Every finding on record at Life Care Center of Bruceton-Hollow Rock

Based on policy review, control drug record review, and interview, the facility failed to properly document the disposal of controlled medications for 5 of 5 (Resident #41, #72, #74, #75, and #76) sampled residents reviewed for controlled medication disposition. The findings include: 1. Review of the facility policy titled, Management of Controlled Substances, dated 3/4/2025, revealed .The facility will maintain a system to account for controlled medications' receipt and disposition in sufficient detail to enable an accurate reconciliation, and that the facility conduct periodic reconciliation.facility must employ or obtain the services of a licensed pharmacist who .Establishes a system of records of receipt and disposition of all controlled drugs.and that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.Disposition - the process of returning and/or destroying unused medications.Reconciliation - system of recordkeeping that ensures an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, administered, and/or including the process of disposition. 1.Review of the facility policy titled, Destruction on Medication Policy, dated 3/4/2025, revealed .establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. 2. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, and Spondylosis. Review of the Physician's Order dated 12/19/2025, revealed Resident #41 had an order for Morphine Sulfate (concentrate) solution (a Schedule II medication used to treat moderate to severe pain) 20mg (milligram)/ml(milliliter) 0.25ml by mouth every 2 hours for pain and dyspnea. Review of Resident #41's Controlled Drug Record revealed, Morphine Sulfate 20mg/ml with 28.50 ml remaining for disposal. The facility was unable to provide documentation of the disposal of the medication. 3. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Osteomyelitis of Vertebra, Sacral, and Sacrococcygeal Region, and Cardiomyopathy. Review of the Physician's Order dated October 10, 2025, revealed Resident #72 had an order for Morphine Sulfate (concentrated) Oral solution 20mg/ml 0.25ml every 6 hours as needed for pain; shortness of breath related to Multiple Sclerosis. Review of Resident #72's Controlled Drug Record revealed Morphine 20mg/ml with 29.75 ml remaining for disposal. The facility was unable to provide documentation of the disposal of this medication. 4. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE], with diagnoses including Fracture of Neck of Left Femur, End Stage Renal Disease, Malignant Neoplasm of Prostate. Review of the Physician's Orders dated 10/15/2025, revealed Resident #74 had an order for Oxycodone-Acetaminophen (a Schedule II medication used to treat moderate to severe pain) Oral Tablet 5-325 MG (milligram) 1 tablet by mouth every 4 hours as needed for pain related to Fracture of Left Femur. Review of Resident #74's Controlled Drug Record revealed, Oxycodone-Acetaminophen 5-325 MG with 6 tablets remaining for disposal. The facility was unable to provide documentation of the disposal of this medication. 5. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Chronic Kidney Disease Stage 4, and Aortic Stenosis. Review of the Physician's Order dated 10/20/2025, revealed Resident #75 had an order for Morphine Sulfate Oral Solution (a Schedule II medication used to treat moderate to severe pain) 20mg/ml, give 0.25mg by mouth every 3 hours as needed for pain. Review of Resident #75's Controlled Drug Record revealed, Morphine Sulfate with 26.25 ml remaining for disposal. The facility was unable to provide documentation of the disposal of this medication. 6. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, Sepsis, and Pneumonia. Review of the Physician's Order dated 11/5/2025, revealed Resident #76 had an order for Hydrocodone- Acetaminophen (a Schedule II medication used to treat moderate to severe pain) 5-325 MG 1 tablet by mouth every 8 hours as needed for pain. Review of Resident #76's Controlled Drug Record revealed, Hydrocodone-Acetaminophen 5-325 MG with 30 tablets remaining for disposal. The facility was unable to provide documentation of the disposal of this medication. During an interview on 1/7/2025 at 8:33 AM, the DON (Director of Nursing) stated .that there is no record documenting the disposal of medications obtained from outside pharmaceutical sources used by (Named Hospice agency), or the facilities E cart [Emergency Medication Cart]. The DON stated .Hospice company nurses bring in medications that our pharmacy won't dispose of. The Hospice nurse tells us to dispose of the medications .Floor nurse will place meds [medications] in the drug destruction box in the med room.The ADON (Assistant Director of Nursing) and I will remove the medications from drug destruction box and go to my office .Medication is disposed of into drug destruction liquid (drug buster).there are always 2 people when we do drug destruction.Both people sign our pharmacy controlled drug record sheet showing destruction.We do not document destruction of controlled medication from outside pharmaceutical source or our facilities E cart.medications obtained from the E cart, don't have the information needed to log them into the computer, to have a record of the disposition. During an interview on 1/7/2026 at 9:00 AM, the ADON stated .there is no documentation on the disposal of controlled medications from outside pharmaceutical sources and the facilities E cart.

Based on policy review, observation, and interview, the facility failed to ensure 1 of 4 (Licensed Practical Nurse [LPN] A) nurses followed proper infection control measures to prevent the potential spread of infection and cross contamination while performing blood glucose monitoring during Medication Administration. The findings include: 1. Review of the facility's policy titled Cleaning and Disinfection of the Glucometer dated 9/20/2023, revealed .To prevent the spread of infection, specifically blood borne pathogens through the use of point of care blood glucose monitoring, by cleaning and disinfecting glucometers after each resident use . 2. Observation in Resident #6's room on 7/23/2024 at 7:37 AM, revealed Licensed Practical Nurse (LPN) A gathered supplies, removed the glucometer from the medication cart drawer, and placed it on top of the medication cart. LPN A preceded to perform a blood glucose check on Resident #6 and returned the glucometer to the medication drawer. LPN A failed to clean the glucometer in accordance with the facility policy. During an interview on 7/23/2024 at 11:59 AM, LPN A confirmed that she should have cleaned the glucometer before and after use. During an interview on 7/23/2024 at 3:42 PM, the Interim Director of Nursing confirmed that the glucometer should be cleaned before and after each resident use.

Based on policy review, medical record review, observation, and interview the facility failed to ensure that medications were properly and securely stored when medications were left in a resident's room for 1 of 71 (Resident #60) sampled residents. The findings include: 1. Review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals dated 8/7/2023, revealed .Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size .Store all drugs and biologicals in locked compartments .permanently affixed compartments, permitting only authorized personnel to have access .Facility should ensure that all medications and biologicals, including treatment items are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors .Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration . Review of the facility policy titled, Self Administration of Medications dated 11/28/2016, revealed .Facility .should assess and determine, with respect to each resident whether Self-Administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition .Facility should ensure that orders for self-administration list specific medication(s) the resident may Self-Administer .Facility should document the Self-Administration of medications in the resident's care plan .Facility should document the self-storage of medications in the resident's care plan . 2. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE], with diagnoses including Osteoarthritis, Diabetes, Fibromyalgia, and Fusion of the Spine. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #60 was cognitively intact. Review of the Medication Self-Administration review dated 5/14/2024, revealed Resident #60 was not assessed for self-administering the medication Hylands Restful legs [used to calm restless legs]. Review of the Care Plan dated 6/14/2024, revealed Resident #60 was not care planned for medication self administration. Review of the Physician Orders dated July 2024, revealed .Hylands Restful legs Give 3 tablets every 4 hours as needed for restless legs . Random observation in the Resident's room on 7/22/2024 at 9:15 AM, revealed 3 white tablets in a medication cup on the Resident's nightstand. During an interview on 7/22/2024 at 9:18 AM, Licensed Practical Nurse (LPN) B confirmed that the medication should have been administered to Resident #60 the previous night (7/21/2024) and medications should not be left at the bedside. During an interview on 7/23/2024 at 3:42 PM, the Interim Director of Nursing confirmed that medications should not be left at a Resident's bedside.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 2 of 18 staff members (Activity Assistant and Certified Nursing Assistant (CNA) #9) failed to perform proper hand hygiene during meal service and failed to ensure temperatures for the nutrition freezers were documented daily in 2 of 2 nutrition refrigerators observed in the facility's Nutrition Rooms. The findings include: 1. Review of the facility's policy titled, Sanitation and Food Safety, dated 9/8/2022, revealed .Temperatures are recorded at least twice daily on the Refrigerator/Freezer Temperature Log using an inside thermometer placed near the door . Review of the facility's policy titled, .Hand Hygiene, with a revised date of 6/13/2023, revealed .Associates perform hand hygiene (even if gloves are used) in the following situations .Before and after contact with the resident .After contact with objects and surfaces in the resident's environment . 2. Observation in the resident's room on 8/28/2023 at 7:51 AM, revealed the Activity Assistant entered Resident #126's room, placed the tray on the overbed table, adjusted the bed with her bare hands, touched the remote, turned on the light, and touched the plug in the wall. She proceeded to set up the tray by removing the plate lid and the lids off the coffee and tea. The Activity Assistant touched the rim of the milk carton when she opened it up then proceeded to cut up the residents meat. The Activities Assistant failed to perform hand hygiene after touching dirty and contaminated objects in the residents room before setting up the resident's meal tray. Observation on the D Hall on 8/28/2023 at 8:04 AM, revealed the Activity Assistant failed to perform hand hygiene before removing a tray from the meal cart. The Activity Assistant knocked on Resident #16's door and raised the bed using the remote. She donned her gloves and set up the tray on the over the bed table. Activity Assistant failed to perform hand hygiene after taking off her gloves Observation on 8/28/2023 at 8:17 AM, revealed the Activity Assistant failed to perform hand hygiene after pulling up Resident #11 in bed. She put gloves and set up tray. She did not perform hand hygiene after taking off gloves or leaving the room. Observation in the Resident's room on 8/28/2023 at 8:22 AM, revealed the Activity Assistant placed the meal tray on the overbed table. Resident #66 requested to go to the bathroom. Activity Assistant donned gloves to assist Licensed Practical Nurse (LPN) #1 to transfer resident to the wheelchair and into the bathroom. The Activity Assistant helped Resident #66 out of the bathroom while in the wheelchair. The Activity Assistant locked the wheelchair, pushed the over the bed table up to Resident #66, and removed the lid from the breakfast tray before removing her gloves. The Activities Assistant failed to perform hand hygiene after assisting Resident #66 to restroom and then setting up the meal tray. Observation in the resident's room on 8/29/2023 at 12:31 PM, revealed CNA #9 entered Resident #116's room, placed the tray on the overbed table, adjusted the bed with the remote with her bare hands, and continued with the tray setup by removing the plate lid. CNA #9 pulled the trash can close to the bed with her bare hands and opened the lid of the trash can with her bare hands when she threw the plastic lids away. CNA #9 then cut up the meat, opened the straw with bare hands and placed straw paper into the trash can. CNA #9 failed to perform hand hygiene after touching dirty and contaminated objects in the residents room before setting up trays. During an interview on 8/31/2023 at 2:05 PM, Infection Preventionist confirmed that hand hygiene should be performed before gloves are donned and after gloves are doffed. Infection Preventionist was asked when should hand hygiene be performed during dining. Infection Preventionist stated, .before and after their [staff] hand touches anything . Infection Preventionist was asked what they should do if they raise the head of the bed. Infection Preventionist stated, They've got to wash their hands . 3. Observation in the Nutrition Room on the A/B Hall on 8/30/2023 at 4:06 PM, revealed the Nutrition Refrigerator did not have a Temperature Log attached. Observation in the Nutrition Room on the C/D Hall on 8/30/2023 at 4:15 PM, revealed the Nutrition Refrigerator did not have a Temperature Log attached. During an interview on 8/30/2023 at 4:30 PM, the ADON (Assistant Director of Nursing) confirmed the Temperature Logs were at the Nurse Station. Review of the Temperature Logs revealed only the refrigerator temperatures had been recorded in both Nutrition Rooms. Both Temperature Logs did not have freezer temperatures documented for the months of April, May, June, and July 2023. During an interview on 8/30/2023 at 5:00 PM, the ADON stated, I guess I put out the wrong temp sheet. There isn't a place to put the freezer on this sheet .I will find it and replace it. That's my fault . During an interview on 8/31/2023 at 9:59 AM, the Administrator confirmed staff should record temperatures for the freezer along with refrigerator temperatures.

Based on policy review, observation, and interview, the facility failed to ensure infection control practices to prevent the spread of infection were used when 4 of 5 (Licensed Practical Nurses (LPN) #1, #9, #10, and Registered Nurses (RN) #1) nurses failed to perform hand hygiene during medication administration. The findings include: 1. Review of the facility's policy titled, Hand Hygiene, dated 6/13/2023, revealed .The facility has adopted the CDC [Centers for Disease Control] Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings for indications for hand hygiene .Associates perform hand hygiene (even if gloves are used) in the following situations .Before and after contact with the resident .After contact with objects and surfaces in the resident's environment .After removing personal protective equipment .Before performing a procedure . 2. Observation at the C Hall Medication (Med) Cart during medication administration on 8/29/2023 at 5:05 PM, revealed LPN #9 unlocked her med cart, removed each of Resident #13's medications, and placed them in a separate pill cup. LPN #9 placed each med in a plastic pouch, crushed each med individually, then returned the crushed med to each individual pill cup. LPN #9 removed a bottled purified water from the bottom drawer of her med cart and added water to each of the pill cups. LPN #9 did not perform hand hygiene prior to preparing Resident #13's medications for administration. Observation at the C Hall Med Cart during med administration on 8/30/2023 at 8:53 AM, revealed LPN #1 unlocked her med cart and began preparing Resident #17's medications. LPN #1 locked her cart and went to Central Supply to look for a missing medication. LPN #1 opened the door to the Central Supply room, opened a medication cabinet in the Central Supply room and looked through medication bottles, but was unable to locate the medication. LPN #1 returned to her med cart and continued to prepare each of Resident #17's medications. LPN #1 did not perform hand hygiene prior to preparing the medications or after she returned to her med cart from the Central Supply room and removed the remainder of Resident #17's medications. Observation on the B Hall during medication administration on 8/30/2023 at 11:25 AM, revealed RN #1 performed hand hygiene, walked to Resident #225's room, placed an insulin pen, alcohol pads, syringe, and gloves on top of the isolation cart outside of Resident #225's door. RN #1 donned a gown, knocked on the resident's door, entered the room, donned gloves, removed the syringe from the package, attached the syringe to the insulin pen, and administered insulin to Resident #225. RN #1 failed to perform hand hygiene prior to donning gloves and administering Resident #225's insulin. Observation on the B Hall during medication administration on 8/31/2023 at 8:44 AM, revealed LPN #10 pushed her med cart from the A/B Nurses Station to the B Hall across from Resident #225's room. LPN #10 unlocked her cart, removed each of Resident #225's medication, placed them each in an individual pill cup, crushed each medication separately in a plastic pouch, and returned each medication to the individual pill cups. LPN #10 removed a bottle of purified water from the bottom drawer of her cart and added water to each pill cup. LPN #10 did not perform hand hygiene prior to preparing Resident #225's medications. During an interview on 8/31/2023 at 2:05 PM, the Infection Preventionist was asked when should hand hygiene be performed during med administration. The Infection Preventionist stated, Anytime you touch a surface, before they start it [med administration] and if they touch a surface, and then after the med pass [administration]. The Infection Preventionist confirmed staff should perform hand hygiene before gloves are donned and after gloves are removed.

Based on policy review, medical record review, observation and interview, the facility failed to ensure residents' right to be free from verbal and physical abuse for 1 of 7 (Resident #39) sampled residents reviewed for an allegation of abuse. The findings include: 1. Review of the facility's RESIDENT ADMISSION AGREEMENT, revised 2022, revealed, .The resident has the right to be free from abuse, neglect . Review of the facility's policy titled, Abuse - Conducting an Investigation, dated 7/18/2023, revealed .It is the policy of this facility that allegations of abuse .are promptly and thoroughly investigated. The facility will prevent further abuse, neglect .and mistreatment from occurring while the investigation is in progress .The facility must develop and implement written policies and procedures .Prohibit and prevent abuse, neglect . 2. Review of medical record, revealed Resident #39 was admitted [DATE] with a readmission on 6/23/2023, with diagnoses of Rhabdomyolysis, Crohn's Disease, Dysphagia, Anxiety Disorder and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 had a Brief Interview for Metal Status (BIMS) score of 5, which indicated she was severely cognitively impaired with no behaviors identified and required physical help for most activities of daily living (ADLs). Review of the Social Services Note dated 5/5/2023, revealed .Pt's [patient's] mood throughout assessment was fairly pleasant with a couple isolated instances of tearfulness r/t [related to] home and her husband . Review of the Social Services Note dated 6/19/2023, revealed .SSD [Social Service Director] spoke with pt and husband on 6/18/2023. Both Mr. and Mrs. [Named last name] voicing agitation with one another . Review of the 24-hour Spiral Notebook dated 8/6/2023, revealed .6p-6a [6:00 PM- 6:00 AM] [Named Resident #39] awake @ [at] 6:15p [6:15 PM] .Husband yelling at staff threatening to take her home bc [because] staff would not leave her in bedroom while she was restless & [and] attempting to ambulate without assist . Review of the 24-hour Spiral Notebook undated, revealed . [Named Resident #39] not getting along with husband. Slept in empty room near nurses Station. Please ask weekend Sup [supervisor] to ask him [Resident #39's husband] to leave . Review of the Social Services Note dated 8/14/2023, revealed .Pt's [patient's] husband dropped by SSD's [Social Service Director's] office to discuss ICF [Intermediated Care Facility] plans for September .Requested an estimated cost for ICF .Husband then spoke of wife's confusion and critical statements she makes of him which is often frustration. SSD encouraged husband to take time away from the facility prn [as needed] . Observation and interview in the resident's room on 8/31/2023 at 3:30 PM, revealed Resident #39 covered with blanket resting in bed asleep and husband sitting on empty bed eating a snack. Unable to conduct interview, husband appeared confused and rambling when asked a question. During an interview on 8/30/2023 at 2:28 PM, Certified Nursing Assistant (CNA) #1 was asked if she had observed Resident #39's husband being physically abusive and yelling at her. CNA #1 stated Yes ma'am .I seen him smack her on the hand .I turned it in . he was yelling at her .I was down the hallway .I came back up to her room .she was reaching for the call light .he took it from her and smacked her hand . CNA #1 was asked if Resident #39's husband was banned from the facility after yelling at the staff and after being abusive to the wife. CNA #1 stated, .I believe [Named Social Services Director] escorted him out of the facility . CNA #1 was asked if she wrote a statement and reported the allegation of alleged abuse incident to anyone. CNA #1 stated, .Yes .I don't think I wrote a statement .I informed and reported it to the nurse [LPN #3] .the nurses they have a 24-book they write in when we report it [abuse] . During an interview on 8/30/2023 at 2:44 PM, CNA # 6 was asked if she witnessed Resident #39's husband yelling or being abusive towards her. CNA #6 stated .I was here maybe 2 weeks ago with her .when I seen [saw] him get irritated with her not keeping her feet up while pushing her in her wheelchair .he ran over her foot pushing the wheelchair . CNA #6 was asked if she reported the incident to anyone. CNA #6 stated, .Yes .told the nurse [Named LPN #3] . During an interview on 8/30/2023 at 2:54 PM, Licensed Practical Nurse (LPN) #4 was asked if she was aware of Resident #39's husband being abusive towards her. LPN #4 stated, .Yes .nobody has reported to me .I heard it during change of shift .the nurse would say he was caught yelling at her or talking back to her . LPN #4 was asked if she was aware Resident #39's husband was banned from the facility. LPN #4 stated, .it seems like it was one time they [management] asked him to go home for a few days . During an interview on 8/30/2023 at 3:15 PM and on 8/31/2023 at 8:15 AM, LPN #3 was asked if she had a staff member report an allegation of abuse related to Resident #39. LPN #3 stated .Yes .I had a CNA come to me awhile back .she [CNA #1] came to me told me she saw him [Resident #39's husband] hit her on her hand .I told [Named Social Service Director] or [Named Assistant Director of Nursing (ADON)] . LPN #3 was asked if she had completed an incident report, documented the incident, and gathered statements from staff. LPN #3 stated, .No . LPN #3 was asked if she completed a skin assessment on Resident #39. LPN #3 stated .No . During an interview on 8/30/2023 at 4:07 PM, the Social Service Director was asked if she had investigated the allegation of abuse related to Resident #39. The Social Service Director stated, .I went down to investigate the allegation .I spoke with him [Resident #39's husband] .it was brought to my attention .he said he was trying to get her not to push call light again .she did not need anything .so he was taking the call light from her .we did talk about him getting agitated .him needing to go home .I encourage him to take time for himself .he did verbalize agitation with her confusion .he said he did not hit her, it was brought to my attention he grabbed her hand . The Social Service Director was asked if she should have gathered statements and start an investigation if a staff member reported the husband had slapped/smacked Resident #39's hand. The Social Service Director stated, .Yes .correct .I should have completed an investigation . During an interview on 8/30/2023 at 6:48 PM, CNA #5 was asked if she had witnessed Resident #39's husband being abusive towards her. CNA #5 stated .No . I was briefed on him .by the nurse and the CNA .to keep an eye out because he has been known to . [yell at her] .I was informed [during training] .I was told about certain things I need to watch for . During an interview on 8/30/2023 at 6:54 PM, CNA #4 was asked if she ever witnessed Resident #39's husband yelling or being physically abusive towards his wife. CNA #4 stated, .he has gotten loud with her .he would get mad and try to yell at her [Resident #39] .I would just tell him to calm down .the only time heard him yelling .I was physically in the room . CNA #4 was asked if she had seen the husband being physical abuse to Resident #39. CNA #4 stated .maybe mentally and emotionally never first hand witness physical abuse . CNA #4 was asked if she reported this to anyone. CNA #4 stated, .the nurse [Named LPN #8] .she would go down there and talk to him .we have been told to watch him . [Named DON (Director of Nursing)], Named ADON and Named Scheduler] .they told us to observe and make sure it was not continuing .the hollering .making sure he was not putting his hand on her . The facility was unable to provide documentation the allegation of abuse was reported and thoroughly investigated.

Amended 9/24/2023 Based on policy review, medical record review, observation, and interview, the facility failed to ensure all residents' right to be treated with dignity and respect when 1 of 6 staff member (Licensed Practical Nurse (LPN) #9) failed to provide privacy for Resident #225 during administration of medication through a Percutaneous Endoscopic Gastrostomy tube. The findings include: 1. Review of the facility's policy titled, .Dignity, dated 9/30/2022, revealed .Each resident has the right to be treated with dignity and respect. Interactions .with residents by staff .must focus on maintaining and enhancing the resident's self-esteem, self-worth . 2. Review of the RESIDENT ADMISSION AGREEMENT .Section 11: Resident Rights .The resident has a right to personal privacy includes .medical treatment .personal care . 3. Review of the medical record revealed Resident #225 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Diabetes, Sepsis, Congestive Heart Failure, Polyneuropathy, Dysphagia, Gastrostomy, Cardiomegaly, and Pneumonitis. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #225 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated resident had moderate cognitive impairment and required extensive assistance with for bed mobility, dressing and personal hygiene. Observation in the resident's room on 8/31/2023 at 9:03 AM, revealed the LPN #9 administered medications through Resident #225's Percutaneous Endoscopic Gastrostomy tube (a tube inserted into the stomach through the abdomen). LPN #9 failed to close the blinds, leaving him exposed while administering his medications. There were 2 staff and 3 residents sitting outside the window in the smoking area. During an interview on 8/31/2023 at 9:20 AM, LPN #9 was asked should you have closed his blinds so residents and staff outside could not see him. LPN #9 stated, Yes.

