**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #109) of 4 residents reviewed for elopement on 10/27/24. The facility failed to put interventions in place to prevent Resident #109 from eloping from the facility when she walked out of the memory care unit and exited the fire alarm gate on 10/27/24. Resident #109 was found by an exit door again on 12/01/24 . Resident has history of opening the doors after pushing on them for 15 seconds allowing the door to open. An IJ was identified on 12/12/24. The IJ template was provided to the facility on [DATE] at 3:30 PM. While the IJ was removed on 12/13/24, the facility remained out of compliance at a scope of isolated and severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for unsafe elopements, injuries, and hospitalization. Findings included: Review of Resident #109's admission record, dated 12/12/24, reflected she was an [AGE] year old female who initially admitted to the facility on [DATE], and had diagnoses including Alzheimer's disease (a brain disorder that causes a gradual decline in memory, thinking, and reasoning skills), Hypokalemia (a condition where the potassium levels in the blood are lower than normal), Hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), Hyperlipidemia (a condition where there are abnormally high levels of lipids (fats) in the blood), Essential primary hypertension (a type of high blood pressure that develops gradually over time and has no clear cause), Chronic atrial Fibrillation (a type of heart arrhythmia that causes the upper chambers of the heart to beat irregularly and quickly), unspecified atrial fibrillation (a heart condition where the upper chambers of the heart beat irregularly and out of sync with the lower chambers), seasonal allergic rhinitis (an inflammatory condition of the upper airways that occurs when the immune system overreacts to airborne allergens), constipation (a bowel dysfunction that makes it difficult or infrequent to have a bowel movement), primary osteoarthritis (is a type of arthritis that develops in joints over time and has no known cause), abnormalities of gait and mobility (any deviation from a normal walking pattern, which can manifest as difficulties with balance, coordination, or the rhythm of walking, often caused by underlying neurological, musculoskeletal, or sensory issues, leading to symptoms like limping, shuffling, dragging feet, or an unsteady gait), Altered mental status (a general term that describes a change in how well the brain is working) and cognitive communication deficit (a communication difficulty caused by a cognitive impairment). Review of Resident #109's comprehensive MDS assessment, dated 10/16/24, reflected a BIMS of 2 indicated severe cognitive impairment. MDS review reflected wandering - Presence and Frequency: Resident score 1 indicating behavior of this type occurred 1 to 3 days. Review of Resident #109's care plan, dated 10/11/24, reflected Resident #109 has impaired cognitive function with potential for worsening cognition related to progression of disease along with adjusting to new environment. Staff were instructed to keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Resident #109 is an elopement risk/wanderer related to disoriented to place, Impaired safety awareness. Staff were to maintain resident's safety will be maintained through the review date . Review of Resident #109's progress notes, from 10/10/24 through 12/1/24 , reflected, -A note by RN A on 10/10/24 at 5:09 AM, Late entry, which stated, behaviors: Wandering, Chronic. There have not been any recent medication reductions. -A note by LVN I on 10/10/24 at 1:54 PM, stated admission details: Mental Status: Resident is confused. Resident is inattentive. Resident is experiencing signs of short-term memory loss. Resident is disorganized in thinking. Oriented to person. Confused: Chronic. Short term memory loss: Chronic. Safety: Utilizing wander elopement alarm. -A note by LVN T, on 10/11/2024 at 10:54 AM, stated elopement evaluation: history of elopement while at home. Yes. Wandering behavior, a pattern or goal directed. Yes. Wanders aimlessly or non-goal-oriented: No. Wandering behavior likely to affect the safety or well-being of self/others: No. Wandering behavior likely to affect the privacy of others. No. Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: No. Elopement Score: 5.0 Score of 5.0 means: High risk of elopement. -A note by LVN E, on 10/13/2024 at 11:10 AM stated, note text: Resident exit seeking currently. Resident pushed on doors until they came open. Resident walked through doors down hall. RN charge and I were able to redirect resident back onto secure unit, with no resistance. Directed resident to her room. - A note by LVN E, on 10/13/2024 at 2:57 PM stated, note text: Resident in exit seeking, in search of her car to go home. Redirected resident to different activities with other residents. Redirection effective currently. Will continue with current plan of care. - A note by LVN E, on 10/13/2024 at 3:52 PM stated, Mood and behavior: Resident is currently experiencing unwanted behaviors. Wandering: Chronic. Mood and behavior note exit seeking. -A note by LVN U, on 10/13/2024 at 8:00 PM stated, note