**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for one (1) of four (4) residents (Resident #1) reviewed for accident hazards and supervision. The facility failed to ensure a cognitively impaired resident (Resident #1) had adequate supervision on 09/01/2024 which allowed him to elope from the facility from an unknown door after lunch on 09/01/2024 and was not located until 02:40 a.m. on 09/02/2024 at a local hospital. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 09/05/2024 at 04:24 p.m. The IJ template was provided to the facility on [DATE] at 05:17 p.m. While the IJ was removed on 09/08/2024 at 02:14 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for serious injuries and accidents. Findings included: Record review of Resident #1's admission Record, dated 09/04/2024, revealed Resident #1 was a [AGE] year-old male admitted on [DATE] from an acute care hospital. Record review of Resident #1's Diagnosis Report, dated 09/04/2024, revealed Resident #1 was diagnosed with dementia (a general term for impaired ability to remember, think, or make decisions) during his stay at the facility, the onset of the diagnosis was dated 08/16/2024. Resident #1 had additional diagnoses which included: hypertension (a condition of high pressure in the vessels that carry blood from the heart to the rest of the body), muscle weakness, and alcohol use. Record review of Resident #1's MDS BIMS assessment, dated 07/02/2024, revealed a score of 2.0, indicating the resident had severe cognitive impairment. A second MDS BIMS assessment, dated 07/18/2024, revealed a score of 2.0, indicating the resident had severe cognitive impairment. Record review of Resident #1's Order Recap Report, order date: 06/26/2024 - 09/30/2024, revealed the following orders: - Add Dementia with Behaviors to diagnosis list, ordered date 07/09/2024 - May go on leave of absence with medications and responsible party, ordered date 06/26/2024 - q1hr (every one hour) checks monitoring for elopement risk every hour for elopement risk, ordered date 09/03/2024 Record review of Resident #1's Community Safety Awareness Summary assessment, dated 06/26/2024, revealed Resident #1 was moderately impaired for his ability to make decisions regarding tasks of daily living. Resident #1 was indicated to be unsafe for being capable of safely crossing the street without or without light, was not safe to leave the facility on pass, and was easily confused and could become lost. Record review of Resident #1's Elopement Risk Assessment, dated 06/26/2024, indicated Resident #1 had dementia and ambulated independently. He was cognitively impaired with poor decision-making skills, had a substance use disorder, and was at risk for elopement. He was indicated as at risk for elopement. Record review of Resident #1's Psychiatry Initial Evaluation, dated 07/09/2024, revealed Nurse reports pt (patient) with attempts to elope last week, however none this week. He was easily redirectable by staff at times of elopement attempts. He is ambulatory with no recent falls. Under Assessment and Plan, revealed 1. Dementia with behaviors: Noted recall issues and memory impairment .Pt with recent elopement attempts from facility Provide supportive cues and redirection Expect further decline secondary to disease course Orders written to add diagnosis to medical diagnosis list. Record review of Resident #1's Care Plan, accessed 09/04/2024, revealed Resident #1 with focus for having been at risk for elopement and had left the faciity on [DATE]. Focus initiated on 07/01/2024 and revised on 09/04/2024. Interventions included: Assess for risk of elopement per living center policy, initiated 07/01/2024; Involve patient in preferred activities, initiated 09/04/2024; and Redirect patients from doors, initiated 09/04/2024. Record review of Resident #1's Out of Facility Release of Responsibility Sheet, undated, revealed a document with two main columns titled, 'SIGNING OUT' and 'SIGNING IN', with each column having a location to document the date, time, and signature. Above the columns revealed, Authorization must be signed by the resident, or by the nearest relative in the case of a minor or when resident is physically or mentally incompetent. Resident #1's sheet revealed no documented dates, times, or signatures for Resident #1 signing out or signing in. Record review of Resident #1's Progress Notes, dated 09/01/2024 at 07:24 p.m. by LPN A, revealed Resident left out of building has not returned, Resident known to ask if he can go outside and be easily redirected and told only with a staff or family member. Today resident did not ask and has not been seen since eating lunch in dining room. Record review of a police report, dated 09/01/2024 at 07:47 p.m., revealed at 06:38 p.m. on 09/01/2024 the PO was dispatched to the facility for a report of a missing person and a city-wide [NAME] (be on the lookout) was issued for Resident #1. The PO spoke to LPN A, who stated Resident #1 had last been seen around 11:00 a.m. The PO contacted missing persons and a silver alert (missing persons alert for an older adult) was entered. Record review of Resident #1's Progress Notes, dated 09/02/2024 at 02:40 a.m. by LPN B, revealed Received call from [hospital staff member at local hospital] stating resident was currently in the ED (emergency department). He was brought in @ 2000 (at 08:00 p.m.) for disorientation (confused and unable to think clearly), dehydration (condition of having not enough water in the body) and intoxication (state of having an altered mood and abilities caused by alcohol or drugs). Resident underwent testing that was WNL (testing results were within normal limits or ranges). 1L (liter) IV (intravenous) fluids given. Resident will be discharged . Record review of Resident #1's Hospital Notes, dated 09/04/2024, revealed Resident #1 arrived at the emergency room on [DATE] at 08:26 p.m. via EMS (emergency medical services) with complaints of weakness prior to arrival. Resident #1's stated complaint was noted as weakness with a chief complaint of fall, trauma. Per the initial comments, .patient was a poor historian and had a very confusing story where he was walking outside possibly fell and had urinated oneself. Patient states he was walking outside felt weak as though he was about to fall but was able to catch himself. Resident #1's skin was noted as warm, non-mottled (not patchy or with irregular colors), no rashes. Resident #1's laboratory results, dated 09/01/2024 at 08:57 p.m. revealed an ethyl alcohol level of 24 (a level less than 50 mg/dL would not be considered not intoxicated). A chest x-ray (a type of scan to create detailed images of your bones) and head or brain CT (a type of scan to create detailed images of your bones and soft tissues) revealed no acute injuries. Resident #1's clinical impression was noted as dehydration after exertion. Record review of Resident #1's Progress Notes, dated 09/02/2024 at 04:05 a.m. by LPN B, revealed Resident arrived to facility via EMS x 2 in stable condition via stretcher. No N/O (new orders) per discharge papers. During an interview on 09/04/2024 at 04:10 p.m. with the DON and the RECPST, the DON revealed the front facility door was unlocked on weekdays (Monday through Friday) from 08:00 a.m. to 