**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being transferred for 1 of 7 residents reviewed for accidents and hazards. CNA A failed to transfer Resident #1 received assistance with the mechanical lift on 12/14/2024. This failure could result in residents receiving injuries. The noncompliance was identified as PNC. The IJ began on 12/14/24 and ended on 12/16/24. The facility had corrected the noncompliance before the survey began. Findings included: Record review of Resident #1's Face sheet dated 12/31/2024 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cognitive communication deficit (problems with communication), pressure ulcer of right heel (wound on heel), dysphagia (difficulty swallowing), difficulty walking, repeated falls, lack of coordination, osteoarthritis (joint disease), cerebrovascular disease (a range of conditions that affect the blood flow to the brain), nutritional deficiency,. Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 12, indicating she was moderately impaired. Her Functional Status reflected she required substantial/maximal assistance with transfers. Record review of Resident #1's care plan, dated 10/7/24, reflected she was a mechanical lift transfer. The care plan also revealed two persons assist with all transfers. Record review of facility investigation dated 12/20/2024 revealed CNA A did not see anyone in the area, so she attempted to transfer the resident from her wheelchair to bed by herself. She was unable to transfer the resident and lowered the resident to a sitting position on the floor. It was noted that the resident was not injured at the time of incident. Record review of employee coaching and counseling record dated 12/14/2024 revealed CNA A documented under employee remarks Resident did not fall! I tried to pivot the resident from chair to bed. When at the bedside resident begun to go down, so I sat the resident on the floor and went for help. During an interview with Residents on 12/31/2024 starting at noon revealed that Residents did not have any concerns about their care. Residents stated the staff transfer them correctly and were not afraid of being transferred by staff. A telephone interview with CNA A attempted on 12/31/2024 at 3:49pm was unsuccessful. She did not call surveyor back. A telephone interview attempt with CNA A on 01/14/2025 at 2:05 pm was unsuccessful; at 5:26 pm another attempt was made to CNA A; she answered the telephone. CNA A stated she had not had any in-services, but she did state she was trained on how to operate a mechanical lift. CNA A then stated she was at work, and she would contact me back. No return call was received. During an interview with CNA B on 12/31/2024 at 3:15pm revealed he had been trained on transfers, abuse and neglect and fall prevention. He said he was at the nurse's station when CNA A came to get him and asked him for help. He said the resident had come back from being out on pass at round 9:00pm. He said that CNA A asked him for help at 9:30pm. He said the mechanical lift sling was under the resident, and he went to get the mechanical lift. He said when he got to the room Resident #1 was sitting on the floor. He said he told CNA A she needed to have the nurse evaluate the resident before they moved her. He said Resident #1 complained of pain in her left shoulder and told the nurse she had the pain before the fall. He said Resident #1 was a two-person mechanical lift transfer. During an interview with LVN C on 12/31/2024 at 3:48pm revealed she had been trained on transfers, abuse and neglect and fall precautions. She said the resident came back from pass with her family. He said the CNA A went to put the resident in bed and tried to transfer the resident by herself. He said CNA A knew the resident was a two-person mechanical lift transfer. He said CNA A came and told him what happened, and she needed to be assessed. He said when he arrived at the room to assess Resident #1, she was sitting on the side of the bed on her buttocks. LVN C performed a head-to-toe assessment on Resident #1 including vitals and pain assessments, ROM to all extremities with no negative findings. LVN C stated he asked the resident was she in pain and she stated she was hurting but she had been hurting all day. LVN C stated after the he completed the assessment of the resident, LVN C along with CNA A and CNA B transferred the resident with the mechanical lift to the bed. LVN C then notified the NP, RP and DON of the incident. LVN C stated a while back (no specific time given) that the resident wore a sling on her left arm. LVN C stated Resident # 1 did not complain of any pain the rest of the night. During an interview with the ADM on 12/31/2024 at 4:17pm revealed she and staff have been trained on transfers. She said the staff can find the transfer status of a resident in their care plan. She said CNA A did not see anyone in the hall or at the nurse's station to help transfer Resident #1. She said CNA A told her she thought she could transfer the resident by herself. She said CNA A realized she made a mistake and lowered the resident to the floor and went to get CNA B to help her. She said CNA B told CNA A she needed to have the nurse evaluate Resident #1 before transferring her since she was sitting on the floor. ADM stated LVN C advised her Resident #1 advised him she had been hurting since earlier in the day. The ADM stated she received a call from the SW on 12/15/2024 and she stated the family decided Resident #1 will not be returning to the facility. During an interview with the DON on 01/14/2025 at 1:50pm revealed Resident #1 was out on pass with her family on or about 4:30/5:00pm and returned to the facility at 9:00pm. He received a call from LVN C that CNA A attempted to transfer Resident #1 to the bed by herself and without the mechanical mechanical lift. DON stated LVN C stated CNA A advised him she did not see anyone to assist her with transferring the resident. DON stated Resident #1 has been a 2 person assist since he has been employed at the facility for the last 2 years. DON stated he was advised Resident #1 ended up on the floor because CNA A attempted to lift resident by herself, and she could not hold her. DON stated Resident #1 always complained on/off about left arm pain. DON stated when you reposition her you must be careful. DON stated after the incident occurred, he spoke with the RP and advised her they would be reporting the improper fall incident to the state. DON stated they decided to do an x-ray because Resident #1 started to complain of the arm pain the next day. The DON stated he contacted the RP and did not want Resident #1 to go to the hospital because it was late, and she did not want her to be disoriented due to her having dementia. DON advised her of the results of the x-ray and Resident #1 was complaining of arm pain and it was protocol to send a resident