text: Noted with restlessness. Continuously pacing up and down hallway attempting to exit out of locked doors. Has held door long enough to release lock multiple times with staff able to redirect. Continues to state, I need to get to the parking lot and get my grey [NAME]. I am sorry but I am not staying here, especially when I do not belong here. Staff attempt to re-orient resident with no success. Staff continues to redirect currently. Plan of care to continue. - A note by LVN I, on 10/15/2024 at 6:19 PM stated, Behavior notes: Noted with increased restlessness/agitation/exit-seeking - repeatedly ambulating to double doors while stating, I need to go home, I have work to do at home. Initially easily redirected though required x2 staff to redirect from exiting and to dining area for supper. Noted confusion increasing when interacting with peers- staff able to direct to dining area for supper. RP made aware of behaviors. - A note by LVN V, on 10/27/2024 at 1:29 PM stated, note text: Resident was found around back of building approximately at 11:48 am. Resident was redirected back into the building by staff in which she was easily redirected without incidence. Resident assessed and noted no visible injuries, vitals taken 142/76/77, temperature 97.2, respiration rate 18. Skin warm, dry and intact. Resident states she had not been outside today. When question was asked resident stated she followed someone out of the gate and around the building, she also stated she goes out there numerous times. All parties are made aware including, MD, Representative, DON and administration. Resident eats her lunch and remains at table until family arrives. -A note by DON, on 10/27/2024 at 2:55 PM , indicates note strike out reason from resident chart: Incorrect documentation. Note text: After review of camera footage; resident noted to be outside for approximately one hour. Weather noted to be 94 degrees. Notified Medical Director Received new orders for labs to be drawn when resident arrives back at facility for CBC, CMP. Diagnosis: Fatigue. Representative made aware of new orders. -A note by DON on 10/27/2024 at 3:00 PM, stated Note text: after review of the camera footage and time stamp; resident noted to be out of sight for 14 minutes . Medical Director updated. -A note by LVN E on 12/01/2024 at 03:46 PM, stated nurse note: Resident was observed at exit doors. Resident pushed on doors until they came open. Resident came through doors to other side. Nurse intervened and assisted in getting resident back on the other side. Review of Resident #109's admission wandering evaluation, dated 10/11/24, reflected she had a history of wandering/elopement. There were no goals or interventions notated on the evaluation for Resident #109. Review of Resident #1's plan of care, from 10/11/24 through 11/03/24, reflected Resident #109 exhibited Problem: The resident is an elopement risk/wanderer related to disoriented to place, impaired safety awareness. 10/27/2024: Resident found outside back of building with no injuries (resident states she followed someone out of gate). Interventions/Tasks: Resident to reside on secured unit. Staff education regarding elopement/wandering with new policy regarding elopement. Date initiated: 10/27/2024. Wander alert: resident may have wander guard applied to alert staff of attempts to exit to facility; check placement and functioning every shift. Problem: The resident has impaired cognitive function with potential for worsening cognition related to progression of disease along with adjusting to new environment. Interventions/tasks: Administer medications as ordered. Monitor/Document for side effects and effectiveness (Namenda and Aricept). Keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Review of the facility's investigation file for Resident #109's incident on 10/27/24 reflected on 10/27/24, ADM investigation summary indicated review of camera footage. Resident observed exiting back door at 11:33 am. Resident noted exiting gate at 11:33 LVN V, observed walking out to the porch and to gate that is sounding at 11:35 am. Resident was escorted back to memory care wing at 11:49 am. Head to toe assessment performed, no injuries noted. Medical Director notified. Resident family member notified. Received new lab orders from doctor. Residents assessed and note no visible injuries, vitals taken 142/76/77, temperature 97.2, respirations 18. Skin was dry and intact. Resident states she had not been outside today. Resident eats her lunch and remains at table until family arrives as resident was scheduled to go out on pass this day to watch family member's theater performance. Action taken 10/27/24: Dementia training with appropriate interventions. Abuse and Neglect. Elopements. State reportable. 