05:00 p.m. and monitored by the RECPST. The DON stated the doorbell outside the front doors was to be used for anyone wanting to enter the facility after those hours or on the weekend and the weekend supervisor or nurses stationed at the South Nursing Station could hear the doorbell and respond. The RECPST revealed the nurses had the code to the front door alarm if the alarm was triggered and stated the alarm would automatically go off after two to three minutes. During an observation and interview with the DON on 09/04/2024 of the facility doors from 04:10 p.m. to 04:32 p.m., the facility was observed to have fourteen (14) exterior or exit doors. The front access doors and the laundry access doors each consisted of two doors for access. Additional exterior doors were noted in several resident rooms, but those doors did not have exterior access due to installed deadbolts on the doors with no handle available to operate or attempt to open. The laundry access double doors and a side access door, labeled Door #5, were observed to have a push button or push pad next to the door to disable the door's alarm. The DON revealed Door #5 had the side button and a clicker that allowed staff to disable the door's alarm. The DON revealed Door #5 was used by EMS, resident transport services including to dialysis appointments, and by the facility driver to pick up and return residents into and out of the facility. During an interview on 09/04/2024 at 04:28 p.m. with the ADMIN and the DON, they revealed it was unknown what door Resident #1 eloped from. The ADMIN revealed she did not yet have access to the facility's camera system, due to having been a new employee, and had therefore been unable to review the camera footage of the doors during her incident investigation. During an interview on 09/04/2024 at 03:18 p.m. with Resident #1, he revealed he believed he had lived at the facility for about four years and liked to leave. Resident #1 stated he left the faciity on Saturday or Sunday (he was not sure on the day of the week) with the intention of going to the bank. Resident #1 stated that he just went outside without telling anyone, through a door on the side of the building that one could go through. Resident #1 stated his bank was closed because it was a Sunday, and also stated that he couldn't find his bank or his bank's entrance. Resident #1 stated he was picked up by an ambulance and brought to a hospital. During an interview on 09/05/2024 at 09:15 a.m. and record review of the facility Incident Summary, dated 09/01/2024, the ADMIN read through the facility's Incident Summary. The Incident Summary revealed LPN A notified the ADMIN at 06:15 p.m. on 09/01/2024 that the staff were unable to locate Resident #1 and he was not present for the 05:45 p.m. medication pass. The ADMIN revealed the facility was not a locked facility but upon after-action review and to achieve the safest possible environment for the residents, the facility must secure the doors in such a way that residents that refused to follow facility protocols could be identified, alerting nursing as having left without signing out. The other solution was that noncompliant residents may be reviewed on a case-by-case basis to determine the at-risk nature of that specific resident and if the facility was capable of meeting their needs successfully. During an interview on 09/05/2024 at 10:46 a.m. with CNA C, she stated she worked Sunday, 09/01/2024 between 06:57 a.m. to 03:00 p.m. CNA C stated she did not recall seeing Resident #1 on Sunday and did not recall hearing any door alarms sounding during her shift. During an interview on 09/05/2024 at 01:34 p.m. with MA D, she stated she worked Sunday, 09/01/2024 from 02:00 p.m. to 10:00 p.m. MA D stated she provided Resident #1 with his medications on Sunday morning and remembered seeing him during the day walking to the dining room for coffee. MA D revealed she noticed around 5:30 p.m. to 6:00 p.m., while taking her assigned residents' blood pressures and issuing medications that she could not find Resident #1. MA D stated she checked Resident #1's room, the smoking area, and the dining area, the three areas Resident #1 was typically at but couldn't find him. MA D stated she then notified LPN A. MA D stated LPN A started directing staff to complete a facility search and had called the ADMIN. MA D stated she could not remember any door alarms sounding during the time Resident #1 was suspected as having gone missing. MA D revealed prior to Resident #1's elopement, he would sometimes ask her if he could check out and leave the facility, but he was easily redirected (change his focus to something else). MA D stated Resident #1 was initially antsy (anxious) when first admitted to the facility but had seemed to have calmed down. During an interview on 09/05/2024 at 01:48 p.m. with CNA E, she stated she worked Sunday, 09/01/2024 between 03:00 p.m. and 11:00 p.m. on Resident #1's hall. CNA E stated she did not recall seeing Resident #1 on Sunday and did not recall hearing any door alarms sounding during her shift. CNA E stated she observed an untouched lunch tray in Resident #1's room at the start of her shift (03:00 p.m.) and had notified the nurse, LPN A. CNA E stated she did not follow up with LPN A concerning the lunch tray because she had just started her shift and had left the follow up to the nurse. CNA E stated she believed Resident #1 was already missing at the time her shift began, 03:00 p.m. During a phone interview on 09/05/2024 at 02:13 p.m. with the Maint Dir, he stated due to having been out sick since prior to Resident #1's elopement, he had not been to the facility and had not had a chance to review the facility camera footage. He stated he was unaware of what door Resident #1 eloped from. The Maint Dir stated to his knowledge all the facility doors locked when closed and had alarms. The Maint Dir stated the only exception was the front door, which was open for visitors during work hours (Monday to Friday, 08:00 a.m. to 05:00 p.m.) and was scheduled to automatically lock and alarm at 05:00 p.m. The Maint Dir stated he would complete daily door checks during his morning rounds during the week and would sometimes check the building on Saturdays. During an observation on 09/05/2024 at 02:39 p.m. to 02:41 p.m., two facility staff were observed to separately push the button located next to Door #5, to disable the door's alarm, to exit the facility. A third staff member was observed pushing the button located next to Door #5 to let two individuals into the facility. The staff members were observed disabling the door's alarm in the view of a facility resident. During an interview on 09/05/2024 at 03:28 p.m. with CNA F, she stated she worked Sunday, 09/01/2024 between 03:00 p.m. and 11:00 p.m. on Resident #1's hall. CNA F stated she did not recall seeing Resident #1 on Sunday and was unsure of when Resident #1 had left the facility. CNA F stated she found out Resident #1 was missing around dinner time. CNA F stated during dinner tray delivery, CNA E had mentioned Resident #1's lunch tray was still in his room and untouched. CNA F stated that she had previously observed that Resident #1 would occasionally eat in the dining room. CNA F stated that she and CNA