list of residents who had interventions in place such as a low bed or fall mat. Review of initial comprehension questionnaire dated 05/05/2025 and 05/06/2025 reflected ADM tested comprehension of POR information reviewed with nurses, aides and IDT. Review of QAPI meeting dated 05/05/2025 reflected IDT members and medical director attended. Review of in-service sign-in sheet dated 05/05/2025 reflected subject of fall interventions and rounds completed with IDT reflected IDT should round prior to the morning meeting to assigned ground of rooms and weekends when assigned as weekend manager. Rounds include fall hazards in the resident room, medications at bedside, water or fluid on the floor, anything left out that can be a hazard, fall interventions and to notify nursing management / administrator if interventions are not in place. During interviews on 05/05/2025 with IDT members, BOM, HR, AD, maintenance director and DOR reflected they were provided a list of residents who had fall interventions in place and were responsible to round prior to morning meeting during the week and on weekends when assigned weekend manager. IDT members stated that they can also find fall interventions in the residents care plans. IDT members stated that if interventions were not in place and it was something they could fix they would fix it, but if not they would notify the nurse, ADM or DON. During interviews on 05/06/2025 with 2 CNAs, 2 LVNs, and 1 cook reflected they received an in-service on fall interventions on 05/05/2025 or 05/06/2025 provided by the ADM. Staff stated that they can find fall interventions on the Kardex in PCC or in the resident's care plan. They stated they should round at least every two hours and at the beginning and end of their shift and look that fall interventions are in place. Staff stated they can fix interventions they see out of place and if they see something that could cause harm they would notify the ADON or ADM. During an interview on 05/06/2025 at 3:49 PM, regional nurse stated that ADM would in-service any agency or new hire staff prior to working their first shift on falls and interventions. Regional nurse stated that when fall interventions are put in place, the Kardex and care plan would be updated and an updated IDT list would be provided by the ADM and discussed during morning meeting. She stated staff will have comprehension completed two times a week for a month. Regional nurse stated that falls would be reviewed during daily IDT and discussed and regional nurse until a DON is hired. Regional nurse stated if an issue were found during a fall audit depending on the issue, remedy could include re-educate, if incident report had issue nurse would be reeducated if care plan didn't have interventions MDS nurse would be educated. Duri[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 was not missing from the facility on 10/07/24 for an unknown amount of time until EMS contacted and notified them that he was approximately .9 miles away and had fallen and found on the railroad tracks. Approximately 500 feet from the facility was a busy highway with through traffic of commercial vehicles to include semi-trucks. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/10/24 at 2:47 PM and an IJ template was given. While the IJ was removed on 10/11/24 at 2:38 PM, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk for unsafe elopements, falls, injuries, dehydration, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type II diabetes, history of falling, Parkinson's disease (a movement disorder that affects the nervous system and worsens over time, cerebral infarction (stroke), unsteadiness on feet, and muscle wasting and atrophy (wasting away). Review of Resident #1's quarterly MDS assessment, dated 08/14/24, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section E (Behavior) reflected the behavior of wandering was not exhibited. Review of Resident #1's quarterly care plan, dated 09/17/224, reflected he was at risk for falls r/t poor safety awareness and mobility with an intervention of therapy to evaluate and treat. Review of Resident #1's most recent Fall Risk Assessment, dated 06/09/24, reflected a score of 14 (a score of 10 or higher represented a high risk for falls). Review of Resident #1's Elopement Risk Assessment, dated 12/01/23, reflected a score of 3 (a score of 5 or higher represented a high risk of elopement). Review of Resident #1's Elopement Risk Assessment, dated 10/10/24, reflected a score of 13 (a score of 5 or higher represented a high risk of elopement). Review of Resident #1's progress notes in his EMR, dated 10/07/24 at 1:15 PM and documented by LVN A, reflected the following: [Resident #1] left facility without signing out and facility staff received a call that [Resident #1] had fell while he was away . During an observation and interview on 10/10/24 at 9:55 AM, revealed Resident #1 sitting on his bed with his head dropped down towards his chest. He was asked if he remembered leaving the facility a few days ago and he had a blank stare. He was asked if he had fallen and he nodded his head yes. He was asked if he had been injured and he shook his head no. When he was asked if he could explain what happened in more detail, he began drawing with his finger on his blanket. He continued to have a blank stare. During an interview on 10/10/24 at 10:06 AM, LVN B stated she was familiar with Resident #1. She stated she was not working the day he went missing but she did hear about it. She stated she did not believe he signed out or notified anyone that he was leaving. She stated he sometimes is was alert and oriented x3 (person, place, and time) but his baseline was alert and oriented x2. She stated he would absolutely not be safe to be walking out in the community by himself. She stated when residents leave OOP, they need to sign out and notify the nurse. During an interview on 10/10/24 at 10:18 AM, the RRC stated on 10/07/24 she got a call from a staff member that Resident #1 was gone and was found by the (grocery store) about a mile away. She stated she, the HR Director, and AD went to go get him. She stated when