**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for 2 of 5 residents (Residents #1 and #2) reviewed for comprehensive care plans. 1. The facility failed to develop a comprehensive person-centered care plan with interventions to address Resident #1's behavior of unbuckling the seat belt when transported in the facility van. On 6/13/2025, Resident #1 fell forward while being transported and sustained a laceration to her forehead. 2. The facility failed to develop a person-centered care plan with interventions that addressed Resident #2's fall on 06/18/2025. An IJ was identified on 07/12/2025. The IJ template was provided to the facility on [DATE] at 3:30 PM. While the IJ was removed on 07/13/2025 at 4:20 PM, the facility remained out of compliance at a scope of isolation and severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal. These failures could affect residents who have care areas not addressed by the care plans by not having their behavioral needs identified and addressed and putting them at risk of not having their health and safety needs met. The findings included:1. Record review of Resident #1's admission Record (Face Sheet) dated 07/11/2025 revealed she was a [AGE] year-old resident admitted to the facility on [DATE], readmitted on [DATE] and was discharged on 06/13/2025. Diagnoses listed on the admission Record included heart failure, kidney failure with dependance on dialysis (medical treatment to filter waste and excess water from the blood through a specialized machine), syncope (irregular heartbeat), bradycardia (slow heartbeat), and vascular dementia (impaired cognitive thinking due to constricted blood flow). Record review of Resident #1's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 5 out of 15 which indicated her cognitive skills for daily decision making were severely impaired; was dependent for transfers, and had no other behavioral symptoms not directed toward others. Record review of Resident #1's Physician Order Summary Report, dated 07/12/2025, revealed an order initiated on 01/17/2025 for dialysis on Monday, Wednesday, and Friday at 12:00 PM at a local dialysis center. Record review of Resident #1's Nurses Notes from 03/11/2025 to 06/12/2025 revealed there was no notation of Resident #1 trying to stand up during transport or for trying to unbuckle her seatbelt in the facility van during transport. Record review of Resident #1's Nurses Notes dated 06/13/2025 by the DON, revealed Resident had a fall. Location: in facility van during transport to dialysis. Cognition/Behavior at Time of Event: Cognitive Impairment. The fall caused a skin tear to above left eyebrow.new/bleeding.Administrator received call from Van Driver of resident fall in van. Upon arrival to scene, noted resident on floor of van face down with head partially under 2nd row of seats. Blood noted on floor and on resident's hair. Cream colored emesis (vomit) noted on wc [wheelchair] and unable to check vs [vital signs]. Respirations slow and irregular. 911 called per van driver. Ems arrived and transported to ER. The MD was notified on 06/13/2025 at 12:02 PM. Resident #1's Responsible Party was notified on 06/13/2025 at 11:52 AM. Interventions in place prior to fall: None, Interventions initiated in response to fall: none. Record review of Resident #1's Nurse's Notes dated 06/13/2025 by LVN H revealed the nurse received a call from the hospital emergency room regarding Resident #1's medication list which was faxed to the hospital and the nurse was informed the resident had another episode of vomiting at the hospital and was intubated (a tube inserted into the mouth and throat to hold open the airway so air can be pushed in and out of the lungs via machine) at that time. Record review of Resident #1's Event Nurses' Note-Fall, dated 06/13/2025, revealed the resident had an unwitnessed fall in the facility van during transport to dialysis sustaining a skin tear above her left eyebrow. Resident #1's responsible party was notified on 06/13/2025 at 11:52 AM and her physician was notified on 06/13/2025 at 12:02 PM. Under Interventions in place prior to this fall had None of the above was checked. Under Interventions initiated in response to this fall had None of the above checked and no interventions were listed. Record review of hospital records dated 6/20/2025 revealed Resident #1 had a CT (Computed tomography - type of imaging using x-ray techniques to obtain detailed images) of head was completed 06/19/2025 and showed no acute intracranial finding. Further review reviewed Resident #1 was treated for and placed on seizure precautions and treated also for sepsis-resolved (condition where the body's responses to infection causes injury to its own tissues and organs), likely secondary to aspiration pneumonia (lung infections caused by inhaling something other than air into your lungs, such as food or vomit), and Paroxysmal Atrial Fibrillation (noted she converted to normal sinus rhythm on 6/16/2025). Telephone interview with Family Member #1 on 07/11/2025 at 12:08 p.m. revealed Resident #1 was no longer in hospital and had been moved to a different nursing facility but was still fighting an infection and very weak. He stated Resident #1 had a history of falls but expected the facility to know this and take appropriate precautions. He stated he felt the facility should have sent extra staff instead of just the driver to help take care of vulnerable residents. During interview with the Van Driver on 07/09/2025 at 3:57 PM, she stated she had pulled out of facility to transport Resident #1 to dialysis when she heard Resident #1 make a loud noise, checked her rearview mirror and saw Resident #1 vomiting. The Van Driver stated she started to pull over to get off the road when she saw Resident #1 stiffen up and fall forward, landing face first on the floor of the van. She stated she called the Administrator, who instructed her to call 911. Further interview revealed the Van Driver stated she had secured Resident #1 securely inside the van but believed Resident #1 unfastened the seatbelt as she had done that before on at least 2 occasions in the past. Further interview with the Van Driver on 07/10/2025 at 4:15 p.m. revealed that she stated there were two other prior incidents of Resident #1 removing her seatbelt and trying to stand up in the van. She stated the first incident happened about 2 months prior to the June 13th incident, where Resident #1 took her seatbelt off and she told Resident #1 to keep her seatbelt fastened because she could fall. She stated the second incident happened about 2 weeks prior to the June 13th incident, where Resident #1 attempted to pull herself up to standing by pulling on the seat in front of her during transport. The Van Driver stated she reported one of the incidents to LVN -A, and one incident to the Administrator, who told her to contact therapy to ask what could be done, and therapy told her they could tilt her wheelchair backwards so she couldn't grab things. During an interview with LVN-A on 07/10/2025 at 11:44 a.m., she stated that sometime during that first week of June 2025, the Van Driver came to the Nurse's station after returning Resident #1 back to facility from dialysis, and told her, the DON and former ADON, who were all standing at the nurse's station, that Resident #1 had tried to stand up in the van during transport. LVN-A stated she educated Resident #1 about not standing up in the van, that it was dangerous, and she stated Resident #1 denied that she had done that. LVN-A further stated that she did not report the incident to anyone because the DON was standing at the Nurse's station with her when the Van Driver reported the incident and had instructed her to educate Resident #1 on not unbuckling her seatbelt. During an interview on 7/11/25 at 9:41 AM, the Activity Director stated that he and the other Van Driver were the only 2 employees that transported residents. The Activity Director stated he transported Resident #1 several times and he had seen her undo her seatbelt in the past. He stated he educated Resident #1 to not unbuckle her seat belt, but she got anxious and unbuckled it. He stated he reported the incident to the Van Driver so that she could monitor for the behavior. Record review of Resident #1's Care Plan initiated 07/03/2022 for The resident is risk for falls due to dx [diagnosis] of syncope [irregular heartbeat]. Resident had action [sic] fall in facility van causing laceration to forehead initiated 07/03/2022 and revised 06/14/2025 revealed it did not address the resident's behavior of unbuckling the seat belt and no new interventions were listed. Record review of Resident #1's other Care Plan focus areas revealed there was no care plan for her behaviors of trying to unbuckle the seatbelt and standing up when transported in the van. Interview on 07/10/2025 at 4:30 PM with the Administrator revealed she had never been informed of Resident #1 unbuckling or standing up in the van. She stated she had been informed by the Van Driver of an incident that occurred about 2 months prior to the current incident, where the Van Driver reported Resident #1 had attempted to slide out of her wheelchair and that was when she suggested the Van Driver check with therapy to see if wheelchair could be modified. Interview on 07/11/2025 at 11:45 PM with PT B revealed she confirmed a CNA had asked what could be done about Resident #1 leaning forward in wheelchair. PT B stated she instructed the CNA and Resident #1's family member how to recline the wheelchair and there was no documentation available about the instruction provided. Interview on 07/11/2025 at 11:46 AM with Administrator, revealed had she known about prior incidents of Resident #1 unbuckling her seat belt and trying to stand up in van, she would have assigned an escort to accompany Resident #1 during transport or sought other ambulance transportation services. Interview on 07/12/2025 at 2:04 PM, MDS Nurse RN C stated if a resident had a behavior of removing their seatbelt while being transported, the Administrator would be informed along with the DON, and any interventions implemented would be care planned. MDS Nurse RN C stated Resident #1's Care Plan and MDS were completed by anther MDS nurse who no longer worked in the facility. MDS Nurse RN C reviewed Resident #1's care plan for falls and stated she did not see anything in Resident #1's Care Plans about her behavior of unbuckling the seatbelt when transported in the facility van, and only had just one statement about the resident having a fall in the facility van causing a laceration to her forehead. MDS Nurse RN C stated the harm of not having the behavior of unbuckling the seatbelt during transport in the care plan could result in an injury. Interview on 07/12/2025 at 2:15 PM with the Administrator, she stated the process for reporting resident behaviors was for the nurse to document in the resident's chart the behavior so it could be discussed in daily meetings or directly tell the DON or Administrator. She stated the Interdisciplinary Team (IDT) would be responsible for developing interventions to address the behavior to ensure the resident's safety. The Administrator stated it was her understanding that the behavior [of unbuckling the seatbelt] was not addressed in Resident #1's care plan and the harm could result in further injury. 2. Record review of Resident #2's admission record dated 07/08/2025 revealed she was an [AGE] year-old woman admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: Vascular Dementia-Severe (impaired cognitive thinking due to constricted blood flow), Schizoaffective Disorder (a mental health condition that includes both symptoms of schizophrenia, such as hallucinations and delusion and mood disorders), and Poly- osteoarthritis (condition where cartilage in multiple joints wears down causing bones to rub against each other leading to pain and stiffness). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment and she was assessed as needing substantial/maximal assistance for transfers. Record review of Resident #2's Nurses Notes dated 06/18/2025 at 6:06 p.m. by LVN-I, revealed the resident had an unwitnessed fall from the low bed in her room onto the floor next to the bed sustaining a skin tear that was 2cm. to her right hand, and complaining of head, neck, right arm and right leg pain. Under Interventions in place prior to this fall had Floor mat, Low bed. Under Interventions initiated in response to this fall had Floor mat, Low bed, neuro-checks. Record review of Resident #2's Nurses Notes dated 06/18/2025 at 10:55 p.m. by LVN-I revealed resident had returned from the ER with a diagnosis of right knee patella (kneecap) fracture, with knee immobilizer in place. Record review of Resident #2's Care Plan initiated 07/03/2022 for The resident is risk for falls r/t Poor communication/comprehension.Resident H/O fall out of bed due to self positions to the point of being on the edge initiated 07/03/2022 and last revised 07/07/2023, revealed it was not revised to address the resident's actual fall on 06/18/2025 and no new interventions were listed. Record review of Resident #2's other focus areas of Care Plan initiated 07/03/2022 revealed there was no care plan or new interventions which addressed her fall on 06/18/2025. Interview with CNA-K on 07/09/2025 at 1:52 p.m. revealed she stated she had completed check and change with Resident #2 about an hour before her fall and stated she put the bed in the lowest position, and the head of bed was just slightly elevated. Then as she was walking down hall with LVN-H to leave at end of her shift, she heard Resident #2 mumbling, looked in her room and saw her on the floor, face down. She stated she also observed the bed was not in the lowest position, and the head of the bed was straight up at 90-degree angle. The fall mat was in place by her bed. Interview with LVN-H on 07/10/2025 at 10:40 a.m. revealed she works day shift and was getting ready to leave for the day when she heard Resident #2 talking from her room, and when she went to check on her, found Resident #2 lying on the mat on the floor next to her bed. LVN-H stated she observed that Resident #2's head of bed was up to the full 90 degrees, and the bed was not in lowest position, and stated that Resident #2 had been observed to work the bed controller in the past. LVN H stated she believed Resident #2 had accidentally changed position of bed as she manipulated the bed controller. She stated they always make sure her call light was within reach but does not believe she understands its purpose as Resident #2 will push the button on the call light, but when they answer, she cannot say what she needed or why she activated the light. Interview on 07/10/2025 at 5:59 p.m. with LVN-I revealed she works night shift and had just come on duty on 6/18/2025 when she was called into Resident #2's room after she had been found on the floor. She stated Resident #2 was lying on the mat on the floor next to her bed, and that the mat had been in place. However, she noted the bed was not in its lowest position and the head of the bed was in an upright position and stated Resident #2 will take the bed controller and randomly press buttons on it, which can move her bed out of the lowest position. LVN-I stated they have done interventions to keep her from falling again, such as moving the bed controller to the end of the bed to keep her from moving the bed up higher and moving things away from her bed that she can grab, like the drawers out of her dresser. Interview with the DON on 07/11/2025 at 8:28 a.m. revealed all acute incidents such as falls are discussed in the morning team meetings and the team discusses actions/interventions needed. She did not remember specifically what was discussed regarding Resident #2's fall on 6/18/2025. The DON stated that the MDS Nurse is responsible for revising the care plan per the quarterly and annual MDS assessments, and the DON and ADONs are responsible for updating care plans for acute changes. The DON did not know why there was no care plan revision done following Resident #2's fall on 06/18/2025 and -stated that could result in staff not being aware of the care needs of the residents, and could result in acute events such as falls happening again. During an interview with the Administrator on 07/11/2025 at 10:16 a.m., the Administrator stated that Resident #2's fall on 06/18/2025 was addressed by the team in the morning clinical meeting to review causes of the fall and devise new interventions to prevent other falls in future. The Administrator stated that interventions were put into place, including moving furniture to create a safe space, and moving the bed controller away from Resident #2's reach, so that she could not move the bed out of the recommended low bed position. The Administrator further stated however, that Resident #2's care plan was not revised to include these new interventions to prevent further falls but should have been. She stated that either the MDS Nurse or DON can update the care plan to include new focus areas and interventions after discussion in the morning clinical meeting and did not know why Resident #2's care plan was not revised. The Administrator stated not updating the care plan to include all relevant new information such as interventions put in place to prevent falls, could result in staff not having the needed information to care for the Resident properly. Record review of facility policy titled Fall Policy, undated revealed The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as requires and Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall. Record review of facility policy titled Comprehensive Care Planning, undated, revealed The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. This was determined to be an Immediate Jeopardy (IJ) on 07/13/2025 at 3:30 PM. The facility Administrator and Area Regional Director of Operations were notified. The Administrator was provided with the IJ template on 07/13/2025 at 3:30 PM. On 07/13/2025 the facility provided a plan of removal. The Plan of removal was accepted on 07/13/2025 at 7:05 PM. It was documented as follows: The following in-services were initiated by the Regional Compliance nurse and DON on 7/11/25. Any staff member not present or in-serviced on 7/11/25 will not be allowed to assume their duties until in-serviced. Direct Staff to include therapy staff.1. Implementing interventions to minimize the risk of falls. 2. Fall Prevention Policy 3. Reporting incidents, accidents and changes in condition that may impair resident safety, to the administrator/DON immediately. Direct care staff in-service over management of behaviors (both in the facility and during van transportation) that may lead to injury and when to notify physician and nursing leadership and administrator. This was completed by the Director of Nursing on 7/12/2025. Any staff member not in-serviced on 7/12/2025 will not be allowed to assume their duties and sign to verify understanding. DON/ADON/Administrator will review entries on the dashboard and monitor to assure that the changes were implemented and added to the resident care plan and kisok as appropriate. An abuse and neglect in-service was initiated on 7/12/2025 by the facility Administrator. Any staff member who is not present for the in-service will not be allowed to assume their duties until attending in-service and signing to verify understanding. Van drivers received in-service education on 7/12/2025 by the facility Administrator that if a resident unbuckles their seatbelt during van transportation, the van will be pulled over at the nearest safe place. The driver will sit with the resident and call for assistance. Signature was obtained to signify verbal understanding. Facility transportation staff were removed from transport duties and counseled by Administrator on 07/11/2025 on Van Driving policy. All transportation staff retrained on Incident Reporting Policy to Administrator on 7/11/25 by administrator. The Medical Director was notified of the immediate jeopardy situation on 7/12/25 at 5:54 PM by the facility Administrator. Ad Hoc (something done for a specific, immediate need) QAPI meeting will be held on 7/11/25 to discuss the IJ and review plan of removal. Any falls/incidents that occur over the weekend will be reported to the facility administrator and/or DON. On 07/12/2025, the facility Administrator was in-serviced one-one-one by the Area Director of Operations about ensuring interventions are put into place following an incident. Signature verbalized understanding. All behaviors will be reported to facility Administrator/DON; interventions will be discussed with IDT and interventions implemented and care planned. Behaviors will be documented in chart and reviewed daily in stand-up. All new interventions added to the care plan will be shared with the staff in a written update on the facility dashboard (in the electronic documentation system) available to all direct care staff. DON/ADON/Administrator will review entries on the dashboard and follow to assure that the changes were implemented and added to the resident care plan and kiosk as appropriate. If a resident unbuckles their seatbelt during van transportation, the van will be pulled over at the nearest safe place. The driver will sit with the resident and call for assistance. Real time computer software key word alert and the 24-hour report will be reviewed in morning stand up 5x weekly by the intradisciplinary team, to assess for any documented changes in resident behavior or other incidents. Any interventions will be put in place and added to the facility dashboard for the staff review. Prior to any van transport, the Administrator/DON will review, with the van driver, any special needs for resident safe transport and put them in place prior to the beginning of transportation. Any modifications will be noted on the van transportation calendar. Monitoring: DON and Administrator will review all falls, incidents and accidents and unsafe behaviors during the morning meeting to ensure appropriate interventions have been implemented. These will continue to be reviewed 5x weekly until the identified issue has been resolved and interventions are in place. The weekend supervisor will review the real time system and 24-hour report and report any newly identified issues to DON/Administrator. Identified incidents, accidents and or unsafe behaviors will be added to a tracker for Administrator and DON to complete with interventions and weekly follow up to assure that said interventions are in place and satisfactory to assure the residents' safety. If it is determined not to be effective, new interventions will be added and tracked. This will be done for a period of 6 weeks or until substantial compliance is achieved, reviewed by the QAPI committee prior to any changes. DON and Administrator will review all falls, incidents and accidents during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented and plan of care updated to assure staff know how to care for resident after an event or change in condition. Monitoring will take place weekly for a minimum of 6 weeks. The above will be reviewed during the facility monthly QA meeting for no less than 60 days, or until the Administrator determines substantial compliance has been achieved and maintained. Incidents involving van transport will be reviewed 5x weekly in morning meetings to determine if there were any incidents. The IDT will discuss any necessary interventions to prevent future events and update the residents' plan of care as appropriate. This will continue for a period of 6 weeks and PRN thereafter as determined by the QAPI committee. Regional Compliance Nurse/Area Director of Operations will review incidents and accidents at least once weekly to assure that appropriate interventions are in place to address incidents, accidents and changes in condition were made at the facility level. Verification of the facility's POR for F656 was as follows:Record review of an In-Service Form dated 07/12/2025 revealed the Administrator had in-serviced the Van Driver on If a resident unbuckles their seatbelt during van transportation, the van will be pulled over at the nearest safe place. The driver will sit with the resident and call for assistance. Record review of an In-Service Training Attendance Roster dated 07/12/2025 revealed the Administrator was trained by the Area Director of Operations to ensure interventions were in place for any reported unsafe conditions, reported falls or other accidents/unusual occurrences. Record review of an In-Service Training Attendance Roster dated 07/12/2025 revealed the Administrator was trained by the Area Director of Operations on Abuse and Neglect. Record review of an untitled sheet revealed the Administrator notified the Medical Director of the IJ on 07/12/2025 at 5:50 PM. Record review of a printed calendars of residents who were transported to appointments from 06/15/2025 to 07/12/2025, revealed which residents had escorts accompany them when they were transported in the van, and it was also noted what days the Administrator rode in the van with the Van Driver. Record review of the Behavior Monitoring Tracker revealed residents who had behaviors would be tracked daily with what the behavior was, if there was an intervention placed, if it was care planned and if it was effective. There were 6 weeks of sheets for the monitoring. Record review of an undated employee list revealed the facility had 89 full time employees and 32 part-time/prn employees for a total of 121 employees. Record Review of an In-service record log revealed all 121 employees had been in-serviced by phone or in person on reporting allegations of abuse/neglect immediately to the Administrator; any unsafe conditions that must be reported to the Administrator immediately; all falls and/or other accidents or unusual occurrences would be reported to the administrator; any unsafe behaviors or incidents that occurred on the van during transport needed to be reported to the Administrator and DON immediately; all unsafe behaviors that could lead to a fall must be reported immediately to the Administrator; and on the Fall Policy. In an interview on 07/12/2025 at 4:23 PM, the Administrator stated the SOC was Standard of Care which was a weekly meeting that was held to discuss resident care. Interviews on 07/12/2025 from 4:40 PM to 7:00 PM and 07/13/2025 from 8:30 AM to 4:00 PM with 29 employees out of 121 employees (25 full time employees, 4 prn/part time employees) which consisted of 1 RA (RA W), 2 MA (MA T, MA U), 2 Housekeepers (Housekeeper Q, Housekeeper R), 10 CNAs (CNA L, CNA M, CNA N, CNA O, CNA X, CNA Y, CNA K, CNA BB, CNA AA, CNA Z) 3 of them worked 6 PM to 6 AM shift, 4 LVNs (LVN I, LVN H, LVN J, LVN P) 2 of them worked 6 PM to 6 AM shift), 3 dietary employees (Dietary Aide T, Dietary Supervisor E, and [NAME] S), 1 Activity Director, 1 Van Driver, 2 PTA (PTA EE, PTA CC), 1 OTA (OTA DD) revealed the had received the in-service training as indicated in the POR for F656. All the employees stated they would report any signs of abuse to the Abuse Coordinator who was the Administrator, they had her phone number to contact her. They also stated they would report immediately to the abuse coordinator any falls or unsafe behaviors to the administrator which included any unsafe behaviors when residents were transported in the van. The employees stated they had been in-serviced on the facility's Fall Prevention policy and interventions to minimize falls and provided examples of how that could be done. In an interview on 07/13/2025 at 10:41 AM the Van Driver stated she works full time as the van driver; and received training on reporting incidents, on when to pull the van over, on when to report anything to the administrator about unusual behaviors that occurred when a resident was transported, reporting unusual behaviors from residents. Van Driver D said she was also trained to report any falls a resident had to the administrator, the DON and nurse. The Van Driver stated she was also trained to report any signs of abuse or neglect to the administrator immediately. The Van Driver said she received one-on-one training about the fall with Resident #1, was retrained by administrator on transporting residents, and the Administrator rode with her for a whole week in June 2025. Then the administrator rode with her twice a week for four weeks, then the administrator would randomly ride with her. The Van Driver stated she the Administrator was riding with her twice a week for two more weeks. The Van Driver said she would print out daily the calendar of the residents who would be transported; record on the calendar any behaviors from the resident when they were transported and provided the calendar to the administrator at the end of the day. The Van Driver stated she was also in-serviced recently on abuse and neglect; and would report it immediately to the administrator. In an interview on 07/13/2025 at 2:03 PM, DON stated they would review in the morning meeting which resident would need an escort when transported to their scheduled appointment. The DON said residents who had falls were reviewed daily in the morning meeting. The DON stated she and the Administrator had in-serviced the employees on Abuse and Neglect, on Falls, who to report to, what to report for abuse or neglect, and fall prevention. The DON stated staff were to report to her or the Administrator if they had witnessed any unsafe behaviors from a resident or when the resident was transported. The DON stated if a resident had a fall, the charge nurse would notify her of the fall. The DON said they would review the falls throughout the day to see how they could be prevented. The DON stated the monitoring would be done with the monitoring tools that were developed and reviewed in the daily morning meeting, the weekly SOC meeting and QAPI meetings. The DON stated they would review which residents need to have an escort or need to have a contracted transport company take a resident to dialysis if needed. The DON said they had an Ad Hoc QAPI meeting on 7/11/2025 with the department heads, the Administrator, the Area Director of Operations; and the Medical Director was informed by the Administrator. The DON said she and the ADON would review the 24-hour summary to see if there were any changes that happened such as falls or behaviors and to see if they were reviewed. The DON stated the resident's dashboard would be reviewed throughout the day for any falls or behaviors that would need to be addressed. The DON said she and the Administrator were reviewing residents who were going to be transported, and it was discussed if the resident needed to have an escort. The DON stated the SOC meeting was held weekly on Fridays, and they would review residents who had a fall or accident to see if any interventions were needed. In an interview on 07/13/2025 at 2:23 PM, the Administrator stated the interventions implemented included re-educating all staff on reporting unusual occurrences, and an employee could not return to work unless they received the training. The Administrator said all staff were provided her phone number to contact her to report any abuse or unsafe behaviors. The Administrator stated a monitoring tool was implemented to review all falls in the morning meeting

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 2 residents (Residents #1 and #2) reviewed for accidents. 1. The facility failed to identify and address hazards and risk in Resident #1's environment when staff failed to ensure they addressed Resident #1's behavior of unbuckling the seatbelt during transport in the facility van. On 06/13/2025, Resident #1 sustained a fall during van transport, with the seat belt noted to be on the wheelchair but the fastener unlatched, resulting in a laceration to her forehead. 2. The facility failed to identify and address hazards and risk in Resident #2's environment when staff failed to ensure they addressed Resident #2's fall on 06/18/2025. An Immediate Jeopardy (IJ) was identified on 07/11/2025. The IJ template was provided to the facility on [DATE] at 10:39 p.m. While the IJ was removed on 07/13/2025 at 4:20 p.m., the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal. This failure could place residents at risk for accidents injuries, hospitalization and death related to unsafe vehicle transport. The findings included: 1.Record review of Resident #1’s admission record dated 07/08/2025 revealed she was a [AGE] year-old woman admitted on [DATE] with re-admission on [DATE], and with diagnoses which included: End-Stage Renal disease (condition where kidneys lose the ability to remove waste and balance fluids in balance requiring dialysis); Syncope (fainting or temporary loss of consciousness) and collapse; Vascular Dementia (impaired cognitive thinking due to constricted blood flow) and Bradycardia (slow heart beat). Record review of Resident #1’s Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 5, indicating severe cognitive impairment, and was assessed as being dependent for transfers, and had no behavioral symptoms. Record review of Resident #1’s Care Plan initiated 07/03/2022 revealed a focus area for “The resident is risk for falls due to dx [diagnosis] of syncope,” and included “Resident had action [sic] fall in facility van causing laceration to forehead” initiated 07/03/2022 and revised 06/14/2025. There were no interventions listed which addressed the resident’s behavior of unbuckling the seat belt and no new interventions for this fall were listed. Record review of Resident #1’s other focus areas in her Care Plan initiated 07/03/2022, revealed there was no other focus areas for her behavior of trying to stand up during transport or for trying to unbuckle her seatbelt in the facility van during transport. Record review of Resident #1’s Physician Order Summary Report, dated 07/12/2025, revealed an order initiated on 01/17/2025 for dialysis at 12:05 PM on Monday, Wednesday, and Friday at a local dialysis center. Record review of Resident #1’s Nurses Notes from 03/11/2025 to 06/12/2025 revealed there was no notation of Resident #1 trying to stand up during transport or for trying to unbuckle her seatbelt in the facility van during transport. Record review of Resident #1’s Progress Note dated 6/13/2025 at 11:22 a.m. by the DON revealed “Resident had a fall. Location: in facility van during transport to dialysis. Cognition/Behavior at Time of Event: Cognitive Impairment. The fall caused a skin tear to above left eyebrow. new/bleeding….Administrator received call from Van Driver of resident fall in van. Upon arrival to scene, noted resident on floor of van face down with head partially under 2nd row of seats. Blood noted on floor and on resident’s hair. Cream colored emesis (vomit) noted on wc [wheelchair] and unable to check vs [vital signs]. Respirations slow and irregular. 911 called per van driver. Ems arrived and transported to ER…” The MD was notified on 06/13/2025 at 12:02 PM. Resident #1’s Responsible Party was notified on 06/13/2025 at 11:52 AM. “Interventions in place prior to fall: None, Interventions initiated in response to fall: none.” Record review of Resident #1’s Nurse’s Notes dated 06/13/2025 by LVN-H revealed the nurse received a call from the hospital emergency room regarding Resident #1’s medication list which was faxed to the hospital and the nurse was informed the resident had another episode of vomiting at the hospital and was intubated (a tube inserted into the mouth and throat to hold open the airway so air can be pushed in and out of the lungs via machine) at that time. Record review of Resident #1’s Event Nurses’ Note-Fall, dated 06/13/2025, revealed the resident had an unwitnessed fall in the facility van during transport to dialysis sustaining a skin tear above her left eyebrow. Resident #1’s responsible party was notified on 06/13/2025 at 11:52 AM and her physician was notified on 06/13/2025 at 12:02 PM. Under “Interventions in place prior to this fall” had “None of the above” was checked. Under “Interventions initiated in response to this fall” had “None of the above” checked and no interventions were listed. Record review of hospital records dated 6/20/2025 revealed Resident #1 had a CT (Computed tomography – type of imaging using x-ray techniques to obtain detailed images) of head was completed 06/19/2025 and showed “no acute intracranial finding”. Further review revealed Resident #1 was treated for and placed on seizure precautions and treated also for sepsis-resolved (condition where the body’s responses to infection causes injury to its own tissues and organs), likely secondary to aspiration pneumonia (lung infections caused by inhaling something other than air into your lungs, such as food or vomit), and Paroxysmal Atrial Fibrillation (noted she converted to normal sinus rhythm on 6/16/2025). Telephone interview with Family Member #1 on 07/11/2025 at 12:08 p.m. revealed Resident #1 was no longer in hospital and had been moved to a different nursing facility, but was still fighting an infection and very weak. He stated Resident #1 had a history of falls, but expected the facility to know this and take appropriate precautions. He stated he felt the facility should have sent extra staff instead of just the driver to help take care of vulnerable residents. During an interview on 07/09/2025 at 3:57 p.m., the Van Driver stated that she loaded Resident #1 in the van on 06/13/2025, leaving facility at 11:16 a.m. and after pulling out onto the road, she heard Resident #1 make a loud noise, and saw in the rear-view mirror that Resident #1 had vomit coming from her mouth. She stated that as she attempted to turn to pull off to the side of road, she saw Resident #1 stiffen up and fall forward out of the wheelchair and land face down on the floor of the van. The Van Driver stated she called the Administrator who told her to call 911. The Van Driver further stated that she had secured Resident #1 securely in her wheelchair into the van with 4 straps that were attached to the L-bar of Resident #1’s wheelchair frame, but stated she believed Resident #1 had unbuckled her seatbelt, because she had unbuckled her seatbelt during transport in the past. Further interview with the Van Driver on 07/10/2025 at 4:15 p.m. revealed that she stated there were two other prior incidents of Resident #1 removing her seatbelt and trying to stand up in the van. She stated the first incident happened about 2 months prior to the June 13th incident, where Resident #1 took her seatbelt off and she told Resident #1 to keep her seatbelt fastened because she could fall. She stated the second incident happened about 2 weeks prior to the June 13th incident, where Resident #1 attempted to pull herself up to standing by pulling on the seat in front of her during transport. The Van Driver stated she reported one of the incidents to LVN -A, and one incident to the Administrator, who told her to contact therapy to ask what could be done, and therapy told her they could tilt her wheelchair backwards so she couldn’t grab things. During an interview with LVN-A on 07/10/2025 at 11:44 a.m., she stated that sometime during that first week of June 2025, the Van Driver came to the Nurse’s station after returning Resident #1 back to facility from dialysis, and told her, the DON and former ADON, who were all standing at the nurse’s station, that Resident #1 had tried to stand up in the van during transport. LVN-A stated she educated Resident #1 about not standing up in the van, that it was dangerous, and she stated Resident #1 denied that she had done that. LVN-A further stated that she did not report the incident to anyone because the DON was standing at the Nurse’s station with her when the Van Driver reported the incident and had instructed her to educate Resident #1 on not unbuckling her seatbelt. During an interview with the DON on 07/10/2025 at 4:54 p.m., the DON stated she was never made aware of any prior incidents of Resident #1 taking off her seatbelt or trying to stand up out of her wheelchair during van transport. Interview on 07/10/2025 at 4:30 p.m. with the Administrator revealed she had inspected the van after the incident and observed vomit on the chest strap when she pulled it out from the retracting device, indicating the chest strap had been in place across Resident #1’s chest when she first started to vomit and believed Resident #1 may have pressed down on her abdomen with her hand when she vomited, accidentally pushing on the release button of the seatbelt. When asked about any prior incidents, the Administrator stated that the Van Driver had informed her of an incident where Resident #1 had attempted to slide down out of her wheelchair, could not remember the exact date, but thought it might have been a couple of months prior to the current incident, and that was when she suggested the Van Driver check with therapy to see if wheelchair could be modified. She stated the Van Driver never told her Resident #1 had unbuckled her seatbelt or tried to stand up in van. She stated the Van Driver came back and told her therapy stated the wheelchair could be tilted back slightly, and they agreed that was what they were going to try to do to address the problem. The Administrator further stated that if Resident #1 had intentionally tried to undo her seatbelt or stand up in the van during transport she would expect that to be reported to her, but no one ever had. She stated the team never met to discuss the incident reported to her of Resident #1 trying to slide out of the wheelchair and the intervention they discussed about the therapy assessment of the wheelchair was never care planned but should have been. Interview with PT - B on 07/11/2025 at 11:46 a.m. revealed she confirmed a CNA had come down to ask about what could be done about Resident #1 leaning forward in wheelchair and PT-B instructed CNA and Resident #1’s family member how to recline the wheelchair. No documentation available as Resident #1 was not on services at this time. Interview with the Activity Director on 7/11/2025 at 9:41 a.m. revealed that he also transports residents in the van to recreational activities, but will also transport residents at times to their medical appointments when the primary Van Driver is out sick. He stated the primary Van Driver and he are the only staff who transported residents at the facility. The Activity Director stated he had transported Resident #1 in the van many times and had observed her undo her seatbelt or try to stand up in van during transport several times. The Activity Director further stated he educated Resident #1 not to unbuckle her seat belt, but stated she would get anxious at times and forget. The Activity Director stated he reported this behavior of unbuckling her seatbelt during transport to the primary Van Driver so she could be aware and monitor but did not report the incidents to anyone else. During a telephone interview with the Van Driver on 07/11/2025 at 11:54 a.m., she stated that she did not recall the Activity Director ever informing her or warning her about Resident #1’s behavior of unbuckling her seatbelt during transport. During an interview with the Administrator on 07/11/2025 at 11:46 a.m., the Administrator stated that had she known Resident #1 had incidents of unbuckling her seatbelt in van during transport, she would have assigned an escort to go along with her during transport or contracted with local company for ambulance transportation services for Resident #1. 2. Record review of Resident #2’s admission record dated 07/08/2025 revealed she was an [AGE] year-old woman admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: Vascular Dementia-Severe (impaired cognitive thinking due to constricted blood flow), Schizoaffective Disorder (a mental health condition that includes both symptoms of schizophrenia, such as hallucinations and delusion and mood disorders), and Poly- osteoarthritis (condition where cartilage in multiple joints wears down causing bones to rub against each other leading to pain and stiffness). Record review of Resident #2’s Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment and she was assessed as needing substantial/maximal assistance for transfers. Record review of Resident #2’s Nurses Notes dated 06/18/2025 at 6:06 p.m. by LVN-I, revealed the resident had an unwitnessed fall from the low bed in her room onto the floor next to the bed sustaining a skin tear that was 2cm. to her right hand, and complaining of head, neck, right arm and right leg pain. Under “Interventions in place prior to this fall” had “Floor mat, Low bed.” Under “Interventions initiated in response to this fall” had “Floor mat, Low bed, neuro-checks.” Record review of Resident #2’s Nurses Notes dated 06/18/2025 at 10:55 p.m. by LVN-I revealed resident had returned from the ER with a diagnosis of right knee patella (kneecap) fracture, with knee immobilizer in place. Record review of Resident #2’s Care Plan initiated 07/03/2022 for “The resident is risk for falls r/t Poor communication/comprehension….Resident H/O fall out of bed due to self positions to the point of being on the edge” initiated 07/03/2022 and last revised 07/07/2023, revealed it was not revised to address the resident’s actual fall on 06/18/2025 and no new interventions were listed. Record review of Resident #2’s other focus areas of Care Plan initiated 07/03/2022 revealed there was no care plan or new interventions which addressed her fall on 06/18/2025. Interview with CNA-K on 07/09/2025 at 1:52 p.m. revealed she stated she had completed check and change with Resident #2 about an hour before her fall and stated she put the bed in the lowest position, and the head of bed was just slightly elevated. Then as she was walking down hall with LVN-H to leave at end of her shift, she heard Resident #2 mumbling, looked in her room and saw her on the floor, face down. She stated she also observed the bed was not in the lowest position, and the head of the bed was straight up at 90-degree angle. The fall mat was in place by her bed. Interview with LVN-H on 07/10/2025 at 10:40 a.m. revealed she works day shift and was getting ready to leave for the day when she heard Resident #2 talking from her room, and when she went to check on her, found Resident #2 lying on the mat on the floor next to her bed. LVN-H stated she observed that Resident #2’s head of bed was up to the full 90 degrees, and the bed was not in lowest position, and stated that Resident #2 had been observed to work the bed controller in the past. LVN H stated she believed Resident #2 had accidentally changed position of bed as she manipulated the bed controller. She stated they always make sure her call light was within reach but does not believe she understands its purpose as Resident #2 will push the button on the call light, but when they answer, she cannot say what she needed or why she activated the light. Interview on 07/10/2025 at 5:59 p.m. with LVN-I revealed she works night shift and had just come on duty on 6/18/2025 when she was called into Resident #2’s room after she had been found on the floor. She stated Resident #2 was lying on the mat on the floor next to her bed, and that the mat had been in place. However, she noted the bed was not in its lowest position and the head of the bed was in an upright position and stated Resident #2 will take the bed controller and randomly press buttons on it, which can move her bed out of the lowest position. LVN-I stated they have done interventions to keep her from falling again, such as moving the bed controller to the end of the bed to keep her from moving the bed up higher and moving things away from her bed that she can grab, like the drawers out of her dresser. Interview with the DON on 07/11/2025 at 8:28 a.m. revealed all acute incidents such as falls are discussed in the morning team meetings and the team discusses actions/interventions needed. She did not remember specifically what was discussed regarding Resident #2’s fall on 6/18/2025. The DON stated that the MDS Nurse is responsible for revising the care plan per the quarterly and annual MDS assessments, and the DON and ADONs are responsible for updating care plans for acute changes. The DON did not know why there was no care plan revision done following Resident #2’s fall on 06/18/2025 and -stated that could result in staff not being aware of the care needs of the residents, and could result in acute events such as falls happening again. During an interview with the Administrator on 07/11/2025 at 10:16 a.m., the Administrator stated that Resident #2’s fall on 06/18/2025 was addressed by the team in the morning clinical meeting to review causes of the fall and devise new interventions to prevent other falls in future. The Administrator stated that interventions were put into place, including moving furniture to create a safe space, and moving the bed controller away from Resident #2’s reach, so that she could not move the bed out of the recommended low bed position. The Administrator further stated however, that Resident #2’s care plan was not revised to include these new interventions to prevent further falls but should have been. She stated that either the MDS Nurse or DON can update the care plan to include new focus areas and interventions after discussion in the morning clinical meeting and did not know why Resident #2’s care plan was not revised. The Administrator stated not updating the care plan to include all relevant new information such as interventions put in place to prevent falls, could result in staff not having the needed information to care for the Resident properly. Record review of facility policy titled “Fall Policy”, undated revealed “The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as requires” and “Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall.” This was determined to be an Immediate Jeopardy (IJ) on 07/11/2025. The Administrator was provided with the IJ template on 07/11/2025 at 10:39 PM. On 07/12/2025 the facility provided a plan of removal. The Plan of removal was accepted on 07/12/2025 at 11:33 AM. It is documented as follows: The following in-services were initiated by the Regional Compliance nurse and DON on 7/11/25. Any staff member not present or in-serviced on 7/11/25 will not be allowed to assume their duties until in-serviced. Direct Staff to include therapy staff. 1. Implementing interventions to minimize the risk of falls. 2. Fall Prevention Policy 3. Reporting all incidents and accidents to the administrator immediately. Facility transportation staff was removed from transport duties and counseled by Administrator on 07/11/2025 on Van Driving policy. All transportation staff retrained on Incident Reporting Policy to Administrator on 7/11/25 by administrator. The medical director was notified of the immediate jeopardy situation on 7/11/25 at 10:30 pm by administrator. Ad Hoc QAPI meeting will be held on 7/11/25 to discuss the IJ and review plan of removal. Any falls/incidents that occur over the weekend will be reported to the facility administrator and/or DON. Monitoring: DON and Administrator will review all falls during the morning meeting to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. DON and Administrator will review all falls during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. Above will be reviewed during the facility monthly QA meeting for no less than 60 days, or until the Administrator determines substantial compliance has been achieved and maintained. Incidents involving van transport will be reviewed 5x weekly in morning meeting to determine if there were any incidents. This will be continued for a period of 6 weeks and PRN thereafter as determined by the QAPI committee. Verification of the facility’s POR for F689 was as follows: Record review of an AD Hoc QAPI Contributors signature page dated 07/11/2025 revealed a meeting was held with the Administrator, DON, Medical Director, Social Services, Activity Director and three other employees. Record review of an undated, untitled sheet revealed the Medical Director was notified on 07/11/2025 at 11:04 AM of the IJ situation by the Administrator. Record review of an Incident/Fall Review Monitoring Tool revealed all falls would be reviewed 5 days per week for 6 weeks. Record review of a Falls Review Monitoring Tool revealed the Administrator and the DON would discuss falls and interventions implemented weekly at a SOC (Standard of Care) meeting that was held with the Administrator, DON, and other Interdisciplinary Team members. Record review of the QA Monitoring Tool revealed falls and incidents and if interventions were implemented would be reviewed monthly at the QAPI Meetings that will be held on 07/15/2025 and 08/19/2025. Record review of the Van Incident Monitoring Tool revealed all incidents involving van transport were reviewed five times a week for 6 weeks by the DON and Administrator. Record review of an undated employee list revealed the facility had 89 full time employees and 32 part-time/prn employees for a total of 121 employees. Record review of an In-service record log, dated 07/12/2025 revealed all 121 employees had been in-serviced by phone or in person on reporting allegations of abuse/neglect immediately to the administrator; any unsafe conditions must be reported to the administrator immediately; all falls and/or other accidents or unusual occurrences would be reported to the administrator; any unsafe behaviors or incidents that occur on the fan during transport needs to be reported to the administrator and DON immediately; all unsafe behaviors that could lead to a fall must be reported immediately to the administrator; and on the Fall Policy. In an interview on 07/12/2025 at 4:23 PM, the Administrator stated the “SOC” was Standard of Care which was a weekly meeting that was held to discuss resident care. Interviews on 07/12/2025 from 4:40 PM to 7:00 PM and 07/13/2025 from 8:30 AM to 4:00 PM with 29 employees out of 121 employees (25 full time employees, 4 prn/part time employees) which consisted of 1 RA (RA W), 2 MA (MA T, MA U), 2 Housekeepers (Housekeeper Q, Housekeeper R), 10 CNAs (CNA L, CNA M, CNA N, CNA O, CNA X, CNA Y, CNA K, CNA BB, CNA AA, CNA Z) 3 of them worked 6 PM to 6 AM shift, 4 LVNs (LVN I, LVN H, LVN J, LVN P) 2 of them worked 6 PM to 6 AM shift), 3 dietary employees (Dietary Aide T, Dietary Supervisor E, and [NAME] S), 1 Activity Director, 1 Van Driver, 2 PTA (PTA EE, PTA CC), 1 OTA (OTA DD) revealed the had received the in-service training as indicated in the POR for F689. All the employees stated they would report any signs of abuse to the Abuse Coordinator who was the Administrator, they had her phone number to contact her. They also stated they would report immediately to the abuse coordinator any falls or unsafe behaviors to the administrator which included any unsafe behaviors when residents were transported in the van. The employees stated they had been in-serviced on the facility’s Fall Prevention policy and interventions to minimize falls and provided examples of how that could be done. In an interview on 07/13/2025 at 10:41 AM the Van Driver stated she works full time as the van driver; and received training on reporting incidents, on when to pull the van over, on when to report anything to the administrator about unusual behaviors that occurred when a resident was transported, reporting unusual behaviors from residents. Van Driver D said she was also trained to report any falls a resident had to the administrator, the DON and nurse. The Van Driver stated she was also trained to report any signs of abuse or neglect to the administrator immediately. The Van Driver said she received one-on-one training about the fall with Resident #1, was retrained by administrator on transporting residents, and the Administrator rode with her for a whole week in June 2025. Then the administrator rode with her twice a week for four weeks, then the administrator would randomly ride with her. The Van Driver stated she the Administrator was riding with her twice a week for two more weeks. The Van Driver said she would print out daily the calendar of the residents who would be transported; record on the calendar any behaviors from the resident when they were transported and provided the calendar to the administrator at the end of the day. The Van Driver stated she was also in-serviced recently on abuse and neglect; and would report it immediately to the administrator. In an interview on 07/13/2025 at 2:03 PM, DON stated they would review in the morning meeting which resident would need an escort when transported to their scheduled appointment. The DON said residents who had falls were reviewed daily in the morning meeting. The DON stated she and the Administrator had in-serviced the employees on Abuse and Neglect, on Falls, who to report to, what to report for abuse or neglect, and fall prevention. The DON stated staff were to report to her or the Administrator if they had witnessed any unsafe behaviors from a resident or when the resident was transported. The DON stated if a resident had a fall, the charge nurse would notify her of the fall. The DON said they would review the falls throughout the day to see how they could be prevented. The DON stated the monitoring would be done with the monitoring tools that were developed and reviewed in the daily morning meeting, the weekly SOC meeting and QAPI meetings. The DON stated they would review which residents need to have an escort or need to have a contracted transport company take a resident to dialysis if needed. The DON said they had an Ad Hoc QAPI meeting on 7/11/2025 with the department heads, the Administrator, the Area Director of Operations; and the Medical Director was informed by the Administrator. The DON said she and the ADON would review the 24-hour summary to see if there were any changes that happened such as falls or behaviors and to see if they were reviewed. The DON stated the resident’s dashboard would be reviewed throughout the day for any falls or behaviors that would need to be addressed. The DON said she and the Administrator were reviewing residents who were going to be transported, and it was discussed if the resident needed to have an escort. The DON stated the SOC meeting was held weekly on Fridays, and they would review residents who had a fall or accident to see if any interventions were needed. In an interview on 07/13/2025 at 2:23 PM, the Administrator stated the interventions implemented included re-educating all staff on reporting unusual occurrences, and an employee could not return to work unless they received the training. The Administrator said all staff were provided her phone number to contact her to report any abuse or unsafe behaviors. The Administrator stated a monitoring tool was implemented to review all falls in the morning meeting to ensure interventions were implemented and was care planned. The Administrator said the SOC tool would be used weekly to verify the interventions were listed, if the staff knew about the interventions, and would be reviewed at the next QAPI meeting. The Administrator stated a van monitoring tool was implemented to ensure if anything happened during transport was recorded. The Administrator said the monitoring sheet was reviewed daily to determine if a resident needed an escort or need an ambulance to transport them. The Administrator stated the van drivers would turn in the van monitoring tool at the end of the day with notes about if a resident tried to stand up, any issues with their chair, or if they looked weak. The Administrator said the Van Driver was retrained on transporting residents in the van. The Administrator stated after the incident with Resident #1 she rode in the van daily for the first week, then the second week she rode in the van a twice a week. The Administrator stated an Ad Hoc QAPI meeting was held on 07/11/2025 with the department heads and Area Director of Operations. The Administrator said staff were retained about un-safe behaviors to be reported immediately to her or the DON. The Administrator stated when employees see a resident exhibiting behaviors, they were to stay with the resident to make sure they are safe, call for help, then report it to the administrator. The Administrator said they have a clinical care meeting and will follow-up on the entries on the resident’s clinical record dashboard for behaviors with instructions for that resident, and the interventions were added to the resident’s care plan. The Administrator stated if something happened on the weekend, staff would contact the Administrator. The Administrator said the Van Driver and Activity Director were in-serviced to pull over when a resident did something unsafe in the van and then call her. The Administrator said she a calendar was used with residents who have appointments to determine if a resident needed to have an escort to their appointment. The Administrator stated she and the DON would review all falls to make sure the i

**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 as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision, in that: The facility failed to supervise Resident #1 who eloped from the facility on 06/21/24. The noncompliance was identified as PNC. The IJ began on 06/21/24 and ended on 06/22/24. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings included: Record review of the face sheet for Resident #1, dated 11/15/24, revealed the [AGE] year-old male resident was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia (a condition of cognitive impairment that can have occur for various reasons), peripheral vascular disease ( a circulatory condition in which narrowed blood vessels reduce blow flow to the extremities), and bipolar disorder ( a mental health condition that causes extreme mood swings). Record review of Resident #1's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of a 8 which indicated that the Resident was cognitively impaired. The MDS indicated that the resident exhibited a moderate risk of wandering behavior. Record review of the Quarterly care plan for Resident #1, initiated on 8/8/22, revealed the resident had a risk of wandering behavior. The interventions included identifying the pattern of wandering, observation, and provided structured activities. Further review revealed the resident's care plan was changed on 6/21/24 to include the resident's elopement on 6/21/24. Record review of wandering assessment for Resident #1, dated 4/17/24, noted the resident had a history of wandering aimlessly and was at low risk for elopement. The wandering assessment was revised on 6/21/24 to include the elopement incident. Record review of the physician order summary for Resident #1, dated 6/20/24, revealed the resident was under the care of the medical director for medication management and behavior monitoring. Record review of the one-on-one supervision log for Resident #1, dated 6/21/24, revealed the resident was under continuous one-on -one supervision by nursing staff upon return to the facility from the elopement including supervision during the resident's transfer to the hospital on 6/21/24. Record review of the facility's incident report dated 6/21/24 revealed that the facility's van driver began looking for the Resident #1 at 8:15 a.m. on 6/21/24. Code Orange for elopement protocol was called at the facility on 6/21/24 at 8:30 a.m. Family and physician notifications were initiated. All of the facility's rooms were searched with all other residents' whereabouts being noted. The facility staff conducted a search of the facility grounds and surrounding locale. Resident #1 was located several blocks for the facility at 8:50 a.m. at a convenience store. Local law enforcement was also at this location at the time. Resident #1 was brought back to the facility and a full head to toe assessment was conducted by nursing staff with no injuries noted. Resident #1's physician ordered that Resident #1 be transported to the hospital on 6/21/24 at 9:15 a.m. for further evaluation. The summary of the incident report finding was that the Resident went out of one of the facility entrance doors but the elopement was unwitnessed. Record review of world weather.info website revealed the morning temperature on 6/21/24 in [NAME], TX was 77 degrees Fahrenheit. Review of Google Maps revealed that on 6/21/24 Resident #1 would have crossed one street, E Mockingbird Lane to arrive at the convenience store located at 2602 E Mockingbird Lane, [NAME], TX. Observation from 11/13/24 to 11/15/24 between the hours of 8:00 a.m. and 4:00 p.m., of all the resident corridor hallways revealed the door alarms were in working order. Observation on 11/15/24 at 9:45 a.m. with the Administrator revealed that all of the facility's exit doors were tested for door alarm efficacy with no concerns noted. During an interview with the Administrator on 11/14/24 at 9:55 a.m. regarding the elopement incident, the Administrator stated that Resident #1 had eloped from the facility on 6/21/24 sometime around 8:00 a.m. The Administrator stated that the facility's van driver began looking for the Resident #1 at 8:15 a.m. on 6/21/24. Code Orange for elopement protocol was called at the facility on 6/21/24 at 8:30 a.m. Family and physician notifications were initiated. All of the facility's rooms were searched with all other residents' whereabouts being noted. The facility staff conducted a search of the facility grounds and surrounding locale. Resident #1 was located several blocks for the facility at 8:50 a.m. at a convenience store. Local law enforcement was also at this location at the time. Resident #1 was brought back to the facility and a full head to toe assessment was conducted by nursing staff with no injuries noted. Resident #1's physician ordered that Resident #1 be transported to the hospital on 6/21/24 at 9:15 a.m. for further evaluation. The Administrator stated that she had ordered on 6/21/24 that all facility's exit doors be checked for door alarm and closure viability. The Administrator advised that all of the facility's resident assessments for elopement were updated on 6/21/24. During an interview with the Assistant Maintenance Director on 11/15/24 at 10:45 a.m., the Assistant Maintenance Director stated that regular inspections of all of the facility's exit doors for alarm and door closure effectiveness are done three times a week. Record review of the undated facility's policy titled, Elopement Prevention and Elopement Response revealed, Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. The Administrator was notified on 11/15/24 at 3:00 p.m., that a past non-compliance IJ situation had been identified due to the above failure. It was determined the failures placed Resident #1 in an IJ situation on 6/21/24. The facility implemented the following interventions. The Quarterly care plan for Resident #1 initiated on 5/15/24 revealed was changed on 6/21/24 to include the resident's elopement on 6/21/24. Record review of wandering assessment for Resident #1 was revised on 6/21/24 to include the elopement incident. All of the residents in the facility on 6/21/24 had their elopement risk assessments reviewed and updated. During an interview on 11/14/24 from 11:10 a.m. to 11:55 a.m. with Charge Nurse A, Guest Relations Staff B, Occupational Therapist Staff C, ADON D, Housekeeping Supervisor E, and Van Driver F, they stated that they had participated in the elopement exercise to find Resident #1 on 6/21/24. These staff were all present in the building at the time of the elopement by Resident #1. They stated they had been re-inserviced on the elopement protocol on 6/21/24 and were aware of what to do to monitor and intervene with residents who have exit-seeking behaviors. During an interview with the Human Resources Director (HR Q) on 11/14/24 at 12:30 a.m., she confirmed stated that all of the facility's active staff had been in-serviced on the elopement protocol on 6/21/24. During an interviews on 11/14/24 from 1:00 p.m. to 2:00 p.m. the following staff (Activity Director, CNA G, CNA H, CNA I, COTA J, LVN K, RN L, [NAME] M, DA N, DA O, DA P, HR R, Housekeeper S, Housekeeper T, MA U, MA V, PTA W, PTA X, Rehab Director Y, RA Z stated they had been in-serviced on elopement protocol call Code Orange, what to do when a resident was missing by calling Code Orange, telling staff, and searching for the resident, and what to do when a resident was trying to elope-try and re-direct the resident, tell the nurse, and stay with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that food that accommodates resident allergies, intolerances, and preferences for 1 of 8 residents (Resident #13) reviewed for resident allergies, intolerances, and preferences, in that: On 09/04/2024 Resident #13 was given meatloaf with egg causing an allergic reaction. Requiring Resident #13 to use emergency medication and be transferred to the hospital for further evaluation. The noncompliance was identified as PNC. The IJ began on 09/04/24 and ended on 09/05/24. The facility had corrected the non-compliance before the survey began. These failures could place residents at risk of harm, serious injury, or death. Findings were: Record review of Resident #13's face sheet dated 11/13/2024, revealed an original admission date of 8/31/2024 and a re-admission date of 10/08/2024 with diagnoses of: personal history of anaphylaxis (a severe, life-threatening allergic reaction), chronic obstructive pulmonary disease (lung disease making it hard to breathe), angina pectoris (chest pain/discomfort). Record review of Resident #13's MDS, dated [DATE], showed a BIMS score of 13 indicating intact cognition. Record review of Resident #13's Care Plan, dated 10/23/2024, showed, Allergic to Influenza Vaccine Live, Chicken Derived Substance, Levaquin and Eggs. Record review of Resident #13's electonic health record revealed on 09/24/2024 Resident #13 was given meatloaf for lunch which contained egg as a binding agent. Record review of nursing note dated 9/4/2024 revealed Resident #13 alerted nursing staff via call light that he was having symptoms of allergic reaction after consuming meatloaf and self-administered epi-pen at bedside. Record review of nursing note dated 9/4/2024 revealed Resident #13 alerted nursing staff via call light that he was having symptoms of allergic reaction after consuming meatloaf and self-administered epi-pen at bedside. - 9/4/2024 at 16:02 [4:02 p.m.], Resident Tranfered to [hospital name] ER By EMS, NP notified at 13:32 [1:32 p.m.], DX: Allergic Reaction, Epi-pen administered at 13:12 [1:12 p.m.], Resident is his own RP and Family [family member name] notified, DON in room and aware, O2 at 15L per non-rebreather mask administered. Tongue was swollen at time of epi-pen given and hd subsided by the time EMS arived at 13:35 [1:35 p.m.]. V/S B/P-150/90, P-84, R-14, T-97.1 O2 Sat 100% via non-rebreather mask at 15L. Resident has allergy to eggs and chicken derived substances. Meatloaf tray present in Room, but tray looked untouched. Report called into to ER Nurse at [hospital name] hospital at 13:46 [1:46 p.m.]. called [hospital name] ER for patient status. ER Nurse reported to this nurse at 15:59 [3:59 p.m.] that patient is stable but unsure if he is being admitted or returning to facility. - 9/4/2024 at 21:26 [9:26 p.m.], At 21:19 [9:19 p.m.] resident returned from ER per facility van with no N/O. Resident up walking and V/S 158/107 P-85, R-18, T-97.4, O2 sat 100%. Resident eating noodles from home in room. no c/o Epi-pen in lock box at bed side Record review of Resident #13's hospital record, dated 9/4/2024, revealed: Allergic reaction secondary to eggs. Record review of written statement from cook dated 9/4/2024 showed, I know I made meatloaf for lunch didn't follow the recipe . During an interview on 11/13/2024 at 1:00 p.m. with DFN stated that prior to giving the meatloaf to the resident, she had asked CC if egg was used, and CC denied using egg. She stated after the allergic reaction to the resident and once the resident returned from the hospital, she again asked CC if egg was used. She stated CC admitted to using egg in the meatloaf. During an interview with Resident #13 on 11/13/2024 at 1:30 p.m., the resident stated he did recall the incident in question. He said injected himself with his epi-pen which he keeps in his room in a locked box. He said he found out later that they had used egg in the meatloaf he had consumed during lunch on 9/4/2024. He stated he has had no further issues. An interview was attempted on 11/15/2024 at 12:53 p.m. with the Cook. There was no answer and voice message was left for a return call. At 12:55 p.m. a person returned the call form the cook's phone number and said this was not the cook's number anymore and to stop calling this number. The facility administration staff were notified on 11/15/2024 at 3:00 p.m., that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Resident #13 in an IJ situation on 9/4/2024. Prior to the investigation on 11/13/2024, the facility had put into place interventions to prevent allergic food reactions. Interventions included: Assessment of Resident #13 was completed on 09/04/24. Inservice training to all dietary staff related to food allergies and food preparation for residents with food allergies was conducted on 08/31/2024 and 09/05/2024, after the incident occurred. Simplified menus created with resident regarding safe foods and preferences, completed 9/5/2024. All residents with known allergens will have colored meal cards at every meal completed 9/5/2024. All meals will be made separately and in a designated area completed 9/5/2024. All meals will be approved by DFN and RN then taken to resident by authorized staff completed 9/5/2024. Resignation of [NAME] on 9/5/2024. ANE training was completed for all staff, including the dietary staff, on 11/11/2024. During an interview on 11/14/2024 from 12:00 p.m. and 12:30 p.m. with dietary staff [NAME] M, DA N, DA O and DA P, they stated they had participated in the in-service regarding food allergies and food preparation for residents with food allergies. During an interview on 11/14/2024 from 1:00 p.m. to 2:00 p.m. the following staff, CNA G, CNA H, CNA I, RN L, [NAME] M, DA N, DA O, DA P, stated they had been in-serviced on Abuse, Neglect and Exploitation regarding identification, interventions and reporting ANE. During an interview on 11/14/2024 at 4:20 p.m. with LVN AA stated that for residents with food allergies, their food was prepared separately from other residents and that nurses had to go to the kitchen to check the tray before it was given to the resident. During an interview on 11/14/2024 at 4:49 pm with Dietary Supervisor stated that residents with food allergies trays were prepared in separate area. For food preparation the meal ticket listed the resident's allergies and dietary staff keep a copy of the resident lists with food allergies in the kitchen too. Only 1 dietary person prepared the food for residents with food allergies to help prevent cross-contamination of allergens. On 11/15/2024, Records reviewed showed, Dietary staff have been re-educated regarding resident's specific allergy to chicken and eggs. A simplified menu was created with the resident regarding safe foods and his preferences. The DM and/or designee checks residents food trays for potential allergens. The Charge Nurse will also check food trays for potential allergens prior to serving. Observation on 11/15/2024 at 12:00 p.m. revealed dietary staff prepared trays for residents that have a food allergy. There was only 1 staff that prepared the trays for residents with food allergies. The trays were prepared in another area of the kitchen, away from the regular food. Observed that the meal tickets with residents with food allergies were color coded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of eighteen residents reviewed for elopement. The facility failed to implement measures to adequately supervise Resident #1 and prevent her from eloping the facility on 12/23/2022. The failure could place residents at risk for possible elopement, serious injuries, and harm. The noncompliance was identified as Past Non-Compliance. The Immediate Jeopardy began on 12/18/2022 and ended on 12/27/2022. The facility had corrected the noncompliance before the survey began. Findings include: Record review of Resident #1's Face Sheet dated 12/27/2022 revealed a [AGE] year-old woman who admitted to the facility on [DATE] with diagnoses Parkinson's Disease (a disorder of the nervous system that affects movement, often including tremors), Dementia (a general term for impaired ability to remember, think, or make decisions), Schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disordered thinking), and Muscle Wasting and Atrophy (the shrinking of muscle or nerve tissue). discharge date noted as 12/24/2022 at 7:00 p.m. to Other Nursing home. Record review of Resident #1's MDS dated [DATE] revealed Resident#1's BIMS score was 07 (scores 00-07 suggest severe impairment), and the resident had wandered daily. The resident required supervision or limited assistance with activities of daily living. Record review of Resident #1's Care Plan noted as last care plan review completed 12/24/2022 revealed, noted Focus initiated 11/21/2022, resident is at risk for wandering. Resident #1 Care Plan included Focus initiated 12/27/2022, Resident Elopement; noted Goal, Resident will remain secure and safe without any other elopements; and noted Interventions include: Q15 monitoring and Resident referred to a secured care unit. Record review of Resident #1's Order Summary Report dated 12/28/2022 and noted as Active Orders As of: 12/24/2022, revealed the following order: Behavior Monitoring 29. Wandering . Order dated to start on 11/09/2022 and status Active. Record review of Resident #1's Elopement Risk Assessment effective date 11/01/2022 at 2:00 p.m. revealed Resident #1 ambulates independently or with device, understands and verbalizes acceptance of need for nursing home care, and has had no attempts to leave own residence/facility. Record review of Resident #1's Elopement Risk Assessment effective date 12/7/2022 at 10:46 a.m. revealed Resident #1 ambulates independently or with device, has had statements and/or threats to leave facility, has moderately impaired cognitive skills for daily decision making, has had one or more previous attempts to leave facility in last year, has restless behaviors, does not recognize stop lights and signs, does not know precautions when crossing streets, and does not know location of current residence. Record review of Resident #1's Progress Note dated 12/18/2022 at 5:47 p.m., written by LVN B, revealed [3:00 p.m.]- Resident was down A-Wing and she opened door and walked out of facility . Record review of Resident #1's Progress Note dated 12/18/2022 at 8:24 p.m., written by LVN C, revealed F/U for elopement earlier today. Resident wandering about facility at this time. Doesn't appear to be seeking an exit at this time. Record review of Resident #1's Progress Note dated 12/21/2022 at 9:05 p.m., written by LVN C, revealed Resident continues with confusion and wandering . Record review of Resident #1's Progress Note dated 12/22/2022 at 4:04 p.m., written by LVN B, revealed resident still with increased weakness and confusion . Record review of Resident #1's Progress Note dated 12/22/2022 at 8:52 p.m., written by LVN C, revealed Resident continue with confusion and wandering. Record review of Resident #1's Progress Note dated 12/23/2022 at 10:00 p.m., written by LVN A, revealed Bring to this nurse attention by aide of Hall E .that resident was not in the facility. Instructed all the staffs to search for her. On call nurse informed. Approximately about 11 pm, a gentleman called the facility .He informed that [Resident #1] was found on the road and he told this nurse EMS had picked her and already on the way to [the hospital] at [city] . Record review of Resident #1's Elopement Risk Assessment effective date 12/23/2022 at 10:00 p.m. revealed Resident #1 ambulates independently or with device, understands and verbalizes acceptance of need for nursing home care, has moderately impaired cognitive skills for daily decision making, has had zero previous attempts to leave residents/facility, has no restlessness or anxiety, does not recognize stop lights and signs, does not know precautions when crossing streets, and does know location of current residence. Additional information included Resident is wanderer, calm, not angry/aggressive behavior or threatening to leave facility. Record review of Police Event Report dated 12/27/2022 revealed, call received 12/23/2022 at 10:21:26 p.m. Event Notes include female came running into the street and fell . Record review of Apple Maps reflected the location Resident #1 was found, was approximately 1.5 miles from the nursing facility. Record review of the weather conditions on 12/23/2022, according to the National Weather Service accessed 01/02/2022, revealed the low temperature at 17 degrees Fahrenheit and high temperature was 35 degrees Fahrenheit. Record review of Resident #1' hospital Emergency Department record dated 12/27/2022, arrival date and time 12/23/2022 at 10:55 p.m. revealed admitting diagnosis of Trauma, Head with history of Abrasion after fall crossing street. The patient is nursing home resident. Trauma. Record review of Resident #1's Event Nurses' Note 12hr- Elope or Attempt effective date 12/23/2022 at 10:00 p.m. revealed resident's physician was notified on 12/23/2022 at 11:46 p.m., resident's responsible party was notified on 12/23/2022 at 11:50 p.m., interventions initiated by the nurse included: 1 on 1 supervision and Interval monitoring- Q15 minutes monitoring; and Resident #1's cognition or behavior at the Time of Event (elopement) included: Cognitive Impairment and Exit seeking. Record review of Resident #1's readmission Nurses' Note effective date 12/24/2022 at 2:00 a.m., written by LVN A, revealed resident readmitted from the hospital or ER following a fall when she was eloped. Resident #1 noted as arriving by EMS. Resident noted as with having Short Term Memory problem, decisions are poor, resident alert, oriented to person and place, and with clear speech. Resident with noted exhibiting behavior of wandering. Record review of Resident #1's Elopement Risk Assessment effective date 12/24/2022 at 2:17 a.m. revealed Resident #1 ambulates independently or with device, understands and verbalizes acceptance of need for nursing home care, has moderately impaired cognitive skills for daily decision making, has had one or more previous attempts to leave facility in last year, has restless behaviors, does not recognize stop lights and signs, does not know precautions when crossing streets, and does not know location of current residence. Record review of Resident #1's Initial Skin assessment dated [DATE] at 2:00 a.m. revealed resident with laceration on chin. Interview with CNA A on 12/28/2022 at 7:16 p.m. CNA A revealed on the night of Resident #1's elopement, Resident #1 was requesting to help put other residents to bed. CNA A revealed she redirected Resident #1 by asking her to clean up around the sink. CNA A revealed that she last saw Resident #1 slightly after 9:00 p.m. prior to being called to assist another CNA on a different hall. CNA A revealed that upon return to her hall, Resident #1 was no longer next to the sink and CNA A could not locate Resident #1 in her room. CNA A revealed that she immediately told the charge nurse (LVN A) that she could not locate Resident #1. CNA A revealed that LVN A directed her and another CNA to check the other facility halls and once checked, LVN A called the code for a missing resident. CNA A revealed that following checking the facility again and checking outside, she was notified that Resident #1 was picked up by EMS. CNA A denied Resident #1's behavior or mood to be different on the day of elopement but revealed that there were times Resident #1 would say she wanted to go home. CNA A denied being notified of Resident #1's prior elopement on 12/18/2022. CNA A revealed that if a resident was an elopement risk an intervention would be to keep all the exits secure and to make sure there are alarms, so if anyone tried to get out the alarm would go off. CNA A revealed that she did not believe there were alarms on the front door or E-wing doors. CNA A revealed that an elopement is a high risk for a resident because it may result in the resident going on the road, walking on the road, getting into a car with someone they do not know, or they could fall down when they are outside. CNA A revealed that Resident #1 was transferred or her safety, where she can be behind locked doors and would not be able to wander so much. Interview with LVN A on 12/28/2022 at 09:11 a.m. LVN A revealed that on the night of Resident #1's elopement, Resident #1 was observed at 9:30 p.m. helping other residents. LVN A revealed she redirected Resident #1 by giving her a sandwich and walking her to her room. LVN A revealed that not long after redirecting Resident #1, CNA A approached her and notified her that she could not find Resident #1. LVN A revealed that she initiated a search of the facility and contacted the on-call nurse. LVN A revealed that around 11:00 p.m. she received a call from an anonymous gentleman reporting that Resident #1 had been located, that EMS had picked her up, and that Resident #1 was being transferred to the ER. LVN A revealed that Resident #1 returned to the facility around 2:30 a.m. and had lacerations on her chin that required sutures. LVN A revealed that Resident #1's behavior and mood were not unusual on the night of her elopement. LVN A revealed that Resident #1 had insomnia, wandering was normal for her, and she liked to participate and help the staff. LVN A revealed that Resident #1 would sometimes look for exits, but it was rare, and she was not an exit seeker. LVN A revealed that interventions in place for wanderers includes completing a head count and extra monitoring for the resident. LVN A revealed that some of the doors of the facility did not lock, and CNAs usually would sit in front of those doors to watch the hall. LVN A revealed that elopements put residents at a big risk and that the facility may not have someone there to watch the doors all the time. Interview with the DON on 12/28/2022 at 12:33 p.m. The DON revealed that to her knowledge, Resident #1 was not considered an elopement risk prior to her elopement on 12/23/2022. The DON revealed that Resident #1 would frequently ambulate around the facility and interact with staff. The DON revealed that Resident #1 was pleasantly confused but easily redirected. The DON revealed that she was not notified of Resident #1's elopement on 12/18/2022. The DON revealed that she discovered the 12/18/2022 incident while reviewing Resident #1's chart following the 12/23/2022 elopement. The DON revealed that the high elopement risk score on the 12/7/2022 Elopement Risk Assessment was the result of an error. The DON revealed that the nursing staff member that completed the 12/7/2022 Elopement Risk Assessment completed an admission assessment versus a standard assessment and contradicted herself in the report. The DON revealed that Resident #1 had had some falls but had not had a change in condition prior to the elopement. Record review of the facility's policy Elopement Prevention, dated revised 10/27/2010, labeled MM TIW WA 03-1.0 revealed, Environmental Modification .5. Use door locks that are out of reach/sight to prevent wanderers from opening doors. 6. Use door alarms or monitoring devices to notify staff when residents try to leave the facility .8. If applicable, consider resident for a secured unit. It was determined these failures placed Resident #1 in an Immediate Jeopardy situation from 12/18/2022 through 12/27/2022. The facility took the following actions to correct the noncompliance on 12/18/2022 through 12/27/2022: Record review of Resident #1's Q 15 Minute Monitoring document dated 12/24/2022 with time range: 2:00 a.m. to 8:15 p.m., revealed Resident #1 was monitored every fifteen minutes from return to the facility to discharge. Record review of Resident #1's Discharge summary dated [DATE] at 7:00 p.m. revealed resident to be discharged on 12/24/2022 with course of treatment noted as transferred to a locked unit for safety. Record review of the facility's self-report titled Assessment History, printed 12/28/2022 at 6:45 p.m. revealed all facility residents were re-assessed with the Elopement Risk Assessment - V 2 between 12/23/2022 to 12/28/2022. Record review of In-service documentation, dated 12/23/2022 to 12/27/2022, revealed an In-service on Elopement and an In-service on Abuse/Neglect was provided to all employees. Interview with LVN D on 12/29/2022 at 2:39 p.m. and LVN E on 12/29/2022 at 3:18 p.m. revealed they had been in-serviced on the facility elopement policy and procedures. Record review of facility's Quality Assurance meeting sign-in sheet, dated 12/26/2022, revealed that the interdisciplinary team met to discuss Resident #1's elopement. Observations on 12/28/2022 from 10:11 a.m. to 10:46 a.m., of the facility's entry, facility staff side entry, and hall doors, with DOM, all exit doors were checked. Exit door from Restorative Therapy room was without an alarm; however, facility entry door into restorative therapy room was locked upon inspection. The facility's front door was not locked or activated alarm during inspection but was monitored by a receptionist present at the entry door. Interview with the DOM revealed he had installed the door alarms on the side entry/exit doors for Halls A, B, C, D, and E, the front entry door, and the staff side entry door on 12/27/2022 around 11:00 p.m. The DOM revealed the doors located at the end of the halls were previously alarmed with maglocks; however, the side hall doors were previously without alarms. The DOM revealed that he does not know if it was determined which door Resident #1 eloped from. Interview with the DON on 12/28/2022 at 12:33 p.m. The DON revealed that the actions put into place to protect Resident #1 from further elopement included placing Resident #1 on monitoring and placing her at another facility. The DON revealed that following the elopement, staff were in-serviced, and the DOM installed alarms on the doors as an immediate necessity. The DON revealed that the locks and alarms on all the doors is the biggest change to occur following the incident. The DON revealed that the change will allow staff to react timely. Interview with the ADMIN on 12/28/2022 at 2:16 p.m. The ADMIN revealed that immediately following the notification of a resident elopement, a QAPI meeting was called to review the facility's elopement protocols, and in-services were initiated on the Code Orange, Elopement protocol. The ADMIN revealed that Resident #1 was placed on monitoring following her return from the hospital and stayed on monitoring until her transfer to a secured unit. The ADMIN revealed that the facility was having maglocks installed on all the doors with the goal to complete by 1/21/2023. The ADMIN revealed that at the time of the elopement, all the facility doors were not alarmed because the facility did not admit residents that were exit seeking. The ADMIN revealed that Resident #1 was discharged due to her requiring a higher level of care for safety precautions. The ADMIN revealed that an elopement puts a resident at risk for falling, having the possibility of injury or duress. The ADMIN revealed that a resident elopement results in stress for the resident physically and emotional stress to the staff.