Based on facility policy review, medical record review, and interview, the facility failed to report an allegation of abuse for 1 of 4 (Resident #39) sampled residents reviewed for allegation of abuse. The findings include: 1. Review of the facility's policy titled, Abuse - Protection of Residents, revised 7/18/2023, revealed .The facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation .Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident . 2. Review of medical record revealed Resident #39 was admitted [DATE] with a readmission on 6/23/2023, with diagnoses of Rhabdomyolysis, Crohn's Disease, Dysphagia, Anxiety Disorder and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 had a Brief Interview for Metal Status (BIMS) score of 5, which indicated she was severely impaired with no behaviors identified and required physical help for most activities of daily living (ADLs). Review of the medial records reviewed there was no documentation of the allegation of abuse related to Resident #39. During an interview on 8/30/2023 at 2:28 PM, Certified Nursing Assistant (CNA) #1 was asked if she had observed Resident #39's husband being physically abusive and yelling at her. CNA #1 stated, .Yes ma'am .I seen him smack her on the hand .I turned it in before .he was yelling at her .I was down the hallway .I came back up to her room .she was reaching for the call light .he took it from her and smacked her hand . During an interview on 8/30/2023 at 3:15 PM, Licensed Practical Nurse (LPN) #3 was asked if she had a staff member report an allegation of abuse related to Resident #39. LPN #3 stated, .Yes .I had a CNA come to me awhile back .she [CNA #1] came to me told me she saw him [Resident #39's] husband hit her on her hand .I told [Named Social Service Director] or [Named Assistant Director of Nursing (ADON)] . During an interview on 8/30/2023 at 4:07 PM, the Social Service Director was asked if she got a report of an allegation of abuse should it be reported to the State Agency. The Social Service Director stated, .Yes . The facility failed to report an allegation of abuse to the State Agency.

Based on facility policy review, medical record review, and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 of 4 (Resident #39) sampled residents reviewed for allegation of abuse. The findings include: 1. Review of the facility's policy titled, Abuse - Conducting an Investigation, dated 7/18/2023, revealed .It is the policy of this facility that allegations of abuse .are promptly and thoroughly investigated. The facility will prevent further abuse, neglect .and mistreatment from occurring while the investigation is in progress .When an incident or suspected incident of resident abuse .is reported, the administrator .will investigate the occurrence .The facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary .The administrator .will review the Incident Report for completeness .The written summary of the investigation should include, but is not limited to .A review of the Incident Report .An interview with the person (s) reporting the incident .Interviews with any witness to the incident .Interview with staff members on all shifts having contact with the resident at the time of the incident .If the accused individual is a family member .the person will be denied unsupervised access to the resident .pending the results of the investigation . 2. Review of medical record, revealed Resident #39 was admitted [DATE] with a readmission on 6/23/2023, with diagnoses of Rhabdomyolysis, Crohn's Disease, Dysphagia, Anxiety Disorder and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 had a Brief Interview for Metal Status (BIMS) score of 5, which indicated she was severely impaired with no behaviors identified and required physical help for most activities of daily living (ADLs). During an interview on 8/30/2023 at 2:28 PM, Certified Nursing Assistant (CNA) #1 was asked if she had observed Resident #39's husband being physically abusive and yelling at her. CNA #1 stated Yes ma'am .I seen him smack her on the hand .I turned it in . he was yelling at her .she was reaching for the call light .he took it from her and smacked on her hand . CNA #1 was asked if she wrote a statement and reported the allegation of abuse incident to anyone. CNA #1 stated .I don't think I wrote a statement .I informed and reported it to the nurse [LPN #3] . During an interview on 8/30/2023 at 3:15 PM, Licensed Practical Nurse (LPN) #3 was asked if she had a staff member report an allegation of abuse on Resident #39. LPN #3 stated, .Yes .I had a CNA come to me awhile back .she [CNA #1] came to me told me she saw him [Resident #39's] husband hit her on her hand .I told [Named Social Service Director] or [Named Assistant Director of Nursing [ADON] . LPN #3 was asked if she had completed an incident report, documented the incident, and gathered statements from staff members. LPN #3 stated, .No . During an interview on 8/30/2023 at 4:07 PM, the Social Service Director was asked if she had investigated the allegation of abuse related to Resident #39. The Social Service Director stated .I went down [Resident #39's room] to investigate the allegation .I spoke with him [Resident #39's husband] .it was brought to my attention .he said she was trying to get her not to push call light again .she did not need anything .so he was taking the call light from her .we did talk about him getting agitated and him needing to go home .I encourage him to take time for himself .he did verbalize agitation with her confusion .he said he did not hit her .it was brought to my attention he got/grabbed her hand . The Social Service Director was asked if she should have gathered statement and started an investigation if a staff member reported the husband had slapped/smacked her hand. The Social Service Director stated .Yes .correct .I should have completed an investigation . The facility failed to complete a thorough investigation of an allegation of abuse.

Based on policy review, medical record review, and interview, the facility failed to conduct Care Plan meetings which included the Interdisciplinary Team (IDT) for 1 of 3 sample resident (Resident #35) reviewed for care plan meetings. The findings include: 1. Review of the facility's policy titled, Comprehensive Care Plans and Conferences, dated 8/22/2023, revealed .Interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative .is involved in developing the care plan and making decision about his or her care .The IDT [Interdisciplinary Team] must, at a minimum, consist of the resident's attending, physician, a registered nurse and nurse aide with responsibility for the resident, a member of the food and nutrition services staff .the resident and resident representative .The facility should provide the resident and resident representative if applicable with advance notice of care planning conferences to enable resident/resident representative participation . Review of the RESIDENT ADMISSION AGREEMENT dated 2022, revealed .The resident has the right to be informed of, and participate in, his or her treatment .the right to participate in the development and implementation of his or her person-centered plan of care . 2. Review of medical record revealed Resident #35 was admitted on [DATE], with diagnoses of Diabetes, Peripheral Vascular Disease, Hypertension, and Chronic Pain. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #35 had a Brief Interview For Mental Status (BIMS) score of 15 which indicated he was cognitively intact and required total care for most of his Activity of Daily Living (ADLS). Review of the CARE PLAN CONFERENCE RECORD dated 3/7/2022, revealed only the Activity Director, Dietary Manager and the Social Service Director signed as attending the meeting. The Care Plan Conference Record had no documentation of what was covered in the meeting. Review of the medical record revealed there were no quarterly Care Plan meetings held for Resident #35 on 6/30/2022, 9/14/2022, 11/16/2022, 2/16/2022, and 5/19/2023 according to the quarterly MDS schedule. Review of the Care Plan Meeting schedule revealed Resident #35 was scheduled for a Care Plan meeting on 11/23/2022 and 4/12/2023. Review of the Progress Note dated 6/7/2023, revealed .Pt [patient] participated in his Care Plan meeting held today. Orders reviewed. Pt very aware of his current care plan and agreeable . FULL code POST reviewed/discussed with pt expressing no desire to make changes at this time. Current plan of care to continue. The facility was unable to provide documentation of who attended the care plan meeting held on 6/7/2023. The facility was unable to provide documentation the Care Plan meeting was held according to the RAI (Resident Assessment Instrument) manual. During an interview on 8/30/2023 at 9:34 AM, Resident #35 was asked if he attended a Care Plan meeting with the social worker on 6/7/2023. Resident #35 stated, .yes with [Named Social Service Director] and the Scheduler only . During an interview on 8/30/2023 at 11:16 AM, the Assistant Director of Nursing (ADON) was asked to tell about the process for the Care Plan meeting and who attend the meeting. The ADON stated, .If me and the Director of Nursing [DON] are here one of us attend .the Scheduler .Social Service Director .MDS Coordinator .Dietary Manager .Therapy .Activity if available she attend also .the resident or the Responsible Party [RP] .we have a paper form we sign .filed in the resident chart .scanned into Point Click Care [PCC] .document what was discussed in the meeting .the meetings are held quarterly .letters are sent out to the RP and resident . During an interview on 8/30/2023 at 12:11 PM, the MDS Coordinator was asked how the Care Plan meetings are scheduled. The MDS Coordinator stated, .I schedule the meeting off MDS schedule .I try to make sure we have them quarterly every 3 months . The MDS Coordinator was asked where Care Plan meetings are documented. The MDS Coordinator stated, .they are documented in PCC .we do have the care plan conference report . The MDS Coordinator was asked who should attend the care plan meeting. The MDS Coordinator stated, .a nurse representative .Social Services .Dietary Manager .Activity .ideally a CNA [Certified Nursing Assistant] direct care .collaborate with the IDT .Nurse Practitioner sometimes comes .the DON and ADON .as for a nurse I attend . The MDS Coordinator was asked did the meeting held on 3/7/2022 have representation from the IDT. The MDS Coordinator stated, .No . During an interview on 8/28/2023 at 3:34 PM, the Social Service Director was asked if she had any documentation of Resident #35's care plan meeting. The Social Service Director stated, .No . I don't have any documentation on the care plan meetings .

Based on facility policy review, medical record review, observation, and interview, the facility failed to administer medications as prescribed by the physician and as recommended for 1 of 3 (Resident #52) sampled residents reviewed for medication administration. The findings include: 1. Review of the facility policy titled, Administration of Medications, dated 8/25/2022, revealed, .The facility will ensure medications are administered safely and appropriately per physicians order to address resident' diagnoses and signs and symptoms .Staff who are responsible for medication administration will adhere to the 10 Rights .Right Drug .Every drug administered must have an order from the provider. Compare the order with the medication administration record (MAR) for accuracy. Compare the label of the drug to the information on the M. A. R. [Medication Administration Record] three times .Right Resident .Right Dose .Right Route .Right Time and Frequency .Right Documentation .Right Assessment .Right to Refuse .Right Evaluation .Right Education and information . Review of the facility policy titled, LTC (Long Term Care Facility's Pharmacy Services and Procedures Manual, dated 1/4/2023 revealed .the procedures relating to automated medication dispensing systems (AMDS) .Assure removal and replacement of controlled substance .is witnessed by Facility staff .Medications removed from the AMDS must have a corresponding Physicians/Prescriber's order .When a facility that has adopted a policy to have another nurse witness the removal of a controlled substance from the AMDS .the nurse removing the dose should have a nurse on the unit or the nursing supervisor verify .the medication .the strength .dosage form .the quantity removed .The verification by the unit nurse or supervisor should be documented in the resident's medical records or the perpetual inventory record . Review of the facility policy titled, Medication Reconciliation across the Continuum of Care, dated 8/17/2022, revealed, .Medications will be reconciled by the Licensed nurse. Clinically significant medications issues identified will be communicated the physician, acted upon, and documented in the medical record .Drug Regimen Review .A drug regimen review includes medication reconciliation, which is a review of all medication a resident is currently using, and a review of the drug regimen to identify and, if possible, prevent potential clinically significant medication adverse consequences .Procedure .Upon admission /readmission or as close to the actual time of admission as possible, medication will be reconciled by the licensed nurse . 2. Review of medical record, revealed Resident #52 was admitted on [DATE], with diagnoses of Dementia, Diabetes, Chronic Kidney Disease, Heart Failure, Anxiety Disorder, and Malignant Neoplasm of Large Intestine. Review of [Named Hospital] records dated 1/26/2023, revealed .Rytary 23.75-95 mg . Take one capsule by mouth 3 .times a day . Review of the Physician Order dated 1/26/2023, revealed .diazePAM Oral Tablet 2 MG [Milligram] (Diazepam) [used to treat anxiety disorders] .Give 1 tablet by mouth two times a day for anxiety for 10 Days .Rytary [treat symptoms of Parkinson's disease] Oral Capsule Extended Release 23.75-95 MG (Carbidopa-Levodopa) Give 3 capsule by mouth three times a day related to .TREMOR . Review of the Order Audit Report dated 1/26/2023, revealed .Created Dated .1/26/2023 .confirmed By . [Named LPN #3] .Queued [a sequence of stored data or programs awaiting processing] By . [Named Director of Nursing (DON)] .Electronic .Signed By . [Named Medical Doctor] on 1/30/2023 . Review of the Incident report dated 2/5/2023, revealed .Resident prescribed 2mg [2 milligrams] Valium [Diazepam] used to treat anxiety disorders] BID [twice a day]. This nurse [Licensed Practical Nurse (LPN) #2] went to Omnicell [automated medication dispensing systems], entered code and pulled 10mg [10 milligrams] of Diazepam used to treat anxiety disorders]. Med [medication] was given. Was later found to be on 2mg [2 milligrams] not 10mg . The nurse administered 10 mgs instead of the 2 mgs prescribed. Review of Progress Note created on 2/7/2023, revealed .Resident prescribed 2mg Valium [Diazepam] BID. This nurse [LPN #2] went to Omnicell, entered code and pulled 10mg of Diazepam. Med was given. Was later found to be on 2mg not 10mg . Review of the Synopsis of a Medication Reconciliation Error revealed .The patient was admitted to [Named Facility] after a hospitalization at [Named Hospital] due to major neuro [neurological]-cognitive disorder on 1/26/2023. On 2/22/2023 it was identified that patient had an order for Rytary 23.75-95 mg [milligrams], transcribed on EMAR [Electronic Medication Administration Record] for 3 caps [capsules], TID [three times a day] for other specified form of tremors. Actual order should have been Rytary 1 cap [capsule], TID [Named LPN #3], LPN completed the reconciliation of mediations after the DON entered the medication in error . [Named Medical Doctor] notified on 2/22/2023 . [Named Daughter] aware on 2/22/2023 . [signed by the DON] . The resident should have been given 1 capsule three times a day and not the 3 capsules three times a day he was administered. Review of Progress Note dated 3/1/2023, revealed .Resident was seen and examined for monthly rounds. Siting [sitting] in wheelchair in the hall. Appears well. Staff report his mental status is improved, he had had some confusion recently. Medication adjustments have been made . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated he was moderately impaired with no behaviors identified and required total care for most activities of daily living (ADLs). Review of the Witness Interview/Statement Form dated 8/29/2023, signed by the ADON revealed . [Named LPN #3] .I second checked The admission orders. I clicked Confirm after reviewing all the orders and continued to work on the rest of the admission. I overlooked the dosage amount on one of his medications when I second checked . Review of the Witness Interview/Statement Form dated 8/29/2023, signed by the Assistant Director of Nursing (ADON) revealed . [Named LPN #2] .Medication not in The drawer. Medication was Valium [Diazepam] 2 mg. I called pharmacy and got code to pull valium 2 mg. I got [Named RN Supervisor] to be witness and I pulled from the Omnicell [automated medication dispensing systems] Valium 5 mg 2 tablets instead of Valium 2 mg one tablet. I administered the medication. The next day, [Named DON] called me to come to the facility because there was a Med [medication] error. I went to facility and did incident report and contracted MD [Medical Director] and family . Review of the Witness Interview/Statement Form dated 8/29/2023, signed by the ADON revealed . [Named RN Supervisor] . [Named LPN #2] asked me for my help to pull Diazepam [Valium] from the Omnicell [automated medication dispensing systems]. We went to the med [medication] room and [Named LPN #2] pulled the medication from Omnicell and I was the witness and had to put my username and fingerprint in After [Named LPN #2] pulled the mediation .I saw [Named LPN #2] had [Named Resident #52] as the resident and Diazepam was the medication pulled . There was no documentation in Resident #52's medical records that he was evaluated by the MD after the medication error that occurred on 2/5/2023 and the medication error that was discovered from 1/26/2023 to 2/22/2023. During an interview on 8/28/2023 at 10:07 AM, Licensed Practical Nurse (LPN) #1 was asked if she could tell me about Resident #52's medication errors. LPN #1 stated, .his daughter is the one who caught it [Rytary medicating error] when she came .there were the orders [Rytary 3 capsules three times a day] in the computer .so that is what he was getting .I just remember it was 3 capsules .he was to get 1 capsule three times a day instead of the 3 capsules three times a day .when first came in he would sleep all the time .we did medication reviews to try and figure out what was making him sleep all the time .on 2/22/2023 they changed medication to 1 capsule three times a day .they discontinued the medication on 4/11/2023 .per family request .the daughter .I know they did a medication error on the Valium [Diazepam] .I don't know what happen .pharmacy called the facility .I answered the phone .they said need to speak to someone .a wrong order had been pulled .the normal dose he gets was 2 mg .I understand it was [Named LPN #2] . LPN #1 was asked at any time did Resident #52 have low blood pressures. LPN #1 stated, .he had a few low blood pressures back in January .it was when he was sleeping .we did his blood pressure first thing in the morning .that would explain that . During an interview on 8/28/2023 10:53 AM, LPN #2 was asked to tell me about the medication error with Resident #52. LPN #2 stated .we needed to pull it [the Valium/ Diazepam] .I went in [Medication room] and had dose in my head .I pulled the wrong dose .I had a second person with me .it was a mistake I made .they [DON] called me .she told me I made a medication error .I need to come and correct it .do the paper work .I contacted the family .the doctor .I had worked the weekends .It was on Monday when the DON called me .I was not aware I gave wrong dose .I thought I checked the dose .I had a witness with me .[Named RN Supervisor] . During an interview on 8/29/2023 at 9:55 AM, the daughter was asked about how she found out about the medication errors. The daughter stated .there was an instance I was called .I don't remember the dosage of the medication with Valium [Diazepam] .staff called to tell me that his blood pressure had dropped that weekend .I was not aware of the over medication till the nurse called me later .he was over medicated .I called the facility and they did some checking on the prescription [Rytary] .it was not what I had or what we sent [orders] .I called the facility and they said they have to call me back .there was an medication error made .but not sure what happen .the DON would not go into details .they paid for all the medication he was billed for .when he left [Named Hospital] .they sent a medication list with him .the DON informed me a mistake .he got 3 pills three times a day .they made a mistake .I found it .when I got the bill . During an interview on 8/29/2023 at 12:02 PM, the ADON was asked what the process was for entering orders for a new admission. The ADON stated, .we have an admission audit check list to remind the nurse to have 2 nurses .one nurse puts the order in .the other nurse checks the orders .the second nurse verifies the orders when the resident come with new orders .check what we have [orders] .reconcile the orders .when the residents arrives we check for changes .make sure all the orders match .we let the MD know when we get a new admission .the MD looks at the orders and signs off on the orders .we initiate the order in PCC [Point Click Care computer system] for each resident .it automatically goes to the MD . The ADON was asked what the process when the facility identifies a medication error. The ADON stated, .notify MD and RP [Responsible Party] .open an incident report .complete an acknowledgement sheet .write the details .what happened .what caused the medication error .why did it occur . The ADON was asked if the facility should have completed an incident report on the medication error for the Rytary and gathered statements for each medication error. The ADON stated, .Yes . The ADON was asked what the process for pulling medications from the automated medication dispensing systems. The ADON stated .when a nurse needs to pull a narcotic .the nurse has to call pharmacy .tell them what resident and what drug .the pharmacy verify current correct script with the dosage .pharmacy gives the nurse a code to pull the drug .need 2 nurses to pull the drug .make sure have the right resident and the right drug .it will say witness needed .the witness hits confirmed .the drawer will open after the witness puts in her identification .the nurse checks right dose .expiration date .right route .right frequency .right resident .the nurse should check the medication before administering . During a telephone interview on 8/29/2023 at 2:37 PM, the Medical Doctor (MD) was asked if she was aware of the medication error with Resident #52. The MD stated, .the nurse put in Rytary 3 pills three times a day and I signed off the medication .the daughter got an incorrect bill .that's when we found out about it .the nurse alerted me, looks like February 22 .the nurse called me, said the DON and nurse put the medication in wrong .the Valium [Diazepam] I don't recall that I was told about it . The MD was asked what type of side effects Resident #52 could have from a higher dose of Valium. The MD stated, .it could drop the blood pressure and cause extra sedation .the respirations could be lower . The MD was asked should the staff follow the 5 rights of medication administration and check the order for accuracy. The MD stated .Yes ma'am .

Based on facility policy review, observation, and interview, the facility failed to ensure that medication records were in order and that an account of all controlled medications were maintained and reconciled for 1 of 6 (Registered Nurse (RN) #1) nurses for 5 of 7 (Resident #14, #34, #35, #63, and #71) residents. The findings include: 1. Review of the facility policy titled, Management of Controlled Substances dated 8/28/2022, revealed .disposition of all controlled drugs .enable an accurate reconciliation .an account of all controlled drugs is maintained . 2. Observation and interview at the B Hall Medication (Med) Cart on 8/30/2023 at 11:37 AM, revealed RN #1 was asked to review Resident #14's narcotic reconciliation. Review of the Controlled Drug Record for Resident #14 revealed, .GABAPENTIN (used to treat seizures and nerve pain) .300 MG [Milligram] CAPSULE .Amount Remaining .11 . Review of Resident #14's narcotic card revealed a count of 10 Gabapentin capsules remained. RN #1 was asked about the difference in the number and stated, I just gave her one, let me sign it out. RN #1 signed out the Gabapentin at that time. RN #1 was asked what time it was given. RN #1 stated, About 10ish [1 hour and 37 minutes prior to this time] He confirmed that 1 Gabapentin was administered and it should have been signed out right away. 3. Observation and interview at the B Hall Med Cart on 8/30/2023 at 11:47 AM, RN #1 was asked to verify Resident #34's Oxycodone count. RN #1 stated, I just gave her one too .about 9:40 [AM] . Review of the Controlled Drug Record for Resident #34 revealed, .Oxycodone (used to treat moderate to severe pain) .Amount Remaining .14 . Review of Resident #34's narcotic card revealed 13 Oxycodone tablets remained. RN #1 was asked to verify all his narcotic counts. RN #1 stated, They're all gonna be the same [incorrect count] . 4. Observation at the B Hall Med Cart on 8/30/2023 beginning at 11:49 AM, revealed the following: a. Review of the Controlled Drug Record for Resident #14 revealed, .HYDROCODONE-ACET [Acetaminophen] (used to treat pain) 7.5-325MG TABLET .Amount Remaining .11 . Review of Resident #14's narcotic card revealed 10 Hydrocodone-Acetaminophen tablets remained. b. Review of the Controlled Drug Record for Resident #35 revealed, .GABAPENTIN .300 MG CAPSULE .Amount Remaining .13 . Review of Resident #35's narcotic card revealed 12 Gabapentin tablets remained. c. Review of the Controlled Drug Record for Resident #35 revealed, .MORPHINE SULFATE 30MG TABLET .Amount Remaining .23 . Review of Resident #35's narcotic card revealed 22 Morphine Sulfate tablets remained. d. Review of the Controlled Drug Record for Resident #63 revealed, .HYDROCODONE-ACET 7.5-325MG TABLET .Amount Remaining .26 . Review of Resident #63's narcotic card revealed 25 Hydrocodone-Acetaminophen tablets remained. e. Review of the Controlled Drug Record for Resident #71 revealed, .HYDROCODONE-ACET 10-325MG TABLET . Review of Resident #71's narcotic cared revealed 8 Hydrocodone-Acetaminophen tablets remained. During an interview on 8/30/2023 at 11:58 AM, RN #1 was asked what the facility's process was for signing out narcotics. RN #1 stated, Should sign them out immediately once you pull them. RN #1 was asked could he explain what happened this morning when all the narcotics were not signed out. RN #1 stated, No, I don't have a good explanation for that. During an interview on 8/30/2023 at 12:00 PM, the Regional Director of Clinical Services (RDCS) confirmed narcotics should be signed out when given.

Based on policy review, observation and interview, the facility failed to ensure medications were properly stored when opened and undated medications and expired formula were observed in 2 of 5 (D Hall Medication Storage Room and D Hall Medication Cart) medication storage areas. The findings include: 1. Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals dated [DATE], revealed .Facility staff should record the date opened on primary medication container . 2. Observation of the D Hall Medication Cart on [DATE] at 5:03 PM, revealed: One opened and undated box of Ipratropium Bromide and Albuterol Sulfate 0XXX,d+[DATE]mg (milligrams) (medication used to treat asthma, chronic bronchitis, and emphysema). One opened and undated bottle of Potassium Chloride 20 milliequivalents (used to treat low potassium). 3. Observation of the D Hall Medication Storage Room on [DATE] at 1:19 PM, revealed the following: 202 individual cartons of Glucerna 1.0 calorie (high calorie nutrition) with an expiration date of [DATE]. 48 individual cartons of Glucerna 1.0 calorie with an expiration date of [DATE]. 4. During an interview on [DATE] at 1:27 PM, the Regional Director of Clinical Services (RDCS) confirmed the expired formula should not be in the medication room and that medications should be dated when they are opened.

Based on policy review, medical record review, observation, and interview, the facility failed to maintain an effective pest control program in 3 of 60 (Resident #7, Resident #13, and Resident #35) resident rooms, failed to prevent parasites or possible maggots for Resident #22, and 1 of 4 (C Hall) Halls on 3 of 4 (8/29/2023, 8/30/2023, and 8/31/2023) days of onsite observations. The findings include: 1. Review of the facility policy titled, Pest Control, dated 6/4/2023, revealed .The facility will maintain an effective pest control program that provides frequent treatment of the environment for pests so that the facility is free of pests .The facility's staff will do monitoring of the environment. Pest control problems will be reported to the Director of Maintenance promptly . 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Chronic Respiratory Failure, Dementia, Schizophrenia, and Severe Protein-Calorie Malnutrition. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated she was cognitively intact. Observation and interview in the resident's room on 8/31/2023 at 8:37 AM, revealed a fly was observed flying around Resident #7's covered meal tray. Resident #7 waved the fly away and stated, He stays in this room .I don't like to fight with him every day . 3. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of Cardiomyopathy, Chronic Kidney Disease, Squamous Cell Carcinoma, and Anemia. Review of the quarterly MDS dated [DATE] revealed Resident #22 had a BIMS score of 5, which indicated he had severe cognitive impairment. Review of the Wound Observation Tool dated 7/28/2023, revealed .Acquired .11/23/2022 .right ear .Type .other .Unchanged .Length .3.6 [centimeters (cm)] .Width .4.2 [cm] .Depth .0.3 [cm] .No improvement expected. Resident often removes dressing and picks at ear .strong foul odor .Xeroform gauze [nonadherent dressing] 3x[times]/wk[week]/prn [as needed] . Review of the Event Note dated 8/5/2023 at 4:00 AM, revealed .Resident remove [removed] dressing to right ear. Blood noted to face and hands. While attempting to perform wound care, staff noted movement in wound. Upon further observation, appears like a parasite to wound bed. Review of Health Status Note dated 8/5/2023 at 4:00 AM, revealed .CNA [Certified Nursing Assistant] asked for resident's bandage to be replaced to his right eat. After assessing the area, MD [Medical Doctor] was notified. Order for wound nurse to come and address the area. Order also received for Ivermectin [anti-parasite to treat infections caused by roundworms, threadworms, and other parasites] and new treatment to area. Review of the physician order dated 8/5/2023 6:00 AM, revealed .CLEAN RGHT EAR WITH DAKINS [a solution used to kill germs in wounds] .APPLY DAKINS DAMP GAUZE WITH AND COVER WITH DRESSING .every day shift for SKIN CANCER AND as needed .Ivermectin .15 milligram (mg) .one time a day every 2 weeks .until 8/12/2023 . Review of the Wound Observation Tool dated 8/5/2023, revealed .Acquired .11/23/2022 .right ear .Type .other .worsening .Length .3.6 [cm] .Width .4.2 [cm] .Depth .0.3 [cm] .Noted small parasites to wound bed. Notified MD with new orders notes .odor remains but not as strong today .Dakin's daily . Review of the Wound Observation Tool dated 8/7/2023, revealed .Acquired .11/23/2022 .right ear .Type .other .improving .Length .4 [cm] .Width .4.2 [cm] .Depth .0.4 [cm] .No parasites noted at this time. Previous strong odor very mild at this time .Dakin's daily . Review of the Wound Observation Tool dated 8/14/2023, revealed .Acquired .11/23/2022 .right ear .Type .other .improving .Length .4 [cm] .Width .4.2 [cm] .Depth .0.4 [cm] .dermatology appointment today. Not a candidate for radiation. Surgeon to call in am [AM] about possible surgical interventions .Dakin's daily . Observation on the C Hall on 8/31/2023 at 8:27 AM, revealed a fly in the hallway outside Resident #22's room. Resident #22's door was opened. 4. Observation in the resident's room on 8/29/2023 at 5:03 PM, revealed a fly was on the light above the head of Resident #13's bed while medications were administered through the resident's percutaneous gastrotomy (PEG) tube. Observation in the resident's room on 8/30/2023 at 9:34 AM, revealed a fly landed on Resident #35's forehead during the resident's interview. Observation on the C Hall on 8/31/2023 at 8:30 AM, revealed a fly in the hallway outside the central bath. 5. During an interview on 8/30/2023 at 4:42 PM, the Regional Director of Clinical Services (RDCS) was asked about the incident on 8/5/2023 where Resident #22 was observed with something moving in his ear wound. The RDCS stated, Sometime that night the patient pulled off his dressing .picked at his ear a lot .CNA told the nurse that he had pulled it off and the nurse had seen something moving in it .she called the Director of Nursing (DON), the DON called the wound nurse and called me .the DON came here to the building, the wound nurse came to the building .she [wound nurse] assessed his ear and notified the doctor, notified the family, obtained the orders . The RDCS was asked did they determine what was in his ear wound. The RDCS stated, They wasn't sure but they thought it was maggots . The RDCS was asked how Resident #22 had gotten maggots in his ear wound. The RDCS stated, I do know that he pulls his dressing off .can only assume there had to be some kind of interaction with a fly . The RDCS confirmed facility staff assessed all residents and no other residents had any skin changes. Continued interview revealed housekeeping came out that day to monitor for pest concerns, they added fly protection measures, and conducted staff in-services. During an interview on 8/30/2023 at 5:36 PM, the Treatment Nurse confirmed that she was notified about Resident #22's ear by text message on 8/5/2023. The Treatment Nurse stated, .I called and came up here .went and looked at it, he had some things moving around in there .called the doctor and got the treatment changed .all the time he was taking the dressing off .squamous cell [carcinoma on right ear] .when I got here Saturday I cleaned it up .I came back later because I had missed some of the bugs .cleaned it up again .came back Sunday and there were none [maggots] Sunday . The Treatment Nurse was asked what the bugs looked like. The Treatment Nurse stated, The little white tiny [bugs] .there were probably a couple of dozen . The Treatment Nurse confirmed there was not a dressing on Resident #22's ear when she arrived at the facility because the resident refused to allow staff to apply one. The Treatment Nurse was asked when she cleaned the wound did Resident #22 say he could feel the bugs. The Treatment Nurse stated, I don't really think he knew they were there . During an interview on 8/31/2023 at 8:00 AM, LPN #6 confirmed that she was working on 8/5/2023 and stated, The CNAs came down and told me his bandage was off his ear and there was blood on his sheets .I took all the stuff to clean the area had never done that treatment before. There was no bandage on there .there was like a clot of blood on his ear and when I cleaned it off that's when I saw the little bitty worms . LPN #6 confirmed that she called the Nurse Practitioner and obtained new orders. LPN #6 stated, Flush it with [hydrogen] peroxide then clean it with soap and water and put a bandage on it. Then she called me back with a medication to order for him. LPN #6 confirmed the Nurse Practitioner ordered Ivermectin. LPN #6 was asked what the bugs looked like. LPN #6 stated, Little tiny white squirmy little bitty worms. LPN #6 was asked what happened when she cleaned the wound with the hydrogen peroxide. LPN #6 stated, They were like trying to get away from it .squirming . LPN #6 confirmed the bugs looked like maggots and they were still present in Resident #22's ear wound after she cleaned it with hydrogen peroxide. LPN #6 confirmed she reported the incident to the DON. During an interview on 8/31/2023 at 11:08 AM, the Administrator stated, We contacted the pest control company .come out .sprayed .gave us 5 fly bags to put out .they are outside the facility out back. The Administrator confirmed the pest control company sprayed Resident #22's room. The Administrator stated, They [flies] had stopped completely and it rained on Sunday [8/27/2023] and we had seen them on occasion, so we contacted the pest control company for them to come back out. The Administrator was asked when they were contacted. The Administrator stated, Tuesday, I believe [8/29/2023].

Based on Centers for Medicare and Medicaid (CMS) guidelines, policy review, and interview, the facility failed to perform tracking of resident and staff testing for COVID-19 (an infectious disease caused by [CONDITION(S)]-CoV-2 virus) according to current guidance to prevent the spread of COVID-19. This had the potential to affect the 62 residents residing in the facility. The findings include: Review of the CMS Center for Clinical Standards and Quality/Survey and Certification Group (QSO-20-38-NH) Memo, revised 9/10/2021, revealed .Swift identification of confirmed COVID-19 cases allows the facility to take immediate action to remove exposure risks to nursing home residents and staff .Documentation of Testing .Facilities must demonstrate compliance with the testing requirements .For symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results .Upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that other residents and staff are tested , the dates that staff and resident who tested negative are retested , and the results of all tests .For staff routine testing, document the facility's level of community transmission, the corresponding testing frequency indicated .and the date each level of community transmission was collected .document the date(s) that testing was performed for unvaccinated staff, and the results of each test .Document the facility's procedures for addressing residents and staff that refuse testing or are unable to be tested , and document any staff or residents who refused or were unable to be tested and how the facility addressed those cases . Review of the facility's policy titled, COVID-19 ([CONDITION(S)]-CoV-2) HCP [Healthcare Personnel]TESTING, dated 2/7/2022, revealed .The LTC [Long Term Care] facility must test residents and facility staff .Conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests .For each instance of testing .Document that testing was completed and the results of each staff test .Document in the resident's records that testing was offered, completed (as appropriate to the resident's testing status), and the results of each test .Upon identification of an individual specified in this paragraph with symptoms consistent with COVID-19, or who tests positive for COVID-19, take actions to prevent the transmission of COVID-19 .Documentation .Facilities must demonstrate compliance with the testing requirements .For staff, including individuals providing services under arrangement and volunteers, the facility must document testing results in a secure manner consistent with requirements specified in 483.80(h)(3) [Code of Federal Regulations-Infection Control Grouping] . The facility was unable to provide documentation of tracking of resident and staff testing for COVID-19 for symptomatic healthcare personnel, which included the dates and times the symptoms were identified, when testing was conducted, results of the test, and actions taken based on the results; upon identification of a COVID-19 outbreak, the date the case was identified, the date that all other staff are tested , the dates that staff who tested negative are retested , and the results of all tests; for routine staff testing, the level of community transmission, the corresponding testing frequency indicated, the date each level of community transmission was collected, the date testing was performed for all unvaccinated staff, and the results of each test; document the facility's procedures for addressing staff that refuse testing or are unable to be tested and document any staff who refused or were unable to be tested and how the facility addressed those cases. During an interview on 2/16/2022 at 6:36 PM, the Administrator confirmed the facility could not provide documentation of tracking of resident and staff testing for COVID-19 that included all of the elements required per the current CMS guidance.

Based on Centers for Medicare and Medicaid (CMS) guidelines, policy review, and interview, the facility failed to perform documentation and tracking of staff vaccinations for COVID-19 (an infectious disease caused by [CONDITION(S)]-CoV-2 virus) according to current guidance to prevent the spread of COVID-19. This had the potential to affect the 62 residents residing in the facility. The findings include: Review of the CMS Center for Clinical Standards and Quality/Quality, Safety & Oversight Group (QSO-22-07-ALL) memorandum dated 12/28/2021, revealed .Medicare and Medicaid-certified facilities are expected to comply with all regulatory requirements . Review of the QSO-22-07-ALL Long-Term Care and Skilled Nursing Facility Attachment A dated 12/28/2021, revealed .The facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19 .Process for tracking staff vaccine status .The facility must track and securely document .each staff member's vaccination status .this should include the specific vaccine received, and the dates of each dose received, or the date of the next scheduled dose for a multi-dose vaccine .any staff member who has obtained any booster doses .this should include the specific vaccine booster received and the date of the administration of the booster .staff who have been granted an exemption from vaccination .this should include the type of exemption and supporting documentation .requirements by the facility .staff for whom COVID-19 vaccination must be temporarily delayed. For temporary delays, facilities should track when the identified staff can safely resume their vaccination .facilities' tracking mechanism should clearly identify each staff's role, assigned work area, and how they interact with residents. This includes staff who are contracted, volunteers, or students . Review of the facility's policy titled, COVID-19 ([CONDITION(S)]-CoV-2) Vaccination Program Policy for Associates, dated 2/10/2022, revealed .The facility will ensure that associates .will be fully vaccinated against COVID-19, unless .otherwise exempted by a medical or religious exemption .Vaccination Tracking Requirement .The facility should track the following for elements related to associate vaccinations .each staff member's vaccination status .this should include the specific vaccine received, and the dates of each dose received, or the date of the next scheduled dose for a multi-dose vaccine .any staff member who has obtained any booster doses .this should include the specific vaccine booster received and the date of the administration of the booster .any staff who have been granted an exemption from vaccination .this should include the type of exemption and supporting documentation .staff for whom COVID-19 vaccination must be temporarily delayed. For temporary delays, facilities should track when the identified staff can safely resume their vaccination .facilities' tracking mechanism should clearly identify each staff's role, assigned work area, and how they interact with residents. This includes staff who are contracted, volunteers, or student . The facility was unable to provide tracking documentation of COVID-19 vaccination status which included each staff member's vaccination status, the specific vaccine received, the date each dose was received, all staff who received the booster, the date the booster was received, staff granted an exemption from the vaccination, the type of exemption granted and supporting documentation, staff for whom the COVID-19 vaccination was temporarily delayed and when those staff can safely resume their vaccination, each staff's role in the facility, their assigned work area, and how they interact with residents. During an interview on 2/16/2022 at 6:36 PM, the Administrator confirmed the facility could not provide documentation of tracking of staff COVID-19 vaccination that included all of the elements required per the current CMS guidance.

Based on policy review, medical record review, observation, and interview, the facility failed to honor the right to self-determination related to resident's choices for bathing and personal hygiene for 1 of 4 sampled residents (Resident #1) reviewed for choices. The findings include: Review of the facility's policy titled, Resident Rights, dated 5/6/2021, revealed .The resident has a right to a dignified existence, self-determination .facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality .The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident . Review of the facility's policy titled, Tub baths and showers, dated 5/21/2021, revealed .Bathing Frequency-Tub baths or showers will be scheduled at least two .times per week based on resident preferences .Tub baths and showers provide personal hygiene, stimulate circulation, and reduce tension for a patient .also allow observation of the condition of a patient's skin . Review of the facility's policy titled, Dignity, dated 8/3/2021, revealed .Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff .must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices .must respect the resident's individuality .honor and value their input .Considering the resident's lifestyle and personal choices identified through their assessment processes to respect and accommodate his or her individual needs and preferences . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 was cognitively intact and required staff assistance for all activities of daily living (ADLs) except eating. Review of the comprehensive Care Plan dated 1/14/2022, revealed .ADL self-care performance deficit .Bathing/Showering .Monday and Thursdays (2-10 shift) .requires assist of 1 staff with all bathing/showering . Review of the facility's Documentation Survey Report dated 1/2022, revealed Resident #1 was scheduled for showers on the second shift, from 2:00 PM to 10:00 PM. Resident #1 did not receive a shower on 1/13/2022 (Thursday), 1/17/2022 (Monday), and 1/20/2022 (Thursday). Review of the Documentation Survey Report dated 2/2022, revealed Resident #1 was scheduled for showers on the second shift, from 2:00 PM to 10:00 PM. Resident #1 did not receive a shower on 2/3/2022 (Thursday). Observation and interview in the resident's room on 2/16/2022 at 9:10 AM, revealed Resident #1 sat in her wheelchair in front of her sink, she was fully clothed, and appeared neat and clean. Resident #1 confirmed that she often sat in a soiled brief for 20 to 30 minutes after she pushed her call bell. Resident #1 confirmed that she did not receive showers according to her preference on her scheduled shower days. Resident #1 confirmed that not receiving timely personal hygiene care and showers according to her preference made her feel dirty. During an interview on 2/16/2022 at 5:43 PM, the Administrator confirmed that residents should receive a bath or shower according to their preference and should not have to wait long periods of time to receive personal hygiene care.

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to prevent pressure ulcers/injuries for 1 of 3 sampled residents (Resident #1) reviewed for pressure ulcers/injuries. The findings include: Review of the facility's undated policy titled, Area of Focus: Basic Skin Management, revealed .the facility must ensure that a resident receives care consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical conditions demonstrate they were unavoidable .All residents have preventative measures in place .incontinent care provided . Review of the facility's policy titled, Documentation & [and] Assessment of Wounds, dated 8/23/2021, revealed .To guide the associates and licensed nurse in the assessment of wounds to include pressure ulcer/injuries .A wound assessment/documentation is required to occur at a minimum 'weekly' .Nurses .would perform a prn [as needed] assessment/documentation if noted change has occurred . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 was cognitively intact and required staff assistance for all activities of daily living (ADL) except eating. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .CLEAN COCCYX WITH NS [normal saline]. APPLY XWEROFORM [Xeroform] [a nonadherent petroleum gauze] AND COMPOSITE DRESSING [soft non-woven fabric coated with hypoallergenic acrylic adhesive and an absorbent pad] .Mon [Monday], Wed [Wednesday], Fri [Friday] related to PRESSURE ULCER OF SACRAL REGION, STAGE 2 . During an interview on 2/16/2022 at 9:10 AM, Resident #1 confirmed she had some places on her buttock and a slit on her bottom which the Treatment Nurse told her was caused by sitting in a soiled brief for long periods of time. Resident #1 was asked when the Wound Nurse told her this. Resident #1 stated, Last week or the week before .not sure of the exact day . During an interview on 2/16/2022 at 11:33 AM, the Treatment Nurse confirmed Resident #1 had some shearing on her left buttock that was resolved when she observed it that morning. The Treatment Nurse stated, She now has a split on her coccyx .identified today .called the Doctor and got an order to treat .almost like a hairline . The Treatment Nurse confirmed she thought the hairline split was caused from wiping the resident's sacral area. Observation in the resident's room on 2/16/2022 at 12:38 PM, revealed Resident #1 pressed her call light for staff assistance. The call light was not answered until 12:58 PM, 20 minutes later. Review of a Wound Observation Tool dated 2/16/2022, revealed Resident #1 had newly developed facility acquired Stage 2 pressure ulcer/injury to her coccyx which was 3 centimeters (cm) long, 0.4 cm wide, and 0.1 cm deep. Review of a Progress Note dated 2/16/2022 at 1:30 PM, revealed .Noted pressure injury to coccyx .Resident has had diarrhea today. Possible cause with increased cleaning . Observation during wound care in the resident's room on 2/16/2022 at 2:03 PM, revealed Resident #1 had a stage 2 pressure injury to her coccyx, and not a hairline split. During an interview on 2/16/2022 at 5:43 PM, the Administrator confirmed that residents should not have to wait 20 minutes or longer for their call light to be answered and they should not have to wear a soiled brief for long periods of time. The Administrator confirmed that prompt incontinence care was crucial for prevention of pressure ulcers/injuries.

Based on policy review, video camera footage review, facility investigation review, Weather Website review, medical record review, observation, and interview, the facility failed to supervise vulnerable confused residents who were at risk for wandering and elopement and failed to thoroughly investigate elopements for 4 of 4 sampled residents (Resident #1, #2, #3, and #4) reviewed for wandering and elopement, which resulted in Immediate Jeopardy for Resident #1, #2, #3 and #4. Resident #1 exited the facility through the B Hall Exit Door and was located in the back parking lot, standing next to a car. She had ambulated approximately 109 feet unsupervised. Resident #2 exited her room, wearing only an open red silky gown, walked approximately 35 feet over landscaped gravel and grass to the front parking lot, and attempted to get into a car unsupervised. Resident #3 exited the facility through the B Hall Exit Door, ambulated unsupervised in the parking lot for approximately 120 feet, and was found standing next to a Maintenance Truck. Resident #4 exited the facility through the B Hall Exit door, ambulated 140 feet in the parking lot and back driveway, and was unsupervised outside the facility for an undetermined amount of time. Adjacent to the parking lot and driveway is a heavily wooded area with a large drainage ditch. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/18/2021 at 5:09 PM, in the Family Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, F-689, F-835, and F-867. The facility was cited at F-689 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 12/12/2020 through 8/22/2021. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 8/19/2021 at 12:29 PM, and was validated onsite by the surveyors on 8/20/2021 - 8/23/2021 through observations, review of audits, meeting minutes, and staff interviews. The findings include: Review of the facility's policy titled, Unsafe Wandering and Elopement, dated 12/13/2018, revealed .To promote Resident safety and reduce unsafe wandering and elopements by proactively identifying .monitoring of Resident .Avoidable Accident .Identify .Evaluate .Implement interventions .Monitor the effectiveness .Wandering may become unsafe .enters an area that is physically hazardous .Elopement drills will be conducted at least quarterly . Review of the facility's policy titled, Event Management System Policy, dated 5/15/2020, revealed .Event Management includes .Elopement/Wandering .the nurse will document an event note, update the care plan .will initiate the incident report .internally reporting to supervisor .Physician and Residents Legal Representative .Externally reporting to state agency as required .Each event will be thoroughly investigated . Review of the facility's policy titled, Unsafe Wandering and Elopement Prevention, revised 6/29/2021, revealed .Elopement drills will be conducted at least quarterly . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction Affecting the Right Dominant Side, Transient [CONDITION(S)], Cerebral Ischemic Attack, Dementia, Chronic Kidney Disease, Pulmonary Hypertension, Pericardial Effusion, and [CONDITION(S)]. Review of the Physician's Order dated 7/30/2021, revealed Resident #1 had a Wanderguard (a mechanical bracelet device that will cause the door to alarm when the resident gets close to the door) on her right ankle. Review of the Care Plan for Resident #1 dated 7/30/2021, revealed .at risk for elopement .wanders and has poor cognition due to dx [diagnosis] of dementia . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment, and was assessed to have wandering behaviors on 1 to 3 days of the 7 day look back period. Review of the Progress Note dated 8/7/2021, revealed there was not a note present which documented Resident #1's elopement from the facility on 8/7/2021. Review of the Progress Note dated 8/17/2021 revealed, .On Aug [August] 7 [2021] around 5pm [5:00 PM] resident got outside of building and alarm sounded. Staff assisted her back in without incident. Family and MD [Medical Doctor] aware . Review of the medical record, revealed the facility failed to document accurate progress notes, complete an Incident Report, and perform a thorough investigation. Review of the facility's video camera footage of the B Hall Exit Door dated 8/7/2021, revealed the following: a. At 4:50 PM, Resident #1 exited the B Hall Exit Door unsupervised, holding a folded blanket, wearing long pants, a shirt, and shoes. b. At 4:51 PM, Resident #1 walked down the entire sidewalk to the parking lot. Resident #1 walked to the right and was then out of view of the video camera. c. At 4:51:48 (seconds) PM, the video camera footage revealed Licensed Practical Nurse (LPN #1) exited the B Hall Exit Door. d. At 4:52 PM, LPN #1 walked to the end of the sidewalk leading to the parking lot walked to the right and was out of view of the video camera. e. At 4:52:53 (seconds) PM, Resident #1 and LPN #1 reentered the video camera view of the sidewalk to the parking lot. Holding Resident #1's arm LPN#1 escorted the resident up the sidewalk. f. At 4:53 PM, Resident #1 and LPN #1 entered the building through the B Hall Exit Door. Review of the TimeandDate.com weather service records documented the recorded temperature on 8/7/2021 at 4:55 PM, was 86 degrees Fahrenheit. Review of the facility's WITNESS INTERVIEW/STATEMENT FORM, dated 8/16/2021 and conducted by the Director of Nursing (DON), revealed Resident #1 eloped on 8/7/2021. LPN #1 heard the door alarm, went to the door and outside the facility. LPN #1 saw Resident #1 in the parking lot and assisted her back into the building. The witness statement documented that on 8/7/2021 LPN #1 notified the on-call Registered Nurse (RN #2). Review of the Incident Report dated 8/18/2021, documented that on 8/7/2021 at approximately 4:51 PM, Resident #1 went outside the facility to the parking lot and was assisted back into the building. Review of the facility's investigation revealed a handwritten statement dated 8/20/2021 by LPN #1 (13 days after the elopement on 8/7/2021), .I didn't see her so I went out the end door to the back parking lot and saw [Named Resident #1] standing by a white car . Review of the Elopement Drill sign in sheets revealed, Elopement Drills were completed on 4/24/2019, 12/14/2020, 2/24/2021, and 5/15/2021 and were not conducted quarterly per facility policy. During an interview on 8/16/2021 at 1:37 PM, LPN #1 confirmed Resident #1 walked out the B Hall Exit Door unsupervised, was outside the building, and was located by a car in the back parking lot. LPN #1 confirmed she found Resident #1 and brought her back into the building. During an interview on 8/16/2021 at 1:48 PM, Confidential Staff Member #2 confirmed RN #2 was notified of Resident #1's unsupervised elopement from the facility on 8/7/2021, and was instructed by RN #2, Not to do anything [related to the elopement]. Observations in the resident's room on 8/17/2021 - 8/22/2021, revealed the resident was in the COVID-19 unit as she had tested positive for COVID-19 on 8/14/2021. Multiple nurses reported she had not been feeling well and her appetite was poor. Random observations showed the resident in bed, covered in a blanket with her eyes closed and no evidence of wandering behavior. During an interview on 8/17/2021 at 12:33 PM, the DON confirmed the on-call nurse, RN #2, did call her on 8/7/2021 regarding the incident. Observation and interview on 8/17/2021 at 4:15 PM, at the location where Resident #1 was found when she eloped on 8/7/2021, revealed the Maintenance Director used a measuring device to measure the distance from the B Hall Exit Door, down the sidewalk to the back parking lot. The distance measured was approximately 109 feet. LPN #1 confirmed Resident #1 was on the left side of a parked car at the passenger door, in the back parking lot. During an interview on 8/19/2021 at 12:51 PM, RN #2 confirmed that staff should document any witnessed or unwitnessed event that occurred in the facility. Staff should chart the event, call the family and physician, complete an incident report, and notify the supervisors. RN #2 also confirmed she was on call the weekend of 8/7/2021 and received a call from the Activities Director related to Resident #1. RN #2 confirmed she spoke with the DON on 8/7/2021, regarding the incident, and Resident #1 was placed on 1 on 1 staff observation at that time. RN #2 confirmed she called LPN #1 to inform her of what action she should take after talking with the DON. RN #2 was asked if LPN #1 told her that Resident #1 was outside the building and had to be returned inside the building by staff. RN #2 stated, Not that I recall . During an interview on 8/19/2021 at 1:16 PM, the Activity Director stated that Resident #1 was at the door but did not leave the facility. The Activity Director confirmed LPN #1 was very busy with Resident #1 at that time, so she telephoned the DON. She confirmed the DON instructed her to call the on-call nurse, RN #2. Later in the interview, the Activity Director admitted that she had told RN #2 that Resident #1 had left the building and was brought back into the building by LPN #1. Review of the medical record revealed, Resident #2 was admitted to the facility on [DATE] with diagnoses of Dementia, Hypertension, Anxiety, Major Depressive Disorder and Cerebral Infarction. Review of the Care Plan for Resident #2 dated 4/3/2020, revealed .at risk for elopement Related/To [related/to] wandering aimlessly Review of the Progress Note dated 12/23/2020, revealed . [Named family member] made aware of climbing out [window] thinking she show [saw] her family. No injuries noted. Review of the facility's WITNESS INTERVIEW/STATEMENT FORM, dated 12/23/2020 at 3:32 PM, and written by the Executive Director, revealed .spoke with [Named Certified Nursing Assistant (CNA) #1] after she assisted [Named Resident #2] back into the facility .[Named CNA #1] stated that she was coming in to get a Covid test and rang the doorbell. As she was waiting for someone to open the door she looked over and saw a red robe. She quickly realized it was [Named Resident #2] and she ran to get her. They met on the sidewalk and [Named CNA #1] assisted her back into the facility . Review of the medical record, revealed no additional progress notes related to this incident of elopement. Review of the TimeandDate.com weather service records documented the recorded temperature on 12/23/2020 between 1:00 PM and 4:00 PM, ranged from 55 - 59 degrees Fahrenheit. Review of the Elopement Risk Evaluation dated 1/20/2021, revealed .Does the resident have a history of Elopement while .exit seeking behavior .checking doors, windows .history of leaving facility without supervision, or history of leaving facility without informing staff .No [Filled in circle] . Review of the Physician's Order dated 1/22/2021, revealed Resident #2 had a Wanderguard on the right ankle. Review of the quarterly MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 4, which indicated she had severe cognitive impairment. Resident #2 required limited assistance for Activities of Daily Living (ADLs), had no impairment of Range of Motion (ROM), and used a wander/elopement guard. Review of the Incident Report dated 8/18/2021, revealed Resident #2 climbed out the window on 12/23/2020 and was brought back into the facility by staff members. She was placed on 1 on 1 supervision until a window alarm could be placed on her window. Observation in the resident's room on 8/16/2021-8/23/2021, revealed Resident #2 was pleasantly confused and sat in her recliner next to the bed frequently. She and her roommate were very friendly with each other and expressed they were great for each other. She smiled frequently, was cheerful, and enjoyed talking with the roommate. Resident #2 did not express any concerns with the care provided by the facility. With laughter, Resident #2 denied she ever climbed out a window. During an interview on 8/16/2021 at 1:56 PM, LPN #1 confirmed Resident #2 climbed out of the window in Room 126 and it was cold outside. LPN #1 confirmed she did not complete an Incident Report because the Executive Director and the DON had looked at the cameras, and said it was not enough time for her to be out of sight or to do anything. During a telephone interview on 8/17/2021 at 9:04 AM, CNA #1 confirmed she was in the facility on 12/23/2020 to do a COVID-19 test. CNA #1 confirmed she rang the doorbell at the front door for entry and while waiting for staff to open the door she saw Resident #2 to her left. The resident was at the vehicles in the front parking lot, looking inside, and trying to get into a car. CNA #1 confirmed the resident was wearing only a red silky gown that was open in the front with 2 unmatched shoes. CNA #1 confirmed she did not know the length of time Resident #2 had been outside as she did not see her climb out the window. CNA #1 confirmed she was aware Resident #2 climbed out the window when she returned the resident to her room and the window was open. CNA #1 reported the occurrence to the Charge Nurse when she entered the building with Resident #1. CNA #1 confirmed she wrote her own witness statement before she left the building that day. The facility was unable to provide the witness statement that CNA #1 stated she provided to the DON related to this incident. During an interview on 8/17/2021 at 10:46 AM, the Social Worker confirmed Resident #2 had climbed out of the window and the Social Worker had requested a window alarm for the window. Observation on 8/17/2021 at 4:40 PM, at the approximate location where Resident #2 was found when she eloped on 12/23/2020, revealed the Maintenance Director used a measuring device to measure the distance from Resident #2's window to a parked car in the front parking lot. There was a city side street immediately behind the front parking lot. The distance measured was approximately 35 feet. A side street was located directly behind the front parking lot. During an interview on 8/18/2021 at 9:11 AM, Residents #2's daughter-in-law stated, I was told she escaped in the nude, running down the street naked and looking for her husband. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] Brain Injury, Anxiety, Chronic Obstructive Pulmonary Disease, Hallucinations, and Dementia with Behavioral Disturbance. Review of the Care Plan for Resident #3 dated 4/8/2021, revealed .At risk for wandering and elopement . Review of a Physician's Order dated 4/12/2021 revealed .Wander guard to right ankle . Review of the 5-day admission MDS dated [DATE], revealed Resident #3 had a BIMs score of 3, which indicated severe cognitive impairment, required extensive assistance with most ADL's, and had no impairment with ROM. Resident #3 had hallucinations, behavioral symptoms not directed toward others, wandering behavior that occurred daily, and a wander/elopement alarm was used daily. Review of the Progress Notes dated 4/20/2021, revealed .Resident opened door alarm was heard staff assisted resident back to room, wander guard in place . There was no documentation in the Progress Notes dated 4/20/2021 at 10:40 AM that Resident #3 eloped through the B Hall Exit Door and was out of the facility for an undetermined amount of time. Review of the Progress note dated 4/20/2021 at 3:08 PM, documented Referral sent to [Named Behavioral Facility] . Review of the Physician's Order dated 4/20/2021 at 7:02 PM, revealed, .Transfer resident to [Named Behavioral Facility] . Review of the medical record documentation dated 4/20/2021, revealed the facility failed to document accurate progress notes, complete an Incident Report, and conduct a thorough investigation. Review of the TimeandDate.com weather service records documented the recorded temperature on 4/20/2021 at 10:35 AM, was 54 degrees Fahrenheit. Review of an undated/untimed written witness statement revealed LPN #2 confirmed Resident #3 eloped through the B Hall Exit Door and was standing by a Maintenance Truck. LPN #2 confirmed it was reported to the DON in her written statement. During an interview on 8/16/2021 at 10:52 AM, LPN #2 confirmed Resident #3 was a wandering resident. LPN #2 confirmed she heard an alarm on the B Hall but did not see Resident #3 on the hall. LPN #2 looked in Resident #3's room and she was not in the room. LPN #2 then went to the B Hall Exit Door, went outside, and did not see Resident #3 so she came back inside the building to recheck Resident #3's room. LPN #2 confirmed the blinds were up on the window in Resident #3's room and through the window she saw Resident #3 in the back parking lot next to a Maintenance Truck, trying to open the door on the passenger side of the truck. LPN #2 confirmed she then went outside to bring Resident #3 back into the building. LPN #2 confirmed she reported this incident to the DON. During an interview on 8/16/2021 at 11:18 AM, Confidential Staff Member #1 confirmed the DON was made aware of Resident #3's elopement from the facility. Confidential Staff Member #1 stated, [Named DON] said we don't want to draw attention [to Resident #3's elopement]. Observation on 8/17/2021 at 4:50 PM, at the approximate location where Resident #3 was found on 4/20/2021, the Maintenance Director used measuring device to measure the distance from the B Hall Exit Fire door, down the sidewalk, and into the back parking lot. The distance measured was approximately 120 feet. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia with Behavioral Disturbances, Coronary Artery Disease, Hypertension, Anxiety, Major Depressive Disorder, [CONDITION(S)], Cognitive Communication Deficit, Dysphagia, and Cardiac Pacemaker. Review of an Elopement Risk Evaluation dated 12/8/2020, revealed Resident #4 was not at risk for elopement. Review of the Progress Notes dated 12/12/2020, revealed .resident noted to go out end door to parking lot. CNAs proceeded to exit the building and assisted resident [Resident #4] back inside to room and resident went to bed stating she was tired. 1 on 1 care provided at this time . Review of the 911 DISPATCHED EVENT SUMMARY, dated 12/12/2020, revealed a 911 call was made from LPN #4 stating there was an elderly woman in the parking lot of the facility that was lost, confused, and not one of their patients. The report shows an officer was dispatched at 9:06 PM. At 9:08 PM, the facility called 911, canceled the officer and stated the woman found in the parking lot was indeed one of their residents. The call was cleared, and the law officer did not continue to the facility. Review of the facility's incident report dated 12/12/2020 at 9:10 PM, revealed .Elopement .CNAs notified per laundry personnel end door alarm was sounding, CNAs ran outside and noted Resident [Resident #4] standing in parking lot and assisted back inside to room .Resident stated she was looking for her van . Review of the facility's investigation revealed a witness statement written by RN #2 dated 12/12/2020 at 9:05 PM, .I was summoned by [Named LPN #4] to go with her outside to back parking lot. Someone had just called on facility phone to say that a woman was in the back parking lot lost and looking for her van. The caller believed the woman was a resident here at [Named Facility]. Upon walking outside and talking with the woman, [Named LPN #4] and I determined she was not a resident here and [Named LPN #4] notified Law Enforcement to come and assist the woman. The caller then assisted the woman into his vehicle as [Named LPN #4] and I headed back inside facility. 2 other staff from [Named Nursing facility] came towards us walking to the woman and stated she belonged on their side of the building . Review of the TimeandDate.com weather service records confirmed the recorded temperature on 12/12/2020 at 9:03 PM, was 43 degrees Fahrenheit. Review of a Physician's Order dated 12/13/2020, revealed .Wander guard to right ankle for safety .1st shift to check placement and working . The Care Plan revised on 12/13/2020, revealed Resident #4 was at risk for elopement. Review of an Elopement Risk Evaluation dated 12/13/2020, revealed Resident #4 was determined to be at risk for elopement. Review of the 5-day admission MDS dated [DATE], revealed Resident #4 had a BIMS score of 6, indicating she was severely cognitively impaired for decision making. Resident #4 was coded for wandering that occurred 1 to 3 days a week. She required limited assistance with most ADL's and had no impairment with ROM. Review of the medical record, revealed the facility failed to document accurate progress notes. During a telephone interview on 8/17/2021 at 9:21 AM, LPN #3 confirmed she was Resident #4's nurse on 12/12/2021. LPN #3 stated, I was at the Nurses' Station and the alarm went off at the end door [B Hall Exit Door] .CNAs immediately went down there where she had walked out and she was walking down the ramp at the end of the hall .I think that's where they said .not going to swear to that .I think the CNAs were [Named CNA #3 and CNA #2] . LPN #3 confirmed that she did not observe Resident #4 exit the facility but heard the B Hall Exit Door alarm sound. LPN #3 confirmed Resident #4 had exit-seeking behaviors prior to this incident of elopement. LPN #3 stated, .She wasn't 1 on 1, we just knew that we needed to watch her close .could be asleep one minute and the next minute was down the hall in someone's room. LPN #3 stated, .got her in, checked her out, notified everybody .[Named DON] .talked to her several times about it . LPN #3 confirmed the time she charted the incident was immediately after it occurred, that it was dark outside, and the temperature was cool. LPN #3 confirmed Resident #4 was wearing pants, a short sleeve shirt, and shoes but was not wearing a jacket. During an interview on 8/17/2021 at 9:52 AM, CNA #2 confirmed he was working on 12/12/2020 when Resident #4 exited the facility. CNA #2 stated, I was here .I had walked into the Activity Room .[Named Housekeeper] had come down and said the alarm was going off, do you know why .I said it should not be going off .she said the only room that looks different is [Named Resident #4]'s room .she is not in there .we went and looked in the room and she wasn't in there .Code Green [the facility code for an elopement] was called . CNA #2 confirmed he did not hear the alarm sounding in the Activity Room with the doors closed. CNA #4 confirmed he did not go outside but remained in the building, checking rooms, and looking for Resident #4. CNA #2 was asked if he remembered the amount of time that lapsed from when the Housekeeper came and got him until the resident was located. CNA #2 stated, It was pretty quick .I would say 7-10 minutes. CNA #2 stated, . [Named Resident #4] was pretty agitated that night .pretty quick on her feet . During an interview on 8/17/2021 at 11:22 AM, the Executive Director confirmed the DON was responsible for elopement incident reports, investigations, and reporting. The Executive Director confirmed she was not made aware of Resident #1's elopement on 8/7/2021 until 8/16/2021, and that she should have been made aware of the incident when it happened. The Executive Director confirmed that she had watched the video camera footage and that Resident #1 was outside the facility unattended. The Executive Director confirmed that an incident report and an investigation into the incident should have been completed. The Executive Director stated, We did not define it as an elopement because the alarm sounded, and they went and got her. The Executive Director was asked if the incident where Resident #2 exited the facility through window in her room should have been investigated, documented, and reported. She stated, It was investigated, it was charted on, but she was never without eyes on her. The Executive Director stated, [Named CNA #1] .she looked over and saw her climbing out the window[the CNA stated she did not see Resident #2 climbing out the window in her interview] .I watched it on camera . The Executive Director confirmed she did not know if CNA #1 had written a witness statement regarding the incident. The Executive Director stated, I watched it on camera .as far as her writing it out [witness statement] I don't know. The Executive Director confirmed she did not know if Resident #2 climbing out of the window was visible on the camera footage. The Executive Director was asked if she was aware of Resident #3's elopement from the facility through the B Hall Door. She stated, Yes, she was only here for a short time .had some behaviors .we were monitoring her on that date .she opened the door .[Named CNA #2] heard it .she was on the hall .brought her back inside . The Executive Director stated she could not remember if she had interviewed LPN #2 about the incident, nor if LPN #2 had written a witness statement. She confirmed LPN #2 should have written a witness statement. The Executive Director stated, .We didn't define it as elopement, we defined it as behaviors .part of exit-seeking behaviors . The Executive Director confirmed that going from the facility to the parking lot unsupervised was unsafe. She stated, .in our discussion everything, our systems worked, as far as elopement systems .alarms .we term it differently because as far as elopement, they get off the premises, they get out and get hurt .or get out and we don't know they're gone .didn't think about it as elopement . The Executive Director was asked about the incident where Resident #4 exited the facility unsupervised on 12/12/2020. She confirmed she was made aware of that occurrence. She stated, .We did find some [NAME] in the way they reacted .she [Housekeeper] should have went out herself .did some education .put a louder buzzer on that door down there so if you're in a resident's room [can hear the alarm] . The Executive Director confirmed she was ultimately responsible for ensuring the regulations were followed in the facility. During a telephone interview on 8/17/2021 at 1:11 PM, LPN #4 confirmed she worked the night Resident #4 eloped from the facility. LPN #4 stated, She was on the other side of the building [facility] .she wasn't my resident .another nurse [could not remember which nurse] came and got me .she [Resident #4] was walking in the back parking lot .she had walked through the back parking lot behind the Dining Room and made it right past our back door where C Hall comes out .short hall on the C/D side .There was a person, not a staff member, someone from the community that had stopped . LPN #4 denied Resident #4 got in the vehicle with the motorist. LPN #2 stated, The staff member couldn't get her to come back in so she asked the community people to watch her so she could run to the building and get some help .I went outside with that staff member .the hall she came from, those girls came out and walked her back in . LPN #4 was asked approximately how long the resident was out in the parking lot. LPN #4 stated, She couldn't have been out there very long .would say she wasn't out over 10 minutes at the most .very confused and trying to go home . Observation on 8/17/2021 at 4:30 PM, at the approximate location where Resident #4 was found on 12/12/2020, the Maintenance Director used a measuring device to measure the distance from the B Hall Exit Door to the C Hall Exit Door, down the sidewalk to the back parking lot and across the driveway. The distance measured was approximately 140 feet. During an interview on 8/17/2021 at 5:03 PM, Housekeeper #1 confirmed she vaguely remembered the incident where Resident #4 got out of the facility. She stated, .Somebody called and said there was a resident in the back parking lot .they went to see and the back door on B Hall was going off [Exit Door alarm] but it was too low to hear, so they went out and got her .someone in a car that was passing by [called the facility] .I was taking linen to the closet and the nurse told me about the call [unsure which nurse] .I told the nurse on A/B Hall .opened the door [double doors to B Hall] and you could barely hear it [alarm] . During a telephone interview on 8/18/2021 at 8:24 AM, the Director of Business Development stated, She [Resident #4] got out in the back parking lot .someone saw her in the back parking lot, pulled in and got her .they [Police] were called .Best I remember they [passersby] pulled around the front of the facility .We did 1 on 1 and I actually sat with her .until we could find placement . During a telephone interview on 8/18/2021 at 8:46 AM, the Sheriff's Department Dispatcher stated, All we have is showing it [Resident #4's elopement] was called in and then was called back to say disregard, it was one of the residents .found in the parking lot .[Called in by] one of the workers . During an interview on 8/19/2021 at 12:51 PM, RN #2 stated, .there was a woman in the parking lot we helped out back .there was some people stopped .it was dark out which is what prompted the people to stop .I was out there with [Named LPN #4] .she didn't want to go out there alone .the people said they called [Named Nursing Facility] .that's how we knew she was out there .we didn't know her because she was from the other side [Hall B]. RN #2 was asked if the resident got in the car with the motorist. RN #4 stated, I don't recall .we said we need to check with the other side and see if she was from the other side . Refer to F-600, F-609, F-610, F835, and F867. The surveyors verified the Removal Plan by: 1. Resident #3 was discharged from the facility on 4/20/2021. 2. Resident #4 was discharged from the facility on 12/20/2020. 3. By 8/18/2021, Resident #2 had an Incident Report completed, an Elopement Assessment completed, Behavior Management flowsheets reviewed, resident profile Care Plan was reviewed and updated, and the Elopement Book was reviewed with Resident #2's picture in place by a Licensed Nurse. Resident #1 had an Incident Report completed, an Elopement Assessment completed, Behavior Management flowsheets reviewed, resident profile Care Plan was reviewed and updated, and the Elopement Book was reviewed with Resident #1's picture in place by a Licensed Nurse. The surveyors reviewed the Incident Reports, Elopement Assessments, Behavioral Management sheets, Care Plans, and Profile Cards. 4. On 8/18/2021, the Executive Director, DON, and Interdisciplinary Team completed a Root Cause Analysis (RCA). The surveyors reviewed the Root Cause Analysis conducted by the Executive Director and DON. 5. By 8/18/202, the DON/Assistant Director of Nursing (ADON)/Staff Development Coordinator (SDC)/Minimum Data Set Coordinator (MDSC) and/or Licensed Nurse completed 100 percent (%) of at risk for elopement assessments of all active residents and updated resident's Behavior Management flowsheets, behavior Care Plan, resident profile Care Plan, and Elopement Books as indicated. No errors were identified. The Activities Director reviewed

Based on policy review, video camera footage review, Weather Website review, 911 Dispatched Event Summary, medical record review, observation, and interview, the facility failed to provide a safe environment to prevent neglect for 4 of 4 sampled residents (Resident #1, #2, #3, and #4) with wandering and exit-seeking behaviors. The facility's failure to provide care and services to prevent neglect resulted in Immediate Jeopardy (IJ) when Resident #1, a cognitively impaired, vulnerable resident, exited the facility unsupervised and approximately 2 minutes later was located by staff in the back parking lot of the facility standing next to a vehicle; when Resident #2, a cognitively impaired, vulnerable resident, exited the facility through the window in her room and was located by staff an undetermined amount of time later standing in the front parking lot which was adjacent to a side street unsupervised looking into a car window; when Resident #3, a cognitively impaired, vulnerable resident, exited the facility unsupervised and was found by staff an undetermined amount of time later standing next to a vehicle in the back parking lot of the facility; and when Resident #4, a cognitively impaired, vulnerable resident, exited the facility unsupervised for an undetermined amount of time and was found by a motorist in the back parking lot of the facility which was adjacent to a heavily wooded area that had a drainage ditch. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-600 on 8/18/2021 at 5:09 PM, in the Family Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited F-600 at a scope and severity of K, which is Substandard Quality of Care. The IJ was effective from 12/12/2020 through 8/22/2021. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 8/19/2021 at 12:29 PM, and was validated onsite by the surveyors on 8/20/2021 through 8/23/2021 through review of the Incident Reports, Root Cause Analysis, assessments, behavior management flowsheets, care plans, elopement book, audit tools, policies and procedures related to elopement, abuse/neglect, event management system, behavior management, resident rights, in-service records, observations, and staff interviews. The findings include: Review of the facility's undated policy titled, RESIDENT BILL OF RIGHTS 2016, revealed .The resident has the right to be free from abuse, neglect . Review of the facility's policy titled, Protection of Residents: Reducing the Threat of Abuse & [and] Neglect, dated 5/15/2020, revealed .Each resident has the right to be free from abuse, neglect .by anyone .Identify, assess, care plan appropriate interventions, and monitor residents with needs and behaviors which might lead to .neglect, such as .Wandering .Neglect .means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person . Review of the facility's policy titled, Unsafe Wandering and Elopement Prevention, revised 6/29/2021, revealed .Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy titled, Incident and Reportable Event Management, dated 7/19/2021, revealed .Some residents have a heightened vulnerability to hazards in the resident environment .The facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision .to each resident to prevent avoidable accidents . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 7/30/2021, revealed Resident #1 was at risk for elopement and wandering, had impaired cognition, and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment for decision making, and had wandering behaviors on 1 to 3 days of the 7-day look back period. Review of the facility's video camera footage of the B Hall Exit Door dated 8/7/2021, revealed the following: a. At 4:50 PM, Resident #1 exited the B Hall Exit Door unsupervised wearing pants, a shirt, and shoes, and holding a folded blanket. b. At 4:51 PM, Resident #1 walked the length of the sidewalk to the parking lot, walked to the right and was then out of view of the video camera. c. At 4:51:48 (seconds) PM, Licensed Practical Nurse (LPN) #1 exited the B Hall Exit Door to the back parking lot. d. At 4:52 PM, LPN #1 walked the length of the sidewalk to the parking lot, then walked to the right and was no longer visible on the video camera screen. e. At 4:52:53 (seconds) PM, Resident #1 and LPN #1 reappeared on the video camera screen from the parking lot and walked to the sidewalk. LPN #1 was holding Resident #1's arm. f. At 4:53 PM, Resident #1 and LPN #1 entered the facility at the B Hall Exit Door. Review of the TimeandDate.com weather service records revealed the recorded temperature for 8/7/2021 at 4:55 PM, was 86 degrees Fahrenheit. Review of the Progress Notes dated 8/7/2021, revealed no documentation of Resident #1's elopement from the facility. Review of the Progress Note dated 8/17/2021, revealed .On Aug [August] 7 [2021] around 5pm [5:00 PM] resident got outside of building and alarm sounded. Staff assisted her back in without incident. Family and MD [Medical Doctor] aware . The facility did not document Resident #1's elopement from the facility on 8/7/2021 until 8/17/2021, 10 days after the incident occurred, and 1 day following the State Survey Team's entrance into the facility to investigate the incident. Review of the Facility's Incident Report dated 8/18/2021 at 8:48 PM, revealed .Elopement .On 8/7/2021 at approximately 4:51 PM, the patient [Resident #1] exited the B Hall Exit Door with alarms sounding. [Named LPN #1] responded to the alarm, went outside in the parking lot. Assisted her [Resident #1] in facility with no injuries noted . Review of the facility's investigation revealed LPN #1 wrote a statement regarding the incident on 8/20/2021 (13 days after the incident). LPN #1 confirmed she heard the alarm on 8/7/2021 but did not observe anyone leave the facility. LPN #1 went out the B Hall Exit Door to the back parking lot, saw Resident #1 standing beside a vehicle, and assisted the resident back into the building. Review of the medical record, revealed the facility failed to document accurate progress notes, complete an Incident Report, and conduct a thorough investigation. The facility did not complete an Incident Report identifying that Resident #1 eloped from the facility on 8/7/2021 until 8/18/2021, 11 days after the incident occurred. During an interview on 8/16/2021 at 1:48 PM, Confidential Staff Member #2 confirmed Registered Nurse (RN) #2 was notified of Resident #1's unsupervised elopement from the facility on 8/7/2021, and was told by RN #2, .not to do anything [related to elopement]. Observation in the resident's room from 8/17/2021 through 8/22/2021, revealed Resident #1 remained in bed with her eyes closed and covered in a blanket. Observation and interview on 8/17/2021 at 4:15 PM, at the location where Resident #1 was found when she eloped on 8/7/2021, revealed the Maintenance Director used a measuring device to measure the distance from the B Hall Exit Door, down the sidewalk to the back parking lot. The distance measured was approximately 109 feet. LPN #1 confirmed Resident #1 was on the left side of a parked car at the passenger door, in the back parking lot. During an interview on 8/19/2021 at 12:51 PM, RN #2 confirmed she was the on-call nurse on 8/7/2021 and that she received a call from the Activity Director related to Resident #1. RN #2 confirmed she called the DON and discussed the resident, and Resident #1 was placed on 1 on 1 monitoring at that time. RN #2 denied that staff reported that Resident #1 exited the facility unsupervised. During an interview on 8/19/2021 at 1:16 PM, the Activity Director confirmed that Resident #1 had exited the facility unsupervised and that she had called the DON. She confirmed that the DON instructed her to notify the on-call nurse. The Activity Director confirmed she had notified RN #2 that Resident #1 had exited the facility unsupervised. Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 4/3/2020, revealed Resident #2 was at risk for elopement and wandering. Review of the Progress Note dated 12/23/2020, revealed .[Named family member] made aware of climbing out thinking she show [saw] her family. No injuries noted. Review of the medical record, revealed no additional progress notes related to Resident #2's elopement from the facility and no documentation to determine when Resident #2 was last observed by staff prior to the elopement incident on 12/23/2020. Review of the TimeandDate.com Weather Service records revealed the recorded temperature for 12/23/2020 between 1:00 PM and 4:00 PM, ranged from 55-59 degrees Fahrenheit. Review of the Elopement Risk Evaluation dated 1/20/2021 revealed Resident #2 was assessed as an elopement risk. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 4, which indicated she had severe cognitive impairment for decision making, required limited assistance for Activities of Daily Living (ADLs), had no impairment in Range of Motion (ROM), and used a wander/elopement guard. Review of a Facility Incident Report dated 8/18/2021, revealed Resident #2 climbed through her window on 12/23/2020, exited the facility, and was brought back into the facility by staff. She was placed on 1 on 1 monitoring until an alarm could be placed on her window. Review of the medical record, revealed the facility failed to document accurate progress notes, complete an Incident Report, and conduct a thorough investigation. The facility did not complete an Incident Report identifying that Resident #2 eloped from the facility on 12/23/2020, until 8/18/2021, 8 months after the incident occurred. Observation in the resident's room from 8/16/2021 through 8/23/2021, revealed Resident #2 was pleasantly confused and frequently sat in the recliner at her bedside. During an interview on 8/17/2021 at 9:04 AM, Certified Nursing Assistant (CNA) #1 confirmed she was the staff member who observed Resident #2 in the parking lot on 12/23/2020. CNA #1 confirmed she had to be tested for COVID-19 on that day but had an appointment earlier in the day and arrived late at the facility for her test to be done. CNA #1 did not know the exact time that she arrived at the facility, but thought it was between 1:00 PM and 4:00 PM. CNA #1 stated that it was a stormy day, was cool, and the wind was blowing fairly hard. She confirmed that while ringing the facility's doorbell she looked to her left and saw Resident #2 looking inside a vehicle and trying to get inside. CNA #1 stated Resident #2 told her it was storming, and she had to get the kids at school. CNA #1 confirmed that Resident #2 willingly went into the facility with her, and she reported the occurrence to the charge nurse. CNA #1 stated, I was the only one there [in the parking lot] .no one even noticed she was gone . CNA #1 stated, Her [Resident #2] red, silky robe .half of it was unbuttoned .2 different [shoes] on . CNA #1 confirmed she did not witness Resident #2 exit through her window and was unaware how the resident had gotten out of the facility until she entered her room and saw the window open. CNA #1 stated she had written a witness statement that day after the incident occurred. The facility was unable to provide the witness statement written by CNA #1. Observation on 8/17/2021 at 4:40 PM, at the approximate location where Resident #2 was found when she eloped on 12/23/2020, revealed the Maintenance Director used a measuring device to measure the distance from Resident #2's window to a parked car in the front parking lot. There was a city side street immediately behind the front parking lot. The distance measured was approximately 35 feet. A side street was located directly behind the front parking lot. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Initial Care Plan dated 4/8/2021, revealed Resident #3 was at risk for wandering and elopement. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the 5-day admission MDS dated [DATE], revealed Resident #3 had a BIMS score of 3, which indicated severe cognitive impairment, required extensive assistance with most ADLs, had no ROM impairment, had hallucinations, behavioral symptoms not directed toward others, and daily wandering behaviors. Resident #3 used a wander/elopement alarm daily. Review of a Progress Note dated 4/20/2021, revealed .Resident [Resident #3] opened door alarm was heard staff assisted resident back to room, wander guard in place . Review of the Progress Note dated 4/20/2021 at 10:40 AM, did not reflect that Resident #3 eloped through the B Hall Exit Door unsupervised and was in the back parking lot of the facility, which is adjacent to a heavily wooded area with a large drainage ditch, for an unknown amount of time. Review of the medical record, revealed the facility failed to document accurate progress notes, complete an Incident Report, and conduct a thorough investigation. Review of the medical record revealed no additional progress notes related to Resident #3's elopement from the facility and no documentation to identify when Resident #3 was last observed by staff prior to the elopement incident on 4/20/2021. During an interview on 8/16/2021 at 10:52 AM, LPN #2 confirmed Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #2 checked Resident #3's room and she was not in the room. LPN #2 then went to the B Hall Exit Door and went outside looking for Resident #3. She still did not see Resident #3 and came back into the building to check Resident #3's room again. LPN #2 confirmed that Resident #3's window shades were raised, and at that time she saw Resident #3 in the back parking lot through the resident's window. LPN #2 confirmed she then returned outside to get Resident #3, who was standing in the back parking lot next to a Maintenance Truck. LPN #2 confirmed she reported the elopement incident to the DON. During an interview on 8/16/2021 at 11:18 AM, Confidential Staff Member #1 confirmed the DON was made aware of Resident #3's elopement from the facility. Confidential Staff Member #1 stated, .[Named DON] said we don't want to draw attention [to Resident #3's elopement]. Observation and interview on 8/17/2021 at 4:50 PM, at the approximate location where Resident #3 was found on 4/20/2021, the Maintenance Director used a measuring device to measure the distance from the B Hall Exit Fire door, down the sidewalk, and into the back parking lot. The distance measured was approximately 120 feet. LPN #2 confirmed Resident #3 was at a Maintenance Truck trying to open the door on the passenger side. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Elopement Risk Evaluation dated 12/8/2020, revealed Resident #4 was not at risk for elopement. Review of TimeandDate.com Weather service records, revealed the recorded temperature for 12/12/2020 at 8:55 PM, was 43 degrees Fahrenheit. Review of the 911 DISPATCHED EVENT SUMMARY, dated 12/12/2020, confirmed a 911 call was made from the facility stating there was a woman in their parking lot who was not a resident. At 9:08 PM the facility staff called 911 again and informed the dispatcher that the woman was a resident of the facility. The call was cancelled and an officer did not make a trip to the facility. Review of a Progress Note dated 12/12/2020 at 9:10 PM, revealed .resident noted to go out end door to parking lot. CNAs proceeded to exit building and assisted resident [Resident #4] back inside to her room .1 on 1 care provided at this time . Review of the facility's Incident Report dated 12/12/2020 at 9:10 PM, revealed, .Elopement .CNAs notified per laundry personnel end door alarm was sounding, CNAs ran outside and noted Resident [Resident #4] standing in parking lot and assisted back inside to room .Resident stated she was looking for her van . Review of the facility's investigation revealed a witness statement written by RN #2 dated 12/12/2020 at 9:05 PM, revealed, .I was summoned by [Named LPN #4] to go with her outside to back parking lot. Someone had just called on facility phone to say that a woman was in the back parking lot lost and looking for her van. The caller believed the woman was a resident here at [Named Nursing Facility]. Upon walking outside and talking with the woman, [Named LPN #4] and I determined she was not a resident here and [Named LPN #4] notified Law Enforcement to come and assist the woman. The caller then assisted the woman into his vehicle as [Named LPN #4] and I headed back inside facility. 2 other staff from [Named Nursing Facility] came towards us walking to the woman and stated she belonged on their side of the building . Review of an Elopement Risk Evaluation dated 12/13/2020, revealed Resident #4 was determined to be at risk for elopement. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan revised on 12/13/2020, revealed Resident #4 was at risk for elopement. Review of the 5-day admission MDS dated [DATE], revealed Resident #4 had a BIMS of 6, which indicated severe cognitive impairment for decision making and was coded for wandering behaviors on 1 to 3 days of the 7-day look back period, required limited assistance of staff for ADLs, and had no ROM impairment. During a telephone interview on 8/17/2021 at 9:21 AM, LPN #3 confirmed she was Resident #4's nurse on 12/12/2020 and she did not observe the resident exit the facility. LPN #3 confirmed Resident #4 had exit-seeking behaviors prior to this incident of elopement and had to be watched closely. LPN #3 confirmed the incident happened at approximately 9:00 PM, and that it was dark and cool outside that night. LPN #3 confirmed Resident #4 was wearing pants, a short sleeve shirt, and shoes, but was not wearing a jacket. During an interview on 8/17/2021 at 9:52 AM, CNA #2 confirmed he was working on 12/12/2020 when Resident #4 exited the facility. CNA #2 confirmed that he and another CNA was in the Activity Room when Housekeeper #1 came in and told them the B Hall Exit Door was alarming. CNA #2 confirmed he could not hear the B Hall Exit Door alarm sounding in the Activity Room. CNA #4 confirmed that a Code Green [the code for elopement] was paged, and he did not go outside but remained in the building, checking rooms and looking for Resident #4. CNA #2 was asked what the time frame was from when the Housekeeper came and got him until the resident was located. CNA #2 stated, It was pretty quick .I would say 7-10 minutes. During an interview on 8/17/2021 at 11:22 AM, the Executive Director confirmed that Resident #1 did exit the facility unsupervised. The Executive Director confirmed she was aware of Resident #3's elopement from the facility through the B Hall Exit Door, and stated, .We didn't define it as elopement, we defined it as behaviors .part of exit-seeking behaviors . The Executive Director confirmed that going from the facility to the parking lot unsupervised was a problem and unsafe. The Executive Director was asked about the incident where Resident #4 eloped from the facility unsupervised on 12/12/2020. She confirmed she was made aware of the incident. The Executive Director confirmed she was ultimately responsible for ensuring the regulations were followed in the facility. During an interview on 8/17/2021 at 12:33 PM, the Director of Nursing (DON) was asked if she was aware Resident #1 had exited the facility on 8/7/2021. The DON stated, Not til [until] yesterday .[she got out] Saturday, 8/7 [2021] .did get a call that day . The DON stated she did not define this incident as an elopement. The DON confirmed the incident should have been documented and investigated. The DON confirmed she was aware of Resident #2 climbing out of the window in her room. The DON confirmed she did not know if CNA #1 wrote a witness statement regarding the incident. The DON confirmed there should have been more documentation on all the elopement incidents. The DON confirmed there was a potential or likelihood for harm to residents who were out of the facility unsupervised. The DON stated she did not remember Resident #4's elopement from the facility but had reviewed the file since the State Survey Team was in the facility. The DON confirmed that Resident #4 got out of the facility into the parking lot and no one in the facility was aware she was not in the building. The DON stated, .somebody came up and found her . The DON confirmed she did not know how long Resident #4 was outside unsupervised. During a telephone interview on 8/17/2021 at 1:11 PM, LPN #4 confirmed she worked the night Resident #4 eloped from the facility. LPN #4 stated, She was on the other side of the building [facility] .she wasn't my resident .she was walking in the back parking lot .she had walked through the back parking lot behind the Dining Room and made it right past our back door .There was a person, not a staff member, someone from the community that had stopped . LPN #4 was asked approximately how long the resident was in the parking lot. LPN #4 stated, She couldn't have been out there very long .would say she wasn't out over 10 minutes at the most .very confused and trying to go home . Observation on 8/17/2021 at 4:30 PM, at the approximate location where Resident #4 was found on 12/12/2020, the Maintenance Director used a measuring device to measure the distance from the B Hall Exit Door to the C Hall Exit Door, down the sidewalk to the back parking lot and across the driveway. The distance measured was approximately 140 feet. During an interview on 8/17/2021 at 5:03 PM, Housekeeper #1 confirmed she vaguely remembered the incident where Resident #4 got out of the facility. She confirmed that someone had called the facility and notified them that they thought a resident was in the back parking lot. Housekeeper #1 confirmed that the alarm on the B Hall Exit Door was alarming but it was too low to hear. Observation and interview at the B Hall Exit Door on 8/18/2021 at 5:50 PM, revealed the Maintenance Director approached the door with a Wanderguard in his hand and the door began to alarm very loudly. The door continued to alarm until the Maintenance Director entered the access code on the keypad. He stepped back from the door with the Wanderguard, and the surveyor pushed the exit bar on the B Hall Exit Door which began to alarm very faintly. After applying pressure to the bar on the door for 15 seconds, the door alarm began to alarm very loudly. After 15 additional seconds, the B Hall Exit Door opened. The alarm sounded until the access code was entered into the keypad by the Maintenance Director. The Maintenance Director confirmed that he conducted elopement drills about every 6 months or sooner if they had an incident of elopement. During an interview on 8/20/2021 at 12:58 PM, the DON confirmed that the first, very faint sounding alarm the surveyors heard during their observation on 8/18/2021 with the Maintenance Director, was the only alarm on the B Hall Exit Door at the time when Resident #4 eloped from the facility on 12/12/2020. Refer to F-609, F-610, F-689, F-835, and F-867. The surveyors verified the Removal Plan by: 1. Resident #3 was discharged from the facility on 4/20/2021. 2. Resident #4 was discharged from the facility on 12/20/2020. 3. Resident #1 had an Incident Report completed, Elopement Assessment completed, Behavior Management flowsheets reviewed, resident profile Care Plan reviewed and updated, and the Elopement Book was reviewed with Resident #1's picture in place. The surveyors reviewed the Incident Reports, Elopement Assessments, Behavioral Management sheets, Care Plans, and Profile Cards. By 8/18/2021, Resident #2 had an Incident Report completed, an Elopement Assessment completed, Behavior Management flowsheets reviewed, resident profile Care Plan reviewed and updated, and the Elopement Book was reviewed with Resident #2's picture in place. 4. On 8/18/2021, the Executive Director, DON, and Interdisciplinary Team completed a Root Cause Analysis (RCA). The surveyors reviewed the Root Cause Analysis conducted by the Executive Director and DON. 5. By 8/18/2021, the DON/Assistant Director of Nursing (ADON)/Staffing Development Coordinator (SDC)/Minimum Data Set Coordinator (MDSC) and/or Licensed Nurse completed 100 percent (%) of at risk for elopement assessments on all active residents, updated the resident's Behavior Management flowsheets, behavior Care Plan, resident profile Care Plans, and Elopement Books as indicated. No errors were identified. The Activities Director reviewed and updated person-centered Care Plans for memory impaired residents with wandering behaviors. The surveyors reviewed all active residents for the Elopement Risk Assessments, the updated residents' Behavior Management flowsheets, Behavior Care Plans, Resident Profile Care Plans, and Person-Centered Care Plans. The surveyors reviewed the Elopement Books at each Nurses' Station and the front office, and the surveyors verified they contained face sheets and picture identification of each resident with wandering/exit seeking behaviors. 6. The Executive Director will be responsible for reviewing the abuse reporting log and compliance rounds trends and patterns. The surveyors reviewed the Abuse Reporting Log audit tool interviewed the Executive Director. 7. The Director of Social Services will be responsible for reviewing the Behavior Management flowsheets for trends and patterns. The surveyors reviewed the Behavior Management flowsheets audit tool and interviewed the Director of Social Services. 8. The Director of Nursing will be responsible for reviewing the Event Management System for trends and patterns. The surveyors reviewed the Event Management System policy and interviewed the DON. 9. The Staffing Development Coordinator (SDC) will be responsible for reviewing the Unsafe Wandering and Elopement Prevention Education for trends and patterns. The surveyors reviewed the Unsafe Wandering and Elopement Prevention Education audit tool and interviewed the SDC. 10. On 8/18/2021, the Regional Director of Clinical Services (RDCS) provided education to the Executive Director (ED) and DON on the following to ensure the abuse policies are implemented: Protection of Residents: Reducing the threat of Abuse and Neglect and Unsafe Wandering and Elopement Prevention. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed the RDCS, the Executive Director, and the DON. 11. The ED, DON, ADON, SDC, and/or Licensed Nurse will provide education to all facility staff on the following: Protection of Residents: Reducing the threat of Abuse and Neglect and Unsafe Wandering and Elopement Prevention. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed staff on all shifts. 12. The DON, ADON, SDC, and/or Licensed Nurse will provide education to all licensed nurses and certified nursing assistants on the following: Event Management System, Residents Rights, and Behavior Health Management. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed staff on all shifts. 13. Any associate who has not completed training by 8/18/2021, will not be allowed to work until training is completed. The ED, DON, SDC, and/or Licensed Nurse will provide education to all new associates upon hire during orientation. The surveyors validated staff could not return to work prior to receiving the education through review of schedules and staff interviews on all shifts. 14. By 8/18/2021, the Executive Director and/or Social Services will provide education on Unsafe Wandering and Elopement Prevention to all active residents and responsible parties by delivering a letter in person to alert and oriented residents and by mail to all resident representatives. The surveyors interviewed alert and oriented residents and called family members to verify the education had been received. 15. The Regional Vice President (RVP) and/or RDCS will be notified of any allegation of abuse and/or neglect at the time the ED or DON are notified and provide documentation that the allegation has been reported as required. The surveyors validated the action plan through interview. 16. Prior to submitting final investigation to required agencies, a member of the Regional Team (RVP, RDCS) will review investigations to ensure a thorough investigation was completed. The surveyors validated the action plan through interview. 17. The RVP will review the abuse reporting log and investigations during weekly facility visits. The surveyors validated the action plan through interview. 18. On 8/19/2021, the Medical Director reviewed and agreed with this plan of removal. The surveyors reviewed the Quality Assurance Performance Improvement (QAPI) sign-in sheet with the Medical Director's signature. 19. On 8/19/2021, a QAPI meeting was held regarding this plan of removal. The surveyors reviewed the QAPI sign-in sheet. The facility's noncompliance at F-600 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, 911 Dispatched Event Summary, medical record review, observation, and interview, the facility failed to report incidents of elopement for 4 of 4 sampled residents (Resident #1, #2, #3 and #4) reviewed for wandering and elopement. The facility's failure to report incidents of elopement and neglect to the State Survey Agency and Adult Protective Services (APS) resulted in Immediate Jeopardy when Resident #1 eloped from the facility unsupervised for approximately 2 minutes. Resident #1 exited the B Hall Exit Door, was located outside the facility in the back parking lot standing next to a car, approximately 109 feet from the facility door. Resident #2 eloped through the window in her room into the facility parking lot unsupervised for an undetermined amount of time. Resident #2 was in the front parking lot which is next to a side street, walked over landscape gravel and grass to the pavement, and walked to a car that she tried to open. This was approximately 35 feet from the facility. Resident #3 eloped from the facility through the B Hall Exit Door and ambulated to the back parking lot unsupervised for an undetermined amount of time. Resident #3 had ambulated approximately 120 feet and was found next to a Maintenance Truck. On a dark December night, Resident #4 exited the B Hall Exit Door and ambulated approximately 140 feet, unsupervised, for an undetermined amount of time. Members of the community notified the facility that Resident #4 was outside the facility and remained with her until facility staff identified that she was their resident and returned her to the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Executive Director and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/18/2021 at 5:09 PM, in the Family Room. The facility was cited Immediate Jeopardy at F-609. The facility was cited F-609 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 12/12/2020 through 8/22/2021. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 8/19/2021 at 12:29 PM, and was validated onsite by the surveyors from 8/20/2021 through 8/23/2021 through observations, review of audits, meeting minutes, and staff interviews. The findings include: Review of the facility's policy titled, Event Management System Policy, dated 5/15/2020, revealed .Provide an environment that is free from accident hazards .This includes: Identifying hazard (s) and risk (s), evaluating and analyzing .Event Management includes .the following events .Alleged abuse .neglect .Elopement/Wandering .Notification and Reporting of a Event .the facility will immediately respond to resident events .internally reporting to supervisor .Physician and Residents legal Representative .Externally reporting to state agencies .the Director of Nursing and/or the Executive Director will notify the Region/Divisional Staff event is reported to any regulatory body .the Executive Director or Director of Nursing is responsible for reporting .to the compliance department .Refer to state specific guidelines for reporting of events .elopement .the results of the investigation will be reported to external reporting agencies including the state survey . Review of the facility's policy titled, Incident and Reportable Event Management, dated 7/19/2021, revealed .An effective way for the facility to avoid accidents is to develop a culture of safety .Ensure that all alleged violations involving abuse, neglect .are reported immediately . Review of the facility's policy titled, Protection of Residents: Reducing the Threat of Abuse & [and] Neglect, dated 5/15/2020, revealed .Each resident has the right to be free from abuse, neglect .report the results of all investigations to the administrator .and to other officials in accordance with State law, including to the State Survey Agency .This facility does not condone resident abuse and/or neglect .All personnel will promptly report any incident or suspected incident of abuse and/or neglect .All associates are mandated to immediately report .Incident will be reported immediately to the administrator and the director of nursing .and to other officials including the State Survey Agency and adult protective services . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's video camera footage of the B Hall Exit Door dated 8/7/2021, revealed Resident #1 exited the B Hall Exit Door unsupervised at 4:50 PM, Resident #1 walked down the entire sidewalk, to the parking lot. At 4:52 PM, Resident #1 and Licensed Practical Nurse (LPN) #1 walked from the parking lot to the sidewalk. At 4:53 PM LPN #1 entered the building with Resident #1 at the B Hall Exit Door holding Resident #1's arm. Review of the Facility's Incident Report dated 8/18/2021, revealed on 8/7/2021 at approximately 4:51 PM, Resident #1 went outside to the parking lot and was assisted back into building. Review of the facility's investigation contained a handwritten statement by LPN #1 dated 8/20/2021, that documented .I didn't see her, so I went out the end door to the back parking lot and saw [Named Resident #1] standing by a white car . Observation and interview on 8/17/2021 at 4:15 PM, at the location where Resident #1 was found when she eloped on 8/7/2021, revealed the Maintenance Director used a measuring device to measure the distance from the B Hall Exit Door, down the sidewalk to the back parking lot. The distance measured was approximately 109 feet. LPN #1 confirmed Resident #1 was on the left side of a parked car at the passenger door, in the back parking lot. This incident of elopement on 8/7/2021, was not reported to the State Survey Agency and APS. Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Note dated 12/23/2020, revealed .[Named family member] made aware of climbing out thinking she show [saw] her family. No injuries noted. Review of the Incident Report dated 8/18/2021, revealed Resident #2 climbed out her window on 12/23/2020 and was brought back into the facility by staff. She was then placed on 1 on 1 until an alarm could be placed on her window. During an interview on 8/16/2021 at 1:56 PM, LPN #1 confirmed Resident #2 climbed out the window on 12/23/2020 and it was cold outside. LPN #1 confirmed she did not complete an Incident Report because the Executive Director and the DON looked at the cameras, and it was not enough time for her to be out of sight to do anything. During an interview on 8/17/2021 at 9:04 AM, Certified Nursing Assistant (CNA) #1 confirmed she had come to the facility on [DATE], rang the doorbell at the front door for entry, and saw Resident #2 at the vehicles in the front parking lot, looking inside the vehicles, and trying to get into a car. CNA #1 confirmed the resident was wearing a red, silky gown that was open, had no other clothing underneath the robe, and was wearing 2 different shoes. CNA #1 confirmed she didn't know how long Resident #1 had been outside because she didn't see her climb out the window. She confirmed it was determined Resident #2 climbed out the window was because the window in the resident room was open. CNA #1 reported the event to the Charge Nurse when she entered the building with Resident #1. Observation on 8/17/2021 at 4:40 PM, at the approximate location where Resident #2 was found when she eloped on 12/23/2020, revealed the Maintenance Director used a measuring device to measure the distance from Resident #2's window to a parked car in the front parking lot. There was a city side street immediately behind the front parking lot. The distance measured was approximately 35 feet. This incident of elopement on 12/23/2020, was not reported to the State Survey Agency and APS. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Notes dated 4/20/2021, revealed .Resident opened door alarm was heard staff assisted resident back to room, wander guard [a mechanical bracelet device that will cause the door to alarm when the resident gets close to the door] in place . Review of the Progress Notes dated 4/20/2021 at 10:40 AM, did not reflect that Resident #3 eloped through the B Hall Exit Door unsupervised for an unknown amount of time on 4/20/2021. The facility did not report this elopement to the State Survey Agency or APS. During an interview on 8/16/2021 at 10:52 AM, LPN #2 confirmed Resident #3 was a wandering resident. LPN #2 confirmed she heard an alarm on B Hall and did not see Resident #3 on the hall. LPN #2 checked the resident's room and she was not in the room. LPN #2 then went to the B Hall Exit Door, went outside the building, did not see Resident #3, and went back in the facility to check Resident #3's room again. LPN #2 stated the window shades were up on the window in Resident #3's room and she saw Resident #3 in the back parking lot next to a Maintenance Truck. She went outside to bring Resident #3 back into the facility. LPN #2 confirmed she reported the incident to the DON. Observation on 8/17/2021 at 4:30 PM, at the approximate location where Resident #3 was found when she eloped on 4/20/2021, revealed the Maintenance Director used a measuring device to measure the distance from the B Hall Exit Door, down the sidewalk to the back parking lot. The distance measured was approximately 120 feet. This incident of elopement on 4/20/2021 was not reported to the State Survey Agency and APS. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 911 DISPATCHED EVENT SUMMARY, dated 12/12/2020, revealed a 911 call was made from the facility by LPN #4 stating there was an elderly woman in the parking lot of the facility who was lost, confused, and not one of their residents. An officer was dispatched at 9:06 PM. At 9:08 PM, the facility called 911, cancelled the call for the officer and stated the woman found in the parking lot was a resident of the facility. The call was cancelled, and the officer did not come to the facility. Review of the facility's Incident Report dated 12/12/2020 at 9:10 PM, revealed .Elopement .CNAs notified per laundry personnel end door alarm was sounding, CNAs ran outside and noted Resident [Resident #4] standing in parking lot and assisted back inside to room .Resident stated she was looking for her van . Observation on 8/17/2021 at 4:30 PM, at the approximate location where Resident #4 was found on 12/12/2020, the Maintenance Director used a measuring device to measure the distance from the B Hall to the C Hall Exit door, and .down the sidewalk to the back parking lot. The distance measured was approximately 140 feet. During an interview on 8/19/2021 at 12:51 PM, Registered Nurse (RN) #2 stated, .there was a woman in the parking lot .some people stopped .it was dark out which is what prompted the people to stop .I was out there with [Named LPN #4] .she didn't want to go out there alone .the people said they called [Named Nursing Facility] .that's how we knew she was out there .we didn't know her because she was from the other side [Hall B]. RN #2 was asked if the resident got in the car with the motorist. RN #4 stated, I don't recall .we said we need to check with the other side and see if she was from the other side . This incident of elopement on 12/12/2020, was not reported to the State Survey Agency and APS. During an interview on 8/17/2021 at 11:22 AM, the Executive Director was asked who was responsible for reporting such events to the state or to APS. The Executive Director stated, That would be me. The Executive Director confirmed she was made aware of Resident #1's elopement on 8/16/2021. The Executive Director confirmed she should have been notified before 8/16/2021 of the elopement and that review of the camera footage showed Resident #1 was outside unattended. The Executive Director was asked if someone should have completed an Incident Report, an incident investigation, and notified the state. The Executive Director stated, No, we did not define it as an elopement . The Executive Director confirmed Resident #3's elopement was not reported to the State Agency or APS and that she was ultimately responsible for ensuring the regulations were followed in the facility. During an interview on 8/17/2021 at 12:33 PM, the DON was asked if a resident was outside, unattended and if that resident had the potential for harm. The DON stated. Yes. The DON confirmed the Executive Director makes the decisions regarding reporting occurrences to the state. The DON stated, .Now looking back on them [elopement incidents] I feel like, yeah, I could have done a better job. During an interview on 8/19/2021 at 2:42 PM, the DON confirmed Elopements are reportable to the state. Refer to F-600, F-610, F-689, F-835, and F-867. The surveyors verified the Removal Plan by: 1. Resident #3 was discharged from the facility on 4/20/2021. 2. Resident #4 was discharged from the facility on 12/20/2020. 3. By 8/18/2021, Resident #2 had an Incident Report completed, Elopement Assessment completed, Behavior Management flowsheets were reviewed, the resident profile Care Plan was reviewed and updated, and the Elopement Book was reviewed with Resident #2's picture in place by a Licensed Nurse. Resident #1 had an Incident Report completed, Elopement Assessment completed, Behavior Management flowsheets reviewed, resident profile Care Plan reviewed and updated, and the Elopement Book was reviewed with Resident #1's picture in place by a Licensed Nurse. The surveyors reviewed the Incident Reports, Elopement Assessments, Behavioral Management sheets, Care Plans, and Profile Cards. 4. On 8/18/2021, the Executive Director, DON, and Interdisciplinary Team completed a Root Cause Analysis (RCA). The surveyors reviewed the RCA conducted by the Executive Director and DON. 5. By 8/18/2021, the DON/Assistant Director of Nursing (ADON)/Staff Development Coordinator (SDC)/Minimum Data Set Coordinator (MDSC) and/or Licensed Nurse completed 100 percent (%) of at risk for elopement assessments of all active residents and updated the residents' Behavior Management flowsheets, behavior Care Plan, resident profile Care Plan, and elopement books as indicated. No errors were identified. The Activities Director reviewed and updated person-centered Care Plans for memory impaired residents with wandering behaviors. The surveyors reviewed all active residents for the Elopement Risk Assessments, the updated residents' Behavior Management flowsheets, Behavior Care Plans, Resident Profile Care Plans, and Person-Centered Care Plans. The Elopement Books at each Nurses' Station and the front office were reviewed, and the surveyors verified they contained face sheets and picture identification of each resident with wandering/exit seeking behaviors. 6. The Executive Director will be responsible for reviewing the abuse reporting log and compliance rounds trends and patterns. The surveyors reviewed the Abuse Reporting Log audit tool interviewed the Executive Director. 7. The Director of Social Services will be responsible for reviewing the behavior management flowsheets for trends and patterns. The surveyors reviewed the Behavior Management Flowsheets audit tool and interviewed the Director of Social Services. 8. The Director of Nursing will be responsible for reviewing the Event Management System for trends and patterns. The surveyors reviewed the Event Management System policy and interviewed the DON. 9. The SDC will be responsible for reviewing the Unsafe Wandering and Elopement Prevention Education for trends and patterns. The surveyors reviewed the Unsafe Wandering and Elopement Prevention Education audit tool and interviewed the SDC. 10. On 8/18/2021, the Regional Director of Clinical Services (RDCS) provided education to the Executive Director (ED) and DON on the following to ensure the abuse policies are implemented (reporting requirements), to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the Administrator, and are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to other officials (including to the State Survey Agency and adult protective services); Protection of Residents; Reducing the threat of Abuse and Neglect and Unsafe Wandering and Elopement Prevention. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed the staff, the RDCS, the Executive Director, and the DON. 11. The ED, DON, ADON, SDC and/or Licensed Nurse will provide education to all facility staff on the following (reporting requirements) to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the Administrator, and are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services): Protection of Residents: Reducing the threat of Abuse and Neglect and Unsafe Wandering and Elopement Prevention. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed staff on all shifts. 12. The DON, ADON, SDC, and/or Licensed Nurse will provide education to all Licensed Nurses and Certified Nursing Assistants on the following: Event Management System, Residents Rights, and Behavior Health Management. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed staff on all shifts. 13. Any associate who has not completed training by 8/18/2021, will not be allowed to work until training is completed. The ED, DON, SDC, and/or Licensed Nurse will provide education to all new associates upon hire during orientation. The surveyors validated staff could not return to work prior to receiving the education through staff interviews on all shifts. 14. By 8/18/2021, the Executive Director and/or Social Services will provide education on Unsafe Wandering and Elopement Prevention to all active residents and responsible parties by delivering a letter in person to alert and oriented residents and by mail to all resident representatives. The surveyors interviewed alert and oriented residents and called family members to verify the education had been received. 15. All resident comment and concern cards will be reviewed for allegation of abuse during daily stand-up meeting. The ED will be responsible for ensuring appropriate reporting and investigation. The surveyors reviewed the comment and concern cards and interviewed the Executive Director regarding the comment and concern cards. 16. On 8/19/2021, the ED posted signage by time clock identifying all allegations of abuse are to be reported to the ED immediately, with their contact number. It will also include a second person, the DON, and their contact number to be notified, when ED cannot be reached. The surveyors reviewed the signage post in the Break Room related to abuse reporting and staff telephone numbers, and interviewed staff on all shifts. 17. The Regional Vice President (RVP) and/or RDCS will be notified of any allegation of abuse and/or neglect at the time the ED or DON are notified and provide documentation that the allegation has been reported as required. The surveyors validated the action plan through interview. 18. Prior to submitting final investigation to required agencies, a member of the Regional Team (RVP, RDCS) will review investigations to ensure a thorough investigation was completed. The surveyors validated the action plan through interview. 19. The RVP will review the abuse reporting log and investigations during weekly facility visits. The surveyors validated the action plan through interview. 20. On 8/19/2021, the Medical Director reviewed and agreed with this plan of removal. The surveyors reviewed the QAPI sign-in sheet with the Medical Director's signature. 21. On 8/19/2021, a QAPI meeting was held regarding this plan of removal. The surveyors reviewed the QAPI sign-in sheet. The facility's noncompliance at F-609 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, facility investigation review, medical record review, observation, and interview, the facility failed to thoroughly investigate incidents of elopement for 3 of 4 sampled residents (Resident #1, #2, and #3) reviewed for wandering and exit-seeking behaviors. The facility's failure to thoroughly investigate incidents of elopement resulted in Immediate Jeopardy for Resident #1, #2, and #3. Resident #1 eloped from the facility, without staff supervision through the B Hall Exit Door, ambulated approximately 109 feet down a sidewalk to the facility's back parking lot, and was found by staff standing next to a vehicle. Resident #2 eloped from the facility, without staff supervision through the window in her room, ambulated approximately 35 feet to the front parking lot, which is adjacent to a city side street, and was found by staff looking in a car window, later. Resident #3 eloped from the facility, without staff supervision through the B Hall exit door, ambulated approximately 120 feet, down a sidewalk and was found by staff standing next to a vehicle, an undetermined amount of time later. The facility's back parking lot is adjacent to a heavily wooded area with a large drainage ditch. Resident #1, #2, and #3's elopements from the facility were not thoroughly investigated. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. The Executive Director and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/18/2021 at 5:09 PM, in the Family Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited F-610 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 12/12/2020 through 8/22/2021. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 8/19/2021 at 1:58 PM, and was validated onsite by the surveyors on 8/20/2021-8/23/2021 through review of Incident Reports, Root Cause Analyses, assessments, behavior management flowsheets, care plans, elopement book review, audit tools, policies and procedures related to elopement, event management system review, behavior management review, resident rights policy review, in-service records review, observations, and staff interviews. The findings include: Review of the facility's policy titled, Protection of Residents: Reducing the Threat of Abuse & [and] Neglect, dated 5/15/2020, revealed .Each resident has the right to be free from abuse, neglect .In response to allegations of abuse, neglect .the facility must .Have evidence that all alleged violations are thoroughly investigated .Neglect .means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect may be the result of a pattern of failures .Investigation and Protection .It is the policy of this facility that reports of abuse .neglect .are promptly and thoroughly investigated .When an incident or suspected incident of resident abuse and/or neglect .is reported .the administrator/designee will investigate the occurrence .will complete an Incident Report and will utilize the Incident Investigation Questionnaire Form to document the investigation .will review the Incident Report for completeness .If it is determined that alleged abuse and/or neglect .has occurred, the administrator, director of nursing, or his/her designee will promptly notify officials in accordance with state laws (i.e. state licensing and certification agencies) .The written summary of the investigation should include but not be limited to .A review of the Incident Report .An interview with the person(s) reporting the incident .Interviews with any witnesses to the incident .An interview with the resident, if appropriate .A review of the resident's medical record .An interview with the employee(s) .A review of the employee's file .Interviews with staff members on all shifts having contact with the resident at the time of the incident .Interviews with the resident's roommate, family, and/or visitors who may have information regarding the incident .A review of all circumstances surrounding the incident . Review of the facility's policy titled Event Management System Policy, dated 5/15/2020, revealed, .Each event will be thoroughly investigated .the following areas will be considered during an event investigation .Witness interviews and statements with resident, family, and staff as indicated .Predisposing Environmental Factors .Predisposing Physiological Factors .Predisposing Situational Factors .Each event investigation will be reviewed by the interdisciplinary team .The Director of Nursing is responsible for validating the event level prior to resolving the event .The Executive Director/Director of Nursing is responsible for final resolution .The signature of the Executive Director is validation that the investigation has been completed and reviewed for allegations of abuse and/or neglect . Review of the facility's policy titled, Incident and Reportable Event Management, dated 7/19/2021, revealed .An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents .Investigate/Prevent/Correct .In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must .Have evidence that all alleged violations are thoroughly investigated . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Care Plan dated 7/30/2021, revealed she was care planned for elopement, wandering behaviors, impaired cognition, and had a Dementia diagnosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment, and had wandering behaviors on 1 to 3 days of the 7-day look back period. Review of the Progress Notes dated 8/7/2021, revealed there was no documentation of Resident #1's elopement from the facility. Review of the Progress Note dated 8/17/2021, revealed Resident #1 exited the facility on 8/7/2021, the alarm sounded, staff assisted her back into the building, and her family and Medical Doctor (MD) were notified. The facility's investigation was provided to the surveyors and included the following: a. An Elopement Risk Evaluation dated 8/16/2021, revealed .Resident is at risk for elopement at this time .Yes .she wanders and has poor cognition due to dx [diagnosis] of dementia .Personal safety alarm device .Wander guard in place . b. A WITNESS INTERVIEW/STATEMENT FORM, dated 8/16/2021 at 3:00 PM and signed by the DON, revealed .On today 8/16/2021 [Named Licensed Practical Nurse (LPN) #1] came to my office and reported to me that on Sat. [Saturday] Aug [August] 7 [2021] @ [at] approx [approximately] 5pm [5:00 PM] she heard the alarm sounding on B-Hall. She went to the door & [and] outside & saw [Named Resident #1] in parking lot. She assisted her back in building. [Symbol for no] injuries noted. She notified supervisor on call [Named Registered Nurse (RN) #2] . c. A Quality Assurance and Performance Improvement Plan (PIP) dated 8/16/2021, revealed .On August 7, 2021 at approximately 4:50 pm [Named Resident #1] .[LPN #1] stated that the door alarm On B Hall sounded and patient was found on parking lot. Approximately 2 minutes later she was escorted into the facility .Root Cause .anxiety due to new admission/environment . d. A handwritten witness statement dated 8/20/2021, 13 days after the elopement on 8/7/2021, and signed by LPN #1, revealed I heard B Hall door alarming. As I went down B Hall I was looking in rooms for [Named Resident #1]. I didn't see her so I went out the end door to the back parking lot & saw [Named Resident #1] standing by a white car. Resident was assisted back inside the building [symbol for without] injury. Review of the facility's investigation revealed the facility failed to investigate Resident #1's elopement on 8/7/2021 from the facility until 8/17/2021, 10 days after the incident occurred, and 1 day following the State Survey Agency Team's entrance into the facility to investigate the incident. The facility failed to accurately document Resident #1's elopement, complete an incident report, and conduct a timely investigation. During an interview on 8/16/2021 at 1:48 PM, Confidential Staff Member #2 confirmed RN #2 was notified of Resident #1's unsupervised elopement from the facility on 8/7/2021, and was told by RN #2, Not to do anything [related to elopement]. Observation in the resident's room beginning 8/17/2021 and continuing through 8/22/2021, revealed Resident #1 remained in bed with her eyes closed and covered with a blanket. During an interview on 8/17/2021 at 12:34 PM, the DON confirmed that RN #2 called her on 8/7/2021. Observation and interview on 8/17/2021 at 4:15 PM, at the location where Resident #1 was found when she eloped on 8/7/2021, revealed the Maintenance Director used a measuring device to measure the distance from the B Hall Exit Door, down the sidewalk to the back parking lot. The distance measured was approximately 109 feet. LPN #1 confirmed Resident #1 was on the left side of a parked car at the passenger door, in the back parking lot. During an interview on 8/19/2021 at 12:51 PM, RN #2 confirmed she spoke with the DON on 8/7/2021, and Resident #1 was placed on 1 on 1 monitoring at that time. RN #2 was asked if she was made aware that Resident #1 was outside the building and brought back inside. RN #2 stated, Not that I recall . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 4/3/2020, revealed Resident #2 was at risk for elopement due to aimless wandering. Review of a Progress Note dated 12/23/2020, revealed the family was made aware of Resident #2 climbing out but when discussing it with the family did not specify where she climbed out or tell the family that she was outside the facility unattended by staff. There were no additional progress notes regarding the incident of elopement. Review of the Elopement Risk Evaluation dated 1/20/2021, after the incident of elopement, revealed documentation stating the resident did not have a history of leaving the facility without supervision. Review of the quarterly MDS dated [DATE], revealed Resident #2 had severely impaired cognition, required limited assistance for activities of daily living (ADLs), had no Range of Motion (ROM) impairment, and used a wander guard (a mechanical bracelet device that will cause the door to alarm when the resident gets close to the door). The facility's investigation provided to the surveyors included the following: a. An Elopement Risk Evaluation dated 10/14/2020, revealed Resident #2 was not at risk for elopement. b. A handwritten WITNESS INTERVIEW/STATEMENT FORM, dated 12/23/2020 at 3:32 PM, and written by the Executive Director, revealed .spoke with [Named Certified Nursing Assistant (CNA) #1] after she assisted [Named Resident #2] back into the facility .[Named CNA #1] stated that she was coming in to get a Covid test and rang the doorbell. As she was waiting for someone to open the door she looked over and saw a red robe. She quickly realized it was [Named Resident #2] and she ran to get her. They met on the sidewalk and [Named CNA #1] assisted her back into the facility . c. A handwritten summary signed by the DON dated 12/24/2020, revealed At approximately 4pm [4:00 PM] I was informed that [Named Resident #2] had opened a window & climbed out. Staff member was coming in to work to be tested for COVID & she saw resident. She went to assist her. When she [CNA #1] got to resident she [Resident #1] was to walkway (sidewalk in front of her room) Resident stated she thought she saw her family outside in the truck .assisted back inside .was placed in one-on-one until facility obtained an alarm to be placed on window to alert staff .12/24/2020 .Resident has made [symbol for no] attempts to open window .has never been an exit seeker & still has not wandered or attempted to exit seek . d. A Quality Assurance and Performance Improvement (QAPI) Plan dated December 2020, revealed On December 23, 2020 at approximately 4pm .[Named CNA #1] seen [saw] the patient [Resident #2] climbing out her window in a red housecoat. She watched her climb out of the window and then went to the sidewalk and walked her back in . The Performance Improvement Plan (PIP) had action items documented which included the family and physician were notified, an alarm was ordered for the window, the Elopement Risk Evaluation was updated on 1/20/2021, elopement books were updated, and the team would discuss wandering residents daily during Grand Rounds. The action items were not documented as completed, the additional columns on the PIP document were blank, and there was no signature to indicate the PIP had been completed. e. A typewritten statement from the Executive Director dated 12/23/2020, revealed 12/23/2020-at approximately 4:00 pm I reviewed the video footage of the front parking lot. It showed that at 3:29 pm, [Named CNA #1] walked from her car to the front door and rang the doorbell to enter. While she was standing there, [Named CNA #1] observed [Named Resident #2] climb out her window and begin walking towards the parking lot. [Named CNA #1] ran and met her [Resident #2] on the sidewalk and brought her back inside. f. A Progress Note dated 12/23/2020 at 7:45 PM, revealed .[Named family member] made aware of climbing out thinking she show [saw] her family . The note was printed for the investigation on 2/9/2021, over a month after the incident occurred. g. An Elopement Risk Evaluation dated 1/20/2021, revealed documentation that indicated the resident did not have a history of leaving the facility without supervision, but was at risk for elopement. The Elopement Risk Evaluation was not completed until 1/20/2021, approximately 1 month after Resident #2 eloped from the facility through the window. The facility failed to accurately document the elopement incident, complete an incident report, obtain witness statements from staff working that day, and thoroughly investigate the incident. Observation in the resident's room beginning 8/16/2021 and continuing through 8/23/2021, revealed Resident #2 was pleasantly confused, frequently sat in the recliner next to her bed, and appeared neat and clean. During a telephone interview on 8/17/2021 at 9:04 AM, CNA #1 confirmed she came to the facility for COVID-19 testing on 12/23/2020, between 1:00 PM and 4:00 PM, but did not know the exact time she arrived. CNA #1 confirmed she rang the doorbell of the facility and while waiting for the door to be unlocked she glanced to her left and observed Resident #2 standing beside a car, looking in the window, and trying to get into the vehicle in the facility's front parking lot. CNA #1 confirmed Resident #1 was wearing a red, silky robe that was partially opened, was not wearing anything under the robe, and wore 2 different shoes. CNA #1 confirmed she did not see the resident climb out of the window in her room and did not know how long she had been outside. CNA #1 confirmed she went to Resident #2, talked with her, and convinced her to return inside the facility. CNA #1 confirmed she reported the incident to the charge nurse, was unaware how the resident had gotten out of the facility until she went to Resident #1's room and saw the open window. CNA #1 confirmed there were no staff in the parking lot. CNA #1 stated, Who knows what would have happened if I wouldn't have come for testing that day . CNA #1 confirmed she wrote a witness statement prior to leaving the facility that day. Review of the facility's investigation revealed there was not a signed witness statement from CNA #1 included in the file. The facility was unable to provide CNA #1's witness statement. Observation on 8/17/2021 at 4:40 PM, at the approximate location where Resident #2 was found when she eloped on 12/23/2020, revealed the Maintenance Director used a measuring device to measure the distance from Resident #2's window to a parked car in the front parking lot. There was a city side street immediately behind the front parking lot. The distance measured was approximately 35 feet. A side street was located directly behind the front parking lot. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 4/8/2021, revealed Resident #3 was at risk for wandering and elopement. Review of the 5-day admission MDS dated [DATE], revealed Resident #3 had severe cognitive impairment, had no ROM impairment, had wandering behaviors, and used a wander guard. Review of the Progress Notes dated 4/20/2021 at 10:20 AM, revealed Resident [Resident #3] opened door, alarm was heard staff assisted resident back to room, wander guard in place. The Progress Note did not reflect that Resident #3 ambulated out the B Hall exit door unsupervised for an unknown amount of time on 4/20/2021. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's investigation was provided to the surveyors and included the following: a. An undated/untimed witness statement signed by LPN #2 revealed, I heard the alarm door sound on B-Hall and went to check out if it was opened. I noticed that res [Resident #3] was not in her room. I went outside to end of ramp [sidewalk at the end of B Hall Exit Door] and did not see her [Resident #3]. I came back in [the facility] went to her room noticed outside by her window res. [Resident #3] was standing next to a truck parked there. I ran outside brought res [Resident #3] back to facility .Reported [incident] to DON . b. A PIP dated April 2020, revealed, .On 4/20/2021, Nurse [Named LPN #2] heard door alarm sounding and looked out (B Hall) door with no one seen on ramp. She knew that it was probably [Named Resident #3] as she likes to wander around. Went to her [Resident #3's] room and looked out her window and seen [saw] her [Resident #3]. [Named LPN #2] went outside and asked to reenter with her and she did so without incident . The PIP included documentation of action items which included notified family and physician, psych consult, elopement books current/updated, would discuss all wandering residents daily in Grand Rounds, would discuss in monthly Quality Assurance Performance Improvement (QAPI) for 3 months. The action items were not documented as completed, the additional columns on the PIP document were blank, and there was no signature to indicate the PIP had been completed. No additional documentation was present in the facility's investigation of Resident #3's elopement from the facility. The facility failed to accurately document the elopement incident, complete an incident report, and thoroughly investigate the incident. During an interview on 8/16/2021 at 10:52 AM, LPN #2 confirmed she heard the B Hall Exit Door alarm sound but did not observe Resident #3 exit the facility. LPN #2 confirmed she looked in Resident #3's room immediately after she heard the alarm and the resident was not present, so she went outside to see if the resident was out there. LPN #2 confirmed she did not see the resident so came back into the facility to check the resident's room again. LPN #2 confirmed the window shades in Resident #3's room were raised, and she saw Resident #3 outside her window standing next to a Maintenance Truck. LPN #2 confirmed she returned outside to get the resident. LPN #2 confirmed she reported the incident to the DON. During an interview on 8/16/2021 at 11:18 AM, Confidential Staff Member #1 confirmed the DON was made aware of Resident #3's elopement from the facility. Confidential Staff Member #1 stated, .[Named DON] said we don't want to draw attention [to Resident #3's elopement from the facility] . Observation on 8/17/2021 at 4:50 PM, at the approximate location where Resident #3 was found on 4/20/2021, the Maintenance Director used measuring device to measure the distance from the B Hall Exit Fire door, down the sidewalk, and into the back parking lot. The distance measured was approximately 120 feet. During an interview on 8/17/2021 at 11:22 AM, the Executive Director was asked who was ultimately responsible for elopement incident reports, investigations, and reporting. The Executive Director stated, I think [Named DON] is . The Executive Director confirmed she was not made aware of Resident #1's elopement on 8/7/2021 until 8/16/2021, and that she should have been made aware of the incident when it happened. The Executive Director was asked if an incident report and investigation should been completed on Resident #1's elopement from the facility. The Executive Director stated, No, we did not define it as an elopement because the alarm sounded, and they went and got her. The Executive Director was asked if the incident where Resident #2 exited the facility through her window should have been investigated, documented, and reported. She stated, It was investigated, it was charted on, but she was never without eyes on her. The Executive Director was asked who always had eyes on Resident #2. The Executive Director stated, [Named CNA #1] .she [CNA #1] looked to her left .that's how I know [CNA #1 saw Resident #2 climb out of her window] .as far as her writing it out [witness statement] I don't know. The Executive Director confirmed she did not know if the camera footage had shown the actual footage of Resident #2 climbing out the window. The Executive Director was asked if she was aware of Resident #3's elopement from the facility through the B Hall Door. She stated, Yes .we were monitoring her on that date .she opened the door .[Named LPN #2] heard it .brought her back inside . The Executive Director stated she could not remember if she had interviewed LPN #2 about the incident. The Executive Director confirmed that going from the facility to the parking lot unsupervised was unsafe. The Executive Director confirmed there should be documentation in the Progress Notes regarding the elopement of Resident #3. The Executive Director confirmed she was ultimately responsible for ensuring Federal and State regulations were followed in the facility. During an interview on 8/17/2021 at 12:33 PM, the DON was asked when she was made aware of Resident #1's elopement from the facility. The DON stated, Not til [until] yesterday .[she got out] Saturday, 8/7 [2021], about 3:30 PM .but when we looked at the camera I think maybe it was closer to 5 .I did get a call that day .[Named RN #2] [the person she received the call from] .The DON confirmed the incident should have been documented in the progress notes and an investigation conducted. The DON confirmed the incident where Resident #2 climbed out the window should have been documented in the progress notes. The DON was asked if the incident should have been investigated. The DON stated, I don't know that I would consider that an incident .never out of the eyesight of somebody who worked for us, was more of a behavior and should have been charted on the behavior sheet or note .found out what happened, notified family .1 on 1 monitoring until we could get a thing [window alarm] to ensure she could not go out the window again . The DON confirmed that the Executive Director talked to CNA #1. The DON confirmed there should be more thorough charting on the incidents of elopement. The DON stated, I feel like I did an investigation .I did not put it in the chart . The DON confirmed that after review of the elopement incidents she could have done a better job in her investigation of the incidents. During an interview on 8/17/2021 at 4:13 PM, the Regional Director of Clinical Services, (RDCS) was asked what should be included in an investigation. The RDCS stated, .hear the story, listen to the people that know about the story .ask them to write their statement .response time .what door [exited from] .what they think is the root cause . The RDCS was asked if she documented a witness statement for someone, would she have them to read and sign it later for example over the telephone. She stated, I would. The RDCS confirmed the facility would follow the incident management policy, notify the family, notify the physician, and the nurses on the unit would sometimes notify the DON. The RDCS was asked when a nurse on the unit should notify the DON of incidents that occur. The RDCS stated, .if you had an elopement you would. The RDCS stated, [Her definition of elopement] Someone being a patient that you can't find, you don't know when they got out or where they are at . The RDCS confirmed that elopement incidents should be documented in the chart and an incident report should be completed. During an interview on 8/17/2021 at 5:13 PM, the Regional Vice-President confirmed that if the facility had an incident of suspected elopement he would expect to see the incident documented in the medical record. The Regional Vice-president confirmed he had not been notified of the elopement incidents until today. The Regional Vice-President was shown the facility's investigation folders for Resident #1, #2, and #3's elopement incidents and was asked if they were thorough investigations. The Regional Vice-President stated, .No . The Regional Vice-President was asked what should be included when conducting a facility investigation on an elopement incident. The Regional Vice-President stated, .how they got out of the building .how they are doing once we got them back in .have something in place to prevent it from happening again .get statements from anyone that saw it .create awareness .expect to see a note [Nursing Note] or something . The Regional Vice-President was asked if the facility should have investigated these elopement incidents. The Regional Vice-President stated, .Yes . During an interview on 8/19/2021 at 2:42 PM, the DON confirmed that staff should have documented the status of the residents after the incidents of elopement for 72 hours and an Incident Report should have been completed on each incident. Refer to F-600, F-609, F-689, F-835, and F-867. The surveyors verified the Removal Plan by: 1. Resident #3 was discharged from the facility on 4/20/2021. 2. Resident #4 was discharged from the facility on 12/20/2020. 3. By 8/18/2021, Resident #2 had an Incident Report completed, an Elopement Assessment completed, Behavior Management flowsheets reviewed, resident profile Care Plan was reviewed and updated, and the Elopement Book was reviewed with Resident #2's picture in place by a Licensed Nurse. Resident #1 had an Incident Report completed, an Elopement Assessment completed, Behavior Management flowsheets reviewed, resident profile Care Plan was reviewed and updated, and the Elopement Book was reviewed with Residents pictures in place by a Licensed Nurse. The surveyors reviewed the Incident Reports, Elopement Assessments, Behavioral Management sheets, Care Plans, and Profile Cards. 4. On 8/18/2021, the Executive Director, DON, and Interdisciplinary Team completed a Root Cause Analysis (RCA). The surveyors reviewed the Root Cause Analysis conducted by the Executive Director and DON. 5. By 8/18/2021, the DON/Assistant Director of Nursing (ADON)/Staff Development Coordinator) SDC/Minimum Data Set Coordinator (MDSC) and/or Licensed Nurse completed 100 percent (%) of Elopement Assessments of all active residents and updated residents' Behavior Management flowsheets, behavior Care Plan, resident profile Care Plan, and Elopement Books as indicated. No errors were identified. The Activity Director reviewed and updated person-centered Care Plans for memory impaired residents with wandering behaviors. The surveyors reviewed all active residents for the Elopement Risk Assessments, the updated residents' Behavior Management flowsheets, Behavior Care Plans, Resident Profile Care Plans, and Person-Centered Care Plans. The Elopement Books at each Nurses' Station and the front office were reviewed, and the surveyors verified they contained face sheets and picture identification of each resident with wandering/exit seeking behaviors. 6. The Executive Director will be responsible for reviewing the abuse reporting log and compliance rounds trends and patterns. The surveyors reviewed the Abuse Reporting Log audit tool interviewed the Executive Director. 7. The Director of Social Services will be responsible for reviewing the Behavior Management flowsheets for trends and patterns. The surveyors reviewed the Behavior Management flowsheets audit tool and interviewed the Director of Social Services. 8. The Director of Nursing will be responsible for reviewing the Event Management System for trends and patterns. The surveyors reviewed the Event Management System policy and interviewed the DON. 9. The SDC will be responsible for reviewing the Unsafe Wandering and Elopement Prevention Education for trends and patterns. The surveyors reviewed the Unsafe Wandering and Elopement Prevention Education audit tool and interviewed the SDC. 10. On 8/18/2021, the RDCS provided education to the Executive Director (ED) and DON on the following to ensure the abuse policies are implemented to ensure all allegations of abuse and neglect are promptly and thoroughly investigated: Protection of Residents: Reducing the threat of Abuse and Neglect and Unsafe Wandering and Elopement Prevention. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed the RDCS, the Executive Director, and the DON. 11. The ED, DON, Assistant Director of Nursing, Staff Development Coordinator and/or Licensed Nurse will provide education to all facility staff on the following to ensure the abuse policies are implemented to ensure all allegations of abuse and neglect are promptly and thoroughly investigated: Protection of Residents: Reducing the threat of Abuse and Neglect and Unsafe Wandering and Elopement Prevention. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed staff on all shifts. 12. The DON, ADON, SDC, and/or licensed nurse will provide education to all Licensed Nurses and Certified Nursing Assistants on the following: Event Management System, Residents Rights, and Behavior Health Management. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed staff on all shifts. 13. Any associate who has not completed training by 8/18/2021, will not be allowed to work until training is completed. The ED, DON, SDC, and/or Licensed Nurse will provide education to all new associates upon hire during orientation. The surveyors validated staff could not return to work prior to receiving the education through review of the schedules and staff interviews on all shifts. 14. By 8/18/2021, the Executive Director and/or Social Services will provide education on U[TRUNCATED]

Based on policy review, Executive Director job description review, Maintenance Director job description review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to resident neglect, identified incidences of elopement, investigated incidences of elopement, reported incidences of elopement to the State Survey Agency and Adult Protective Services (APS), performed tracking and trending of incidences of elopement, and failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to abuse/neglect and incidences of elopement. The QAPI committee failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI committee to ensure residents were free from abuse/neglect and ensure incidences of elopement were identified, thoroughly investigated, and reported to the appropriate agencies, resulted in Immediate Jeopardy (IJ) when Resident #1 exited the facility unsupervised by staff through the B Hall Exit Door in 86 degree weather, ambulated approximately 109 feet and was found in the back parking lot; when Resident #2 exited the facility unsupervised by staff through the window in her room, ambulated approximately 35 feet in 55 degree weather, wearing only a silky robe and unmatched shoes, and was found looking in car windows and trying to open car doors in the front parking lot that is adjacent to a city side street, an undetermined amount of time later; when Resident #3 exited the facility unsupervised by staff through the B Hall Exit Door in 54 degree weather, ambulated approximately 120 feet unsupervised, and was found by staff in the back parking lot an undetermined amount of time later; and when Resident #4 exited the facility through the B Hall Exit Door in 43 degree weather unsupervised by staff, ambulated approximately 140 feet, and was found in the back parking lot by a passing motorist who notified the facility that the resident was outside. Resident #4 was outside for an undetermined amount of time. The facility's back parking lot was adjacent to a heavily wooded area with a large drainage ditch. Immediate Jeopardy (IJ) is a situation in which the provider's compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Executive Director and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-867 on 8/20/2021 at 1:35 PM, in the Family Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, F-689, F-835, and F-835. The facility was cited F-600, F-609, F-610, and F-689 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 12/12/2020 through 8/22/2021. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 8/23/2021 at 3:11 PM, and was validated onsite by the surveyors on 8/23/2021, through review of Incident Reports, Root Cause Analysis, assessments, behavior management flowsheets, care plan reviews, elopement book review, audit tools, policies and procedures related to elopement, abuse/neglect, event management system, behavior management, resident rights, in-service records, observations, and staff interviews. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement Program Framework, dated 12/20/2019, revealed .The focus of the QAPI [Quality Assurance and Performance Improvement] program is to promote excellence in quality of care, quality of life, resident/patient choice, and person centered care .Any system that affects the satisfaction of resident/patients, families and associates will be considered an area for improvement .QA [Quality Assurance] is ongoing .in its efforts to identify why facility performance .has failed to meet standards Each LTC [Long Term Care] facility .must .maintain documentation and demonstrate evidence of its ongoing QAPI program .Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency .upon request .facility must establish .adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information .executive leadership .is responsible and accountable for .The QAPI program .Clear expectations are set around safety, quality, rights .must develop and implement appropriate plans of action to correct identified quality deficiencies . Review of the facility's policy titled, Performance Improvement Projects (PIPs), dated 12/20/2019, revealed .This facility will conduct .(PIPs) designed with a systemic approach to improve care and services in areas that are identified as an opportunity for improvement .will address system changes .to have a positive impact on the .quality of care of the residents .in any area identified as needing attention .based on the needs of the residents .The facility will utilize a systematic approach in identifying potential PIPS .will gather and analyze data on a quarterly basis from established sources to determine if gaps in process or patterns are identified in facility systems that may impact quality of care or quality of life .priority will be given to the high-risk .areas that have the potential for .systemic failures in quality of life and quality of care .The QAA [Quality Assessment and Assurance] Committee will provide guidance on how to address issues that arise and need immediate corrective action .PIP team will be accountable to the QAA Committee .will determine and gather available data .about the opportunity for improvement .develop an action plan .conduct a root cause analysis .will establish measurement tools .determine if change has had its desired effect . Review of the facility's policy titled, QAPI - Systematic Analysis and Systemic Action, dated 12/20/2019, revealed .provide guidance for .(QAPI) activities to continuously improve care provided .Federal Regulations .(QAA) committee will use a systematic approach .to fully understand problems, causes of problems .how .problems may be caused or exacerbated by the way care and services are delivered .once the root cause is identified, the team will develop and implement sustainable corrective actions and implement planned changes .All corrective .activities will be evaluated to ensure changes are implemented and effective . Review of the facility's policy titled, Event Management System Policy, dated 5/15/2020, revealed .Assessing for trends and patterns is necessary to determine if the facility has systemic event management compliance .Executive Director is responsible for coordinating and monitoring Event PIPs with other members of the QAPI Committee Monthly .training will be provided to all associates upon hire, annually and as indicated by .QAPI activities . Review of the facility's policy titled, Protection of Residents: Reducing the Threat of Abuse & [and] Neglect, dated 5/15/2020, revealed .Assure that residents are free from neglect by having the structures and processes to provide needed care and services to all residents .Trends identified .will be reviewed by the QAPI Committee. Follow-up interventions by the committee may include .creating and implementing a plan of action .to be communicated to staff through in-services, orientation, care planning and/or staff meetings . Review of the facility's policy titled, Incident and Reportable Event Management, dated 7/19/2021, revealed .QAPI review will be conducted to identify trends, patterns, and overall performance of the facility Event Management System .Reviewing performance routinely supports action-planning activities that result in facility-wide, systemic improvement and a reduction in patient-specific events .Assessing for trends and patterns is necessary to determine if the facility has systemic event management compliance . Review of the Executive Director Job Description revised 1/8/2021, revealed .The Executive Director provides leadership and direction for overall facility operations to provide quality patient care in accordance with all laws, regulations .Implements policies pertaining to patient care .support staff .Must be knowledgeable of .laws, regulations, and guidelines governing administrative functions in the post-acute care facility .Must perform proficiently in all .areas including .regulatory compliance, patient rights, and safety .Must ensure patients receive high quality care .ensure facility is compliant with all Federal, State, local .requirements .Must ensure facility is .safe .Must effectively supervise team .Aware of all incidents and accidents and takes proper action including appropriate documentation .Involved in risk management initiatives .Encourages open communication .regarding compliance concerns and issues without fear of retaliation or retribution .Ensures that issues or concerns .state reportables .are reported as soon as practical .Investigates all allegations of patient abuse, neglect . Review of the facility's DON Job Description, revised 1/8/2021, revealed .The Director of Nursing plans, organizes, develops, and directs the overall operation of the Nursing department to assure patient safety and attain or maintain the highest practicable physical, mental and psychosocial well being of each patient in accordance with all applicable laws, regulation, and Life Care standards .Weekend supervision responsibilities .works beyond normal working hours, on weekends and holidays .Must be able to communicate effectively with physicians, nursing staff and all other staff .Must be able to collect, analyze, and manage data .Must possess the ability to make independent decisions when circumstances warrant such actions .Must be knowledgeable of nursing administration practices and procedures as well as the laws, regulations and guidelines governing nursing administration .Must perform proficiently in all applicable competency areas .Must understand and follow company policies .Must be able to plan, develop, organize, implement, evaluate, establish benchmarks, and direct staff .Must be able to train .counsel and supervise staff .Must be able to direct care .Must be able to concentrate, and use reasoning skills and good judgement .Must be able to communicate and function productively on an interdisciplinary team . Review of the Maintenance Director Job Description revised 5/17/2016, revealed .The Maintenance Director is responsible for the overall operation of the Maintenance department in accordance with all applicable laws, regulations, and Life Care standards .Must perform proficiently in all competency areas including but not limited to .general maintenance responsibilities .patient .safety . Review of the facility's Quality Assurance and Performance Improvement Plan, dated 12/12/2020, revealed the facility conducted a PIP on Resident #4's elopement from the facility. The PIP included an action plan that Elopement Risk Evaluations were performed on all residents in the facility by 12/14/2020. Review of the medical records revealed Elopement Risk Evaluations were not completed on every resident from 12/12/2020 through 12/14/2020. Review of the facility's Grand Round binder dated 12/14/2021, revealed Resident #4's elopement from the facility was discussed with the Interdisciplinary Team (IDT). The Medical Director was not present. An ad hoc QAPI meeting was not conducted related to Resident #4's elopement from the facility. A Quality Assurance and Performance Improvement Plan, dated 12/2020, revealed a PIP was begun on Resident #2's elopement from the facility on 12/23/2020. The PIP had action items documented which included the family and physician were notified, an alarm was ordered for the window, the Elopement Risk Evaluation was updated on 1/20/2021, the elopement books were current/updated, and the team would discuss wandering residents daily during Grand Rounds. The action items were not updated nor documented as completed, the additional columns on the PIP document were completely blank, and there was no signature or date to indicate the PIP had been completed. Review of the facility's Grand Round binder dated 12/28/2020, revealed Resident #2's elopement through the window of the facility on 12/23/2020 was discussed with the IDT during Grand Rounds, 5 days after the incident occurred. The Medical Director was not present. An ad hoc QAPI meeting was not conducted related to Resident #2's elopement from the facility. Review of the .QUALITY ASSESSMENT/ASSURANCE COMMITTEE SIGN-IN SHEET, dated 12/2020, 1/2021, 2/2021, 3/2021, and 4/2021, revealed the document did not address Elopement as a current PIP. A Quality Assurance and Performance Improvement Plan, dated 4/2021, revealed a PIP was begun on Resident #3's elopement from the facility on 4/20/2021. The PIP included documentation of action items which included the family and physician were notified, psychiatric consult was obtained, elopement books were current/updated, the team would discuss wandering residents daily in Grand Rounds and monthly in QAPI for 3 months. The action items were not updated nor documented as completed, the additional columns on the PIP document were blank, and there was no signature or date to indicate the PIP had been completed. Review of the QAPI minutes for May and June, did not include elopement as a PIP. Review of the facility's Grand Round binder dated 4/21/2021, revealed Resident #3's rehospitalization s were discussed with the IDT. The Medical Director was not present. The Grand Round Binder did not address Resident #3's elopement from the facility on 4/20/2021. An ad hoc QAPI meeting was not conducted related to Resident #3's elopement from the facility. Review of the .QUALITY ASSESSMENT/ASSURANCE COMMITTEE SIGN-IN SHEET, dated 5/2021 and 6/2021, revealed the document did not address Elopement as a current PIP. Review of the PERFORMANCE IMPROVEMENT MEETING SIGN IN, dated 8/16/2021, revealed only the Executive Director, Director of Nursing (DON), and the Medical Director attended the ad hoc QAPI meeting regarding Resident #1's elopement on 8/7/2021. During an interview on 8/18/2021 at 3:50 PM, the Executive Director provided the Grand Round book/binder for review. The Executive Director stated, .held daily in the morning .includes all department heads [managers], myself, DON, ADON [Assistant Director of Nursing], Admissions Coordinator, Social Services .both of them [Social Service Director and Assistant], Central Supply .It's part of the QA process .discuss everything like incident reports .did an incident report and called that an elopement [Resident #4] . The Executive Director confirmed she called an ad hoc meeting when she found out about Resident #1's elopement from the facility. The Executive Director confirmed there were 3 attendees, the DON, the Medical Director, and herself, who attended the ad hoc QAPI meeting. The Executive Director confirmed the facility did not have an ad hoc QAPI meeting when Resident #2, #3, and #4 eloped. The Executive Director provided the January minutes for the surveyor's review and stated, .You can see here where we talk about behavior management . The QAPI minutes listed behaviors but did not reflect Resident #2 and Resident #4's elopement from the facility on 12/12/2021. The Executive Director provided the May QAPI minutes for the surveyor's review and stated, We discussed behavior management .Cannot find documentation where elopement was discussed [for Resident #3] .discussed her transfer to [Named behavioral facility] . During an interview on 8/18/2021 at 5:00 PM, the Executive Director was asked how often the facility does elopement drills. The Executive Director stated, .Not sure if it's quarterly .[Named Maintenance Director] keeps up with those . During an interview on 8/19/2021 at 8:37 AM, the Executive Director was asked if the IDT discussed Resident #3's elopement from the facility on 4/20/2021. The Executive Director stated, Not a specific elopement, no ma'am . During an interview on 8/19/2021 at 2:42 PM, the DON confirmed that Administration was notified the following morning in Grand Rounds of any significant incidents or events that occurred throughout the facility the previous evening and night. The Executive Director and DON were asked why Resident #2's elopement through the window on 12/23/2020 was not discussed in the morning meeting or an ad hoc QAPI meeting was not conducted until Grand Rounds on 12/28/2020, 5 days after the incident occurred. The Executive Director stated, .happened on 12/23 [2020] .we had interviewed [named CNA #1 who found the resident in the parking lot] .then it's Christmas .the weekend and all of that .so the 28th is the next day . The DON was asked about Resident #1's elopement from the facility on 8/7/2021. The DON confirmed she received a call from the on-call supervisor on 8/7/2021, the day Resident #1 eloped from the facility. The DON was asked why she did not follow up on the incident when she returned to the facility on Monday, 8/9/2021, after being notified on 8/7/2021. The DON stated, .nobody elaborated . The Executive Director and DON were asked if the facility held an ad hoc QAPI meeting after Resident #4 eloped on 12/12/2020, Resident #2 eloped on 12/23/2020, and Resident #3 eloped on 4/20/2021. The DON stated, They did call me at home .we might discuss over the phone things we need to be doing but we wouldn't come in over the weekend . The Executive Director confirmed that she expected to be notified of incidents that occurred in the facility and that she was responsible for all federal and state regulations, definitions, and reportable incidents. The Executive Director confirmed the facility considered an ad hoc quorum to be herself, the DON, and the Medical Director but could not provide documentation of the quorum requirements. The Executive Director was asked if the ad hoc meeting should include the IDT. The Executive Director stated, If they're there and available we'll include them .we [Executive Director and DON] would talk to each other and talk to the Medical Director, that's what I would consider an ad hoc .then come Monday we would take it to stand up [Morning Stand-Up meeting] so everybody is aware . The Executive Director was asked if Resident #2 and #3's elopement incidents were included in QAPI tracking and trending. The Executive Director stated, I don't think so .we didn't define those as elopements . The Executive Director confirmed there were no elopement drills from 4/2019 until 12/2020. The DON stated that Resident #1's elopement had not been discussed with the IDT in Grand Rounds on 8/17/2021 - 8/19/2021, because they had not held Grand Rounds due to the State Survey Team's presence in the facility. During an interview on 8/20/2021 at 10:00 AM, the Executive Director informed the survey team that they had a Grand Round meeting that morning and discussed Resident #1's elopement from the facility. The Executive Director stated, In the normal situation we do [have Grand Rounds daily Monday through Friday], but since y'all [you all] have been here we have not had the opportunity to do our official Grand Rounds . The Executive Director confirmed the IDT conducted the Performance Improvement Project (PIP) on Resident #4's elopement from the facility. The Executive Director confirmed the PIP stated Elopement Risk Evaluations were completed on all residents. The Executive Director was asked if the Elopement Risk Evaluations were completed on every resident in the facility between 12/12/2020 and 12/14/2020. The Executive Director stated, I'll have to check with [named DON] on that. The Executive Director confirmed the Medical Director was not part of the Grand Rounds that occur every weekday. During an interview on 8/20/2021 at 12:58 PM, the DON confirmed the Elopement Risk Evaluations were not performed on every resident from 12/12/2020 through 12/14/2020. The DON stated, It was not, and I have no explanation .would have been mine [responsibility] to oversee it .to make sure it was completed and when it said completed out there [on the PIP form] it was mine to make sure that was correct . The surveyors verified the Removal Plan by: 1. On 8/18/2021, the Executive Director, DON, and Interdisciplinary Team completed a Root Cause Analysis (RCA). The surveyors reviewed the RCA conducted by the Executive Director and DON. 2. On 8/18/2021, the facility completed an Elopement Drill. The surveyors reviewed the in-service sign-in sheets and interviewed staff on all shifts. 3. The Executive Director will be responsible for reviewing the abuse reporting log and compliance rounds trends and patterns. The surveyors reviewed the Abuse Reporting Log audit tool interviewed the Executive Director. 4. The Director of Social Services will be responsible for reviewing the Behavior Management flowsheets for trends and patterns. The surveyors reviewed the Behavior Management flowsheets audit tool and interviewed the Director of Social Services. 5. The Director of Nursing will be responsible for reviewing the Event Management System for trends and patterns. The surveyors reviewed the Event Management System policy and interviewed the DON. 6. The Staffing Development Coordinator (SDC) will be responsible for reviewing the Unsafe Wandering and Elopement Prevention Education for trends and patterns. The surveyors reviewed the Unsafe Wandering and Elopement Prevention Education audit tool and interviewed the SDC. 7. On 8/18/2021, the Regional Director of Clinical Services (RDCS) provided education to the Executive Director (ED) and DON on the following to ensure the abuse policies are implemented (reporting requirements) to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator, and not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to other officials (including to the State Survey Agency and adult protective services): Protection of Residents: Reducing the threat of Abuse and Neglect and Unsafe Wandering and Elopement Prevention. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed the RDCS, the Executive Director, and the DON. 8. The ED, DON, Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC) and/or Licensed Nurse will provide education to all facility staff on the following (reporting requirements) to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator, and not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to other officials (including to the State Survey Agency and adult protective services): Protection of Residents: Reducing the threat of Abuse and Neglect and Unsafe Wandering and Elopement Prevention. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed staff on all shifts. 9. The DON, ADON, SDC, and/or Licensed Nurse will provide education to all Licensed Nurses and Certified Nursing Assistants on the following: Event Management System, which includes notification and documentation requirements, Residents Rights, and Behavior Health Management. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed staff on all shifts. 10. Any associate who has not completed training by 8/18/2021, will not be allowed to work until training is completed. The ED, DON, SDC, and/or Licensed Nurse will provide education to all new associates upon hire during orientation. The surveyors validated staff could not return to work prior to receiving the education through staff interviews on all shifts. 11. The RDCS provided education by 8/20/2021, to the ED and to the other QAPI Committee Members which include, the ED, DON, Medical Director, MDS Nurse, Food and Nutrition Services representative, Pharmacy representative, Social Services representative, Activity and Recreational Services representative, Environmental Services representative , Human Resources representative, Staff Development Coordinator, Safety representative, Health Information Management representative, Rehab Services representative, Business Office representative on the following: Performance Improvement Projects, QAPI feedback, Data Systems, and Monitoring, QAPI Systematic Analysis and Systematic Action, Quality Assessments and Assurance Committee Meeting, and Quality Assessment and Assurance Committee Roles and Responsibilities. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed members of the QAPI Committee. 12. The facility will implement quarterly Elopement Drills. The surveyors validated the action plan through staff interviews. 13. The Regional Vice President (RVP) and/or RDCS will be notified of any allegation of abuse and/or neglect at the time the ED or DON are notified and provide documentation that allegation has been reported as required per Center for Medicare and Medicaid Services (CMS) specific timeframes. The surveyors validated the action plan through staff interviews. 14. Prior to submitting final investigation to required agencies, a member of the Regional Team (RVP, RDCS) will review investigations to ensure a thorough investigation was completed. The surveyors validated the action plan through interviews. 15. The RVP will review the abuse reporting log and investigations during weekly facility visits. The surveyors validated the action plan through interview. 16. The RVP and RDCS will conduct facility visits at least weekly until substantial compliance is received. The surveyors validated the action plan through interview. 17. On 8/19/2021, the Medical Director reviewed and agreed with this plan of removal. The surveyors reviewed the QAPI sign-in sheet with the Medical Director's signature. 18. On 8/19/2021, a QAPI meeting was held regarding this plan of removal. The surveyors reviewed the QAPI sign-in sheet. The facility's noncompliance at F-867 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, Executive Director and Director of Nursing job description review, and interview, the facility Administration failed to administer the facility in a manner that protected wandering and exit seeking residents from elopement. Administration failed to recognize the definition of elopement provided by Federal Regulations to monitor and protect residents. Administration failed to identify, investigate, and report incidents of elopement to the State Survey Agency and Adult Protective Services (APS) which resulted in Immediate Jeopardy for Residents #1, #2, #3 and #4. Resident #1 eloped from the facility and was found in the back parking lot. She had ambulated unsupervised for approximately 109 feet. Resident #2 eloped through the window in her room. She had ambulated approximately 35 feet and was found in the front parking lot an had been there for an undetermined amount of time. Resident #3 eloped from the building and was found in the back parking lot unsupervised for an undetermined amount of time. She had ambulated approximately 120 feet. Resident #4 eloped from the facility to the back parking lot and walked approximately 140 feet. She was outside unsupervised for an undetermined amount of time. Three of these residents were found in the back parking lot that is adjacent to a heavily wooded area with a large drainage ditch. Immediate Jeopardy (IJ) is a situation in which the providers noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Executive Director and Director of Nursing (DON) were notified of the Immediate Jeopardy on 8/20/2021 at 1:34 PM, in the Family Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, F-689, F-835, and F-867. The facility was cited F-600, F-609, F-610, and F-689 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from 12/12/2020 through 8/22/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 8/23/2021 at 3:11 PM and was validated onsite by the surveyors 8/23/2021 through review of audits, assessments, elopement books, care plans, policy reviews, and staff interviews. The findings include: Review of the facility's policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, dated 5/15/2020, revealed .To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices .zero tolerance approach to resident abuse .each resident has the right to be free from abuse, neglect .Ensure all alleged violations involving abuse, neglect .are reported immediately .and to other officials including the State Survey Agency and adult protective services .Identify, assess, care plan for appropriate interventions .monitor residents with needs and behaviors which might lead to conflict or neglect such as .wandering .It is the policy of this facility that reports of abuse .neglect .are promptly and thoroughly investigated .When an incident or suspected incident of resident abuse and/or neglect .is reported the administrator [Executive Director]/designee will investigate the occurrence .The administrator/designee will complete an Incident Report .The administrator/designee will review the Incident Report for completeness and assure the physician and resident representative have been notified .If it is determined that alleged abuse and/or neglect .has occurred, the administrator, director of nursing .will promptly notify officials in accordance with state laws .state licensing and certification agencies .The Administrator, director of nursing .will complete an investigation of the incident including a written summary of the findings .Facilities must ensure that all alleged violations involving abuse, neglect .are reported immediately, but no later than 2 hours after the allegation is made . Review of the facility's policy titled, Event Management System Policy, dated 5/15/2020, revealed .Supervision/Adequate Supervision .determination is based on the individual .assessed needs and identified hazards .To help reduce the risk of an event, all patients will receive assistance and supervision .If an event occurs, the facility will assess, report, investigate, and determine the root cause .Event Management includes .Elopement/Wandering .the facility will immediately respond to resident events .Internally reporting .Physician and Resident's Legal Representative Notification .Externally reporting to state agencies as required .Conducting a thorough investigation .Refer to state-specific guidelines for reporting .elopement .Each event investigation will be reviewed by the interdisciplinary team .The Director of Nursing is responsible for validating the event .The Executive Director /Director of Nursing is responsible for final resolution .The signature of the Executive Director is validation that the investigation has been completed and reviewed for allegations of abuse and/or neglect . Review of the facility's Executive Director Job Description, revised 1/8/2021, revealed .The Executive Director provides leadership and direction for overall facility operations to provide quality patient care in accordance with all laws and regulations .Must be knowledgeable of administration practices and procedures as well as the laws, regulations, and guidelines governing administrative functions .Must perform proficiently in all competency areas including .regulatory compliance, patient rights, and safety .Must understand and follow company policy's including .compliance procedures .Must ensure patients receive high quality care .Must ensure facility is compliant with all Federal, State, and local .requirements .Must ensure facility is .safe for the comfort, convenience and safety of patients, families and staff .Must effectively supervise team .Must be able to .use reasoning skills and good judgement .Aware of all incidents and accidents and takes proper action including appropriate documentation .Ensures that issues or concerns in his/hers facility related to .quality of care, inaccurate, missing .medical documentation .are reported .Maintains working knowledge of the current laws, regulations, and policies that affect his/her position and level of responsibility .Provides guidance as necessary regarding regulatory compliance .Investigates all allegations of patient abuse, neglect . Review of the facility's DON Job Description, revised 1/8/2021, revealed .The Director of Nursing plans, organizes, develops, and directs the overall operation of the Nursing department to assure patient safety and attain or maintain the highest practicable physical, mental and psychosocial well being of each patient in accordance with all applicable laws, regulation, and Life Care standards .Weekend supervision responsibilities .works beyond normal working hours, on weekends and holidays .Must be able to communicate effectively with physicians, nursing staff and all other staff .Must be able to collect, analyze, and manage data .Must possess the ability to make independent decisions when circumstances warrant such actions .Must be knowledgeable of nursing administration practices and procedures as well as the laws, regulations and guidelines governing nursing administration .Must perform proficiently in all applicable competency areas .Must understand and follow company policies .Must be able to plan, develop, organize, implement, evaluate, establish benchmarks, and direct staff .Must be able to train .counsel and supervise staff .Must be able to direct care .Must be able to concentrate, and use reasoning skills and good judgement .Must be able to communicate and function productively on an interdisciplinary team . During an interview on 8/17/2021 at 11:22 AM, the Executive Director confirmed she is responsible for notifying the state agency of any adverse event and she would report anything that falls under abuse. The Executive Director was asked if she would report a resident exiting the building unsupervised. The Executive Director stated, I don't . The Executive Director confirmed she would not report to State Agency if the resident left the building unless they were off the premises or injured. The Executive Director confirmed she was not made aware of the 8/7/2021 elopement, until state surveyors entered the building on 8/16/2021. She confirmed on 8/16/2021 she looked at the video surveillance dated 8/7/2021 and Resident #1 was unattended outside. The Executive Director was shown the definition of elopement and she stated, I was not aware of it, but she has wandering behaviors, so we defined that as a behavior not an elopement . The Executive Director was asked if by regulatory definition should Resident #1's exit from the facility have been documented as an incident, should an investigation have been conducted, and should the incident have been reported to the State Agency. The Executive Director stated. No, because we [the facility] defined that as a behavior . The Executive Director confirmed she didn't feel a resident being outside unsupervised should have been reported. The Executive Director confirmed Resident #2 did leave the facility through her room window and felt that incident was also not reportable. The Executive Director confirmed Resident #3 had exited the facility unsupervised and felt this was also an unreportable event due to it being a behavior. The Executive Director confirmed Resident #4 did exit the facility unsupervised, but she felt that staff did what they were supposed to do, and Resident #4's elopement was not reported. During an interview 8/16/2021 at 5:16 PM, the Regional Vice President confirmed the documentation of all these events was incomplete and the investigations were not thorough. During an interview 8/17/2021 at 12:33 PM, the DON was asked about the elopement events. The DON stated, .Now looking back on them [elopements] I feel like, yeah, I could have done a better job. During an interview 8/18/2021 at 5:00 PM, the Executive Director was asked what her definition of elopement was. Our definition of elopement was either like leaving the premises, going outside, and getting injured, or being outside like they are lost, and we don't know where they are . During an interview on 8/19/2021 at 2:41 PM, the DON confirmed she was called on 8/7/2021 related to Resident #1's incident, confirmed she did not follow up on Resident #1's incident and did not investigate the incident further. The DON confirmed the staff should call her immediately with anything reportable, such as elopements, misappropriation, and a fall with injury. The DON confirmed elopements are reportable to the state. Refer to F-600, F-609, F-610, F-689, and F-867. The surveyors verified the Removal Plan by: 1. On 8/18/2021, the Executive Director, DON, and Interdisciplinary Team completed a Root Cause Analysis (RCA). The surveyors reviewed the RCA conducted by the Executive Director and DON. 2. On 8/18/2021, the facility completed an Elopement Drill. The surveyors reviewed the in-service sign-in sheets and interviewed staff on all shifts. 3. The Executive Director will be responsible for reviewing the abuse reporting log and compliance rounds trends and patterns. The surveyors reviewed the Abuse Reporting Log audit tool and interviewed the Executive Director. 4. The Director of Nursing will be responsible for reviewing the Event Management System for trends and patterns. The surveyors reviewed the Event Management System policy and interviewed the DON. 5. On 8/18/2021, the Regional Director of Clinical Services (RDCS) provided education to the Executive Director (ED) and the Director of Nursing (DON) to ensure the abuse policies are implemented (reporting requirements), to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the Administrator immediately, and not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (including to the State Survey Agency and adult protective services): Protection of Residents: Reducing the threat of Abuse and Neglect and Unsafe Wandering and Elopement Prevention. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed the RDCS, the Executive Director, and the DON. 6. The ED, DON, ADON, Staffing Development Coordinator (SDC) and/or Licensed Nurse will provide education to all facility staff on the following (reporting requirements) to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator, and not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (including to the State Survey Agency and adult protective services): Protection of Residents: Reducing the threat of Abuse and Neglect and Unsafe Wandering and Elopement Prevention. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies, interviewed staff on all shifts, and interviewed the Administrator and DON. 7. The DON, ADON, SDC, and/or Licensed Nurse will provide education to all Licensed Nurses and Certified Nursing Assistants on the following: Event Management System, Residents Rights, and Behavior Health Management. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed staff on all shifts. 8. Any associate who has not completed training by 8/18/2021, will not be allowed to work until training is completed. The ED, DON, SDC, and/or Licensed Nurse will provide education to all new associates upon hire during orientation. The surveyors validated staff could not return to work prior to receiving the education through staff interviews on all shifts. 9. By 8/20/2021, the Regional Director of Clinical Services (RDCS) provided education to the Executive Director (ED) and to the other Quality Assurance and Performance Improvement (QAPI) Committee Members which include, the ED, DON, Medical Director, MDS Nurse, Food and Nutrition Services representative, Pharmacy representative, Social Services representative, Activity and Recreational Services representative, Environmental Services representative, Human Resources representative, Staff Development Coordinator, Safety representative, Health Information Management representative, Rehab Services representative, Business Office representative on the following: Performance Improvement Projects, QAPI feedback, Data Systems, and Monitoring, QAPI Systematic Analysis and Systematic Action, Quality Assessments and Assurance Committee Meeting, and Quality Assessment and Assurance Committee Roles and Responsibilities. The surveyors reviewed the in-service sign-in sheets for staff education of the above policies and interviewed members of the QAPI Committee. 10. The facility will implement quarterly Elopement Drills. The surveyors validated the action plan through staff interviews. 11. All resident comment and concern cards will be reviewed for allegation of abuse during daily stand-up meeting. The ED will be responsible for ensuring appropriate reporting and investigation. The surveyors reviewed the comment and concern cards and interviewed the Executive Director regarding the comment and concern cards. 12. On 8/19/2021, the ED posted signage by time clock identifying all allegations of abuse are to be reported to the ED immediately, with their contact number. It will also include a second person, the DON, and their contact number to be notified, when the ED cannot be reached. The surveyors reviewed the signage posted in the Break Room related to abuse reporting and the staff telephone numbers, and interviewed staff on all shifts. 13. Prior to submitting final investigations to required agencies, a member of the Regional Team (RVP, RDCS) will review the investigations to ensure a thorough investigation was completed. The surveyors validated the action plan through interviews with the Administrator, RVP and RDCS. 14. The RVP will review the abuse reporting log and investigations during weekly facility visits. The surveyors validated the action plan through interview with the RVP. 15. The RVP and RDCS will conduct facility visits at least weekly until substantial compliance is received. The surveyors validated the action plan through interview with the RVP. The facility's noncompliance at F-835 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.