they arrived, he was sitting in his rolling walker with EMS. She stated he told them he was going to (grocery store) for some ice cream. She stated the EMT's informed them he had been found on the railroad tracks and the train station had contacted the police, who had contacted them. The EMT's informed them he was okay and they took him back to the facility. She stated when residents leave OOP, they were expected to notify their nurse and sign themselves out. She stated she was not sure if he did that as she had not followed up on that part. She stated she was not sure how long he was gone but did believe he had the ability to leave the facility unsupervised. During a telephone interview on 10/10/24 at 10:34 AM, the MD stated Resident #1 looked normal, but when you assessed him in detail - he was slow to think. He stated he was not always oriented and was often confused. He stated the streets around the facility were extremely busy and he would need supervision if he left the facility grounds. During a telephone interview on 10/10/24 at 10:51 AM, Resident #1's FM C stated she was notified that he left the faciity on [DATE]. She stated, in her opinion, he should not be able to leave the facility alone at all due him hardly being able to walk. She stated he was not safe to be unsupervised outside of the facility. She stated she last saw him in August (2024). An attempt to interview CNA D by telephone was made on 10/10/24 at 11:59 AM and 2:01 PM. A returned call was not received prior to exit. CNA D worked the morning Resident #1 left the facility (10/07/24). During a telephone interview on 10/10/24 at 2:06 PM, CNA E stated he worked the afternoon shift on 10/07/24. He stated Resident #1 may sometimes have the ability to be unsupervised if he left the facility, but he was sometimes nonverbal. He stated his cognition varied day-to-day. He stated Resident #1 would not be able to remember the rules to sign out before leaving OOP. During an interview on 10/10/24 at 2:27 PM, the NP stated he was notified of the incident with Resident #1 on 10/07/24. He stated he did not remember if he was told how long he had been gone from the facility. He stated he did not believe Resident #1 could be out in the community unsupervised due to both physical and cognitive reasons, but more so cognitively. He stated he was very cognitively impaired and was not there. He stated he did not believe he could understand the process of signing out even if you were to explain it to him. He stated it was a very unsafe area to be out in. NP stated he definitely believed the facility needed to come up with safer protocols should the residents want to leave the facility. During a telephone interview on 10/10/24 at 3:54 PM, LVN A stated she worked the morning of 10/07/24. She stated it was her first time working at the facility as she was an agency nurse. She stated the other scheduled nurse that day had called out to work so she was the only nurse working the shift and it was a very hectic morning. She stated she did not know around what time Resident #1 left the facility but knew he returned around 11:45 AM. LVN A stated due to it being her first time to work at the facility, she was unable to speak on Resident #1's cognitive abilities. During an interview on 10/10/24 at 2:34 PM, the CRN stated the facility found out Resident #1 was missing on 10/07/24 when EMS called to inform them, he (Resident #1) was found on the railroad tracks approximately a mile from the facility. The CRN stated the train station contacted the police who then contacted EMS. The CRN stated he was assessed with no injuries and brought back to the facility. The CRN stated (and the ADM agreed) that the definition of elopement was a resident who left the facility and was in harm's way mainly because of their cognition or could not make good decisions because of a diagnosis of dementia. The ADM stated if a resident wanted to leave, and they were their own RP, and their BIMS was high enough, then they were able to leave. The ADM stated the importance of notifying the staff they were leaving was to help them make good decisions. The ADM stated he thought Resident #1 did sign out but did not tell anyone where he was going. The ADM stated no one really knew how long he had had been missing, but he could not imagine it had been more than one hour. The ADM stated a negative outcome of a resident not following their OOP protocols was that they could get very hurt. Observation made on 10/10/24 at 8:30 AM revealed the highway approximately 500 feet from the facility was busy and saturated with cars. Review of the facility's Signing Residents Out Policy, Revised August 2006, reflected the following: 1. Each resident leaving the premises (excluding transfers/discharges) must be signed out. 2. A sign-out register is located at each nurses' station. Registers must indicate the resident's expected time of return. The ADM and CRN were notified on 10/10/24 at 2:47 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 10/10/24 at 5:47 PM: On 10/10/24, an abbreviated survey was initiated. 0n 10/10/24, the surveyor provided an Immediate Jeopardy notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate states jeopardy as follows: The facility failed to ensure that resident #1 was not missing from the facility for an unknown amount of time until contacted by EMS. Action: Resident #1 was immediately placed on 1:1 oversight. A full- house the interdisciplinary team completed check to validate that all residents were accounted for. The resident is on therapy and received treatment by physical therapy on 10/7/24. Start Date: 10/10/24. Completion Date: 10/10/2024 Responsible: Administrator Action: A secured facility will be located for resident #1 Start Date: 10/10/2024. Completion Date: open (1:1 oversight will remain until placement is found) Responsible: Administrator Action: All residents residing in the facility will have an updated Elopement Assessment completed and reviewed by the Administrator and the Regional Nurse for being at risk of leaving the facility. The Any nursing management nurses completed these assessments. Residents