E told LPN A about Resident #1's lunch tray at that time and LPN A started making phone calls and asking staff to start searching the facility. CNA F stated she did not hear any door alarms sounding during her Sunday shift. During an interview on 09/06/2024 at 08:05 a.m. with LPN A, she stated she worked Sunday, 09/01/2024 between 07:00 a.m. and 07:00 p.m. LPN A stated she was covering the shift for another nurse and her assigned residents on Sunday were not her typical residents. LPN A stated she typically worked night shift. LPN A stated she had been assigned to Resident #1 before, but it was usually at night and he was either asleep or if he did get up, it was to go smoke. LPN A stated that the last time she recalled seeing Resident #1 on Sunday was around lunch time. She stated that he was walking the opposite way down the hall from her, and then she saw him again on her way back, eating lunch in the dining room. LPN A stated around 06:00 p.m. MA D notified her that she couldn't locate Resident #1, and Resident #1 was not supposed to be able to sign himself out without family because he had dementia. LPN A stated MA D had told her several times during the day that she was looking for Resident #1 but did not say anything about him not being able to sign himself out. LPN A stated she had known that the staff couldn't find Resident #1 but was not aware that he was not supposed to be able to sign himself out like the rest of the residents. LPN A stated she first checked the facility sign-out book and observed that Resident #1's page was blank. LPN A revealed she had not seen any interventions in place for staff to be able to identify which residents were not supposed to be able to sign themselves out. LPN A stated it was not until a shift following the incident that she observed a notice on the communication sheet that identified a different resident as not being allowed to sign himself out without family or other. LPN A stated that that was the first time she had seen a warning such as that. LPN A stated she had not considered Resident #1 an elopement risk because he would usually ask a staff member about signing out and he would allow the staff member to redirect him. LPN A stated prior to Resident #1's elopement, she had not seen any facility procedures in place to let the nursing staff know which residents were considered safe to sign themselves out. Record review of facility policy, Wandering and Elopements, dated revised March 2019, revealed, 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 .1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. An Immediate Jeopardy (IJ) was identified on 09/05/2024 at 04:24 p.m. The IJ template was provided to the facility's ADMIN, DON, and RNC on 09/05/2024 at 05:17 p.m. A plan of removal was requested. On 09/06/2024, the facility provided a plan of removal titled: Plan of Removal for Immediate Jeopardy. The following plan of removal (POR) was accepted on 09/06/2024 at 03:16 p.m. PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On September 4, 2024, an investigation was initiated at [facility name and address]. At approximately 5:15p.m on September 5, 2024, a surveyor provided verbal notification that [state name] Health and Human Services had determined the conditions at [facility name] constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F-0689 - Free of Accident Hazards/Supervision/Devices Immediate Corrections Implemented for Removal of Immediate Jeopardy. On September 2, 2024, at approximately 4:05am Resident#1 returned to the facility from the Emergency Department. Action: Resident #1 is a current resident and was brought back to facility on 9/2/2024. The resident was immediately assessed by the charge nurse and a head-to-toe assessment was completed. The responsible party, physician, DON and Administrator were notified of the resident's safe return. Resident#1 was placed on 15 minutes monitor checks for safety. A community safety awareness assessment for Resident #1 was completed by the DON. IDT reviewed and interventions initiated, and care plan updated reflect elopement risk. On September 1, 2024, at approximately 9:20pm the following action was taken: Action: Education initiated Elopement risk, Abuse/Neglect/Exploitation, Signs to watch for with residents exhibiting potential for elopement, increased wandering, exit seeking, increased behaviors. Start Date: 9/1/2024 Completion Date: 9/4/2024 Responsible: Administrator Action: Signs were posted on all doors, that were not already marked as emergency exit only, instructing all visitors and residents to enter and exit through main facility entrance only. Start Date: 9/1/2024 Completion Date: 9/1/2024 Responsible: Administrator 0n September 5, 2024, at approximately 6:00pm the following actions were taken: Action: Education initiated with all staff on Elopement, Abuse and Neglect, Resident Rights, Environment Free from Accident Hazards Start Date: 9/5/2024 Completion Date: 9/5/2024 Responsible: Administrator Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on Elopement, Abuse and neglect, and Plan of removal/response to Immediate Jeopardy Citation on 9/5/2024 Start Date: 9/5/2024 Completion Date: 9/5/2024 Responsible: Administrator IDENTIFICATION OF OTHER AFFECTED: All residents have the potential to be affected. Action: Facility reviewed and ensured Elopement Risk Assessments were complete and current for all residents. 96 of 96 residents were reviewed. All residents identified as at risk of elopement were reviewed to have appropriate interventions and plan of care in place per risk assessment. 38 of 96 residents were newly identified as at risk for elopement. Physician and responsible parties were notified of assessment results and care plan interventions. Start Date: 9/5/2024 Completion Date: 9/5/2024 Responsible: Director of nursing/designee SYSTEMIC CHANGES AND/OR MEASURES: Action: In-service and education was provided to facility staff regarding the process for residents who have been identified as an elopement risk and proper steps to take to assure residents remain safe without risk for elopement, including monitoring, and care plan updates. Start Date: 9/5/2024 Completion Date: 9/5/2024 Responsible Party: Director of Nursing/Designee Action: Education was provided to all staff on Elopement policy, Abuse/Neglect/Exploitation, Resident Rights, Free from Hazards, Notification of behaviors, wandering or elopement attempts, Start Date: 9/5/2024 Completion Date: 9/5/2024. Responsible Party: Director of Nursing/Designee Action: New position opened and assigned for evening and weekend monitoring by additional receptionist or security guard. Weekend receptionist or security guard will have access to resident list that will include photo of resident for identification and will verify any resident who has orders to sign self out on pass without accompaniment. Start Date: 09/06/2024 Completion Date: ongoing until position is filled Responsible Party: Administrator Action: Scheduled installation for alarms for 14 of 14 doors Start Date: 09/06/2024 Completion Date: 09/06/2024 Responsible Party: Maintenance Director/designee Action: Front doors to facility will be alarmed at all times. Access to front door will be monitored by receptionist Monday