300 hall education: No propping open door, roller shades to be open. 10/28/24 Wander guard system placed for additional monitor placement on exit gate. Created new policy and procedure to follow for when exit alarms sound that include nursing staff conducting a roll call for all residents. During an interview on 12/11/24 at 9:50 AM, LVN H stated Resident #109 was outside in the smoking area. LVN H noticed her outside and realized that she was a little confused and then realized she was a resident from the facility. She was standing outside the gate; the gate was propped open in the smoking rest area for residents. LVN H redirected the resident back inside. LVN H verbalized, I'm not sure how long she was outside, I didn't see her when I passed by the window but when I went outside to take a break, I noticed her outside, it could not have been that long voiced LVN H. During an interview on 12/12/24 at 9:36 AM, LVN V stated she was the charge nurse for the memory unit on 10/27/24. She verbalized that staff were not very familiar with Resident #109 and the resident's family member had called that morning and asked that the staff get the resident ready for an outing. Staff got the resident ready and that morning staff had residents out in the outside area enjoying the weather. LVN V verbalized she is not sure if the resident was with the group but when the staff brought the residents back in shortly after the gate alarm went off outside. LVN V voiced she went out to check the gate and it was closed. She said she did not see anyone outside, so she closed the door that was left propped open during the process of bringing the residents back in that morning. LVN V verbalized she just thought someone pushed up on the gate and that is why the alarm went off. So, she turned the alarm off. LVN V, voiced another nurse came up to her at one point and told her he found one of her residents near the smoking area. LVN V provided a skin assessment on the resident and notified the doctor and family. LVN V, voiced she thinks the resident was gone for about 10 to 15 minutes. LVN V, verbalized that administration came in and re-checked everything to make sure staff complied and provided an in-service on elopements, abuse, and neglect. LVN V was sent home and informed that this was just part of the investigation process. During an interview on 12/12/24 at 10:16 AM, LVN E verbalized Resident #109 can read so she knows that the instructions on the door say to hold for 15 seconds, and it will open. LVN E, verbalized after the 10/27/24 elopement staff have been instructed to see who is at the door if the alarm goes off and do a head count of all the residents. During an interview on 12/12/24 at 10:28 AM, the DON verbalized she was not here the day Resident #109 eloped, but staff informed her of the elopement. DON voiced she is not sure if the resident walked through the grass around the back to reach the other end, or if she walked through the street that is located directly behind the building. DON acknowledged there was a potential for the resident to get hurt when she walked out of the memory care unit gate. DON verbalized that there were no other elopements since 10/27/24. During an interview on 12/12/24 at 11:12 AM the ADM verbalized that the videos show the resident leaving the facility at 10:33 AM but that the video was behind the regular time by one hour. ADM verbalized that the back cameras behind the building were not working. During an observation of the facility video footage on 12/12/2024, it reflected on 10/27/2024 resident exiting the alarm door outside the memory unit. During a telephone interview with Resident #109's family member on 12/12/24 at 1:24pm, she stated they called her about the elopement that she was in their outdoor patio and waited long enough that she stated that they did not tell her about the incident. Resident daughter verbalized she does not have any concerns about her being able to get out she is very normal, and a lot of people do not realize that she belongs there. Daughter verbalized if the resident does get out, she is not going to get hurt and not going to get far and stated with the nature of her disease it will happen from time to time. During an interview on 12/12/24 at 2:11 PM, maintenance employee W, stated that the alarms on the doors are checked monthly and records were provided and reviewed by survey team. During an interview on 12/12/24 at 2:15 PM, ADM verbalized that the back door was propped open for about 15 minutes on 10/27/24 after the residents were brought back into the building that morning. ADM verbalized she is trying to provide video footage, but it keeps freezing on her end. During an interview with DON on 12/12/24 at 3:02 PM, DON stated the nurse that was working on the 300-memory unit hall is was PRN nurse and 2 CNAs, along with an LVN and med aide. DON verbalized, I was not here that day, but I was told she walked outside the side door in front of the day room. The resident walked out the gate to the right, went out that door the blinds were closed in day room. Nurse went outside and she looked but the resident had closed the gate, so she just assumed that one of the residents pushed up on it. She was not gone that long at all. I will be honest less than 30 minutes. I will be honest the time stamp on the video footage is off. I believe when I calculated the time it was less than 30 minutes. Since then, we have done an in-service that includes staff need to make sure they are doing a roll count. Anytime alarms sound if it is not a planned exit, they need to make sure the residents are safe and all in the building. Make sure no doors are propped open. DON