identified as being at risk as identified by a score over a 5 on the risk assessment will be evaluated further by the IDT to determine safety interventions. Residents will have an elopement assessment completed with their quarterly MDS and with any change of condition by nursing management. All scores and concerns will be reviewed by the interdisciplinary team and recommendations/interventions implemented. The regional nurse educated the administrator on processes for the residents to follow. The administrator educated the residents on the process of notifying facility staff of their desire to leave the facility for any reason. The facility staff will then sign off with the resident in the sign out book. Any concerns will be discussed with the administrator/designee before the resident will be given permission to leave the facility. The nursing management educated the facility staff on the process for residents signing out and monitoring the residents at least every hour to validate that everyone is accounted for. Any concerns will be brought to the attention of the administrator/designee. Staff, including PRN and agency not receiving the initial education will be required to receive it before starting their next assigned shift. Start Date: 10/10/2024. Completion Date: 10/11/24 Responsible: Administrator Action: An ad hoc QAPI meeting was completed with the medical director and the interdisciplinary team to discuss this plan of removal. Start Date: 10/10/24. Completion Date: 10/10/24 Responsible: Administrator Action: Any new admissions, ongoing, will have an elopement assessment completed, and interventions implemented if indicated, upon admission. The administrator/designee will review the elopement assessment to determine concerns. Start Date: 10/10/24 Completion Date: Ongoing Completion Date Responsible: Administrator Action: The administrator initiated an Abuse and Neglect in-service with facility staff. Start Date: 10/10/24 Completion Date: 10/11/24 Responsible: Administrator The Surveyor monitored the POR on 10/11/24 as followed: Observations made on 10/11/24 from 12:38 PM - 2:31 PM revealed CNA F outside Resident #1's room while he was sleeping. She stated when he left his room, she stayed with him to ensure his safety. During an interview on 10/11/24 at 12:42 PM, the CRN stated elopement risk assessments had been completed on all residents and there was only one (excluding Resident #1) who scored as high. She stated the resident often went out on pass and was very responsible. She stated he always notified a nurse that he was going to the (grocery store) and signed himself out and in when he returned. She stated all staff, including agency staff, were being in-serviced before their shifts. She stated the ADM had spoken with residents in groups to remind them of the OOP protocols. During interviews on 10/11/24 from 12:50 PM - 2:18 PM, staff from all shifts, including the AD, one HSK, three LVNs, and three CNAs all stated they were in-serviced prior to their shift on abuse and neglect and residents leaving the facility and resident supervision. All staff members knew that their ADM was their Abuse and Neglect Coordinator and that he should be notified any time there were any suspicions of abuse or neglect. They were all able to give examples of abuse such as verbal, physical, emotional, and psychosocial. They all stated a head count should be completed for each resident at least every hour. They all knew that if a resident wanted to leave the facility, the charge nurse needed to be notified and the resident needed to sign out. They all stated the importance for the protocols was to ensure all residents were accounted for, the staff knew where all residents were, who they went with, where they went, and an ETA for their return. The nurses stated they knew which residents were able to go OOP independently by the residents' elopement risk assessments and there was also a list in the sign-out book. All staff stated the facility was responsible for the residents' safety at all times. Review of the facility's QAPI meeting agenda, dated 10/10/24, reflected the ADM, the CRN, the RRC, the ADON, the AD, the HRD, and MD were in attendance. Review of four residents' (including Resident #1) Elopement Risk Assessments in their EMR, on 10/11/24, reflected they had all been completed on 10/10/24. Review of in-services dated 10/10/24 - 10/11/24 and conducted by the ADM, reflected all staff were in-serviced on ANE - All allegations must be reported immediately to the ADM, the Abuse Coordinator. Review of in-services, dated 10/10/24 - 10/11/24 and conducted by the CRN, reflected all staff were in-serviced on the following: It is our responsibility at (facility) to keep the residents safe from harm. The interdisciplinary team and front-line nursing staff must regularly round to identify any residents that are missing and quickly intervene. Staff will follow this process: 1. If a resident wants to leave the facility grounds, they have been instructed to notify a staff member. That staff member must sign off in the sign out book as well as the resident signing. 2. If you are not sure if a resident can sign himself out and leave the grounds, you must ask a management team member; ADM, DON, ADON, HR, before agreeing to allow them to leave the facility grounds. 3. Any concerns must be brought up to the immediate attention of the management or the nurse in charge, if management is not available. 4. Walking rounds must be done every hour to make sure that all residents are accounted for and on facility grounds. Any concerns must be acted upon immediately. Review of in-services, dated 10/10/24 and conducted by the ADM, reflected residents were in-serviced on the following: Any resident who leaves the facility and does not sign out and provide information such as where you are going, when you will return, and who you are going with will be placed in another facility which may be a secure unit. Staff and resident will enter the entry in the sign-out book. While the IJ was removed on 10/11/24 at 2:38 PM, the facility remained at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.