to the hospital for further care. DON stated there is always someone around that could have assisted and she was just impatient. DON stated in-services on Mechanical Lift, Abuse and Neglect, and timely Incident Reporting, Prevention of Falls and Significant Injuries by Utilizing Daily Care guides. DON stated CNA A was off on 12/15/2024 and returned to work on 12/16/2024 in which she was suspended pending the investigation and terminated on 12/18/2024. DON stated the self-report was completed, pain assessment completed, interviewed staff of abuse and neglect, also filled out the forms with the resident if they witness or happened to have had abuse or neglect and interview the staff on abuse and neglect. DON stated Resident #1 was a heavy wetter and wondered how the family handled Resident #1 when out on pass regarding incontinent care. DON stated the resident would be out with the family at a minimum of 4 to 5 hours. During an interview with the RP on 01/14/2025 at 1:10pm revealed Resident #1 was out on leave with her sibling, and she was returned to the facility at 9:00pm on 12/14/2024. RP stated prior to Resident #1 leaving out on pass, she stated CNA A was rude to her. Upon Resident #1 return and CNA A trying to place her in the bed, Resident #1 was advised to hug CNA A so she can pick her up. RP stated Resident #1 figured she was trying to be nice to her because she was rude to her earlier. RP stated she received a call stating her mom had a fall, but she was alright. It was explained to her CNA A attempted to pick her up by herself. RP stated she asked was the mechanical lift used because her mother had been using the mechanical lift since she had been at the facility since 2018. RP stated she was advised the next day her mother complained of arm pain and the NP had an x-ray done and it revealed she had a humeral fracture. RP stated she did not want her to go the hospital because she did not want her to be disoriented due to her dementia that time of the night. RP stated there was no documentation of her having any pain. RP stated the hospital advised her to send Resident #1 to another facility with her having sub-acute fractures which appeared to be a few weeks old. RP stated she did not have a fall or complain of any pain while she was out on pass with her sibling. RP stated the other time she fell was when she about a month in the facility. Resident #1 was reaching for something, and she hurt her shoulder when she fell out of her wheelchair. Her arm was placed in a sling. RP stated Resident #1 had a bedside table that tipped over on her and she had an x-ray on her toes it was just swelling. Resident #1 complained her foot was hurting in the ER and they showed a fracture on her toes. She has a shoe on her foot. RP stated it happened a couple of months ago. Record review of CNA A's employee coaching and counseling record dated 12/14/2024 revealed the fall during the transfer may have been preventable with adherence to proper facility protocol, including using assistive devices, foot ware, timely reporting to the charge nurse and asking for assistance from colleague. CNA A was placed on suspension on 12/16/2024 and terminated on 12/18/2024. Record review of the facilities investigation summary report dated 12/14/2024 revealed the ADM and ADON contact with CNA A and obtained the statement: CNA A stated it was the end of her shift and she did not see anyone in the area, so she attempted to move her from the wheelchair to the bed herself. This was unsuccessful, resulting in CNA A lowering the Resident #1 to a sitting position on the floor. CNA A requested assistance from CNA B who directed her to the LVN to report the fall requires an assessment. CNA A notified LVN C of the incident and he responded to assess Resident #1 and there were no negative findings, LVN C completed a Coaching and Counseling record for CNA A regarding improper transfer, adhering to facility protocol including using assistive devices; footwear; timely notifications. CNA A insisted she tried to pivot Resident #1, and when she was unable to complete the turn, she then lowered her to the floor and asked for help. During an interview with the ADM on 12/31/2024 at 2:13pm with the Transfer policy was requested but was not provided prior to exit. Record review of the facility CNA Job Description revised in January 2017 revealed staff were to comply with requirements of procedures for safe lifting an/or safe transfer of patients per established policies and procedures. Record review of Resident#1 x-ray dated 12/15/2024 at 8:37pm revealed the bones appear diffusely demineralized. Left humeral neck fracture with no mature callus seen. No joint dislocation. No comparison studies. During an interview with NP on 01/14/2025 revealed she was not the NP on call that weekend, and she only read the results from the x-ray. She stated Resident #1 was discharged when she came in on Monday. NP stated she does not have permissions at the hospital to collect any information regarding the resident. She stated she would attempt to get in contact with the NP that was on call. During an observation on 1/14/2025 at 5:25pm, CNA B, CNA C, CNA D, and CNA E was observed properly operating the mechanical lift with 2 residents. Record review of Skills checks on Transfers revealed that staff had been done on 12/16/2024. Record Review of in-services completed on 12/15-12/16/2024 on Mechanical Lifts, Abuse and Neglect, and timely Incident Reporting, and Prevention of Falls and Significant Injuries by Utilizing Daily Care guides revealed staff had been trained. Record review revealed that Resident #1 was discharged to the hospital on [DATE] and did not return to the facility. The noncompliance was identified as PNC. The IJ began on 12/14/24 and ended on 12/16/24. The facility had corrected the noncompliance before the survey began.

**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 as is 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 did not elope from the facility on 08/22/24. She was found less than two hours later approximately one mile away at a gas station on a busy street. She had a fall which resulted in a swollen face and a cheek abrasion. This noncompliance was identified as PNC IJ. The deficient practice began on 08/22/24 and ended on 08/23/24. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for, falls, injuries, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including cognitive impairment, unspecified dementia, history of fractures, muscle spasms, and shortness of breath. Review of Resident #1's admission MDS assessment, dated 05/06/24, reflected a BIMS of 3, indicating a severe cognitive impairment. Section D (Mood) reflected the behavior of wandering had not been exhibited. Review of Resident #1's quarterly care plan, dated 05/24/24, reflected she was at risk for falls related to impaired mobility with an intervention of keeping areas free of obstructions to reduce the risk of falls or injury. It further reflected she had the potential risk for elopement with an intervention of assessing her for elopement on admission, readmission, quarterly and with any significant changes. Review of Resident #1's quarterly Elopement Risk Assessment, dated 08/09/24, reflected she was a moderate risk for elopement due to her cognitive impairment and wandering aimlessly. Review of Resident #1's quarterly Fall Risk Assessment, dated 08/22/24, reflected she was a high risk for falls. Review of Resident #1's progress notes, dated 08/22/24 a 6:56 PM and documented by RN A, reflected the following: [Resident #1] was in her room at 3:35 PM evening meds was administered. At 3:45-4:30 [Resident #1] was noted in activity room with other residents. At 5:25 PM while passing dinner tray, [Resident #1] was not in her room this nurse checked the bathroom and [Resident #1] was not in the bathroom. CNA working in 300 hall stated that did not see [Resident #1], roommate stated that ([Resident #1] took her parse [sic] and said I will be back shortly). This nurse alerted all staff at the station of [Resident #1] not in the room, staff start searching for resident in all the rooms and bathrooms, outside the building and around, as well as the next building (facility name) and staff driving out on the streets looking for her, second nurse's station also were looking for her, family called and notified . DON notified at 5:35 PM and 6:10 PM when family arrived at the facility, [Resident #1] was found the roadside on (road name) near the (gas station), by a passerby whom the (family member) reported called family member and told them that [Resident #1] is on the road side and has fallen. Then brought [Resident #1] to the facility . head to toe assessment completed, abrasion to left check [sic] with some dried blood, face swollen, resident was agitated, confused, and combative . EMS was called at 6:15 PM per family request . Observations made on 08/24/24 from 10:45 AM - 10:58 AM revealed the MRD testing all eight exit doors throughout the facility to ensure the alarms worked. Each door sounded appropriately at the door and at the nurses' station. The MRD utilized the door code to turn off the alarm at each door. Observation of facility video footage, dated 08/22/24 at 5:12 PM, revealed Resident #1 ambulating independently out the front door behind a family member. During an interview on 08/24/24 at 11:01 AM, LVN F stated he was the nurse weekend supervisor. He stated he had been briefed regarding the incident with Resident #1 and in-serviced by the DON . He stated Resident #1 had a history of ambulating around the building but never saw her attempt to leave or exit-seek. He stated the facility does not have any residents that he has witnessed exhibiting any exit-seeking behaviors. During an interview on 08/24/24 at 11:55 AM, the DON stated he was notified immediately when Resident #1 could not be found. He stated he headed to the facility and advised his staff to keep searching. He stated she was found less than two hours later near a gas station . He stated she had fallen onto her knees and two pedestrians went to assist her and saw her phone in her purse and contacted the last person she had contacted (FM D). He stated she was sent to the hospital per family request and was assessed with no further injury. He stated she was still in the hospital while the family decided on which facility to send her to that had a locked unit. He stated she had no prior history of attempting to leave or any exit-seeking behaviors. He stated they initially thought she may have exited through a side emergency exit door, but they were all tested and in working condition. He stated after reviewing video footage they were able to observe her walking out the front door behind a family member . He stated all staff were in-serviced before their shifts. During an interview on 08/24/24 at 1:42 PM, the REC stated on 08/22/24 she was in the front area and had clocked in around 3:30 PM. She stated she was doing her normal work duties and did not witness Resident #1 by the front desk or leaving the facility. She stated she went to clock out around 5:45 PM and an aide asked if she had seen Resident #1. She stated all staff began looking for her. She stated she had a high-elopement risk binder at her desk and knew not to let any resident leave unless she knew they were allowed to sign out on pass. She stated that same day staff were in-serviced like crazy. She stated they were in-serviced on abuse and neglect, the elopement process, and exit door codes. She stated the door codes of the emergency doors (excluding facility entrance/exit door) should never be given out to family or residents. During an interview on 08/24/24 at 1:53 PM, LVN B stated she had been in-serviced before her shift on elopement, rounding on residents every two hours, answering call lights in a timely manner, and abuse and neglect. She stated if a resident was missing, she would notify the DON and ADM immediately. She stated the emergency exit side doors were not to be used unless there was an emergency. She stated she would never give the exit code out to anybody. She stated there were binders with high-risk elopement residents at the REC's desk as well as at each nurse's station. During an interview on 08/24/24 at 2:34 PM, LVN C stated she was not working the day Resident #1 left the facility. She stated Resident #1 sometimes talked about wanting to go to the bank but never exhibited any exit-seeking behaviors. She stated she had been in-serviced before her shift on abuse and neglect, elopement, and door codes. She stated if a resident could not be found, the DON and ADM needed to be notified immediately after she ensured all staff started searching. She stated she would call the REC to see if any residents had left the facility. She stated it was important to lay eyes on all residents every two hours to ensure all are accounted for. She stated the exit doors are not to be used unless there was an emergency. During an interview on 08/24/24 at 2:59 PM, RN A stated Resident #1 did not have a history of trying to leave the facility. She stated she never even talked about wanting to leave. She stated on 08/22/24, she last saw her around 3:45 PM when she gave her medication. She stated when she took her dinner tray to her room, she noticed she was not in there. She stated she immediately started searching for and asking staff members. She stated the CNA told her she had seen her in the activity room around 4:45 PM. She stated she went to the activity room but she was not in there. She stated she searched all rooms on her hallway, and contacted her family to ensure she was not with them. She stated at that time, all staff started searching the facility, outside, and the courtyard. She stated she contacted the DON and ADM. She stated shortly after, Resident #1's FM D called her and informed her that a passer-by found her by the gas station down the street and dialed the last person that had been called on Resident #1's phone (FM D). She stated she knew none of the exit door alarms had gone off and she knew she had not left through the side doors. She stated all staff were immediately in-serviced by the DON on elopement, who to notify, when you hear an alarm go off to do a head count your residents immediately, and knowing where they were at all times. During an interview on 08/24/24 at 3:11 PM, CNA E stated she was working the day Resident #1 left but was not working her hall. She stated she was familiar with Resident #1 and had never seen her attempt to exit the facility. She stated when it was noticed Resident #1 was missing on 08/22/24, everybody stopped what they were doing and started looking in all of the rooms, bathrooms and outside. She stated in-services conducted by the DON started that evening on elopement and exit doors. She stated it was important to check on the residents constantly and the residents that were a high-risk of elopement (per elopement bind er) should be checked on more often. She stated the only door that should be used to enter/exit the facility was the front door. Review of an in-service entitled Building Entrances and Emergency Exits, dated 08/22/24 - 08/23/24 and conducted by the DON, reflected all staff were in-serviced on the following: Visitors and staff should be only utilizing the front entrance. Side doors are for emergency only and no persons should be coming in or going out of these doors. Review of an in-service entitled Elopement, dated 08/22/24 - 08/23/24 and conducted by the DON, reflected all staff were in-serviced elopement procedures. Review of an in-service entitled Abuse and Neglect, dated 08/22/24 - 08/23/24 and conducted by the DON, reflected all staff were in-serviced abuse and neglect. Review of an in-service confirmations, dated 08/22/24 - 08/23/24, reflected all staff signed an attestation form that they were in-serviced on the following: Elopement and missing persons, shift change walking rounds, Q2 hours body count and sign offs, procedure for missing/elopement patients - q 15 shift, how to identify change in condition, i.e. exit seeking and who to report it to. Review of an audit conducted by the DON, on 08/22/24, reflected all residents had a new elopement risk assessment conducted and no residents were deemed as a high risk. Review of the facility's Elopements policy, revised December of 2007, reflected the following: Staff shall investigate and report all cases of missing residents. 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. This noncompliance was identified as PNC. The deficient practice began on 08/22/24 and ended on 08/23/24. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and that the resident environment remained as free of accident hazards as was possible for one of five residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 who was identified as being at moderate risk for elopement was adequately supervised. The resident was identified as missing on 1/6/23. He was found at least seven (7) hours later on 1/7/23, in an internal courtyard of the facility across from his room. An IJ was identified on 01/27/23. The IJ template was provided to the facility on [DATE] at 05:07 PM. While the IJ was removed on 01/30/23, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility continued to monitor to ensure assessments for elopement were accurate for all residents. This failure placed residents at risk of injury due to not being supervised and placed at risk of accidents/hazards. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia associated with Parkinson's and neurological disorder with Lewy bodies (protein deposits, called Lewy bodies, develop in nerve cells in the brain regions involved in thinking, memory and movement- can cause visual hallucinations and changes in alertness and attention). Review of the admission MDS for Resident #1 dated 01/19/23 reflected a BIMS score of 3, indicating a severe cognitive impairment. It reflected that wandering behavior had occurred one-three days of the lookback period. It reflected Resident #1 required the limited assistance of one person for locomotion. Review of the Elopement Risk section of the Nursing admission Assessment for Resident #1 dated 12/29/22 reflected he was a Moderate Risk, meaning 1) he was cognitively impaired and 2) he ambulated or propelled self. It also reflected Resident #1 went outdoors on occasion but did not try to leave the grounds. Review of the care plan for Resident #1 dated 01/27/23 reflected the following: Potential for elopement as evidenced by going out to room across hall and exiting into patio. Exit seeking. Maintaining the least restrictive environment while providing for (Resident #1) safety for 90 days. Frequent monitoring. All staff. Photo in MAR and Elopement risk book. All staff to be made aware of (Resident #1) risk status, via staff sign-in book and verbal reports qs and prn. If possible, have family or volunteers visit on a regular basis. Keep MD and family informed. Reorient/Redirect prn. Reassess as needed. Review of nursing progress notes for Resident #1 reflected the following: 01/06/23 at 08:23 PM by LVN A Rhabdomyolysis (breakdown of skeletal muscle due to direct or indirect muscle injury) resident AAO times 2 (oriented to person and place but not time and situation), forgetful with short term memory. Continually reminding resident to stay seated or to use the call light. Resident unable to recall any education. Bed in lowest position. Continued rounds on resident the shift for safety. Call light within reach for resident at all times; does not use it. 01/07/23 at 05:55 AM by LVN B While doing rounds patient not in the room. This nurse called and spoke to patient (family member). (Family member) stated the patient not with (family member). Management notified. Local police notified. 01/07/23 at 07:27 AM by LVN B Resident on patio in opposite room, laying in bushes on his back, staff and management present. Resident alert and oriented to self but confused about where he is and why. Staff and local police assisted patient to wheelchair, resident, cooperative, and telling jokes. (Family member) present. Resident has no visible, bruising or swelling noted. 01/07/23 at 08:48 AM by LVN B Spoke with on-call NP to notify her of resident's fall. Stat labs ordered for CBC and BMP. No UA order due to resident just getting off ABT from UTI. Order has been placed. 01/07/23 at 06:16 PM by DON Late entry: this writer notified that resident could not be located during morning med pass. When arrived at the facility, this writer spoke with Administrator. This writer searched the empty room across the hall and discovered resident around 6:30 AM on the patio laying in the bushes. This writer and a ADON notified police and administrator. Police assisted this writer assess and get resident out of the bushes. Resident had no broken skin or new bruises and had redness from the brush. Resident was pleasantly confused A&O times two making jokes with the officers and staff. This has been resident baseline. Complete head to toe and clothes changed. (family member) arrived and spoke with her and advised her that it will be best to have resident assessed in the ER as a precaution. (Family member) was hesitant but agreed. Paramedics arrived and assessed VS WLN and spoke with (family member) and stated that they did not feel he needed to go, but it was her final decision. (Family member) stated that she really did not want him to go to the ER and wanted facility to manage his care. On-call NP notified and labs ordered and resident placed on 15 minute checks. (Family member) is OK with plan and resident is resting in bed and (family member) at bedside. Review of the provider investigation report dated 01/10/23 reflected the following: Other pertinent history: has history of confusion, no wandering per family. Description of the allegation: Missing resident Description of assessment: Head to toes assessment completed by DON. No injuries noted at this time. Investigation summary: On 1/7/23 at approximately 5 AM, this writer received a call that patient one was not in room. This writer notified nurse to call family and have all staff begin to search the interior and exterior of the building. This writer made it to the facility at approximately 528 to begin search for the patient. We confirmed with family that patient was not with them or other family members. Staff continued search for patient and this writer at approximately 5:45 AM called 911 to report a missing patient. The police arrived at facility and asked for floor plan of facility and received description of patient as well as picture of patient. The DON continued to search for the patient, and at approximately 6:45 AM found patient on the patio in a room adjacent to his. Patient was lying in bushes on his back. Patient was pleasantly confused and did not seem to have injuries noted. The DON took the patient back to his room and did a full body assessment. The Patient had minimal scratching on his back and some redness on his back, which was all resolved by the end of the assessment. The Patient did not note any pain at this time. We did call EMS as precaution, but they did not see a needed for patient to go to ER and stated we can run labs and assess at facilityThe Ffamily did sign a waiver to not transport to EMS. Facility NP requested stat labs. Labs completed with no intervention necessary. UA was not completed as patient had just finished a round of antibiotics. Patient was put on Q15 minute checks. Patient did not exit seek at all during observation. He has a high fall risk so he does require frequent monitoring and fall intervention. Patient was moved to room that does not have a patio room adjacent to it to prevent patient from entering vacant room to exit to enclosed patio. Patient has not had any behaviors of exit seeking prior or before incident. Review of facility NP exam dated 12/30/22 reflected the following: HPI limited D/T dementia diagnosis. Information supplemented by hospital records and staff report. Patient is AAO to self, calm, property. He is up in recliner, eating lunch and denies N/V/C/D, dyspnea, and pain. He is ambulatory, incontinent of B/B and lives at home with his family member. He is a retired police officer. VSS on RA, no concerns reported by staff. Psychiatric: insight: poor insight. Mental status: normal mood, affect, and attentiveness and active and alert. Thought process: ordered. Orientation: oriented to person. Memory: recent memory, abnormal, and remote, memory abnormal. Speech normal speech, and comprehension. Assessment/plan: Dementia associated with Parkinson's disease- per records, patient's (family member) reported he no longer takes carbidopa levodopa. No tremors noted on exam, patient alert and oriented to self with some remote memory intact. Review of an Elopement Risk Assessment for Resident #1 dated 01/07/23 reflected that Resident #1 was an Imminent Risk in that 1) he ambulated or propelled himself and/or wandered and had intentionally or unintentionally attempted to leave the community. Review of facility NP exam dated 01/09/23 reflected the following: Medications not reviewed (last reviewed 12/31/2022) Patient is new to me. Chart reviewed. Patient seen today for SNF management of multiple medical problems. Over the weekend, patient reportedly fell in a bush in the courtyard. Family requested labs be drawn. CBC and BMP was ordered. WBC elevated at 12.1. Patient seen today, awake, alert, resting in recliner. No acute distress noted. Patient denies chest pain, SOB, N/V/D/C, urinary urgency, or frequency. Per nursing, no concerns. Lungs clear on exam. No suprapubic tenderness noted. Patient denies concerns. Physical exam Psychiatric: insight: poor insight. Mental status: normal mood, affect, and attentiveness and not active and alert. Thought process: ordered. Orientation oriented to person. Memory: abnormal and remote, memory abnormal. Speech normal speech, and comprehension. Assessment/plan: Dementia associated with Parkinson's disease- per records, patient's (family member) reported he no longer takes carbidopa levodopa. No tremors noted on exam, patient alert and oriented to self with some remote memory intact. Poor concentration in for short term memory. Review of Psychosocial Well-Being Assessment for Resident #1 dated 01/13/23 reflected the following: Current psychosocial/relationship problems, consistent with patient's long-standing lifestyle, or is this relatively new for the patient? Onset of dementia has become hard for a (family member) to be able to care for resident. Referral to (psych services provider). An attempt to interview LVN A by telephone was made on 01/27/23 at 12:56 PM. A voicemail message was left. During observation and an interview on 01/27/23 at 11:35 AM, Resident #1 was sitting up in his wheelchair, dressed, groomed, and clean with no visible injuries and a tray from his meal in front of him Resident #1 stated he did not remember spending a night outside and had no complaints. Resident #1 stated his sister also lived there and would not let anything happen to him. During an interview on 01/27/23 at 01:00 PM, CNA C stated she worked the overnight shift the night Resident #1 went missing. CNA C stated she came in on her shift at 10:30 PM, clocked in, and immediately did a walk through. CNA C stated she always worked on the same hall and Resident #1 lived on that hall in the first room. CNA C stated he was not in his room, but she continued to do her walk through. CNA C stated when she was done with her rounds, she went to the nurses, who were giving each other shift report. CNA C stated LVN A was going home and giving report, and LVN B was coming on shift and receiving report. CNA C stated LVN A told LVN B and her Resident #1 was not there, and CNA C thought she remembered LVN A saying Resident #1 was not there. CNA C stated she figured LVN A would explain to LVN B why Resident #1 was not there, and she went about her duties. CNA C stated she did not ask anything else at that time. CNA C stated she was supposed to check each of her residents every two hours regularly. CNA C stated she did not conduct room checks on Resident #1 that night, because she thought Resident #1 was not in the building. CNA C stated they finally took notice that Resident #1 should have been there when LVN B was going around to give medication at around 05:00 AM and Resident #1 was not there. CNA C stated LVN B called the family to verify he did not leave with them, and from there they started looking for him. CNA C stated everyone in the building stopped and looked everywhere- every room, every closet, and walked outside the perimeter. CNA C stated their administrator was the manager on call, and the administrator made sure they did the proper missing resident protocol. CNA C stated the proper protocol was to look everywhere, notify the police, notify the family, and to keep looking. CNA C stated her shift ended at 06:00 AM, and she only stayed long enough to give a statement for the police and went home. CNA C stated she did not hear any updates until she came back to work and heard that he was found in their courtyard inside a bush. CNA C stated they had made changes, and she and her coworkers had been in-serviced on the changes. CNA C stated now they immediately had to go check all the resident rooms, share report with the nurses, and the nurses did their own room checks. CNA C stated they were still doing the checks each fifteen minutes on Resident #1, but they were not documenting it. CNA C stated she was in-serviced was about safety and awareness of protocols for elopement. CNA C stated there were no other residents she worked with who were similarly at risk. CNA C stated Resident #1 was generally very confused, and at night, he would always be up and confused about the time of day. CNA C stated they just gave Resident #1 reminders that it was nighttime. CNA C stated she would usually catch Resident #1 standing up by his restroom, and he thought he was about to go to work, or his family member was coming for him. CNA C stated Resident #1 did not have a door to the patio in his room, but there was one in the empty room across the hall. CNA C stated she assumed that was how he got out. During an interview on 01/27/23 at 02:03 PM, the DON stated she received a call at 05:00 AM on 01/07/23 from the overnight nurse. The DON stated LVN B told her she had thought Resident #1 was signed out on pass but when she went to give him his medication, he was not marked as gone in the electronic charting system. The DON stated LVN B told her she had gotten from shift change report that Resident #1 was out on pass. The DON stated she understood LVN B called the ADM, called the family, and when no one knew where Resident #1, the alarm went out. The DON stated they got conflicting stories from LVN A and LVN B. The DON stated LVN A said she had seen him sitting in his chair throughout the evening, and the CNAs on the overnight shift both told the DON LVN A had said Resident #1 was out on pass. The DON stated the police were at the facility, and all the staff searched for him. The DON stated she lived an hour away, and when she arrived at the facility, she and the ADON searched together. The DON stated the family told her Resident #1 could not get far. The DON stated they searched the neighborhood in their cars. The DON stated she was standing outside his room looking around, thinking he could not get far and she had seen him use his wheelchair as a walker. The DON stated she noticed the vacant room across the hall, and she saw the bed in that room was a little messed up. The DON stated she asked her staff if they had checked the courtyard, and they told her they had been out there with flashlights, calling Resident #1's name. The DON stated she decided to go out the patio door in the room across from his, and Resident #1 was right there laying in some bushes. The DON stated Resident #1 woke up immediately, looked at her and said Hi! The DON stated Resident #1's wheelchair was sitting on the patio with some of the patio furniture stacked on it. The DON stated they did an assessment, brought the police, and got Resident #1 in the wheelchair. The DON stated Resident #1 was just talking and laughing and being his usual self. The DON stated they did a full assessment without Resident #1's clothing, and he had bright red marks where the bushes brushed against him, but they were gone by the time the assessment was over. The DON stated they had a hard time convincing the family to send him to the ER, but they convinced the family to let them call 911. The DON stated the EMTs arrived, assessed him, and decided not to take him to the ER. The DON stated the NP ordered lab work minus a urinalysis, because Resident #1 had just finished antibiotics for a UTI. The DON stated after the incident, they did not do an elopement assessment on all the residents in the facility but they did do one on the two they knew had a risk of elopement. The DON stated it was very hard to prevent elopement for those residents, and they basically tried to redirect the ones who were a risk. The DON stated they put Resident #1 onto every-15-minute watches. The DON stated there was no wander guard system at the facility, and they were not entirely equipped for residents who wandered or exit-sought. The DON stated they moved Resident #1 into a room where he no longer had access to any patio doors. The DON stated they also put together a system of walking rounds during which both the off-going and oncoming nurses on every hall did full walking rounds together and both put eyes on every resident before shift change. The DON stated the CNAs were still checking on residents every two hours, at least. The DON stated she had told the CNAs they needed to round on the residents with elopement risk more frequently, but there was no formalized system in place for that. The DON stated the staff knew if a resident was out on pass by marking it in the computer. The DON stated if the nurse who had worked the overnight shift the night Resident #1 slept on the porch had checked the computer system, she would have known Resident #1 was not on pass, and they would have found him sooner. The DON stated LVN B had just assumed, and assuming got them into the situation where Resident #1 could have been seriously harmed. The DON stated the patio doors were the same and still opened out into the courtyard without locks. The DON stated there was a book at each nurse's station and the front of the building that contained information about the residents with a risk of elopement. The DON stated they had a QAPI meeting about the situation, but she was unable to attend. The DON stated there was a Performance Improvement Plan in place that came from the QAPI meeting. During an interview on 01/27/23 at 2:39 PM, LVN B stated she had worked the night shift on 01/06/23 when Resident #1 went missing. LVN B stated her recollection was she had gotten shift report from the off-going nurse, went down the hall for something, and when she came back and asked why Resident #1 was gone, the off-going nurse had already left. LVN B stated she asked CNA C if there was someone living in Resident #1's room, and CNA C told her he had left with his family. LVN B stated at that point, she didn't think anything about it. LVN B stated later in the shift, when she was passing medications, she looked on the computer and Resident #1's chart did say Leave Of Absence or Resident #1 was out on pass. LVN B stated she asked CNA C again at that point if she was sure LVN A had said Resident #1 was gone. LVN B stated she tried to call LVN A who texted after a long while that Resident #1 had not left that she knew of. LVN B stated at that point she started alerting the staff and looking for Resident #1. LVN B stated LVN A was very fast during the shift change report and did not say anything at all about Resident #1. When asked if a CNA approached and asked about Resident #1 while they were sharing shift report, LVN B stated she could not remember. LVN B stated when she returned to work the next night, the only change was a 15-minute check on Resident #1, which was only for that day. LVN B stated she had never seen any resident wander out of the patio door. LVN B stated she had one other resident with wandering or exit-seeking behaviors, and it was Resident #2. When asked what she did to ensure residents were safe from wandering, LVN B stated when she workeds she checkeds at night anywhere from every 30 minutes to an hour. LVN B stated she put eyes on every other resident at shift change. During an interview on 01/27/23 at 3:45 PM, the ADM stated she got a call at 05:00 AM asking if she knew anything about Resident #1 leaving or going out on pass, but she did not. The ADM stated she told the staff to call Resident #1's family and said she was on her way to the facility. The ADM stated she got to the facility in 15 minutes. The ADM stated when she learned from the family Resident #1 was not with them, she knew he was somewhere at the facility. The ADM stated no alarms had gone off at the facility, which is what would have happened if anyone had gone out any of the exit doors. The ADM stated they searched the inside and outside of the facility and then called 911. The ADM stated she was doing her investigation after Resident #1 was found, and CNA C told her the LVN A had said Resident #1 left. The ADM stated LVN B told her that CNA C said he had left but that she did not remember hearing it directly from LVN A. The ADM stated LVN A did not say when she last saw Resident #1 the night of 01/06/23, but LVN A did say she remembered him being present on her shift but did not specify when she last saw him. The ADM stated, prior to this incident, it was a requirement to do a shift report at shift change, but it was not required to do walking rounds at shift change. The ADM stated they did not have a sign out book for residents going on pass, but they had an option in the EMR to mark the residents out on pass and doing this was their policy and procedure. The ADM stated the DON did all the in-servicing after the incident. The ADM stated part of the change they implemented was walking rounds at shift change, which meant that the off-going nurse and oncoming nurse had to physically walk through their halls together and put eyes on every single resident. The ADM stated she, the DON, and the ADON followed along on these rounds at every shift change for a full week to ensure the nurses got into the habit. The ADM stated Resident #1 had no history of exit seeking prior to this incident, and when she spoke to the family about the incident, they all said he could not get far with his level of ambulation. The ADM stated they always performed an elopement assessment with the admission assessment, and Resident #1's elopement assessment had a result of low risk. When asked what was being done to prevent Resident #1 from eloping again, the ADM stated he no longer had access to the patio doors and could not see any patio doors from his current room. The ADM stated that was the biggest and most crucial intervention. The ADM stated they did lab work, and the results showed no abnormal values. The ADM stated he was positive for COVID-19 shortly after that, so it was possible the change in his behavior was related to COVID-19. The ADM stated he had just been on antibiotics for a UTI, so they were sure it was not that. The ADM stated they also did individual counseling with each staff person involved in Resident #1's incident. The ADM stated LVN B took CNA C's word for it and did not check, CNA C did not follow protocol and clearly report the missing resident, and LVN A did not give a thorough enough shift report. The ADM stated they had three people listed in their wandering/elopement risk binder that was placed at both nurse's stations and the front desk, but the other two residents (Residents #2 and #3) had not exhibited those behaviors in a very long time, and Resident #3 was no longer at the facility. The ADM stated the facility did not accept residents with a known history of wandering and elopement. The ADM stated they were a short term, high volume facility, and they were not equipped to monitor residents who had that risk. The ADM stated, if they had a resident with cognitive impairment who began to exhibit exit seeking behavior, they would monitor closely for a week and then begin to have discussions about discharge to a more appropriate facility. Record review of facility in-services reflected the following: 01/07/23 Elopement 01/07/23 Abuse & Neglect 01/07/23 Leave of Absence 01/07/23 Walking Rounds Review of the facility's QAPI Performance Improvement Plan dated 01/07/23 reflected a subcommittee comprised of the ADM, DON, and ADON. It reflected a subject of To ensure safety and acknowledge the presence of residents admitted to facility. It reflected the following changes implemented: 1) In-service staff on high risk patients and preventative measures. 2) All patients on admission will be assessed for elopement risk. 3) Nurses/CNAs are to perform walking rounds during shift changes. 4) Nurses/CNAs round frequently on the halls. It was marked that the QAPI committee approved the plan. Review of Frequent Monitoring Record for Resident #1 dated 01/08/23 to 01/10/23 reflected documentation of checks on Resident #1 each 15 minutes for the 72-hour period. Review of facility policy dated April 2019 and titled Abuse Protocol reflected the following: Missing patient: if a patient is not located within eight hours during a search of the facility, facility grounds, and immediate vicinity, and there are circumstances, which placed the patient's health, safety, and/or welfare at risk. Review of facility policy dated May 2016 and titled Elopement Response Protocol reflected the following: Upon the occurrence of an allotment or suspected elopement, the following steps must be immediately taken: 10. Based on the elopement risk; the patient may be discharged . The facility administrator, facility DON, and the corporate nurse consultant were notified on 01/27/23 at 05:05 PM that an Immediate Jeopardy situation had been identified due to the above failures. The following Plan of Removal submitted by the facility was accepted on 01/29/23 at 11:45 AM and included: [NAME] Air at Teravista Immediate Jeopardy Plan of Removal January 27, 2023 Impact Statement: On 1/27/2023 complaint survey was initiated at [NAME] Air at Teravista, 4105 Teravista Club Dr. Round Rock, TX 78665. On 1/27/2023, the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute an immediate jeopardy to resident health. The facility neglected to provide adequate supervision to 1 patient as he was missing for an extended period of time. Resident was missing for approximately 9 ½ hours. Immediate action: Please accept this as a Plan of Removal to remove the IJ Identified F689- The facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents. initiated on 1/27/22 at 5 P.M. Residents that can be affected are those with imminent elopement risk assessments. At this time, the facility had one resident who could be affected. There were two residents that were identified during the investigation that was ambulatory with low BIMs, however, neither resident was triggered for imminent risk due to no history of elopement attempts, wandering, or leaving the community without informing staff. After completing the elopement assessments, on 1/27/2023, facility had one resident identified as imminent risk by the elopement risk assessment. Systematic Approach: 1. Assessment o All residents will have an elopement risk assessment updated by the Director of Nurses, Assistant Director of Nurses, and Patient Care Coordinator on 1/27/23 to identify any current patients that are at imminent risk for elopement. No residents were deemed at imminent risk for elopement. There were two residents identified during the investigation who were ambulatory and had low BIMs; however, neither resident was triggered for imminent risk on a previous or updated elopement assessment due to no history of elopement attempts, wandering, or leaving the community without informing staff. The assessment is a (Electronic Medical Record) Document and includes the following information: The assessment to determine if patient is an imminent risk for elopement. The resident will have to intentionally or unintentionally attempt to leave the community or verbalize a plan to elope the community to be documented in the elopement assessment as an imminent risk for elopement. o Start Date: 1/27/2023. o End Date: 1/29/2023 o Who will be Responsible: Nurse Managers o Who Will Monitor: Executive Director/Director of Nursing o Beginning 1/27/23, elopement assessments will be completed upon admission, condition change, and quarterly by the charge nurse and/or nurse managers, and for any patient that triggers an imminent risk for elopement, the elopement response protocol will be initiated. The ED and DON will monitor for compliance daily by running an audit of the elopement assessments. o Start Date: 1/27/2023. o End Date: Audits will be completed weekly for 3 months until 4/27/2023 and then monthly on an ongoing basis. o Who will be Responsible: Nurse Managers o Who Will Monitor: Executive Director/Director of Nursing ? Beginning 1/27/23, any patient who triggers an imminent risk of elopement, meaning the patient intentionally or unintentionally attempts to leave the community or verbalize a plan to elope the community, will have notification placed in the elopement binder by the Nurse Manager and monitored by Clinical Staff in accordance with the Elopement Response Protocol- A (Facility Company) Policy ? Facility staff will conduct thorough rounds of facility grounds. ? If patient is not found within 15 minutes charge nurse will call the Executive Director. ? Executive Director will call family, police and notify Physician. ? Executive Director will notify HHSC of incident. ? Facility Staff will continue to search for resident until found. ? Once Resident is found a nurse will do head to toe assessment and provide care accordingly. ? In addition, the physician and responsible party will be notified of the results. Until alternative and or safe living arrangements are made the patient will be placed on one-to-one supervision with facility staff. The patient's picture and face sheet will be placed in an elopement binder. Patient care plans will also be updated. The Director of Nursing and/or Nurse Managers will monitor weekly for compliance by completing an audit of the elopement assessments and the elopement binders. o Start Date: 1/27/2023. o End Date: Audits will be completed weekly for 3 months until 4/27/2023 and then monthly on an ongoing basis. o Who will be Responsible: Nurse Managers o Who Will Monitor: Executive Director/Director of Nursing 2. In-Services o Clinical Staff were in-serviced by the Director of Nursing and/or Nurse Managers. All new clinical staff will receive the Elopement in service as part of the onboarding orientation process prior to being assigned and providing care to residents. No clinical staff member will be allowed to work in the facility until the above required in-services are completed. Any line staff that does not complete in-service will be terminated by 1/29/2023. o Start Date: 1/27/2023. o End Date: 1/29/2023 o Who will be Responsible: Nurse Managers o Who Will Monitor: Executive Director/Director of Nursing o Shift to Shift Reporting process will be as follows. ? As part of shift to shift report the charge nurse will print the census to identify patients who are on leave and not in the facility. ? At shift change, 6a.m., 2p.m., 10p.m.- the oncoming nurse will conduct walking rounds the outgoing nurse and account for each patient on the census. ? At shift change, 6a.m., 2p.m., 10p.m.- Certified Nurse Aides must conduct walking rounds and visually account for each patient. All new clinical staff will receive the Elopement in service as part of the onboarding orientation process[TRUNCATED]