verbalized that all staff have been in-serviced and they were informed not to prop doors open, keep blinds open. During an interview on 12/12/24 at 3:15 PM, ADM voiced new policies and procedures to do roll call will, new wander guard ordered to be installed by 12/16/24 . They have increased staffing levels. Staff have dementia training that they must update monthly. During an interview on 12/12/24 at 3:48 PM with Alarm Representative X, the delayed egress should not be used for resident protection. An observation of the outside of the back gate on 12/12/2024 at 11:00 AM where Resident #109 exited to the smoking gate where she was found by LVN H on 10/27/24 reflected approximately 200 - 225 feet of distance that the resident walked. There was a residential road directly behind the facility and a parking lot for employees to park. This was determined to be an Immediate Jeopardy (IJ) on 12/12/24, The Administrator was notified. The Administrator was provided with the IJ template on 12/12/24 at 3:30 PM. The following Plan of Removal submitted by the facility was accepted on 12/13/24 at 11:08 AM Plan of Removal Immediate Threat On 12/12/2024 an abbreviated survey was initiated at facility. On 12/12/2024 the surveyor provided an Immediate Jeopardy that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: state the issue you will find the info on the template you were provided. Action: 1:1 Monitoring; assess staff is required to be always within arm's reach of resident. Start Date: 12/12/2024 at 1:35 PM Completion Date: In progress, will not complete until additional hardware (wander guard is installed on 12/16/2024) Responsible: Facility's staffing nurse, the QM nurse, & Director of Nursing is responsible for ensuring the adequate 1:1 Monitoring of resident. 12-12-24 (Thursday): Staff #1 from 4 till left on bus. Staff #2- while on the bus 12-12-24 (Thursday): staff # 3 from 8P-6A 12-13-24 (Friday): staff #4 from 6A-6P 12-13-24 (Friday): staff #3 from 6P-6A 12-14-24 (Saturday): staff #5 from 6A-6P 12-14-24 (Saturday): staff #6 from 6P-6A 12-15-24 (Sunday): staff #4 from 6A-6P 12-15-24 (Sunday): staff # 7 from 6P-6A 12-16-24 (Monday): staff # 4 from 6A-6P 12-16-24 (Monday): staff # 8 from 6P-6A Action: Door Monitoring Start Date: 12/12/2024 6:00 PM. Completion Date: In progress until new locking mechanisms is installed, date pending. Responsible: Facility's staffing nurse, the QM nurse, & Director of Nursing is responsible for ensuring the adequate 1:1 Monitoring of resident. 12/12/24 7P- 6A Staff member #9 12/13/23 6A-6P Staff member #10 12/13/24 6P- 6A Staff member #10 12./14/24 6A-6P Staff member #9 12/14/24 6P- 6A Staff member #11 12/15/24 6A-6P staff member #9 12/15/24 6P- 6A staff member # 11 12/16/24 6A-6P Staff member #12 12/16/24 6P- 6A Staff member # 13 Action: Training regarding: Abuse/Neglect, 1:1 Monitoring / Guarding of exit Doors, Elopement. A new policy and procedure , initiated on October 28, 2024, this procedure implements a roll call for all residents within the building. Medical Director, Director of Nursing, and Administrator created the policy and procedure 10/28/24. The CNAs receive training from charge nurses or administrative nurse, charge nurses are trained by the administrative nurses, who receive training from the DON, the DON receives training from Administrator; the Administrator receives training from Facility Consultant. Start Date: 12/12/2024. Completion Date: 12/13/2024 Responsible: In-service was conducted by previous ADON on roll call 10/28/2024 & again 12/12/2024 by IP and QM . Agency staff will receive in-services prior to their shift begins by the charge nurse on shift. Staff members who are off shift or PRN will receive in-service training via portal. Action: Door Signage posted as a reminder to staff not to prop the door open. In-service training provided by QM to re-iterate that doors are not to be propped open at any time. The CNAs receive training from charge nurses or administrative nurse, charge nurses are trained by the administrative nurses, who receive training from the DON, the DON receives training from Administrator; the Administrator receives training from Facility Consultant . Start Date: 12/12/2024. Completion Date: 12/12/2024 6:30 PM Responsible: QM Admin Nurse Action: Elopement Assessments Completed monthly and Care plans Updated as needed. Findings will be reported monthly to QA committee for review, with changes made to the plan as required. Start Date: 12/12/2024 5:30 PM Completion Date: 12/12/2024 09:30 Responsible: Assessments Charge Nurse #1, Care plans updated by designated MDS administrative nurse Action: The facility will conduct monthly audits to ensure that all assess Start Date: 12/12/2024 5:30 PM Completion Date: 12/12/2024 09:30 Responsible: Assessments Charge Nurse #1, Care plans updated by designated MDS administrative nurse. QAPI attendees include Facility Consultant, Administrator, Medical Director, Director of Nursing, and all administrative nursing personnel. The Administrator receives training from facility consultant. The Survey Team monitored the Plan of Removal on 12/13/24: Observation on 12/13/2024 at 8:30 and 11:15am staff member sitting by the door . Observation on 12/13/2024 at 11:15am revealed a staff member was in arm reach of Resident #1 . Further observation revealed that door signage was posted on both doors . Observation on 12/13/2024 at 1:27pm revealed a staff member was sitting by the door . Observation on 12/13/2024 at 1:28pm revealed a staff member was in arm reach of Resident #1 . During an Interview on 12/13/2024 at 2:27 pm, LVN I stated and confirmed she took the training this month. LVN A stated that she was trained on one-on-one monitoring, Resident #109 is within arm's length and to always know the resident's location, and to keep the resident distracted. LVN, I stated she has been trained on monitoring the exit doors and she took all the training today. LVN, I stated when the alarm sounds, we must do a head count on all residents, monitor the doors, and keep them closed, do not leave them open. LVN, I stated she took the elopement training today, and to keep the door closed, perform head counts if the alarm goes off, and to always know the locations of all residents. LVN, I stated if a resident elopes, I must notify the ADM and DON, call 9-1-1, and to notify staff and attempt to locate the resident. LVN, I stated if the alarm goes off, I go to the location of the alarm, investigate what is going on, if I see a resident by the door I redirect the resident, I conduct a head count on the residents, and notify the ADM and DON. LVN I stated when completed the Charge nurse will ensure each resident is accounted for and after roll call, I keep a mental note of the findings and I then review our wander guard list and ADL list. During an interview on 12/13/2024 at 2:37 pm, CNA M stated she took the in-service yesterday (12/12/2024), she has been educated on resident rights, she has been in-serviced on one-on-one monitoring. CNA M stated the training covered on how not to leave the resident's (Resident #109) side, and that a staff must be always at their side. CNA M stated he has been trained on monitoring exit doors, and that if the alarm goes off, we look at the surrounding area and ensure no resident got out, we do a head count and we can reset the alarm. CNA M stated that she has been trained on elopement procedures and that if a resident elopes or even steps on the other side of the door we must intervene and report to the charge nurse on duty, the charge nurse then reports the elopement up the chain of command, the goal is ensure no residents eloped. CNA M stated if a resident attempts to elope we must act, we redirect the resident and have them come back inside, we make sure there are no other residents out, we immediately notify the charge nurse on duty and we do a head count. CNA M added that we (staff) are all responsible that each resident is accounted for, one of us goes down the hall, another staff goes to the day area, and a third staff check the other doors, and that after the roll call we notify the nurses where all the residents were located, and we make a mental note on the residents and we communicate with all staff to assure all residents are accounted for. During an interview on 12/13/2024 at 2:52 pm, CNA L stated she has been in-serviced on one-on-one monitoring on residents, and that we must keep residents safe, keep them from falling, assure residents are taken care of, and assure residents are within arm's reach. CNA L stated that she was trained on monitoring the exit doors and that she took the training today. CNA L stated the training covered the importance of watching and monitoring the doors, calling the ADM for all elopements, and the importance on all staff locating the residents. CNA L stated we immediately notify the charge nurse if a resident elopes, and if I hear an alarm I get up and check what set the alarm off; I see who went in our out, who is close to the door, I check outside to assure no residents are outside. CNA L stated that all staff are responsible for assuring each resident is accounted for, and that after roll call I confirm findings with nurse. CNA L stated that after our roll call we are checking all residents are accounted for, we are checking the number of residents locations and his or her ADL sheets. During an interview on 12/13/2024 at 2:58 pm, CNA K stated she has taken the training, she has been trained on one-on-one monitoring. CNA K stated that she was in-serviced on having the resident stay within arm's reach, and if the resident (Resident #109) attempts to leave outside we must redirect the resident and have them come back inside, we were educated on redirecting the resident, keeping the resident busy by communicating with the resident. CNA K stated she was in-serviced on monitoring the exit doors, and we cannot leave doors cracked or propped open, we cannot let residents leave unsupervised. CNA K stated she was trained on elopement procedures, CNA K added if I see a resident g out , I intervene, I notify the nurse on duty, I tell the charge nurse, I start looking for the residents, and we notify the ADM and DON. CNA K stated if an alarm goes off, I will run and investigate who is going out of the door, I investigate if it was a resident or if a resident is outside the door. CNA K stated all staff, the charge nurse, everyone is responsible on assuring all residents are accounted for, and that after we complete our roll call for residents we communicated with the nurse on findings. CNA K stated that during the roll call, we confirm all residents, we count and make sure all residents are here and we review the ADL sheet for the residents. During an interview on 12/13/2024 at 3:20 pm, LVN J she took trainings today, she has been trained on one-on-one monitoring and that we always have eyes on resident, within arm's reach, and if a staff member needs to go on break, we notify another staff to assure we are always doing these things. LVN J stated if an alarm goes off, we act, we do a head count, then a roll call to account all residents are here. LVN J confirmed she has taken the elopement trainings today, and added that if an alarm goes off, we act, the system will inform us what number band (wander guard) set off the alarm, and we follow the location of residents and roll call procedures. LVN J stated we must report all elopements to the DON, and if an alarm goes off, we find out if a resident went out of the building, we check outside the surrounding areas for any residents, and that we are all responsible that each and all residents are accounted for. After the roll call, I would take a mental note and recall each resident, if a resident is missing or not accounted for, I check our computer (records) and review who has been checked out (signed out on pass, appointment, et all) of the facility and reference that for all residents that should be present in the facility. During an interview on 12/13/2024 at 3:22 pm, DON stated training was completed today, on the importance of one-on-one monitoring, how residents must be within arms always reach and for staff to communicate if they need a break, staff must assure another staff takes over the important duties until they return. DON stated we had education on guarding or monitoring the doors today and that staff should be at the door 24/7 and that the elopement training was done this morning. DON stated the training covered what to do if there is an elopement; there needs to be a roll call and if it is in the secured unit, we need to do an elopement assessment to determine who is at risk of an elopement, we always respond to alarms or if a resident elopes. DON also stated if nursing staff will assure the roll calls are completed for the whole facility, I (DON) will notify ADM and do a self-reported incident to HHSC . DON stated staff are to respond immediately, to get our residents to safety, staff need to communicate and get in touch with the charge nurses to do a roll call of the entire facility, charge nurses will use a printed midnight census to assure all residents are in the building and after the roll call staff are to huddle, assure all is clear on resident head counts and locations and to report all findings to myself and ADM. During an interview on 12/13/2024 at 3:29 pm, ADM stated we must report all findings of abuse, we have trained staff on one-on-one monitoring, we educated staff that one-on-one is defined as you (staff) stay within arm's reach of the resident that needs the monitoring and to communicate and call if they (staff) need a break so one-on-one can continue. ADM stated I have been trained on monitoring exit doors, and that guarding or monitoring the exit doors mean to redirect or ask for additional staff to assist with residents who are trying to enter or exit. ADM confirmed the elopement training education conducted today, this morning, that in the elopement training we check for resident's safety, staff must notify us, administration, the residents RPs and Doctors. ADM added that we placed interventions to keep our residents safe and from further elopement. ADM added we have been trained in an elopement situation staff are to perform if an alarm goes off, even if it is just a fire alarm, all residents must be accounted for, we look around the premises, we locate the residents, we call local law enforcement advise of a silver alert, we notify doctors or nurse practitioners, we were trained on the importance of a roll call being completed and that we can just clear or turn off the alarm, all residents must be accounted for prior to resetting any alarm. ADM stated that the charge nurses for each hallway are responsible for assuring the residents are accounted for by matching face to name on the midnight census, after the roll call this will be submitted to the nursing office. Record Review of In-Services for 1:1, door monitoring, door propping, elopement, abuse, and neglect, exit alarm sounding and Dementia revealed that 110 out of 129 staff have been in serviced. Staff [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation for one (Resident #1) of three residents reviewed for use of side or bed rails, in that: The facility failed to ensure full length bed rails were securely fastened to Resident #1's bed. She became entrapped between the rail and her mattress on 01/06/23, sustaining a femur fracture. This deficient practice could affect residents who use bed or side rails as enablers, resulting in entrapment or injury. An Immediate Jeopardy (IJ) existed from 01/06/23 - 01/07/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. The findings included: Review of Resident #1's undated face sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses including osteoarthritis (inflammation of joints), spinal stenosis (a condition where spinal column narrows and compresses the spinal cord), and muscle weakness. Review of Resident #1's quarterly MDS assessment, dated 10/15/22, reflected a BIMS of 11, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required extensive assistance with repositioning. Section P (Restraints and Alarms) reflected she did not require bed rails. Review of Resident #1's quarterly care plan, dated 10/23/22, reflected she was at risk for future falls with serious injuries related to past history of falls with fractures with an intervention of using full side rails on both sides of bed to aide in bed mobility and to provide sense of security when in bed (per MD and family request). It further reflected she needed bilateral full siderails related to recent fall with fracture with potential for serious adverse effects with an intervention of ensuring the resident was positioned correctly with proper body alignment while restrained. Review of Resident #1's hospital discharge orders, dated 07/08/21, reflected an order for bed rails on both sides of bed. Review of Resident #1's Bed Side Rail Permission form, dated 07/08/21, reflected her RP was aware of the risks of using a bed rail and consented to full side rails x2 per resident, family, and physician to aide her with bed mobility and repositioning and to provide sense of security in bed. Review of Resident #1's Side Rail Evaluations, dated 07/08/21, 10/22/22, and 01/18/23, reflected she was able to express her desire for use of side rails and that the side rails did not put her at risk. Review of Resident #1's quarterly MDS assessment, dated 10/15/22, reflected a BIMS of 11, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required extensive assistance with repositioning. Section P (Restraints and Alarms) reflected she did not require bed rails. Review of Resident #1's quarterly care plan, dated 10/23/22, reflected she was at risk for future falls with serious injuries related to past history of falls with fractures with an intervention of using full side rails on both sides of bed to aide in bed mobility and to provide sense of security when in bed (per MD and family request). It further reflected she needed bilateral full siderails related to recent fall with fracture with potential for serious adverse effects with an intervention of ensuring the resident is positioned correctly with proper body alignment while restrained. Review of Resident #1's progress notes in her EMR, dated 01/07/23 at 2:12 AM, documented by RN B, reflected the following: [CNA A] alerted need for reposition [Resident #1] in bed. Upon entering the room, [Resident #1] was laying on her left side against the side rail. [Resident #1] did not voice any pain. With assistance from [CNA A], [Resident #1] was repositioned comfortably in bed in a supine position, with assistance of the draw sheet . Review of Resident #1's progress notes in her EMR, dated 01/07/23 at 7:00 AM, documented by RN C, reflected the following: .[Resident #1] stated that her left hip hurts too bad and doesn't want to get up . Noted swelling to left hip area and leg slightly deformed . will be sending [Resident #1] to ER for eval. Review of Resident #1's progress notes in her EMR, dated 01/07/23 at 12:05 PM, documented by RN C, reflected the following: Received a call and [Resident #1] was being admitted to (hospital) for Dx: left femur fracture. Review of a witness statement for Resident #1, dated 01/07/23, documented by RN B, reflected the following: On 01/06/23, [CNA A] requested my presence . [Resident #1] was lying in bed but was up against the railing to her left side . When we proceeded to adjust her, the bottom railing to her left side fell to the floor . Review of a witness statement for Resident #1, dated 01/07/23, documented by CNA A, reflected the following: On 1/6/2023 I entered [Resident #1]'s room and found her on her side crunched up by the bed rails. I called [RN B] to [Resident #1]'s room to help adjust her in bed. When [RN B] and [CNA A] first entered the room to adjust [Resident #1], the rail at the foot of the bed was loose and slipped out of position . During an interview on 01/24/23 at 9:59 AM with CNA A, she stated when she checked on Resident #1 on 01/06/23, the bed rail was loose, and she was lodged between it and the bed. She stated the resident complained of hip and head pain. She stated the bed rail was often loose, but it had never caused an issue, so she had not notified anyone. Observation on 01/24/23 at 11:22 AM revealed Resident #1 asleep in her room. Her bed was in a low position and her call light was by her left hand. The side rails were sturdy and did not budge when pushed on. During an interview on 01/24/23 at 11:30 AM with the ADM and DON, the DON stated when Resident #1 returned from the hospital after sustaining a femur fracture as a result of a fall from her bed on 07/14/21, there were orders for bed rails on both sides of her bed. The DON stated she was against bed rails, but Resident #1's RP was insistent. She stated they spoke about the risks involved and suggested other alternatives such as a low bed or scoop mattress. The DON stated the RP would not budge on the topic. She stated they had an old hospital bed with rails from a resident who had passed away years before, so they put the hospital bed in Resident #1's room. She stated there was no medical necessity for the hospital bed, but it had bed rails that were easy to lock in place. The DON stated the hospital bed apparently broke and MAINTW D moved in a new bed and attached old school railing that should not have been in the facility at all. The DON stated she was never made aware that Resident #1's bed had broken until after the incident on 01/06/23. She stated she nor the ADM were also not notified that the rails on the new bed were loose. The ADM and DON both stated it was their expectation to be notified upon any kind of equipment malfunction, as it could place residents at risk of being injured. The ADM stated he also expected for anything that needed repair to be written in the maintenance request log binder, but the staff had a bad habit of just verbally telling the maintenance team. The DON stated she did not allow Resident #1 to be readmitted from the hospital until they had purchased the correct mattress that was manufactured to fit with the appropriate rails, and she was currently utilizing the purchased bed. The DON stated the staff had not been educated on ensuring bed rails were attached properly or what to look for until after the incident with Resident #1. She stated there were no other residents in the facility with full length bed rails. During an interview on 01/24/23 at 11:44 AM with MAINTW E, she stated Resident #1's hospital bed broke about three weeks before the incident on 01/06/23. She stated she did not specifically remember notifying the ADM or DON, but it was probably talked about in morning meeting. She stated MAINTW D moved in a new bed with an air mattress and attached some old rails they had outside in their storage. She stated neither she nor MAINTW D measured the distance from Resident #1's head to the bed rail, as they must have forgotten to do so. She stated the rails that were put on the bed were easy to make loose just by pulling on them. She stated she had not realized it could cause Resident #1 to be at risk of getting hurt. During an interview on 01/24/23 at 12:14 PM with MAINTW D, he stated when he attached the rails to Resident #1's bed, he tightened the screws real tight. He stated did not check on bed rails to ensure they were in need of maintenance on a regular basis. He stated if an aide told him something was wrong with a bed rail, he would then go look at it. He stated he was not notified by any staff members that the rails were loose on Resident #1's bed, and no maintenance requests were made in the maintenance request log binder. On 01/24/23 from 12:10 PM 1:04 PM, three aides, 1 nurse, and one housekeeper were interviewed and were able to identify when/who to notify when any resident equipment needed repair. Review of the Maintenance Request Log from 12/01/22 01/24/23, reflected no requests maintenance of bed rails. Review of QAPI minutes, dated 01/13/23, reflected bed rails safety/installation was discussed. Review of an in service, dated 01/07/23, reflected the MAINTW's were educated on not using the old bed rails in the facility. Review of an in service , dated 01/07/23, reflected the following education was provided: Nursing Administration and/or Facility Administrator should be notified of all safety concerns including, but not limited to: malfunctions of beds, side rails, bed canes, loose boards, wheelchairs, hoyer lifts, and furniture and other miscellaneous devices that could pose risks to resident safety. After notifying nursing administration, ALL concerns should be written in the maintenance log. Review of signatures reflected all staff were in serviced. On 01/24/23 from 12:10 PM 1:04 PM, three aides, 1 nurse, and one housekeeper were interviewed. Thy acknowledged being in serviced and were able to identify when/who (DON immediately then document the request in the maintenance request log book) to notify when any resident equipment needed repair. Review of the facility's Bed Safety policy, revised December of 2007, reflected the following: Policy Statement: Our facility shall strive to provide a safe sleeping environment for the resident.2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattresses, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; .d. Ensure that bed side rails are properly installed and other pertinent safety guidance to ensure proper fit (e.g. ensure proper distance from the headboard and footboard, etc.) Review of the facility's Maintenance Service policy, revised December of 2009, reflected the following: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Review of the facility's Identifying Neglect policy, date April of 2021, reflected the following: .3. 'Neglect' is defined as the failure of the facility to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress. An Immediate Jeopardy (IJ) existed from 01/06/23 - 01/07/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation.