**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 1 resident (R56) reviewed for wandering and elopement potential. R56 has dementia and mild intellectual disabilities and has an Activated Power of Attorney for Health Care (APOAHC). R56 eloped from the facility on 8/5/24. The facility did not have adequate supervision to ensure they were aware of R56's whereabouts and did not have security measures and monitoring in place to ensure R56 could not access various locations in the building. R56 exited a door at the rear of the facility; the door alarm was disengaged allowing R56 to exit a door into a fenced-in courtyard and out through a gate without sounding an alarm and alerting staff R56 had exited the facility. The facility's failure to provide adequate supervision for R56 and to ensure R56 did not have a means of exiting the facility created a finding of immediate jeopardy that began on 8/5/24. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on 9/25/24 at 10:55 PM. The immediate jeopardy was removed on 8/5/24, however, the deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility implements its removal plan. Findings include: The facility's policy titled, Policy & Procedure Elopement Risk and Prevention, last revised 7/15/23, states in part . Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual care plan. Procedure: 1. Residents who have been assessed at risk for elopement shall have interventions in place in their plan of care. 2. As part of the facility's Preventative Maintenance Program, all secured doors and elevator keypads (if applicable) will be checked for proper function on a weekly basis by the Maintenance department. These checks will be documented with date and time completed. 3. The Administrator and Director of Nursing will be notified immediately of any concerns with secured doors or keypads. 4. Resident's arm/leg monitor bracelet will be checked every shift for placement and daily to ensure device is functioning properly. 5. At no time shall a door alarm be turned off, without the continual supervision of the exit. In the event that the door locks/alarms of a secure unit become disabled (ex. (example) Power failure/fire alarm) the facility must ensure a temporary protective system is in place (ex. Battery activated alarm; staff monitored exits, etc.). Routine Procedure for Wandering Residents and Prevention of Missing Residents/Elopement: 1. All residents shall be reviewed for safety awareness, cognitive impairment (i.e. Dementia diagnosis, BIMS <7 (less than), and history or current risk of elopement/wandering/exit seeking upon admission, readmission, quarterly and as needed. 3. Residents who are at risk for possible elopement shall be accompanied by staff, or responsible party, when outside of the facility this would include on and off facility grounds. The facility employs a Wanderguard system attached to approximately 3 doors within the facility. The Wanderguard system will alarm when a resident with a Wanderguard tab (either on their person or wheelchair) passes through a doorway with a compatible installed alarm system. The facility uses a model of Wanderguard that is good for 1 year once activated. At the end of 1 year, a new Wanderguard tab must be placed on the resident. The Wanderguard tab has an activation date printed on it, much like an expiration date, that the Wanderguard must be activated to start the 1-year clock. Residents in the facility that are deemed elopement risks have Wanderguards. All other doors leading outside are armed with a tab alarm (a string with a magnet is attached to the door frame and a box that the magnet attaches to is connected to the door itself). When a door is opened, the magnet releases from the box causing it to alarm. R56 was originally admitted to the facility on [DATE] and has diagnoses that include dementia, alcohol abuse, mild intellectual disabilities, unspecified symptoms, and signs involving cognitive functions and awareness, unspecified fall, muscle wasting and atrophy, unsteadiness on feet, congestive heart failure (CHF), cardiomyopathy, and paroxysmal atrial fibrillation. R56's most recent Minimum Data Set (MDS), dated [DATE], indicates that R56 has a Brief Interview for Mental Status (BIMS) of 13. R56 has an activated power of attorney for healthcare. R56's MDS indicates he has no behaviors and does not wander. R56 is independent with oral hygiene, toileting hygiene, upper and lower body dressing, personal hygiene, roll left to right, sit to lying, lying to sitting, sit to stand, chair to bed transfers, toilet transfers, and walking. R56 requires setup or clean up assistance with personal hygiene and is occasionally incontinent of bowel and bladder. R56's care plan states in part . Care Plan Focus: The resident has limited physical mobility r/t (related to) CHF and deconditioning. Interventions: Ambulation/Locomotion Assist - Independent, may ambulate with no AD (assistive device) distances to tolerance WBAT (weight bear as tolerated). Date Initiated: 7/21/24. R56's Elopement Risk Assessments are documented as follows . 6/12/2024 Elopement Risk - 1 Month Low Risk 4.0 6/15/2024 Elopement Risk - admission Low Risk 2.0 6/20/2024 Elopement Risk - Quarterly Low Risk 6.0 Progress Note from 6/18/2024 at 16:30 (4:30 PM) states, Health Status Note. Note Text: Nursing updated this writer that resident is trying to leave. Writer found resident sitting in his room in his recliner. Two adults present in res (resident) room who were introduced to this writer as old friends. The male friend explained res has been living next to them, renting from them for 40 years. Writer asked resident if we could talk. He agreed. Writer reiterated with resident the concern of him wanting to leave the SNF (Skilled Nursing Facility) today. He shook his head yes. Writer explained that if he were to leave today, it would be against medical advice which could follow up w/negative outcome financially and for his health. His friends agreed with this writer and also attempted to explain negative effects of leaving AMA (Against Medical Advice). Writer suggested a care conference to discuss with his care team the future plans for him. Writer explained he would be able to voice his thoughts and concerns and the team could collaborate to get him a safe and correct discharge. Resident shook his head in agreement the entire conversation as writer empathized with him regarding his current SNF stay. Writer assured him that follow-up with the social worker regarding a care conference would be done, and that writer will update him with further information when able. Writer contacted SNF SW (Social Worker) to update and request care conference. SW replied stating she would see resident tomorrow a.m. and get it scheduled. Writer updated nursing on conversation and instructed to continue to monitor. Progress Note from 6/19/2024 at 20:23 (8:23 PM). Health Status Note. Note Text: Resident more confused this shift. Calling the bar and requesting pizzas and cases of beer to be delivered. Thinks leaving tomorrow and wants to have party. Family came in and did bring small pizza and sodas. Resident relaxing in room with family. Progress Note from 6/20/2024 at 11:06 (11:06 AM). Health Status Note. Note Text: Nursing called this writer this a.m. (morning) to report resident increased agitation. Nursing reports resident has belongings packed in a bag and with him as he is demanding to leave facility. Writer instructed nursing to attempt to redirect resident and distract resident until IDT (Interdisciplinary Team) arrives. Writer instructed nursing to call resident sister as she is involved in his care. Writer arrived at facility and resident brother and sister present speaking with NP (Nurse Practitioner). DON (Director of Nursing) reported to this writer that brother and sister are requesting to have a care conference. Writer updated SW (Social Worker). SW, this writer, res (resident), his brother, and his sister present w/ (with) Physical Therapist met to discuss resident's mood, concerns, and possible activation of POA (Power of Attorney). Conversation included resident not making safe decisions and not understanding his medical conditions and his increased confusion/irritability/agitation. Sister suggested PO (by mouth) Lorazepam for increased agitation and states she believes he took this medication some time back. Sister also requested to have UA (urinalysis) done as she believes his behaviors are exacerbated. Brother and sister are in agreement that resident is not making safe decisions as far as wanting to leave. Sister is POA listed and is agreeable to activation. Therapy discussed home visit planned to happen next week and determined Wednesday would be the day that worked for everyone. Staff to make resident a calendar with dates listed of upcoming appointments, therapies, and home visit so he can see plan himself. Resident appeared calmer and more cooperative after meeting. SW asked resident if he'd be willing to have a medication as needed for anxiety and he was agreeable. Writer contacted NP and rec'd (received) new orders: 1) Lorazepam 1mg tab PO q (every) 6H (hours) PRN (as needed), anxiety; 2) UA clean catch for increased agitation and anxiety; 3) CBC w/diff (complete blood count), CMP (complete metabolic panel), Lipase, Amylase, TIBC (total iron binding capacity), B12, & TSH (thyroid-stimulating hormone), orders noted. Progress Note from 6/20/2024 at 21:21 (9:21 PM). Health Status Note. Note Text: Resident kept wanting to go outside. Writer spoke with NP and obtained order for Wanderguard. Wanderguard placed on resident left wrist. Progress Note from 6/21/2024 at 22:24 (10:24 PM). Daily Skilled Charting. Note Text: resident wandering in the hallways frequently, no exit seeking at this time, WG (Wanderguard) on arm, orient to self, seeks nurse out for tums for complains of (c/o) gas with relief, vss (vital signs stable). Progress Note from 6/22/2024 at 22:19 (10:19 PM.) Daily Skilled Charting. Note Text: Wanders halls in wheel chair [sic], calls [name of bar] nightly to order beer and pizza. Delusional, thinks he has billions of dollars coming on Friday. Receiving skilled nursing care for CHF and fluid volume overload. A&Ox3-4 (Alert and Oriented) with mild confusion r/t (Related to) hx (history) of ETOH (alcohol) use. Denies SOB (shortness of breath), trace edema to BLEs (bilateral lower extremities), no change in mental status. 1 A (assist) ADLs (activities of daily living) and transfers, no acute change in condition noted, cont (continue) plan of care. Progress Note from 6/26/2024 at 16:37 (4:37 PM). Health Status Note. Note Text: MD (medical doctor) in facility this afternoon and provided signature to POA activation form. This writer called sister [sister's name] who is listed as POA in his paperwork. Writer informed her resident is now activated. She asked, So what does this mean now? Writer informed her that resident is no longer able to make his final decisions regarding his healthcare. Writer explained that moving forward, staff will be calling her with updates and anything medically involving resident. She stated understanding and call was ended. Writer updated NP that MD was in and signed form in agreeance of activation. Progress Note from 6/30/2024 at 23:28 (11:28 PM). Incident Note. Note Text: RN [initials] witnessed resident exiting second set of doors in the front of the facility. RN [initials] immediately and quickly went out to speak with the resident. Resident stood up, RN [initials] asked resident to sit down and redirected. RN [initials] wheeled resident back into facility. A facility document titled, Elopement, dated 6/30/24 at 23:09 (11:09 PM), states in part . Incident Description: Nursing Description: RN witnessed resident outside 2nd set of front doors. Resident was in his wheelchair. Resident stood up. RN asked resident to sit and walked him in. Resident was compliant. Immediate Action Taken: RN redirected and brought resident back inside. Injuries Observed at Time of Incident: No injuries observed at time of incident. Mental Status: Oriented to Place and Oriented to Person. Predisposing Physiological Factors: Confused. Other Info: Resident unaware of situation. Habitual bar person. Talks about beer often. Plans on returning to bar ASAP (as soon as possible). Statements: RN witnessed resident outside 2nd set of front doors. RN went outside and brought resident back in. Notes: IDT (Interdisciplinary Team) reviewed event from 6/30. Resident does have activated POA however is able to make decisions. He wanted to go sit outside. This event would not be considered an elopement. Resident was in WC (wheelchair) and exited the front door, staff followed him outside with no time unsupervised. No concerns noted and was easily redirected back into the building. Resident able to state he just wanted some fresh air. Note: Facility did not complete an Elopement Risk Assessment following R56 leaving the building without staff knowledge on 6/30/24. Progress Note from 7/2/2024 at 01:15 (1:15 AM). Health Status Note. Note Text: Up wandering about the facility searching for food and soda, asks visitors, residents, and staff for beer. States waiting for the bar to fax over papers to order beer. Redirected from resident refrigerator several times. Sleeping in bed without behaviors noted since 10pm. Progress Note from 7/4/2024 at 23:20 (11:20 PM). Daily Skilled Charting. Note Text: Noted with inappropriate behavior redirected. Resident has not had any behaviors this shift. Progress Note from 7/10/2024 at 12:43 (12:43 PM). Health Status Note. Note Text: Patient discharged home this AM shift. Transported by POA/sister. Note: R56 discharged home on 7/10/24 and returned to the facility on 7/19/24 due to increased dementia symptoms and poor medication/health management. R56's Elopement Risk Assessment was documented as follows . 7/19/2024 Elopement Risk - readmission Low Risk 4.0 Progress Note from 7/23/2024 at 22:53 (10:53 PM). Daily Skilled Charting. Note Text: Resident admitted to facility on 7/19/24 from home d/t an increase in dementia symptoms & poor medication/health mgmt. He is A/Ox3 with periods of confusion/agitation. Not always pleasant or cooperative. Can be non-compliant at times. Sees therapy as scheduled. Transfers 1A. WC (wheelchair) for mobility & can self-propel but is often found standing or walking. 1A w/bathing, drsg (dressing), bed mobility, PO (oral)/hygiene cares, & toileting. Continent of b&b (bowel and bladder). Skid resistant shoes on when up. Wanderguard present to L. (left) wrist. Care Plan Focus: Wander Risk Assessment per facility policy. Reassess risk periodically according to policy, initiated 7/19/24. Wanderguard placement and checks per facility policy: LEFT ANKLE, revised 7/29/24. WANDER/ ELOPEMENT RISK- Add to at risk books and lists, initiated 7/19/24. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, initiated 7/19/24. Progress Note from 8/5/2024 at 20:01 (8:01 PM). Health Status Note. Note Text: Received call from resident's family stating that resident made it back home, Writer asked if family is able to return resident to facility and family agreed, Resident was brought back to facility in 20 minutes. Resident walked back in facility, had confused speech, refers to staff members using made up names and sticks to them. Resident has Wanderguard to left wrist. Front door alarm sounded when resident returned into facility. No alarm sounded when resident left, and no staff noticed him leave. According to DON (Director of Nursing) some residents saw the resident leave the premises from the back. Resident gets comfortable walking around the facility wandering all hallways usually during the day. Resident stated that the Judge told him that he could go out of the building . The facility document titled, Elopement, dated, 8/5/24 at 15:00 (3:00 PM), states in part . Incident Description: Nursing Description: Received call from resident's family stating that resident made it back home. Writer asked if family is able to return resident to facility, and family agreed. Resident was brought back to facility in 20 mins (minutes). Resident walked back in the facility. Had confused speech. Refers to staff members using made up names and stick [sic] to them. Resident had wonder [sic] guard to left right [sic]. Front door alarm sounded when resident returned into the facility. No alarms sounded when resident left, and no staff noticed him leave. According to the DON, some residents saw resident leaving the premises from the back. Resident gets comfortable walking around in the facility wandering all hallways usually during the day. Resident stated that the judge had told him that he can go out the building. Immediate Action Taken: DON and ADON (Assistant Director of Nursing) notified immediately. NP notified as well. POA called, no answer but voicemail left. Injuries Observed at Time of Incident: No injuries observed at time of incident. Mental Status: Oriented to person. Statements: No statements found. Notes: 8/6/24, IDT team met to discuss resident elopement yesterday. He walked to his nephew's house here in town with the intent to get snacks and return. SW met with resident upon his return to facility and reeducated him that he cannot leave facility. Intervention is to have Activities offer resident to join monthly shopping trip to buy more snacks. 8/9/24, Current alarm system and Wanderguard system being reviewed. Audits in place to ensure resident informs staff if he would like to go on a leave or have family bring snacks. Investigation to root cause initiated and audits/education implemented. 8/13/24, Self-report submitted. Conclusion is that magnet on 300 door, a secondary magnet was engaged by another resident. Other resident [resident initials] admitted to using the magnet to disengage alarm. Resident [resident initials] was educated on not tampering with any alarms or security systems. Resident had an updated elopement assessment which indicated high risk. R56 Wanderguard still in place. Audits are continuing at least daily to ensure that alarms are engaged and working on all doors. Will continue to review at QAPI (Quality Assurance and Performance Improvement) to see if additional audits are needed. A new Wanderguard system is being pursued. The facility documented and reported to the state agency the incident that occurred on 8/5/24, stating, On August 5th, 2024, resident's nephew called facility and told staff that resident was at his house to visit and was wanting snacks. Resident was interviewed as to why he left. He stated that the judge (this is what he calls the Social Worker at the facility) told him he could leave facility and he went to get snacks from his family member's house. Social Services reeducated resident that he cannot leave the facility without someone accompanying him and that he must tell nursing staff where he is going and sign out. Upon investigation it was discovered that resident had exited the 300-wing lounge door into the courtyard. The alarm that was on the door was disengaged and a separate magnet was placed on the alarm so it would not sound. The magnet was taken away so it could not be used to shut off the alarm moving forward. The alarm is now re-engaged so it cannot be shut off without intervention. Separate magnet was taken away on 300 wing door so the alarm cannot be shut off without alarming and intervention. Additional details included in the report: * Skin assessment was conducted, and resident sustained no injuries and had no skin alterations. *Police were not notified due to resident being safe in facility and no evidence of a crime being committed. *Facility is continuing to investigate to ensure no other processes or protocols were violated. *Resident's last elopement assessment on 7/19/24 was low risk. *An updated elopement assessment will be conducted. *R56 had updated SLUMS (St. Louis University Mental Status), MOCA (Montreal Cognitive Assessment), and MMSE (Mini-Mental State Examination) (Cognitive tests) and overall, functionally, a moderate cognitive-linguistic impairment is identified. Specific difficulties are noted in executive functioning and reasoning/judgement, problem solving, attention, and delayed recall/memory. *Staff educated on not disengaging alarm. *Daily audits are being conducted to ensure all the exit door Wanderguard and alarm systems are working properly. Note: R56 left the facility and went to his brother's home which is approximately 0.7 miles from the facility in a residential area. The facility was unaware that R56 was not in the building until R56's brother called to report that he was at his home. R56's Elopement Risk Assessment was documented as follows . 8/12/2024 Elopement Risk - Significant Change High Risk 11.0 The care plan for R56 was updated. Care Plan Focus: The resident is an elopement risk/wanderer/at risk to leave facility without notice. 8/5/24 Purposefully left building to walk to nephews' home to get snacks and return. Date Initiated: 8/12/24. Interventions: 8/5/24 Purposefully left building to walk to nephews' home to get snacks and return. SW (Social Worker) met with resident upon his return to facility and reeducated him that he cannot leave facility. Intervention is to have Activities offer resident to join monthly shopping trip to buy more snacks, initiated 8/6/24. Monitor for exit seeking and document episodes. Interventions for exit seeking behaviors: 1) provide 1:1 and reassurance, 2) offer distraction such as activity or snack, revised 7/22/24. On 9/24/24 at 1:05 PM, Surveyor interviewed SW C (Social Worker). Surveyor asked SW C if she could tell Surveyor what she knows about R56's elopement on 8/5/24. SW C stated, I was made aware of the elopement when R56 returned. When R56 came back I did tell him he needed to let someone know if he was going to leave and sign out at the front. Surveyor asked SW C if R56 was able to leave the facility unsupervised. SW C stated, R1 does have POA - I don't believe when he left, he was able to leave on his own. Surveyor asked SW C what R56 told her during her interview with him. SW C stated, R56 and I took a walk, and he showed me how he left. He left through the courtyard. Surveyor asked SW C if there was always an alarm on the door going out to the courtyard. SW C stated, at that time don't know if there was an alarm on that door or not. There was a gate that he was able to open. Gate is locked now but was not at that time. Surveyor asked SW C if R56 had a Wanderguard at the time of his elopement. SW C stated, R56 had Wanderguard I believe at the time. Surveyor asked SW C what doors leading outside of the facility have Wanderguard alarms. SW C stated, Wanderguard doors are by the kitchen, front and lounge/TV/common area, those are the ones that I can think of. Surveyor asked SW C if she ever witnessed the 300-wing door alarm disengaged. SW C stated, they used to put a magnet up on the door to silence the alarm. Education was done after R56 eloped with staff to no longer use a magnet to disarm the alarm. Surveyor asked SW C if she knew what R56 was wearing the day he eloped. SW C stated, I am unsure what resident was wearing. On 9/23/24 at 5:40 PM, Surveyor spoke with R24 and asked if he ever used a magnet to get out the door on the 300 wing. R24 stated he had a magnet for a while that he could put on the outside door alarm to disarm it. R48 had one as well. We were trustworthy to go outside unattended. The magnets were taken away after R56 got outside into the courtyard and through the gate. On 9/24/24 at 3:10 PM, Surveyor interviewed R48. Surveyor asked R48 if he remembers an incident where he saw another resident leave the facility. R48 stated, I remember it. I was out in gazebo with a friend. They had a red magnet attached to the doorframe so if you wanted to go in or out you could use it to silence the alarm. We were on the honor system. Anyone who went out the door knew it was there to use. It was hot that day. Surveyor asked R48 if he remembers what time this occurred. R48 stated, my friend comes at 1:00 PM and leaves around 3:00 PM. We had been out there a half hour to an hour before R56 came out. I have seen him out there multiple times. R56 used to be in wheelchair, would wheel over to the gate, stand up take his shirt off and wave it over his head, sit back down and come back in. R48 stated, this day, R56 went to the gate let himself out, walked along the edge of the property along the fence till out of view. Then 45 minutes to an hour later the DON came out looking for him and asked if we had seen him. R56 had a Wanderguard placed because he would exit the building frequently and we were short staffed then. R56 would be at the end of the lot before someone got out there to bring him back. We are all being penalized now. We can't go out without setting the alarm off and before we could go out on our own recognizance. On 9/24/24 at 11:50 AM, Surveyor interviewed Activity Aide K. Surveyor asked Activity Aide K if she uses or has seen anyone use the magnet on the 300-wing door. Activity Aide K stated, I use a red magnet when I take residents out to the gazebo area for organized activities. This makes it so I can open the door from outside and inside without the alarm going off. The magnet is now kept in the front office. It was on the door frame before. On 9/24/24 at 11:55 AM, Activity Aide K came back to speak with Surveyor stating, I was wrong, we no longer use the red magnet. On 9/24/24 at 1:32 PM, DON B (Director of Nursing) and NHA A came into the conference room to report to Surveyor that they believe that R56 returned about 3:00 PM. R56 was last seen by R48 and his family. R48 saw the resident leave but they did not report this to anyone, but they saw R56 leave through the courtyard gate. Surveyor asked DON B if the gate was open or closed. NHA A states, we were unable to establish if the gate was open but normally it is closed so we assumed R56 opened it. We also have a new Wanderguard system being installed as we speak, they started working on it yesterday. All doors will have Wanderguard alarms. Surveyor asked NHA A if there were any other doors that she was aware of that had magnets on them to silence the alarm. NHA A stated, that was the only door with a magnet. The gate on the fenced in area is now locked and we will also be getting, at some point, new fencing that I believe will also be alarmed if someone tries to exit it. Additional Progress Notes for R56: Progress Note from 8/10/2024 at 10:14. Daily Skilled Note. Note Text: Resident has been pleasant this shift, has confused speech. Resident wanders the hallways. Progress Note from 8/10/2024 at 19:38 (7:38 PM). Health Status Note. Note Text: Resident attempted to get out of the building a few times. Was redirected by staff and resident was able to turn his focus on something else and behavior stopped. Wanderguard on left wrist. Progress Note from 8/27/2024 at 12:37. Daily Skilled Note. Note Text: Patient at baseline able to make needs known. Minimal wandering this shift redirectable. On 9/23/24 at 2:15 PM, Surveyor observed R56 in his room, lying in bed. R56 sat up independently. R56 is noted to have a Wanderguard on his left wrist. On 9/23/24 at 7:15 PM, Surveyor interviewed FM/POA F (Family Member/Power of Attorney). FM/POA F stated, R56 is a bachelor and always lived alone with his dog. R56 has lived in the community all his life and has a history of walking all over town with his dog. R56 has some intellectual deficits and sometimes needs help, has been this way his entire life. R56 had been at the facility in June and discharged early July, he lives in an upper apartment, 21 steps, and he did not do well at home by himself; he did not take his meds and ended up back at the hospital. R56 then readmitted to the facility from the hospital due to weakness and needing more therapy. R56 was in a wheelchair when he first returned to the facility. R56 would go throughout the facility, sometimes he sat out front of the building and the staff would bring R56 back in. In August R56 left the facility and walked to his brother's home, it is about 3 - 4 blocks from the facility. I think he probably cut through yards to get there. He showed up at the house looking for snacks and his brother called the facility to say he was there and were taking him to get snacks and would bring him back. On 9/24/24 at 8:35 AM, Surveyor interviewed LPN G (Licensed Practical Nurse). Surveyor asked LPN G if R56 was known to wander. LPN G stated, initially there was no wandering then once R56 cleared and became clearer he attempted to elope and a Wanderguard was placed as an intervention. During his first stay R56 would sit out front. He went home then and then came back as he did not do well at home. R56 was readmitted to the 400 unit. R56 absolutely has cognitive issues. Prior to admission was very active in the community, would walk around town with his dog all day long. On 9/24/24 at 8:45 AM, Surveyor interviewed CNA H (Certified Nursing Assistant). Surveyor asked CNA H if R56 wanders in the facility or attempts to leave the facility. CNA H stated, in the morning R56 is usually out walking around. R56 spends a decent amount of time in his room. I have never heard that he was at risk for elopement. I am also not aware of R56 ever eloping from the facility. Surveyor asked CNA H where she would locate the information that a resident was at risk for wandering. CNA H stated, I would look for that information on the CNA sheets. It should say the resident has a Wanderguard or that they are a wanderer. On 9/24/24 at 1:32 PM, Surveyor asked NHA A if facility has a way for monitoring Wanderguard expiration dates. NHA A stated, it is not in MAR/TAR (Medication Administration record/Treatment Administration Record) to check the Wanderguard expiration date but would expect that to be done. Surveyor asked NHA A if the facility completed any education with staff on the gate. NHA A stated, no, not specifically the gate. Surveyor asked NHA A if any education was completed with residents on the magnet or exit doors. NHA A stated, no, we did not specifically educate residents on magnet or door, at least nothing formally. NHA brought in copies of audits completed on doors, audits started 8/9/24 and continue. On 9/24/24 at 2:30 PM, Surveyor went into front office to ask NHA A to check doors with Surveyor. RDC D (Regional Director of Clinical Services) stated, we are now adding the Wanderguard expiration dates to the MAR/TAR as an extra check. Medical Records has been keeping track of the expiration dates as she is the one that orders them. Wanderguards used are good for 1 year. On 9/24/24 at 2:45PM, NHA A and Surveyor checked all doors. All alarms in place and [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that each staff implemented proper safety interventions as directed by a resident's plan of care and did not ensure residents were free from accidents and hazards for 1 of 3 residents (R1) reviewed for falls. On [DATE], a Certified Nursing Assistant (CNA) attempted to provide care to R1 without maintaining the proper safety interventions as directed in R1's care plan. R1 rolled off the bed, falling approximately 2 feet and hitting his head. Facility staff picked up R1 off the floor and placed him in bed before the Registered Nurse (RN) could arrive on the scene to assess R1 for possible injuries. R1 was sent to the hospital where he was found to have suffered a fractured neck, resulting in his death. This created a finding of immediate jeopardy that began on [DATE]. The facility's failure to ensure staff follow proper safety interventions to prevent accidents created a finding of Immediate Jeopardy that began on [DATE]. Surveyor notified INHA C (Interim Nursing Home Administrator) of the Immediate Jeopardy on [DATE] at 3:20 PM. The Immediate Jeopardy was removed on [DATE]; however, the deficient practice continues at a scope/severity of a D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. R1 was admitted to the facility with diagnoses that include: hemiplegia and hemiparesis following cerebral infarction, aphasia, convulsions, dysphagia, right ankle and foot contractures, and tremors. R1 is not ambulatory, is nothing per oral (NPO), and is nonverbal. R1's care plan states he is dependent on two staff for dressing (dated [DATE]), toilet use (dated [DATE]), personal and oral hygiene (dated [DATE]), and transfers (dated [DATE]). R1's comprehensive care plan and [NAME] (CNA care plan), dated [DATE], state, Bed mobility/Assist-Dependent on 2 staff. Bed to be positioned in lowest possible position with fall mat in place when resident in bed. Ensure resident is positioned in the middle of the bed for comfort and safety. Additionally, R1's care plan states, Is at risk for falls .Bed to be positioned in lowest possible position with fall mat in place when resident in bed ([DATE]) .body pillows and/or support device (pillow wedges) bilaterally in place when resident is in bed to assist with proper body position and comfort. ([DATE]) The facility uses the Morse fall scale to determine if a resident is at risk for falls. A [DATE] Morse fall scale assessment for R1 shows a score of 30, indicating R1 is at moderate risk for falling. On [DATE] at approximately 4:00 PM, R1 experienced a fall from his bed. The fall report, documented by LPN D (Licensed Practical Nurse), states, 2 CNAs were putting resident to bed using the Hoyer lift, after he was in bed the second CNA had left. The first CNA (CNA E) turned to get the fall mat and resident crossed his legs quickly and rolled out of the bed to the floor . The facility contacted EMS (Emergency Management Services) emergently. According to EMS records, EMS arrived at the facility at 4:12 PM, then arrived at the hospital at 5:17 PM. Of note, the EMS report for the transfer states that R1's bed was at a height of approximately 2 feet off the ground when they arrived to R1's room. At the hospital, R1 was found to have a fractured C7 lamina (cervical, base of the neck). Hospital notes indicate R1 had a witnessed aspiration event (at the hospital) with significant respiratory compromise. According to hospital records, R1 expired on [DATE] due to hypoxemic respiratory failure due to 1) massive aspiration with complete left lung opacification 2) septic shock and 3) right C7 lamina/facet fracture from fall at skilled nursing facility prior to transfer (which required rigid c-spine collar). Following the fall, the facility's interdisciplinary team (IDT) met and documented the following dated [DATE]: IDT team met to review the witnessed fall that occurred on [DATE] when resident rolled himself out of bed when the CNA turned his back to reach for the fall mat. Resident's bed was low, call light clipped near him on the bed, two CNAs had gotten him into bed when the second CNA left, the first CNA turned to reach for the fall mat and resident crossed his legs and flipped himself to the floor. The CNA called for the nurse and then 911 and was left on the floor for the EMT to assess and get onto the gurney. Root cause of the fall was the inability to stop the motion once started when he crossed his legs his body followed. Intervention both CNAs to complete all cares together. The facility did not provide any other investigation notes, statements, vitals, or assessments of R1 regarding the fall. Surveyors conducted the following interviews on [DATE]: *At 11:40 AM, LPN D stated that on [DATE] she was called to the room by CNA E and then saw R1 on the floor on his stomach. LPN D then called RN F. LPN D stated she, CNA E, and CNA G lifted R1 off the floor before RN F arrived because he was moving in a way that she had never seen before and that he appeared to be in pain. *At 1:40 PM, CNA G stated that on [DATE], CNA E came out into the hall and requested help. When she got to R1's room she saw R1 on the floor on his stomach and then LPN D came to the room. CNA G stated she, LPN D, and CNA E then picked R1 up and put him back into bed. CNA G stated she and CNA E held the shoulders and LPN D held the legs and they lifted him into bed. According to CNA G, shortly after R1 was put back into bed, RN F came into the room and stated that they should not have gotten R1 off the floor until an appropriate assessment was made. CNA G stated that when they rolled R1 over, there was blood gushing from his head. Additionally, CNA G stated the bed was at about knee height when she got to the room and was not all the way to the floor and R1's wedges were not positioned in his bed. CNA G stated the wedges may have been on his chair or at the foot of the bed, but were not in place. CNA G also stated that she would normally provide cares for R1 by herself. The only time she needed help is with transfers. *At 2:39 PM, CNA H stated she had worked with R1 in the past and he frequently kicks his one leg over the other, so he could fall off the bed if left unattended. CNA H also stated that she has provided cares to R1 by herself in the past but would ask for assistance if R1 would clench his legs or be swinging them. *At 3:37 PM, CNA I stated that R1 would frequently lean toward 1 side of the bed and the wedges helped position him correctly and that the wedges were to go under his bed sheet. Surveyors conducted the following interviews on [DATE]: *At 3:00 PM, CNA J stated that 4 wedges were used for R1's positioning to keep him in the middle of the bed. Additionally, CNA J stated R1 would frequently [NAME] one leg over the other and she was concerned he would fall out of bed. *At 3:04 PM, RN F stated that on [DATE] when she responded to R1's room, he was already in bed and she was concerned that staff had moved him. RN F stated that she got there as quick as she could and they hurried before she could respond. RN F stated that she did do vitals and an assessment and usually puts those into the computer, but did not do so on this night. Surveyors interviewed all nursing staff who worked during the time of the incident - LPN D, RN F, LPN K, CNA G, CNA H, CNA I, and CNA J. All stated they had not assisted CNA E with transferring R1 into bed before he had fallen out, nor were any of these staff aware of who assisted CNA E. Surveyor was unable to speak with CNA E. None of the staff who were interviewed by Surveyor had been questioned by the facility about the incident or provided statements and did not receive any education regarding the event. CNA G, CNA H, CNA I, and CNA J all stated that the wedges for R1 were used to help keep him positioned in the middle of the bed. On [DATE] at 8:34 AM, DON B (Director of Nursing) and INHA C (Interim Nursing Home Administrator) stated to surveyors that they had spoken to CNA E late the previous day ([DATE]) and CNA E stated that he was sticking to his story that he had turned his back briefly to R1 and that is when R1 rolled out of bed. Additionally, CNA E had told DON B and INHA C that he does not recall who it was that assisted him with initially getting R1 into bed, nor what the person looked like. INHA C stated that the incident should have been reported as potential abuse as it is unknown how R1 got to the floor and CNA E was the only one in the room. DON B stated that she did not gather any statements other than CNA E's because she considered it a witnessed event. DON B stated that she did not know the details of the fall, such as what the height of the bed was at the time, if other interventions were in place, such as R1's wedges, but an investigation probably would have revealed such information. DON B stated that it is her expectation that if there is an RN in the building, residents should not be moved off the floor until they are assessed by the RN for any signs of injuries. DON B stated that the new intervention of both CNAs to complete all cares together was different than R1's care plan for two (2) staff needed for bed mobility and assist. When asked if she considered bed mobility and the placement of the wedges for proper positioning as cares, DON B stated, Yes. The failure to ensure staff follow proper safety interventions to prevent accidents created a finding of Immediate Jeopardy that began on [DATE]. The facility removed the immediate jeopardy on [DATE] when it had completed the following: ~The facility initiated an investigation and submitted to the state agency. The local police department was notified of suspected neglect and/or abuse. ~A house sweep was conducted to ensure all fall interventions, as indicated on the written plan of care, were in place. Any adverse findings were immediately addressed. ~Risk Management was reviewed to identify residents that had experienced a fall between [DATE] and [DATE] to ensure a thorough investigation was completed to determine root cause and implement new interventions appropriate to prevent reoccurrence. Any adverse findings were immediately addressed. ~On [DATE], education began each shift with nursing personnel regarding Risk Management (Falls) Policies and Procedures; this education included, but was not limited to review of the following: *Not turning ones back to a resident until resident has all care planned interventions in place. *Following residents written plan of care; ensuring interventions established to reduce risk for fall and/or significant injury are in place as indicated on written plan of care. *Per Post Fall Policy, a resident should not be moved from current position, post fall, until licensed nurse collects necessary data to ensure resident is safe to move. *Residents who are deemed safe to move post fall, per a licensed nurse, should be transferred via Hoyer Lift. Staff should not arm/leg lift a resident into bed. *Residents are to be transferred per their written plan of care. *The Interdisciplinary Team was educated on Risk Management (Falls); specifically, as it pertains to the expectation for the team to complete thorough investigations post fall. The purpose of this investigation is to determine root cause and implement new interventions appropriate to prevent reoccurrence. ~ Administrator and/or designee will audit the compliance of this plan via random staff/resident interviews, environmental observation(s), and examination of Risk Management Reports. Findings and trends will be reported to QAPI Committee and Corporate Compliance for further review and consideration.