through Friday from 8am to 5pm. The South Nurses station will monitor access to the front entrance after hours and on the weekend. The receptionist will receive a current list of residents, that will include photo of resident for who may sign out without supervision, from the Director of Nurses. The list will be updated upon resident's admission, discharge, and change in status of resident condition after IDT and physician review. A copy will be available at each nurses' station. Start Date: 09/06/2024 Completion Date: 09/06/2024 Responsible Party: Administrator, Director of Nursing/Designee Tracking and Monitoring - Director of Nursing/Designee will review residents with At Risk for wandering or elopement identified or newly admitted with history of elopements to assure appropriate interventions and plan of care are in place 5 times per week beginning 9/5/2024 for 12 weeks or until sufficient compliance if found. This will be documented in daily clinical meeting with use of electronic log and reviewed monthly in QAPI meeting. - Administrator/designee will complete random audit every shift for 7 days, beginning 9/6/2024 for appropriate staff response to wandering or potentially exit seeking residents, immediate education will be provided, if necessary, then will monitor random shifts, 5 times a week for 12 weeks or until sufficient compliance if found. This will be documented on log to be reviewed in QAPI Meeting Monthly. - Administrator/designee will complete audit of exits for proper functioning of doors and alarms for proper functioning every shift for 7 days, beginning 9/5/2024 then will monitor random shifts, 5 times a week for 12 weeks or until sufficient compliance if found. This will be documented on log to be reviewed monthly in QAPI. - Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review The facility's POR Verification was as follows: During an observation on 09/06/2024 at 10:00 a.m., the R Maint Dir was observed installing new alarms on the facility front entry and exit doors. During an observation on 09/06/2024 from 10:00 a.m. to 08:00 p.m. multiple observations of observing and hearing the facility new door alarms sounding. Observations included staff and facility guests attempting to either enter or exit the facility, without the RECPST or a nurse with a door key disarming the door alarm. During an observation on 09/06/2024 at 04:33 p.m., a binder labeled Residents that may go out on pass without supervision, dated as edited on 09/06/2024 by the ADON was observed. The binder included the names and pictures of 23 residents. During an interview with the R Maint Dir on 09/06/2024 at 04:36 p.m., he stated he ordered fourteen (14) new door alarms for the facility and installed the alarms on ten (10) doors. He stated the additional four (4) doors already had a key alarm. He stated the new alarms required a key to deactivate and/or turn off the alarm and that the alarms would not stop sounding until they were deactivated. He stated that he was told the keys were to only be issued to the nurses, to put on their key rings, the charge nurse, the administrator, and the maintenance director. He stated the doors were to be alarmed at all times and they were battery powered, with the battery expected to only require replacement every 6 months to one year. During an observation and interview with the interim ADMIN on 09/06/2024 at 04:45 p.m., she showed the new job posting for a Receptionist on [a job posting website]. The job was noted to have been just posted. The job duties listed included: This position is for evening/Weekend Receptionist., Monitor the front door of the facility- who comes in/who leaves., and Complete the incident log on a daily basis. Record review of the facility POR Binder on 09/06/2024 at 06:52 p.m. revealed: a. A copy of the AD Hoc QAPI Meeting dated 09/05/2024 and noted with an agenda: IJ 6869 [sic] Review and Review Plan of Removal. Attendees were noted as: the DON, the MD, the ADMIN, and the RNC. b. A document labeled with five (5) areas to notate Staff Response to wandering or potentially exit seeking resident: 1. Have you identified any residents with new exit seeking behavior? 2. Have you identified any residents newly at risk for elopement? 3. Is any additional education needed at this time? Shift:______ Time:______ c. Seven (7) copies of the facility map, labeled Door Check and each subsequently dated from 09/05/2024 to 09/11/2024. The documents dated 09/05/2024 and 09/06/2024 reflected a X marked next to each location on the map where an exterior or exit door was located. The 09/05/2024 document was noted as completed on 09/05/2024 at 09:00 p.m. by the ADMIN. The 09/06/2024 document was noted as completed on 09/06/2024 at 11:00 a.m. and 03:00 p.m. by the interim ADMIN. d. Copies of the facility Daily Census Report, dated 09/05/2024 and 09/06/2024 with each resident named checked off. The documents were observed to be labeled by hand on each first page, Review at risk with an additional label stuck to the initial document, titled Review of residents at risk for Wandering or Elopement. e. A document labeled QAPI Addendum with the following noted under Agenda: Review facility plan of removal for Immediate Jeopardy Verification of audit completion: - DON review at risk for wandering or elopement identified or newly admitted with history of elopements to ensure appropriate interventions and plan of care are in place - 5 times a week beginning 09/05/2024 for 12 weeks - Staff response log to wandering or potentially exit seeking residents - Every shift for 7 days, beginning 09/06/2024 - 5 times a week for 12 weeks - Exit audits completed - Every shift for 7 days beginning 09/05/2024 - 5 times a week for 12 weeks Review for trends identified: Record review of in-service documents included: - Document dated 09/05/2024 at 06:52 p.m. with topic CNA's will document new behaviors in POC (Plan of Care), notify charge nurse, DON, and administrator. The in-service had 29 CNA names as having received training. - Document dated 09/05/2024 at 06:52 p.m. with topic Nurses will document in [Electronic Medical Record, EMR] new behaviors, notify DON, Administrator, and MD Immediately. Document with 6 RN names and 9 LVN names (15 total licensed nurses) noted as having received training. - Document dated 09/05/2024 at 06:52 p.m. with topic Wandering and Elopements. The in-service had 52 nursing and therapy staff names noted as having received training. - Document dated 09/05/2024 at 06:52 p.m. with topic Wandering and Elopements. The in-service had 58 administrative, dietary, plant (housekeeping, laundry, maintenance, driver), and therapy staff names noted as having received training. - Document dated 09/05/2024 at 06:52 p.m. with topic Abuse and Neglect. The in-service had 52 nursing and therapy staff names noted as having received training. - Document dated 09/05/2024 at 06:52 p.m. with topics Abuse and Neglect and Resident Rights. The in-service had 58 administrative, dietary, plant, and therapy staff names noted as having received training. - Document dated 09/05/2024 at 06:52 p.m. with topic Safety and Supervision of Residents. The in-service had 58 administrative, dietary, plant, and therapy staff names noted as having received training. - Document dated 09/05/2024 at 06:53 p.m. with topic Safety and Supervision of Residents. The in-service had 51 nursing and therapy staff names noted as having received training. - Document dated 09/05/2024 at 06:53 p.m. with topic Resident Rights. The in-service had 51 nursing and therapy staff names noted as having received training. - Document dated 09/06/2024 with topic Residents who can sign out on pass without being accompanied by supervision will be placed in a Binder which will be at Receptionist desk and each Nurses station. This will be maintained and updated by Nursing management when new admissions/discharges/ changes in condition or risk status change. The in-service had 111 facility staff names noted as having received training. Record review and interview with the DON and Th Dir on 09/06/2024 at an unknown time, of an undated listing of employee names divided per department and with each employee member's phone number and job title, revealed a total of 106 facility employees with an additional four (4) identified by the DON or Th Dir as gone or no longer employed. Of the four, three (3) were therapy staff and one (1) was an administrative staff. Twenty-two (22) staff were identified as not expected to be present in the facility for multiple days. Seven (7) therapy employees were identified as on vacation. Three (3) employees were out sick, one (1) from the plant department and two (2) from therapy. Elev[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and hazards. Resident #1 was moved rooms within the facility. Nursing staff failed to ensure the bed in the new room had side rails for bed mobility and positioning. Resident #1 rolled out of bed during care and fell to the floor hitting her head. Resident #1 was hospitalized for evaluation and treatment and diagnosed with thoracic spine compression fractures, multiple rib fractures, and subsequently expired. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of potential for more than minimal harm at a scope of isolated. This deficient practice could place residents at risk of falls with major injuries. The findings were: Review of Resident #1's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses including Sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), Systolic Congestive Heart Failure, Alcoholic Cirrhosis of liver w/ascites (end-stage liver disease, is the impaired liver function), and Lack of Coordination. Review of Resident #1's 5-day MDS assessment, dated [DATE], revealed her BIMS was 11 reflective of moderate cognitive impairment; she required extensive assistance by 1 person for bed mobility and transfers; did not have a history of falls prior to her admission to the facility and had not had any falls while at the facility. Review of Resident #1's Care Plan initiated [DATE] revealed she was at risk for falls/injuries related to impaired mobility. One of the staff interventions was to assess Resident #1 for any adaptive equipment needed and to encourage its use if necessary. Review of Resident #1's Siderail Enabler Assessment/Consent, dated [DATE], revealed Resident #1 requested to use side rails related to physical weakness and balance deficit, would assist with bed mobility and transfers and provided a sense of security. Resident #1 elected to use two ¼ side rails and expressed a desire to have the side rails up while in bed. Further review revealed there were no risk identified related to the use of siderails. The family member consented to the use of the Siderails. Review of Resident #1's census revealed she was moved to a room on S. Hall on [DATE]. Review of Resident #1's nurses progress note, dated [DATE], revealed The CNA yelled out for this nurse that the resident was on the floor. Resident stated she was trying to hold on to the siderail while getting changed and there was no siderail there when she reached and ended up rolling too far causing her to fall off the bed. Upon entering the resident's room this nurse assessed the resident while on the floor for injuries. A hematoma about quarter size noted to the right temple and one on the right hairline. Skin tear to R arm. Resident stated pain to the R shoulder and to the back of the head. Further review revealed Resident #1 was picked up soon after and transported to the hospital. Review of Resident #1's pain assessment post-incident, dated [DATE], revealed she was experiencing pain to her right shoulder after the fall and the pain increased with movement. Her level of pain was 6. Review of Resident #1's nurses progress note, dated [DATE], revealed an IDT meeting was held related to Resident #1's fall. The root cause analysis was identified as poor staff positioning, no side rails for mobility. Review of hospital physician progress note, dated [DATE], revealed Assessment: Status post fall from bed with right sided rib fractures. Plan: Continue to monitor on medical/surgical floor. Neurosurgery input much appreciated. Continue conservative medical management. No need for brace Analgesics as needed for pain control. T3, T8, Til thoracic spine compression fractures [(A T3 compression fracture is a type of vertebral fracture that occurs in the upper part of the spine, at the level of the third thoracic vertebra. This type of fracture is typically caused by a fall or a direct blow to the spine, and can lead to severe pain and disability. Compression fractures usually happen in the thoracic (middle) part of the spine, especially in the lower thoracic area. Providers also call them vertebral compression fractures (VCF).] Review of hospital Discharge summary, dated [DATE], revealed Yesterday evening, RN called me stating patient deteriorating, pale, using accessory muscles, short of breath, desaturated and hypoxic, decreased responsiveness. I instructed RN to place patient on BiPAP, transferred to PCU, Lasix 40 mg IV x 1, and get chest x-ray. RRT called 2147 (9:47 PM), blood gas was ordered. This was relayed to the family who made patient DNR/DNI. Patient subsequently expired. Interview on [DATE] at 10:16 AM with LVN B revealed she was an Agency nurse and worked a couple of shifts at the facility through the temporary agency. She stated she started working full time at the facility 1 week ago. LVN B stated on the day Resident #1 fell, CNA C came out of the Resident's room or she yelled out. She entered Resident #1's room and the Resident was on the floor lying on her left side by the bed. The bedside table was positioned on the opposite side of the Resident. LVN B stated Resident #1 told her she was not in pain but stated she hit her head. LVN B stated she assessed Resident #1 and did not note any major injuries. Resident #1 had a hematoma to the right temple, on the hair line and red area to the back of her head. LVN B stated she called the physician and asked for a skull series. She mentioned she was not sure or could not remember if she sent Resident #1 out to the hospital. LVN B stated CNA C told her, she was providing pericare and Resident #1 turned to the left side to reach for side rail and the side rail was not there. The Resident rolled off the bed. LVN B stated Resident #1 was moved to S.hall and the bed in her new room did not have side rails. Resident #1 told LVN B her previous bed had side rails. LVN B confirmed she did not see side rails on Resident #1's bed. She stated she did not know if Resident #1 was a one or two person assist. LVN B reviewed the nurse's progress note, dated [DATE], and stated Resident #1 fell at night and she sent the Resident out after midnight. Telephone interview on [DATE] at 12:29 PM with CNAQ revealed she worked the 11PM to 7AM shift. She stated she learned Resident #1 had a fall during the 3:00 PM to 11PM shift. She reported CNA C told her Resident #1 had fallen during care. Resident #1 complained her body hurt when she was in the room. Resident #1 told her the aid who changed her needed more training because she did not know what she was doing. CNA Q stated she was in the room when CNA C was giving report to LVN B about what happened. CNA C stated she rolled Resident #1 towards the left side away from her. Resident #1 hit the bedside table and then the floor. CNA C told LVN B Resident #1 was used to having a side rail and turned to grab the side rail and it was not there. CNA C stated she turned/rolled Resident #1 from behind (her backside) and did not realize she had used that much force. CNA Q again stated Resident #1 kept complaining of pain that her body was hurting. She stated Resident #1 was sent to the hospital around midnight on the night of the fall. VM for RP, family member, requesting she return the call. Interview on [DATE] at 12:55 PM with the previous ADON R, stated the beds were typically not equipped with side rails. They installed side rails upon a Resident/family's request to use for positioning and mobility. She stated the side rail was considered an adaptive piece of equipment. It required a nursing assessment, consent, physician order and an update of the Care Plan reflecting the implementation of the side rails prior to their use. The previous ADON R stated the nursing staff who moved Resident #1 was responsible for ensuring all equipment was transferred to their new location. She stated she did not remember Resident #1 having a fall and could not provide any additional information. Interview on [DATE] at 1:10 PM with the ADM revealed she confirmed the side rails were an adaptive piece of equipment which required a physician order. She stated the previous DON S moved Resident #1 and she would have been responsible for transferring all adaptive equipment with the Resident. She stated LVN B told her CNA C rolled Resident #1 away from her (rolled the Resident from behind) while in bed, while providing care. Resident #1 fell to the other side. Interview on [DATE] at 1:15 PM with the ADM and the DOR revealed he demonstrated proper bed positioning and safe technique when rolling a resident side to side in bed during the fall in-service dated [DATE]. The ADM stated they had not provided an in-service for the use of side rails since Resident #1's fall. Interview on [DATE] at 1:21 PM with the MS stated the previous DON S would tell him when to install side rails on a bed. It required an assessment and consent prior to installation. He stated the previous DON S would also let him know when a resident was moving. He would have to remove the side rails if moving the bed to the Resident's new location because the bed did not fit through the doorway with the side rails attached. The MS stated since they did not have a DON, it would be either someone in authority to provide him instructions or he would confirm with the ADM and make sure it was ok to install the side rails. The MS stated he did not know Resident #1 was moved and learned afterwards that she needed side rails on her bed but had already been sent out to the hospital. He stated she did not return to the facility. The MS stated either she was moved after he left for the day which was after 3:30 PM or over the weekend when he was not working. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:15 PM and the Administrator was notified. The Administrator was provided with the IJ template on [DATE]. The following Plan of Removal was accepted on [DATE] at 6:15 PM and it included: LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Preparation and submission of this Plan of removal does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of removal is prepared and submitted solely because of requirements under state and federal laws. Verification Plan of Removal: IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEPOARDY: On February 9, 2024, at approximately 4:15 p.m. the following actions were initiated upon facility identification of concern: Resident #1 was discharged from the facility on [DATE] immediately after the fall. IDENTIFICATION OF OTHERS AFFECTED: The Clinical Corporate Resource conducted a chart review and visual audit to determine if side rails were ordered or care planned for any residents who have experienced a room change in the last 90 days to validate that the side rails were in place, orders and consents were present and care plans were up to date. A visual audit of all rooms/beds was conducted by the administrator/designee to determine which residents had bed rails. There was a total of 57 residents with beds that had side rails installed. Need for these rails would be further assessed by Therapy and Nursing for appropriate number and type of rail(s) needed and rails would be removed if deemed unnecessary. Consents and orders would be obtained, and care plans updated for applicable Residents by the Corporate Clinical Resource/designee. Maintenance would install or remove rails as indicated by assessments/orders. The above would be completed by [DATE]. SYSTEMIC CHANGES AND/OR MEASURES: The Administrator/Designee would provide and document education on [DATE] to staff responsible for moving beds which would include IDT (Interdisciplinary Team) members, Nursing staff and Maintenance department on the process for ensuring that fall prevention/assistive mobility rails that were in place prior were transferred or remain in place after any room change. Education included the beds should be moved with the resident to ensure continuity of care associated with mobility rails, and who to notify if a discrepancy related to mobility rails was identified. The Administrator/Designee would educate Social Services on the requirement to communicate the need for bed rails, if applicable, on any resident for whom a bed was ordered to be provided from hospice. An Ad Hoc QAPI meeting was held with the IDT team and Medical Director to review policy on Assistive Devices and Equipment and to review the Plan of Removal/response to the Immediate Jeopardy citation on [DATE] at 5:30 p.m. Those not in attendance at education sessions due to vacation, sick leave, or casual work status would be educated upon their return, prior to their first shift worked. TRACKING AND MONITORING: The Administrator/designee would conduct audits of residents who have had a room change and/or of those who have been provided a bed from an outside agency daily for seven days, then five times per week beginning [DATE] to validate that fall prevention/assistive mobility rails that were in place prior have been transferred or remain in place after any room change and that staff were moving the bed to the new room. Any trends or concerns were/would be addressed with the Quality Assurance Performance Committee and monitoring would continue until a lessor frequency was deemed appropriate. Results of audits would be presented by the Administrator or designee at the monthly QAPI meeting with the IDT and Medical Director on or before [DATE], then monthly and as needed thereafter to identify trends and sustainability. If ongoing deficiencies or concerns were noted through the audits, resident interventions and staff education would be implemented immediately. Monitoring would not be discontinued until the facility completed three consecutive rounds of monthly monitoring that demonstrated sustained compliance as approved by the QAPI committee and Medical Director. Additional interventions, education, and monitoring would be implemented, as needed, based on the recommendations of the QAPI committee for any negative trends identified to ensure sustainability. Verification of the Plan of Removal: In an interview on [DATE] at 12:30 p.m., the Maintenance Supervisor stated he was recently in-serviced on when residents were moved from their room to a new room, staff were to make sure the resident's bed rails were moved to the new room and the resident's bed was moved with the resident. The Maintenance Supervisor stated he verified the beds that were supposed to have bed rails had rails and the beds that were not to have bed rails did not have a bed rail on the bed. The Maintenance Supervisor stated when a resident was discharged from the facility, he would remove the bed rails from the bed. When a new resident was admitted and placed in that bed, they would be assessed to see if they needed a bed rail. Then he would receive a work order to place the bed rails on the bed. The Maintenance Supervisor stated he would inspect the bed rails once a year with an audit and the bed rails would also be checked by the department heads when they did advocate rounds in the residents' rooms to ensure the bed rail was installed correctly. In an interview on [DATE] at 12:36 p.m., the Social Worker stated he was recently in-serviced on when a resident was moved from their room to a new room, a member of the IDT needed to be present to ensure the resident's old bed was moved to their new room, and to make sure the bed rails were attached if there were bed rails on the bed. The Social Worker sated if a member of the IDT was not in the facility when staff moved a resident to a new room, the nurse was to call the Administrator before the resident and their bed was moved. The Social Worker stated before bed rails were placed on a bed, he would get the consent from the resident or their responsible party, a side rail assessment would be done by the nursing staff. The Social Worker said he attended the QAPI meeting held on [DATE], the IDT team was present and the IJ situation was discussed which included the department heads, the administrator, the MDS Coordinator, the Assistant MDS Coordinator, the DOR, and the Assistant DOR. The Social Worker stated at the QAPI meeting the IJ situation was discussed and the facility's POR. In an interview on [DATE] at 12:50 p.m., the DOR stated he was recently in-serviced on making sure when a resident was moved to a new room, a member of the IDT was present to ensure the resident's bed and bed rails were moved to the new room. If the room change occurred after hours, the DOR said the nursing staff were to call the Administrator before the resident was moved. The DOR stated bed rail assessments would be done when a resident was admitted to the facility by the nursing staff, then the therapy staff would do a physical assessment to determine if the resident needed the bed rail, to make sure the bed rail did not restrict the resident's range of motion and the bed rail was correctly installed. The DOR said he attended the Ad Hoc QAPI meeting held on [DATE] around 5 p.m. The DOR stated the Social Worker, the Activity Director, the Administrator, the Maintenance Supervisor, the Assistant Director of Rehabilitation were present in person, and the Medical Director was present via telephone. The DOR said they discussed at the Ad Hoc QAPI meeting the IJ situation, to make sure the resident's adaptive equipment was transferred was transferred with the resident to their new room, the bed rails were moved with the bed to the new room, nursing staff completed their required documentation for the bed rails [bed rail assessment, bed rail consent] and the therapy department would assess the resident to determine if the bed rail was appropriate for the resident. In a telephone interview on [DATE] at 3:41 p.m., the Medical Director stated she was informed of the IJ situation on [DATE] after it was called and was present via telephone for the Ad Hoc QAPI meeting which the IJ situation was discussed and the facility's POR. In an interview on [DATE] at 4:22 p.m., the Administrator stated the nursing staff was in-serviced on the changes to the procedure for when a resident was moved into another room in the facility. The Administrator said any resident room changes would be discussed in the morning meetings and a member of the IDT would be present when the resident was moved to a new room to ensure the resident's belongings and bed with the bed rails was moved to the new room. The Administrator stated she conducted an audit on residents who had room changes that were made in the past 90 days; she checked the resident's care plan and did a visual audit to make sure that everything was moved from the residents' old room to the new room. The Administrator stated an Ad Hoc QAPI meeting was held at 5:30 p.m. on [DATE] with the Medical Director in attendance, the DOR, the Social Worker and all the department heads. The Administrator said the Ad Hoc QAPI meeting topic of discussion was the IJ situation, to discuss the process that failed, what led to the process, and what was going to be changed to ensure this did not happen again. The Administrator stated she reviewed the charts of the residents who had a room change in the past 90 days to verify if they had an assistant device, if it was moved to their new room if the resident had bed rails previously and if the resident currently had bed rails. The Administrator said she used a resident census sheet and went into each resident's room on [DATE] and documented with an x beside their name if they had bed rails. Then on [DATE] they went through the visual audit that she had done on [DATE] and looked at every resident who had bed rails, at the resident's care plans, if they had a consent and if a bed rail assessment had been completed. The Administrator stated the MDS Nurse and Therapy staff visited every resident who had a bed rail to see if the bed rail was needed or wanted. If the resident did not need or want the bed rail, it was removed by the Maintenance Director. The Administrator said she printed an audit report from the electronic clinical record system for residents who had a bed rail care plan and each resident with a bed rail was seen by the therapy staff to determine if it was safe for the resident to have them. The Administrator stated she created a spread sheet for every resident who has a bed rail to verify they had a consent, a bed rail assessment, and a care plan. The Administrator said she created another spread sheet that lists all the residents in the facility and indicates if they have a bed rail or not. The Administrator stated the IDT, the nursing staff, and the Social Worker were in-serviced on the new changes that were made when a resident is moved into a new room. The Administrator stated she created a tracking sheet for the daily monitoring that would be done in the next seven days and another tracking sheet for the monitoring that would be done five times per week. In a telephone interview on [DATE] at 5:42 p.m., the Clinical Corporate Resource stated she conducted a chart audit of every resident who had a room change to verify if the resident had a bed rail, then checked the resident's clinical record to verify they had a bed rail assessment and a care plan for the bed rail. The Clinical Corporate Resource said she assisted with the bed rail audits, with evaluation of the residents who had bed rails which was completed [DATE] and the therapy staff placed a note in the resident's progress notes for residents who had a bed rail. The Clinical Corporate Resource stated when she was in the facility she would conduct an audit to ensure the monitoring of the POR was conducted and she would visit the facility at least twice a month or more frequently if needed. Interviews with 8 day staff (3 nurses and 5 CNAs) and 5 night staff (1 nurse and 4 CNAs) on [DATE] from 2:18 p.m. to 4:05 p.m. revealed they had been in-serviced on to not move a resident to another room without notifying a member of the management staff first and a member of the IDT must be present when the resident was moved from the old room to the new room. The resident's bed from the old room, along with any other assistive devices and personal items, would be moved to the new room. They stated if a member of the management team was not in the facility and an emergency move needed to be made, they would contact the administrator before the resident was moved. Record review of the facility's POR binder revealed the following documents: 1. Under the tab labeled chart review was an undated list of residents (22) who had a recent room change, if they had a bed rail or enabler bar in place, a completed bed rail assessment, a consent, and a care plan for the bed rail. At the bottom of the page was the Director of Clinical Operations name. 2. Under the tab labeled visual audit was a resident room roster dated [DATE] with an x by the resident's name if they had a bed rail or enabler bar and the administrator's name/title was hand-written at the top. 3. Under the tab labeled Therapy/Nursing was a document dated [DATE] labeled Care Plan Item/Task Listing Report that listed residents with care plans for side rails. 4. Under the tab labeled Consent Order was an untitled, undated document with resident's name, if they had side rails, a bed rail assessment, a consent for the bed rail, and a care plan. Also under this tab was a document titled Siderail Enabler Assessment, dated [DATE] which listed residents with side rails. 5. Under the tab labeled Ad Hoc QAPI was an AD Hoc QAPI Meeting/Root Cause Analysis Agenda and Summary dated [DATE], indicated the Administrator, the DOR, the Medical Director, the Maintenance Director, the Social Worker had attended the meeting. The form indicated the facility would strive to ensure that the residents' environment was free of accident hazards, as possible, and each resident received adequate supervision in assistive devices to prevent accidents. 6. Under the tab labeled Documented Education was an in-service training done on [DATE] with 10 of 10 IDT managers; the IDT was educated on the process for ensuring that fall prevention/assistive mobility rails that were in place prior were transferred or remain in place after any room changes, the bed should be moved with the resident to ensure continuity of care associated with mobility rails and to notify the Administrator if a discrepancy related to mobility rails was identified. 7. Under the tab labeled Documented Education was an in-service training done on [DATE] with the Social Worker which indicated the social worker was educated on the requirement to communicate the need for side rails if applicable, on any resident for whom a bed is ordered to be provided by hospice, per the Hospice Plan of Care. 8. Under the labeled Documented Education was an in-service training done on [DATE] with 39 of 42 nursing staff (1 nursing staff was on medical leave and 2 nursing staff were PRN and had not worked in facility in past 30 days - which was noted next to their names) were in-serviced on the process for ensuring that fall prevention/assistive mobility rails that were in place prior are transferred or remain in place after any room change, the resident's bed should be moved with the resident to ensure continuity of care associated with mobility rails, and to notify the Administrator if a discrepancy related to mobility [NAME] was identified. Nursing staff were educated that room moves were conducted by the IDT team with the help of the nursing staff. In the event a room move was emergent, the Administrator/Designee would be notified. 9. Under the last tab that was unlabeled was an undated excel sheet with a list of residents who had recent room changes since [DATE], if they had bed rails/enabler bars, a bed rail assessment, a care plan for the bed rail, a consent for the bed rail, and a place for follow-up daily monitoring for 7 days and then further follow-up in five days. All residents on the list who had bed rails or enabler bars where follow-up on [DATE]. Also under this tab was an undated, untitled sheet that had resident's name, date of their room changes, and columns for day 1 through day 7 with the administrator's initials in the column for day 1 and day 2. Observation on [DATE] at 10:43 a.m. revealed Resident #13 was lying in a bariatric bed with ¼ bed rails on both sides of the bed. Record review of Resident #13's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses which included morbid obesity and high blood pressure. Record review of Resident #13's electronic clinical record revealed a bed rail assessment was completed on [DATE]. Record review of Resident #13's electronic clinical record revealed a Physical Therapy note dated [DATE] by PTA P which indicated the resident demonstrated appropriate use of the bed rails. Observation on [DATE] at 10:36 a.m. revealed Resident #7 was lying in bed with ¼ bed rails on both sides of the bed. Record review of Resident #7's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses which included morbid obesity and high blood pressure. Record review of Resident #7's electronic clinical record revealed a bed rail assessment was completed on [DATE]. Record review of Resident #7's electronic clinical record revealed a Physical Therapy note dated [DATE] by PTA P which indicated the resident demonstrated appropriate use of the bed rails. On [DATE] at 6:15 p.m. the facility's POR verification had been approved. On [DATE] at 6:29 p.m., the Administrator was informed the POR was validated and the immediacy was removed. However, the facility remained out of compliance at a severity of potential for more than minimal harm and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal.