Every finding on record at Mills Nursing & Rehabilitation

Based on observation, interview, and facility document and policy review, the facility failed to store and prepare foods under proper sanitary conditions and failed to ensure food preparation equipment was clean. The deficiency had the potential to affect all residents who received food from the kitchen.The findings include: A facility policy titled, Food Storage: Cold, dated October 2019, revealed, It is the center policy to insure [sic] all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines for the FDA [Food and Drug Administration] Food Code. The policy revealed, 5. The Dining Services Director/ Cook(s) insures [sic] that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. A facility policy titled, Food Storage- Dry Goods, dated October 2019, revealed, It is the center policy to insure [sic] all dry goods will be appropriately stored in accordance with guidelines of the FDA Food Code. The policy revealed, 5. The Dining Services Director or designee ensures that all packaged and canned food items shall be kept clean, dry, and properly sealed. A facility policy titled, Environment, dated October 2019, revealed, It is the center policy that all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition The policy revealed, 3. The Dining Services Director will insure [sic] that all food contact surfaces are cleaned and sanitized after each use. The policy revealed, 5. The Dining Service Director will insure [sic] that all dining areas are cleaned and sanitized after each use, including table surfaces, chairs, and floors. Facility documents titled [NAME] (Daily Cleaning List) included the following tasks to be completed by the AM shift and the PM shift:- Steam Table (Cleaned out, wiped down and refilled for next shift.- Contact Surfaces (Tables, Sinks, shelves wiped down and cleared of all debri [sic].- Fryer (Fryer is to be filtered after ever [sic] use to ensure good oil quality.- Equipment (All used equipment has been properly cleaned and put away in proper place.The documents revealed that staff documented the tasks were completed each shift from 04/26/2026 through 05/17/2026, the day prior to the survey. An initial tour of the kitchen on 05/18/2026 at 9:10 AM, accompanied by Dietary Manager (DM) #1, revealed one dented can of refried beans on the shelf stored alongside all other canned products. A build-up of grease, dirt, dust, and food particles was observed on the inner walls and exterior surface of the fryer. There was dried food residue and splattered grease from the top of the fryer to the base. A roll-up door that was approximately five feet wide and went from the top of the steam table to near the ceiling, used to separate the dining room from the kitchen outside of mealtimes, was observed with a build-up of food, dust, and dirt. The steam table was observed with large amounts of sticky yellow substance, grease, dirt, and food particles on the front area. The shelf at the bottom of the steam table, where serving pans were being stored, and temperature regulating knobs were observed with a build-up of food particles, grease, and dirt. During an interview on 05/18/2026 at 9:15 AM, DM #1 confirmed the presence of the dented can of refried beans on the shelf with the other canned goods. He immediately removed the can and placed it on a separate shelf, stating that he checked all the shelves all the time; I must have missed that one. DM #1 stated that dented cans were usually placed on a separate shelf, and it was everyone's responsibility to check the storage room and remove dented cans and place them on the dented can shelf. An observation of the kitchen on 05/19/2025 at 11:15 AM revealed the roll-up door with food and dirt build-up. The steam table had a sticky discolored substance, dirt build-up, and food particles were on the bottom shelf and temperature control knobs. Oil observed in the deep fryer contained a thick layer of cooled grease on the surface. Food droppings remained at the base of the fryer, with burnt areas observed along the borders of the fryer's inner ring. The exterior of the fryer was observed with grease build-up on the temperature control knobs and the entire front area of the fryer and along the lateral side from top to bottom. An observation of the walk-in freezer on 05/19/2026 at 3:27 PM, accompanied by Regional Director of Operations (RDO) #3, revealed an opened box of raw hamburger patties with the patties having a variation of pink and brown colors, with a light tan color surrounding the edges. RDO #3 acknowledged the findings and immediately removed the box and instructed [NAME] #2 to discard the contents. RDO #3 stated that the patties were not properly stored and that the box should have been sealed. During an interview on 05/19/2026 at 3:38 PM, [NAME] #2 revealed that he assisted with stocking and restocking the storage rooms. He stated that he made sure that there was no spoiled or old food, and if he found any, he removed it. He stated that dented cans were to be placed on a separate shelf, and if he found any, he informed DM #1 so the company could be notified. He stated that it was either him or the other chef who probably left the box of hamburger patties opened due to rushing to get some while cooking. He stated, It is everybody's responsibility to check all the time and make sure things are right. During a follow-up interview on 05/19/2026 at 4:01 PM, RDO #3 stated that everyone should be making sure food containers were closed properly. An observation of the kitchen area on 05/20/2026 at 2:40 PM revealed the roll-up door was observed with food splatter and dirt build-up. The steam table had a sticky discolored substance, dirt build-up, and food particles on the bottom shelf and the temperature regulating knobs. The deep fryer was observed with oil containing droppings from foods fried and food particles clinging to the surrounding surface and the exterior of the equipment. During an interview on 05/20/2026 at 3:08 PM, Dietary Aide (DA) #4 stated that the dietary aides were responsible for cleaning the counters, sinks, and floors in the kitchen and the cooks were responsible for cleaning the fryers, ovens, and the steam table. She stated that there used to be a schedule but had not been lately. During an interview on 05/20/2026 at 3:42 PM, Cook/DA #10 stated that she was the cook on certain days and worked as the dietary aide on other days. She stated that there was a schedule book that listed the responsibilities of the kitchen staff that must be initialed after a task was completed. She stated that she worked in the facility on Saturday, 05/16/2026, and completed all the cleaning at the end of her shift and initialed the schedule book. Cook/DA #10 confirmed the build-up of food particles, grease, and dirt on the steam table and its bottom tray and the external areas, as well as the roll-up door. She also confirmed the dark areas and burned food particles in the oil and on the inside and outside of the deep fryer. Cook/DA #10 stated that the fryer should be filtered after every use by pressing a button and old oil dumped, and cleaning was to be completed weekly and that the fryer should be wiped clean after every use. During an interview on 05/20/2026 at 3:56 PM, RDO #3 stated that the staff had a cleaning schedule and were expected to complete their cleaning task. RDO #3 stated that if staff were at least wiping it daily and completing the weekly cleaning tasks, and cleaning at least every six months, then it would be easier to manage. She stated that the build-up was not from just one day of cleaning tasks not being done. During an interview on 05/21/2026 at 9:58 AM, the Director of Nursing (DON) revealed that he expected the kitchen to be maintained in a clean condition and the equipment to be clean. During an interview on 05/21/2026 at 10:27 AM, the Administrator revealed that it was his expectation that the kitchen be maintained in clean condition and that the facility policy be followed. He stated that food should be labeled and dated. He stated that staff had schedules for cleaning and maintaining, but things happened and things got left open. He stated that there should be a dented can policy that the staff should be following and that there was a separate rack where the dented cans were stored so they could be replaced or sent back to the supplier.

Based on interview and facility document and policy review, the facility failed to report an allegation of abuse for 1 (Resident (R)33) of 1 sampled resident reviewed for abuse. Specifically, an allegation of abuse that Resident 33 made toward Resident 34 was investigated by the facility but not reported to the state agency.The findings include: A facility policy titled, Abuse Neglect and Exploitation Policy, dated 04/2026, indicated, Y. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all required agencies (e.g. [exempli gratia], for example, law enforcement when applicable) within specified timeframes: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. A Resident Face Sheet revealed the facility admitted R33 on 05/05/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of multiple sclerosis, myasthenia gravis, chronic obstructive pulmonary disease, dementia, and major depressive disorder. An annual Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 03/17/2026, revealed R33 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Resident 33's Care Plan, revealed a problem statement dated 01/11/2024, that indicated the resident had behavioral symptoms. Nursing interventions included avoiding over-stimulation, maintaining a calm environment, and providing comfort when the resident became disruptive. 2. A Resident Face Sheet revealed the facility admitted Resident 34 on 02/21/2022. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of Parkinson's disease, major depressive disorder, and dementia. A quarterly MDS, with ARD of 03/17/2026, revealed Resident 34 had a BIMS score of 5, which indicated the resident had severe cognitive impairment. Resident 34's Care Plan, revealed a problem statement dated 12/19/2025, that indicated the resident had behavioral symptoms. Nursing interventions included redirection, avoiding over-stimulation, maintaining a calm environment, and providing comfort when the resident wandered. During an interview on 05/18/2026 at 12:04 PM, R33 stated R34 hit them about a month prior. Resident 33 stated they were unable to provide further details. During an interview on 05/18/2026 at 12:17 PM, the Administrator stated he was familiar with the altercation between Resident 33 and Resident 34 and had already investigated it. A facility document titled, Summary of Investigation dated 02/16/2026 revealed that an alleged altercation between Resident 33 and Resident 34 occurred on 02/15/2026. The summary revealed the facility completed interviews with all staff that worked on 02/15/2026, all residents in the [NAME] Hall were interviewed, and skin assessments were completed on residents that had a BIMS score of less than 8. The summary included a typed interview with Resident 33 conducted by the Administrator and the DON that revealed the resident stated the bruise on their back were due to Resident 34 hitting them and that Resident 34 hit them in the face and kicked them in both legs. Further review revealed Resident 33 stated that Resident 34 was working with two short kids in their 40's and that they wanted to hurt them (Resident 33). The typed interview revealed Resident 33 continued to tell staff that Resident 34 beats them and wants to kill them. The summary included a typed interview with Resident 34 conducted by the Administrator that revealed the resident stated they would never hit anyone. During an interview on 05/19/2026 at 1:41 PM, the Administrator said there was no report made to the state agency for the alleged altercation between Resident 33 and Resident 34. The Administrator stated that the facility handled it internally because Resident 33 had a history of false claims. During an interview on 05/21/2026 at 8:25 AM, the Director of Nursing (DON) stated the facility had a two-hour window to report abuse allegations to the state. The DON stated that Resident 33's abuse allegation was nonsensical. The DON stated staff completed a skin assessment, but there was no bruising other than from a previous fall that he was aware of. The DON stated the facility administration felt the event was not something to be reported and unsubstantiated it at the facility level. During an interview on 05/21/2026 at 8:51 AM, the Administrator stated if they could rule out an abuse allegation on the spot, they used common sense and handled it internally and did not report it. The Administrator stated that they still investigated the incident. The Administrator stated that for abuse allegations that he reported to the state, he tried to have it reported within the hour. During an interview on 05/21/2026 at 2:05 PM, the Administrator stated they had to use common sense with reporting. The Administrator stated if the resident said they were beaten and bruised in the face, but there were no bruises, he did not believe that required reporting to the state agency.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to implement a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, mental and psychosocial needs for one (1) of 29 sampled residents, Resident #1 (R1). On [DATE], Nurse Assistant (NA) #3 (Non Certified) failed to implement R1's Comprehensive Care Plan related to ensuring there were leg rests on the wheelchair and that the resident was positioned correctly in the wheelchair in regards to the pommel cushion. (A pommel cushion is designed to promote proper positioning by preventing residents from sliding forward in the wheelchair and features a raised center section that helps keep legs supported). As NA #3 propelled R1 in the wheelchair, the resident fell face first onto the floor. The facility transferred R1 to the local hospital emergency room (ER). R1's diagnoses included traumatic subarachnoid hemorrhage of the brain, fracture of the first cervical vertebrae (neck), anterior displaced type II odontoid (neck) fracture, fracture of right eye socket on right side, and fracture of right maxillary sinus (cheek). R1 expired on [DATE]. (Refer to F689) The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on [DATE], alleging removal of the Immediate Jeopardy (IJ) on [DATE]. The SSA validated the facility's IJ Removal Plan, on [DATE], and determined the deficient practice was corrected as alleged on [DATE], prior to the initiation of the investigation. Therefore, the IJ was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled Comprehensive Care Plan, dated [DATE] and revised ,d+[DATE] revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, to meet a resident's medical, physical, mental, and psychosocial needs. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services are to be provided or arranged by the facility, as outlined by the comprehensive care plan. The comprehensive care plan will be prepared by an interdisciplinary team and will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of R1's closed medical record Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses to include Alzheimer's Disease, anxiety disorder, open wound left foot, abnormal posture, unspecified dementia, cognitive communication deficit, and depression. Review of R1's Comprehensive Care Plan (CCP), dated [DATE], revealed a category problem of Activities of Daily Living (ADL) self-care performance deficit related to Alzheimer's Disease. The goal revealed the resident would maintain current level of care of ADLs with a target date of [DATE]. The interventions included: Locomotion, assist x one (1) in standard wheelchair; position with pommel cushion for parallel thigh alignment; and bilateral elevating leg rests dated [DATE]. An additional intervention was added for Pommel cushion to wheelchair dated [DATE]. Further review of R1's Comprehensive Care Plan (CCP), dated [DATE], revealed a category problem of being at risk for alteration in skin integrity due to blindness, dementia, incontinence, generalized weakness, and arterial ulcers to the right and left heels. The goal revealed the resident would not experience any unidentified alteration in skin integrity with a target date of [DATE]. Interventions included wheelchair legs to be padded for protection twice a day at 6:30 AM and 6:30 PM with a start date of [DATE]. Review of R1's Resident Profile Care Plan (Kardex -a care plan for nurse aides), undated, revealed interventions including assist x one (1) in standard wheelchair; position with pommel cushion for parallel thigh alignment and bilateral elevating leg rests with start date of [DATE]. In an interview with the Staff Development Coordinator on [DATE] at 2:10 PM, she stated this was the document viewed by the Nurse Aides and SRNAs in providing care for the residents. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of zero (0) out of 15. This score indicated the resident was severely cognitively impaired. Review of R1's Progress Notes, dated [DATE] at 5:45 AM, entered by Licensed Practical Nurse (LPN) #7, revealed the resident was up in the wheelchair, and slid to the floor in prone (chest down) position. An order was obtained from the Medical Doctor to send the resident to the emergency room (ER) and treat. Review of R1's hospital x-ray report, dated [DATE], revealed, Brain: acute hemorrhage in the right frontal region consistent with contusions and subarachnoid hemorrhage. Skull and facial bones: minimally displaced fracture of the right orbital roof. Suspect fracture of anterior wall of the right maxillary sinus. Orbits: external hemorrhage along the right orbital roof process. Fracture of the anterior arch of C1 (first cervical vertebra). Displaced fracture of the left posterior arch of C1 near the junction with the lateral mass in the region of the vertebral artery groove. Continued review of the hospital records, dated [DATE] and [DATE], revealed after consulting with the family, requests were made for comfort measures only. Continued review revealed the resident expired on [DATE] from injuries sustained from a fall at the Nursing Facility. Review of the facility's Incident Report titled, Incident Fall with Major Injury, dated [DATE], revealed on [DATE] at 5:45 AM, NA was pushing resident out of room after morning care. Resident noted to slide from wheelchair onto floor. Audit and interview with staff to ensure all interventions were in place at time of incident according to care plan. On the ADL care plan, the resident should be placed in a standard wheelchair with a pommel cushion for parallel thigh alignment and bilateral leg rest. Per the Incident Report, the leg rests were not used at the time of the fall. This Incident Report was completed by the Director of Nursing (DON) and Administrator. During interview on [DATE] at 9:09 AM, with State Registered Nurse Assistant (SRNA3/NA3) she stated at the time of R1's fall on [DATE], she was a NA (uncertified nurse aide) and since had become a SRNA. Per interview, she stated she had transferred R1 into the wheelchair and noticed the resident was leaning forward in the wheelchair. Further, she stated the pommel cushion was in the wheelchair to help the resident to sit in proper alignment. However, she stated R1 was not in correct alignment because her right leg was on top of the raised center portion of the pommel cushion and she did not want to hurt R1 by pushing her leg down as the resident was very rigid. SRNA #3 stated when she rolled the resident over the threshold of the door, there was a little bump at the threshold and the resident fell out of the wheelchair and went straight to the floor and did not slide out of the chair. In continued interview on [DATE] at 9:09 AM, SRNA #3 stated the leg rests were not on the wheelchair prior to the fall. During further interview related to why she did not put the leg rests on the wheelchair, she stated she had helped to take care of the resident during the last year and she did not think the resident needed the leg rests. SRNA #3 stated after the accident she was educated about the care plans, to look at them often, and if she was unsure about anything, ask a nurse. She stated she should have checked R1's care plan and followed it as it was written. SRNA3/NA3 stated she should have ensured she put the leg rests on the wheelchair and that the resident was positioned properly in the wheelchair with the pommel cushion. During interview with Licensed Practical Nurse (LPN) #7, on [DATE] at 7:41 AM, she stated she was the East Unit Charge Nurse on the night shift. She stated on [DATE] around 5:30 AM, NA #3 who was now a SRNA, came to notify her of R1's fall. LPN #7 stated she came down the hall and saw R1 was on the floor lying prone on the left side and was noted to have swelling with an abrasion to the forehead, and her nose was bleeding. She stated R1 was voicing complaints of hurting all over. LPN #7 stated NA #3 told her she was rolling the resident out to the hallway and the resident fell out of the wheelchair. The LPN stated she noticed the resident's leg rests were not on the wheelchair at the time of the fall. LPN #7 stated R1 was care planned to use the leg rests on the wheelchair and NA #3 should have followed the care plan. During an interview with MDS Coordinator #1, on [DATE] at 12:30 PM, she stated she developed/revised Comprehensive Care Plans for all residents. However, there were many staff members who also wrote care plans including Nurses, Therapists, Social Services, and Administrative staff such as the Director of Nursing (DON). She further stated the Comprehensive Care Plans were used as a guide in caring for the residents and were to be followed as written. She further stated, all nursing staff had access to the residents' profiles and their Comprehensive Care Plans. During an interview with the Staff Development Coordinator (SDC), on [DATE] at 2:10 PM, she stated during general orientation, she used a PowerPoint presentation for staff education and all information was covered regarding the Comprehensive Care Plan and how to find it. She further stated the staff also used a computerized program for training on equipment usage, floor training, care plans, and documentation. The SDC verified that all SRNAs and Nurse Aides prior to becoming SRNAs, received this training. She stated the decision to utilize leg rests on wheelchairs could be made by therapy, nurses or physicians, but typically Physical Therapy would evaluate the residents for the need for leg rests on wheelchairs. She further stated, after R1 fell , she started education and ensured 100 % (percent) of clinical staff was educated related to finding the Comprehensive Care Plans and implementing them. During an interview with the Director of Nursing (DON), on [DATE] at 9:16 AM, he stated after he was notified of R1 sustaining a fall, he immediately started an investigation. The DON stated R1 was being pushed into the hall, and had to have taken a head first fall onto the floor. He stated R1 was being pushed in a wheelchair without the leg rests and was not sitting up in the wheelchair in proper alignment as per the Comprehensive Care Plan and Resident Profile Care Plan (Kardex). He further stated SRNA/NA #3 was educated related to following the CCP and Kardex after the incident. During a phone interview with the Medical Director, on [DATE] at 3:48 PM, he stated on [DATE] he was notified of R1's fall. Per interview, he stated he gave staff orders to send the resident to the Emergency Department for evaluation and treatment. The Medical Director stated the executive staff had a meeting on [DATE] regarding the facility's plan for corrective action. He stated after the incident, corrective action included further education for staff. He stated staff was to follow the Comprehensive Care Plans as written. During an interview with the Administrator on [DATE] at 4:10 PM, he stated he was notified of R1's fall the morning of the incident and the facility started working on the Root Cause. Per interview, he stated education was started on [DATE] for all nursing staff related to the importance of following the care plan. He further stated he expected all staff to follow the Comprehensive Care Plans as written.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (1) of 29 sampled residents (Resident (R1)). On [DATE], Nurse Assistant (NA) #3 (Non Certified) pushed R1 in her wheelchair from her room. However, NA #3 failed to place the leg rests on the wheelchair and failed to ensure the resident was positioned correctly in the wheelchair in regards to the cushion. R1 fell face first onto the floor. The facility transferred R1 to the emergency room (ER) for evaluation. R1 sustained injuries which included: traumatic subarachnoid hemorrhage of the brain, fracture of first cervical vertebrae (neck), anterior displaced type II odontoid (neck) fracture, fracture of right eye socket on right side, and fracture of the right maxillary sinus (cheek). R1 expired in the hospital on [DATE]. (Refer to F656) The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on [DATE], alleging removal of the Immediate Jeopardy (IJ) on [DATE], prior to the State Survey Agency's (SSA's) investigation. The SSA validated the facility's IJ Removal Plan, on [DATE], and determined the deficient practice was corrected as alleged on [DATE], prior to the initiation of the investigation. Therefore, the IJ was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Accidents and Supervision, dated [DATE] and revised [DATE], revealed the resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: (1) identifying hazards and risks; (2) evaluating and analyzing hazards and risks; (3) implementing interventions to reduce hazards and risks, and (4) monitoring for effectiveness and modifying interventions when necessary. Review of the facility's policy titled Falls, dated [DATE] and revised [DATE], revealed the facility strived to maintain a hazard free environment, mitigate fall risk factors, and implement preventative measures. Intensive efforts will be directed toward minimizing or preventing injury. Procedures include: any orders received from the physician should be noted and carried out; the resident's care plan should be updated to reflect any new interventions or change in interventions; discuss risks and interventions with resident and/or responsible party, and communicate interventions during shift report. Review of R1's Face Sheet (closed medical record) revealed the facility admitted the resident on [DATE] with diagnoses that included Alzheimer's Disease, anxiety disorder, open wound left foot, abnormal posture, unspecified dementia, cognitive communication deficit, and depression. Review of R1's Comprehensive Care Plan (CCP), dated [DATE], revealed a problem of Activities of Daily Living (ADL) self-care performance deficit related to Alzheimer's Disease. The goal stated the resident would maintain the current level of care of ADLs with a target date of [DATE]. Approaches included: locomotion, assist x one (1) in standard wheelchair; position with pommel cushion (A cushion designed to promote proper positioning by preventing residents from sliding forward in the wheelchair. It features a raised center section that helps keep the legs supported) for parallel thigh alignment; and bilateral elevating leg rests dated [DATE]. Another approach was added for a Pommel cushion to the wheelchair dated [DATE]. Review of R1's Comprehensive Care Plan (CCP), dated [DATE], revealed a problem of being at risk for alteration in skin integrity. The goal stated the resident would not experience any unidentified alteration in skin integrity with a target date of [DATE]. Approaches included wheelchair legs to be padded for protection twice a day at 6:30 AM and 6:30 PM with a start date of [DATE]. Review of R1's Resident Profile Care Plan (Kardex) undated, revealed approaches included: assist x one (1) in standard wheelchair; position with pommel cushion for parallel thigh alignment and bilateral elevating leg rests with start date of [DATE]. During an interview with the Staff Development Coordinator on [DATE] at 2:10 PM, she stated the Kardex was viewed by the Nurse Aides and SRNAs in providing care for the residents. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of zero (0) out of 15 which indicated the resident was severely cognitively impaired. Review of R1's Occupational Therapist Evaluation, dated [DATE], revealed the reason for the referral by nursing was due to the residents' inability for holding her feet up during transport with nursing providing elevating leg rest. However, poor lower extremity placement with the knees flexed greater than 90 degrees caused the resident's feet to slightly go inward on the foot rest and increased bilateral lower extremity adduction (move toward the midline) impacting care as well as foot placement on the foot rest. The plan was to address positioning with devices that were appropriate and least restrictive. Further review revealed the resident was dependent in areas of eating, oral hygiene, personal hygiene, toileting, shower/bath, transfers, upper body dressing, lower body dressing and putting on or taking off footwear. Review of R1's Progress Notes, dated [DATE] at 5:45 AM, entered by Licensed Practical Nurse (LPN) #7, revealed the resident was up in the wheelchair, slid to the floor in prone (face down) position, and the Certified Nurse Aide (CNA) sent for the nurse. Upon nursing assessment, the resident had a bleeding nose, knot midline that was bleeding to the forehead, and her right eye was swollen shut. R1 had complaints of pain to the head and face. Resident alert to self and pain only, normal for resident. Left pupil three (3) millimeters (mm) and reactive, and unable to assess right due to swelling. Resident's normal is stiff and ridged and unable to assess Range of Motion (ROM). Order obtained from Medical Doctor to send the resident to the emergency room (ER) and treat. Employee to be educated. Power of attorney (POA) and Director of Nursing (DON) aware. Review of R1's hospital Admission Note, dated [DATE] through [DATE], revealed the resident arrived at the hospitalER on [DATE] at 6:27 AM and was transferred from a nursing home for contusion sustained from falling out of her wheelchair. Patient (resident) not very verbal. The hospital x-ray report, dated [DATE], revealed Brain: acute hemorrhage present in the right frontal region consistent with contusions and subarachnoid hemorrhage. Skull and facial bones: minimally displaced fracture of the right orbital roof. Suspect fracture of anterior wall of the right maxillary sinus. Sinuses: fluid in the right maxillary sinus which is mildly hyperdense. Mastoid air cells: small amount of right mastoid fluid without destructive changes. Orbits: external hemorrhage along the right orbital roof process. Fracture of the anterior arch of C1 (first cervical vertebra). Displaced fracture of the left posterior arch of C1 near the junction with the lateral mass in the region of the vertebral artery groove. Further review revealed the resident was admitted to the hospital and after consulting with family, requests for comfort measures only. Patient is a Do Not Resuscitate (DNR). Additional review revealed the resident expired on [DATE] from injuries sustained from a fall at nursing facility. Review of the facility's Incident Report titled Incident Fall with Major Injury, dated [DATE], revealed on [DATE] at 5:45 AM, NA was pushing the resident out of her room after morning care. The resident was noted to slide from the wheelchair onto the floor. Resident noted to be in prone position at the time. NA alerted nurse of event, nurse noted resident to be on floor with blood from nose, raised area to midline and laceration to forehead. Right eye noted to be swollen. Resident assessed for pain and voiced complaints of pain. Resident alert to self and pain, baseline for resident. Medical Director was in the facility for rounds and orders were given to send resident to the hospital ER to evaluate and treat and perform a Computed Tomography Scan (CT). Only history of falls was on [DATE] with no injury noted. Audit and interview with staff to ensure all interventions were in place at time of incident according to care plan. On the ADL care plan, resident should be placed in a standard wheelchair with pommel cushion for parallel thigh alignment and bilateral leg rest. Per the Incident Report, leg rests were not used at the time of locomotion. The Incident Report was completed by the Director of Nursing (DON) and Administrator. During an interview on [DATE] at 9:09 AM, with State Registered Nurse Assistant (SRNA) #3 (NA #3 at time of R1's fall), she stated she had worked at the facility approximately one (1) and a half months and worked the night shift. She stated she had been transferred to the facility from a sister facility. SRNA #3 stated on the morning of [DATE] she went to R1's room to perform morning care, brush R1's teeth, get her clothes on and brush her hair. In further interview, she stated she transferred the resident into the wheelchair by standing and pivoting the resident and sitting the resident down in the chair while the resident held onto her. During interview with SRNA #3, on [DATE] at 9:09 AM, she stated once R1 was in the wheelchair, she noticed she was leaning forward, but she thought the resident was just adjusting herself. SRNA #3 stated the pommel cushion was in the wheelchair, which was to help the resident to sit in proper alignment. However, she stated R1 was not in correct alignment because her right leg was on top of the raised center portion of the pommel cushion and she didn't want to hurt R1 by pushing her leg down as the resident was very rigid. She stated the resident did not respond much during conversation due to her dementia diagnosis. In further interview, SRNA #3 stated when she rolled the resident over the threshold of the door, there was a little bump at the threshold and the resident fell out of the wheelchair and went straight to the floor. She stated R1 did not slide out of the chair. In interview with SRNA #3, on [DATE] at 9:09 AM, she stated on [DATE], the R1's leg rests were leaning against the wall behind the wheelchair at the time she transferred the resident to the wheelchair. She stated the leg rests were not on the wheelchair prior to the fall. SRNA #3 state she did not put the leg rests on the wheelchair, she stated she did not think the resident needed the leg rests. She further stated she had helped to take care of the resident during the last year and had not used them. SRNA #3 stated she had not reviewed the resident's Comprehensive Care Plan or Kardex prior to the transfer. She stated she was unaware of the interventions related to the leg rests on the chair and making sure R1 was correctly positioned in the chair with the pommel cushion. She stated she had since been educated related to ensuring the Care Plan was followed. During an interview with Licensed Practical Nurse (LPN) #7, on [DATE] at 7:41 AM, she stated she was the East Unit Charge Nurse on night shift. She further stated on [DATE] around 5:30 AM NA #3, who was now a SRNA, came to get her. LPN #7 stated she came down the hall and saw R1 on the floor. She stated she told NA #3 to go find the charge nurse. LPN #7 stated R1 was lying prone on her left side on the floor. She further stated the resident had swelling with an abrasion to the forehead, and her nose was bleeding. LPN #7 stated there were no visual injuries to R1's arms or legs. She stated R1 was talking and voicing complaints she was hurting all over. LPN #7 stated NA #3 told her she was rolling the resident out to the hallway and the resident fell out of the wheelchair. The LPN stated the resident's leg rests were not on the wheelchair at the time of the fall. She further stated she had placed the leg rests in the seat of the resident's wheelchair earlier in the night prior to NA #3 assisting the resident to the wheelchair in the morning. In continued interview, LPN #7 stated R1 was care planned for locomotion to use the leg rests on the wheelchair prior to the fall. During a phone interview with SRNA #5, on [DATE] at 9:10 AM, she stated she had been NA #3/SRNA #3's preceptor/trainer since she started. She stated she was not there the night of R1's fall. However, SRNA #5 stated NA #3/SRNA #3 had been trained fully on transfers, reading and following the care plans and finding help if she did not understand or remember how to follow a task. She further stated she had told NA#3/SRNA #3 to always ask her trainer or another person/nurse/SRNA if she needed help with any task. During a phone interview, on [DATE] at 9:30 AM, with SRNA #7, she stated she was working on [DATE] and NA #3 was supposed to come to her if she needed help or had questions. She denied that NA #3 had asked her any questions on [DATE]. SRNA #7 stated she came out of a resident's room and saw R1 on the floor with NA#3 and the charge nurse with the resident. During an interview with the Director of Nursing (DON), on [DATE] at 9:16 AM, he stated he received a phone call related to R1 sustaining a fall and when he arrived at the facility an investigation was initiated. He stated, R1 was being pushed into the hall, and had to have taken a head first fall onto the floor. He further stated R1 was an AM get up which meant the night shift assisted her out of the bed to get her ready for breakfast prior to the end of the shift. The DON stated on the morning of R1's fall, she was being pushed in a wheelchair without leg rests even though it was safer for her to have leg rests on the wheelchair. He stated the resident had not been sitting properly in the wheelchair at the time of the fall. He stated these safety measures were on the resident's Comprehensive Care Plan and Resident Profile Care Plan (Kardex) prior to the fall. During a phone interview with the Medical Director, on [DATE] at 3:48 PM, he stated he had just left the faciity on [DATE] and was called by the facility to advise related to R1's fall. He stated he gave staff the orders to send the resident to the Emergency Department at the local hospital for evaluation and treatment. He further stated he was aware of the resident's outcome. He stated the executive staff had a meeting the day of R1's fall regarding the facility's plan for corrective action which included further education for staff. During an interview with the Administrator, on [DATE] at 4:10 PM, he stated he was aware of R1's fall and it was an unfortunate occurrence. He further stated after the fall, the facility started working on the Root Cause of the incident and education was started immediately for all nursing staff related to the need to follow the care plans, as this was important for the safety of the residents.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure food was stored in a sanitary manner. Observation of the kitchen, on [DATE] at 9:10 AM, revealed two (2) opened bags of grated parmesan cheese were stored in the refrigerator and were not sealed, labeled, or dated. The findings include: Review of the facility's policy titled, Food Receiving and Storage, revised [DATE], revealed foods should be received and stored in a manner that complied with safe food handling practices. Observation of the reach in refrigerator, on [DATE] at 9:10 AM, revealed two (2) opened bags of grated parmesan cheese that had were not sealed, labeled, or dated. During an interview with Cook #1, on [DATE] at 8:07 AM, she stated opened containers or packages of food should have a label for identification of the food, and a date to indicate when the food item was opened to ensure the food had not expired. Further, Cook #1 stated all opened food containers or packages should be sealed properly. During an interview with Cook #2, on [DATE] at 1:15 PM, she stated if a food product was opened, it should be marked with the open date. She stated after food had been opened for three (3) days, it was to be disposed of as it could possibly not be safe. Cook #2 stated if she noticed an item was not labeled or dated, she would throw it away because staff would not know how long it had been there. During an interview with the Director of Culinary Services, on [DATE] at 1:43 PM, she stated when a container was opened, staff should put the product into a bag and then label and date the bag with the date opened. She further stated the item should also be marked with the date denoting three (3) days after it was opened and it would be disposed on that date. She stated if staff forgot to label or date or properly seal a product it should be thrown away. The Culinary Manager stated she always tells her kitchen staff, if in doubt, throw it out. During an interview with the Administrator, on [DATE] at 5:07 PM, he stated he expected food to be labeled, dated, and sealed as appropriate and staff should follow the guidelines and policies.

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. This affected Residents (R), R1, R46, R53, R54, R88, R91 and R403. On 05/10/2024, reconciliation of the controlled drugs, on the East Hall with Licensed Practical Nurse (LPN) #4, revealed narcotics and scheduled drugs had not been signed out on the narcotic sign out book as administered. The findings include: Review of the facility's policy titled, Controlled Substances, dated 08/22/2019 and revised 08/19/2023, revealed the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Review of the facility's policy titled, Medication Administration, dated 01/21/2023 and revised 02/20/2024, revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The Policy Explanation and Compliance Guidelines included: Sign Medication Administration Record (MAR) after the medication was administered. For those medications requiring vital signs, record the vital signs onto the MAR. If the medication is a controlled substance, sign the narcotic book. During a narcotic count on 05/10/2024 at 9:00 AM, with LPN #4, there were discrepancies in the controlled substance drug count and the narcotic sign out sheets. After two (2) discrepancies were found, LPN #4 stated this State Surveyor would find several drugs which had not been signed out on the narcotic sign out sheets. She stated she had not signed out her controlled substance drugs during her morning medication pass, even though she had administered the controlled medications. She stated it was quicker for her to administer the medications and sign them out later. There was a discrepancy in the controlled substance drug count and the narcotic sign out sheets for the following residents: 1. The facility admitted Resident #1 on 01/06/2024 with diagnoses which included paraplegia and spina bifida. During the controlled drug count, an Oxycodone 10 mg (milligram)/325 mg tablet (narcotic pain medication) was missing. 2. The facility admitted Resident #46 on 06/23/2022 with diagnoses which included vascular dementia and chronic pain syndrome. During the controlled drug count a 0.5 mg Alprazolam tablet (anti-anxiety medication) was missing. 3. The facility admitted Resident #53 on 04/03/2023 with diagnoses which included polyneuropathy and rheumatoid arthritis. During the controlled drug count a 0.5 mg Clonazepam tablet (medication used to treat anxiety and neuropathic pain) was missing. 4. The facility admitted Resident #54 on 04/18/2024 was diagnoses which included: type 2 diabetes mellitus with diabetic peripheral angiopathy. During the controlled drug count, a Lyrica 200 mg capsule (medication used to treat nerve and muscle pain) was missing. 5. The facility admitted Resident #88 on 01/05/2024 with diagnoses of rheumatoid arthritis and anxiety. During the controlled drug count an Alprazolam 0.25 mg tablet tablet (anti-anxiety medication) was missing. 6. The facility admitted Resident #91 on 06/27/2023 with diagnoses which included polyosteoarthritis, polyneuropathy, sciatica and pain. During the controlled drug count a 300 mg Gabapentin capsule (medication used to treat nerve pain) was missing. 7. The facility admitted Resident #403 on 04/30/2024 with diagnoses which included pain in the right shoulder, and chronic pain syndrome. During the controlled drug count a Gabapentin 400 mg capsule (nerve pain medication) was missing. During interview with LPN #4, on 05/10/2024 at 9:10 AM, she stated she had not followed the facility's policy and should have signed out each individual controlled substance/narcotic as it was administered during her morning medication pass. During an interview with Registered Nurse (RN) #2, on 05/10/2024 at 10:15 AM, she stated she always signed out medications including narcotics and other controlled drugs as she administered them. During an interview with RN #4, on 05/10/2024 at 2:16 PM, she stated all medications should be signed out at time of administration. During an interview with RN #2, on 05/10/2024 at 3:07 PM, she stated all medications were to be signed out on the MAR at the time of administration. She stated if it was a narcotic or controlled drug it should be signed out on both the MAR and the narcotic sign out sheet. During an interview with the Director of Nursing (DON), on 05/10/2024 at 10:23 AM, he stated all medications should be signed out at time of administration which included narcotics/controlled drugs. Further, he stated if it was a narcotic or controlled drug it should be signed out on both the MAR and the narcotic sign out sheet. The DON stated it was his expectation that staff followed the facility's policies. During an interview with the Administrator, on 05/10/2024 at 10:48 AM, he stated medications should be signed out as per policy at time of administration. He further stated all nursing staff should follow the facility's policies.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for two (2) of 29 sampled residents, Resident 7 (R7) and R16. Observation on 05/08/2024, of R7's left heel wound dressing change, revealed the Assistant Director of Nursing (ADON), removed the soiled dressing and failed to perform hand hygiene before donning clean gloves. After the dressing change, the ADON failed to wash her hands before exiting the room. Observation of perineal care (pericare), on 05/08/2024 for R16, revealed State Registered Nurse Aide (SRNA) #2, placed R16's dirty cloths on the resident's bedspread. SRNA #2 failed to wash her hands or perform hand hygiene. The SRNA pulled the resident's bed linens up, and pulled the bedside curtain open and did not wash her hands. The findings include. Review of the facility's policy titled Infection Prevention and Control Program, dated 09/03/2021 and revised 02/21/2024, revealed the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Further, all staff were responsible for following all policies and procedures. All staff shall assume that all residents were potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures. All staff shall use personal protective equipment (PPE)according to established facility policy governing the use of PPE. Review of the facility's policy, Standard Precautions Infection Control Protocol, dated 2020, revealed Hand Hygiene is to be done, after touching blood, body fluids, secretions, excretions, contaminated items; before and after removing PPE; between resident contacts; before meals and after using the restroom. 1. Review of the facility's policy titled, Wound Care-Dressing Change, dated 01/02/2020 and revised 04/11/2024, revealed the purpose of this procedure was to provide guidelines for the care of wounds to promote healing. Steps in the Procedure included: Wash and dry hands thoroughly, put on exam gloves and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves. Clean wound making sure cleanser does not leave the clean field. Wash hands and don gloves. Apply clean dressing. Discard items into designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry hands thoroughly. Wipe reusable supplies with alcohol as indicated. Wash and dry hands thoroughly. Review of R7's Face Sheet revealed the facility admitted the resident on 11/06/2023 with diagnoses that included polyosteoarthritis, hypertensive heart disease, chronic kidney disease, and pressure induced deep tissue damage of the left heel. Observation on 05/08/2024 at 12:20 PM, of R7's left heel wound dressing change, performed by the ADON (Assistant Director of Nursing), revealed she donned gloves and removed the soiled dressing from the wound. After removing the dressing and her gloves, she failed to wash her hands before donning new gloves. She cleaned the wound and with the same gloves applied the clean dressing to the wound. The ADON then removed her gloves, and failed to wash her hands before exiting the room. During an interview with the ADON on 05/08/2024 at 1:45 PM, she stated it was difficult performing the dressing change with someone watching her. She stated she should have washed her hands after removing the soiled dressing. Further, the ADON stated she should have performed hand washing and gloving at the appropriate times during and after the dressing change. The ADON stated during interview on 05/08/2024 at 2:00 PM, that she was the facility's Infection Preventionist. She stated, she made rounds observing staff for the appropriate use of personal protective equipment and proper handwashing techniques. She further stated, its a lot easier to make sure everyone else is washing their hands properly than performing under pressure myself. However, she stated everyone needs to follow the facility infection control policies. 2. Review of the facility's policy titled, Perineal Care, dated 01/02/2020 and revised 03/02/2024, revealed, it was the facility's practice to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Handwashing was to be done prior to starting and putting on gloves, and with change of gloves when soiled with cleaning. Also, remove gloves and discard and perform hand hygiene. Review of R16's Face Sheet revealed the facility admitted the resident on 12/20/2021 with diagnoses including Alzheimer's disease, dementia, anxiety disorder and depression. Observation of R16's perineal care on 05/08/2024 at 2:40 PM, performed by State Registered Nurse Aide (SRNA) #2, revealed after performing pericare, she placed R16's dirty cloths on the end of the bed on the bedspread as she did not have a bag open and available to place the dirty cloths. Further observation revealed she removed her soiled gloves and placed them in the trash can. However, she failed to wash her hands or perform hand hygiene. She then pulled the resident's bed linens up and into place, pulled the bedside curtain open, bagged the trash and wash cloths, then opened the resident's door. Observation revealed she walked out of the resident's room and entered the dirty utility room, raise the lids of the trash and linen cans, and placed them in the cans. She then walked to the nurse's station and washed her hands. During an interview on 05/05/2024 at 2:48 PM with SRNA #2, she stated she could not recall anything she did wrong related to infection control during or after performing perineal care for R16. However, she then stated she should have had an open bag ready to place the soiled wash cloths in after use. During an interview with the Staff Development Coordinator, on 05/08/2024 at 3:00 PM, she stated the staff was inserviced on correct hand washing multiple times a year and she completed random spot checks to make sure staff was using proper handwashing. She further stated more education would be needed related to handwashing and infection control. During an interview with the Director of Nursing (DON), on 05/08/2024 at 3:40 PM, he stated it was his expectation that all staff follow the wound care, perineal care, and handwashing policies to ensure no cross contamination from resident to resident. He also stated the Staff Development Coordinator (SDC) inserviced staff often on infection control. During an interview with the Administrator, on 05/10/2024 at 4:10 PM, he stated it was his expectation staff followed the handwashing and infection control policies as written.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide effective monitoring and supervision to prevent elopement for one (1) of six (6) sampled residents assessed for elopement risk (Resident #1). The facility assessed Resident #1 to be at risk for elopement on 08/22/2023. Staff observed the resident to wander throughout the facility searching for his/her family members; however, the staff were not alerted to provide increased supervision to the resident as this was the resident's normal behavior. Therefore, on 09/17/2023, the resident exited the facility undetected by staff. The resident was found approximately six hundred (600) feet outside of the facility by a citizen in the community. The facility's failure to have an effective system to ensure the resident's environment remained free of accident hazards and failure to ensure each resident received adequate supervision to prevent accidents has caused or is likely to cause serious injury, serious harm or death to residents. Immediate Jeopardy (IJ) was identified on 09/29/2023 and was determined to exist on 09/17/2023, with deficiencies cited at 42 CFR 483.21, Comprehensive Resident Centered Care Plans, (F657); and 42 CFR 483.25, Quality of Care, (F689); both at a Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25, Quality of Care, (F689). The facility was notified of the Immediate Jeopardy on 09/29/2023. An acceptable IJ Removal Plan was received on 10/12/2023, which alleged removal of the Immediate Jeopardy on 10/01/2023. The State Survey Agency (SSA) validated the removal of the IJ, as alleged, on 10/14/2023, prior to exit on 10/14/2023. IJ was removed at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, (657); and 42 CFR 483.25, Quality of Care, (F689); both were lowered to a S/S of a D, while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. (Refer to 657) The findings include: Review of the facility's policy titled, Accidents and Supervision, revised 03/20/2023, revealed the resident's environment would remain as free of accident hazards as possible. Continued review of the policy revealed each resident would receive adequate supervision and assistive devices to prevent accidents. This included identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The facility policy further stated that supervision was an intervention and a means of mitigating accident risk. The facility would provide adequate supervision to prevent accidents. Adequacy of supervision was defined by type and frequency and was also based on the individual resident's assessed needs and identified hazards in the resident environment. Review of the facility's policy titled, Elopement and Wandering Residents, revised 01/02/2023, revealed the facility utilized a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering to include identifying and assessing residents at risk, evaluation, and analysis of hazards and risks, implementing interventions to reduce hazards and risks, monitoring for the effectiveness and modifying interventions when necessary. Further review of the policy revealed interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards would be added to the resident's care plan and communicated to appropriate staff. Closed record review revealed the facility admitted Resident #1 on 11/01/2021 with diagnoses which included: Unspecified Dementia, Generalized Anxiety Disorder, and Major Depressive Disorder. Further review of the record revealed Resident #1 was discharged home with family on 09/20/2023. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 08/22/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) which indicated the resident was severely cognitively impaired. Review of Resident #1's elopement care plan initiated on 02/16/2023 revealed, interventions to include: Resident #1's room was to be decorated with items from his/her home and had pictures of his/ her family so when the resident wanders, he/she would see something familiar; check placement and function of safety monitoring device every shift; and distract the resident from aimless wandering by offering food, pleasant diversions, structured activities, conversation, television, or book. Review of Resident #1's Elopement Assessment Risk dated 08/22/2023, revealed the facility assessed Resident #1 as being at risk for elopement based on him/her being ambulatory, cognitively impaired, having poor decision-making skills, and history of wandering. Review of a Progress Note dated 09/17/2023 at 3:00 PM, completed by Unit Manager #1 revealed the facility was notified that Resident #1 was outside the facility. Further review of the Note revealed Resident #1 was escorted back into the facility by staff with his/her wanderguard bracelet in place and it was in working order as Resident #1 entered the building. The Note revealed Resident #1 was assessed by staff with no injuries noted. Review of the Facility's Investigation, completed by the Administrator and Director of Nursing (DON) on 09/20/2023, revealed on 09/17/2023 at 2:40 PM, the facility was notified that Resident #1 was found outside the facility at approximately six hundred (600) feet from the front entrance. Resident #1 was escorted back into the facility by two (2) staff members at 2:45 PM. In an interview with Licensed Practical Nurse (LPN) #7, on 10/05/2023 at 10:55 AM, she stated she was working on 09/17/2023. She stated she had seen Resident #1 the morning of the elopement as she was walking by the [NAME] Side nurse's station. LPN #7 stated Resident #1 did not say anything at that time. She further stated Resident #1 would normally walk the halls and talk about his/her baby doll, or would ask when his/her family was coming to get him/her. In an interview with Certified Nurse Aide (CNA) #2, on 09/23/2023 at 7:14 PM, he stated he last saw Resident #1 on 09/17/2023 at 2:30 PM, walking down the East Long Hall. CNA #2 stated shortly after seeing Resident #1, he was then informed that he/she had been found outside and that two (2) staff members had gone to retrieve Resident #1. CNA #2 further stated he had never known Resident #1 to attempt to make attempts to exit the facility; however, the resident wandered around the facility asking staff where his/her brother was located. CNA #2 stated he did not believe the resident needed increased supervision because the resident had never tried to exit the facility before. In an interview with CNA #3, on 09/27/2023 at 9:45 AM, she stated she was assigned to Resident #1's hall on 09/17/2023. She stated she last saw Resident #1 around 2:40 PM-2:45 PM, in the living area after church services ended, and was walking on the East Short Hall asking staff if they had seen his/her momma. CNA #3 stated she was in another resident's room providing care when Licensed Practical Nurse (LPN) #2 informed her that Resident #1 had exited the facility. She stated it was normal for Resident #1 to walk the halls and ask for his/her family members or sit in the living area. Review of the facility's in-coming call log revealed Caller #1 had called the facility on 09/17/2023 at 2:46 PM, to inform staff Resident #1 was outside of the facility. In an interview with Caller #1, on 09/27/2023 at 11:00 AM, she stated she was on her way from the grocery store when she saw Resident #1 at the end of the street near a daycare close to the highway. She stated she immediately called the facility because she recognized the resident, adding she had a family member who was also a resident of the facility. Caller #1 stated the resident was holding a baby doll and was observed walking down the street as she parked her car. She stated she got out of her car and then walked with Resident #1. Caller #1 stated two (2) staff members came to escort the resident back to the facility. In an interview with CNA #1, on 09/23/2023 at 6:49 PM, she stated on 09/17/2023 as she was walking by the receptionist's desk the telephone rang so she answered it. The caller stated, Resident #1 was outside the facility. CNA #1 stated she immediately hung up the phone, went and got LPN #1 and both of them went outside and found Resident #1 walking back towards the facility. She stated Resident #1 told her, A weird lady opened the door so I left with her. She further stated upon entering the facility Resident #1's wanderguard sounded the door alarm and she escorted the resident back to his/her unit. In an interview with Licensed Practical Nurse (LPN) #2, on 09/26/2023 at 1:43 PM, she stated she was the nurse caring for Resident #1 on 09/17/2023. She stated she last saw Resident #1 in front of the East Hall Nurse's station about ten (10) minutes prior to his/her elopement. LPN #2 stated Resident #1 asked her, Where's Momma? before she proceeded to walk towards the living area where they were having church services at the time. LPN #2 stated the Weekend Receptionist came running down the hall towards her unit to alert her that Resident #1 had eloped. She stated someone found Resident #1 walking down the street and called the facility to alert staff. She stated CNA #1 and LPN #1 had gone to get Resident #1 and escorted him/her back into the facility. LPN #2 stated she and another CNA went outside to help look for Resident #1. Per the interview, she stated that once they were outside, they saw CNA #1 and LPN #1 heading back toward the facility with Resident #1. The LPN stated she performed an assessment on Resident #1 and noted the resident had no injuries. LPN #2 stated she notified the Unit Manager of the event, and the resident was placed on increased supervision. In an interview with LPN #1, on 09/26/2023 at 10:10 AM, she stated she saw Resident #1 around lunchtime, as he/she was walking down [NAME] Hall. She further stated CNA #1 told her a caller had reported Resident #1 as being outside of the facility. She stated she and CNA #1 found Resident #1 outside about 600 feet from the facility. LPN #1 stated the resident was holding his/her baby doll and talking to him/herself. She stated she asked Resident #1 why he/she left the facility and Resident #1 stated, A weird lady wanted to talk to me, so I left and went with her. LPN #1 further stated she asked Resident #1 if he/she had punched in any numbers to get out of the door and the resident stated, No. In interviews with the Weekend Receptionist on 09/26/2023 at 2:45 PM and 09/27/2023 at 10:20 AM, she stated she had stepped away from the front desk to fix a television (TV) for another resident. She stated she saw Resident #1 walking through the living area towards the [NAME] Side of the facility. The Receptionist stated this must have been around 2:30 PM because she had let a visitor out at that time. Per the interview, she stated she returned to the front desk and a staff member ran by her and stated Resident #1 got out. The Receptionist stated she went to the door and saw Resident #1 with CNA #1 and LPN #1 walking towards the facility, and she went to notify Resident #1's nurse. She further stated she should have ensured someone relieved her prior to leaving her post. In an interview with the Minimum Data Set (MDS) Nurse, on 09/28/2023 at 10:52 AM; and 12:19 PM, she stated Resident #1 would normally wander the facility searching for his/her family members. In an additional interview, the MDS Nurse stated the potential for harm was that the resident would be successful with exiting the facility or the resident could have become agitated and potentially violent, when left unsupervised, if he/she could not locate his/her family. In an interview with the Maintenance Director on 09/27/2023 at 9:57 AM, he stated the facility had over nine (9) exit doors which he checked daily to ensure they were operational and functioning properly. He stated Resident #9 had a wander guard bracelet and would not have been able to exit the facility without overriding the door alarm. Further, he stated that when the system detected the wanderguard, the doors would not unlock. In an interview with the Social Services Director (SSD) on 09/22/2023 at 4:40 PM, she stated that on 09/17/2023 she was the weekend Manager on duty. She stated staff reported to her that a caller had notified the facility of seeing Resident #1 walking down the street, a short distance from the facility. She stated the resident returned to the facility by staff and was assessed to have no injuries. The SSD stated the resident was dressed appropriately and had on a shirt, pants, and shoes She stated Resident #1 was asked why he/she left the facility and the resident replied, I left with a crazy lady. The SSD further added this was the first time Resident #1 had exited the facility. She stated she had notified all levels of management so an investigation could be initiated. In an interview with the Director of Nursing (DON) on 09/26/2023 at 10:40 AM, he stated he was notified of the resident's elopement by the SSD. He stated he went to the facility immediately and directed staff to start an investigation of the elopement. Per the interview, the DON stated that the root cause of the resident exiting the facility was related to visitors leaving from attending the church service and that by no staff were present when Resident #1 exited the facility. The DON stated someone turned the alarm off because they did not see a resident at the door, but they were unable to determine from their investigation who the staff member was that reset the door alarm. In an interview with the Administrator on 09/22/2023 at 4:00 PM, he stated the Social Services Director (SSD) informed him of Resident #1's elopement on 09/17/2023 and had initiated an investigation. The Administrator stated he felt Resident #1 was at risk for elopement because he/she was independent with ambulating and blended in easily with visitors. He stated the facility investigation determined the root cause of the resident's elopement was he/she walked out with a group of visitors and that the resident's trigger for wandering was frequent visits outside of the facility with his/her family. ****The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 10/12/2023 that alleged removal of the Immediate Jeopardy (IJ) on 09/20/2023 as follows: 1. Resident #1 was returned to the facility on [DATE] and was immediately assessed for injuries by the Assistant Director of Nursing (ADON), with no injuries noted. 2. A resident head count was completed by the Social Services Director (SSD) and charge nurses on 09/17/2023. All other current residents were accounted for at the facility. 3. On 09/17/2023, Resident #1's wanderguard was checked for placement and function by the Maintenance Director, with no irregularities noted. 4. The Unit Manager checked 6 (six) current residents who had an order for wander guards for placement and functioning with other alarmed doors. No were issues noted. 5. Resident #1 was assisted to his/her room and placed on fifteen (15) minute checks. 6. Unit Manager notified Resident #1's physician and guardian on 09/17/2023. No new orders were received. The written plan of care for Resident #1 was reviewed and updated by the Interdisciplinary Team to reflect his/her increased supervision. 7. On 09/17/2023 the Maintenance Director assessed the wanderguard door system and alarmed doors for functioning with no irregularities noted. All the exit door codes were changed. 8. Beginning 09/17/2023, the Maintenance Director would change all exit door codes monthly and as needed. The Maintenance Director would complete a door code audit monthly and as needed. Further he would report monthly to Quality Assurance Performance Improvement (QAPI) team. 9. A QAPI meeting was held on 09/17/2023 with the Administrator, Director of Nursing (DON), and the Medical Director to discuss Resident #'1's elopement, the root cause of the incident, elopement policy and procedure, and elopement drill scheduling for all shifts. The Maintenance Director would conduct the elopement drills, and staff education would be provided by the Social Services Director (SDC). Additional QAPI meetings were scheduled once a week for four (4) weeks. 10. On 09/17/2023 and 09/18/2023, the Assistant Director of Nursing (ADON), DON, Unit Managers, Staff Development Coordinator, and SDC, conducted a one-time 100% record review for residents who may have increased/unsafe wandering behaviors and/or were increased elopement risk for the past thirty (30) days. The record reviews included but were not limited to physician's orders, care plans, and treatment administration records (TAR). Plans of care for identified residents were reviewed and revised as needed to reflect the resident's status. 11. On 09/19/2023 the DON reviewed current residents to ensure Elopement Risk Assessments and care plans were accurate. 12. On 09/19/2023 the DON and ADON reviewed residents with wander alert bracelets to ensure proper placement and function, with no concerns noted. Additionally, care plans for identified residents were reviewed and revised as needed to reflect the residents' status. 13. On 09/19/2023, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) reviewed the facility assessment to ensure the number of residents with unsafe wandering was correct. 14. On 09/17/2023, the ADON, DON, and SDC initiated re-education on policy and procedure for elopement prevention and management for staff on duty. The re-education continued for all other staff, with a completion date of 09/19/2023. Re-education included but was not limited to checking of immediate surrounding area when responding to an alarm, and notification of the Licensed Nurse, DON, and the Administrator. All licensed nurses, Certified Nurse Aides (CNA's), current CNA students, Maintenance, housekeeping, dietary, and therapy, and included as needed (PRN) staff. any PRN staff. Staff completed a post-test with an overall score of 100%. No staff were allowed to work until they received the education. The information would also be included in the orientation of newly hired staff. The facility had no agency staff. 15. Signage informing visitors to not assist residents in exiting the facility was verified to be in place at the front door on 09/17/2023 by the Director of Nursing (DON) and the Administrator. Additional signage would be added as necessary. 16. The placement and function of resident wanderguards would be checked every shift by a licensed nursing staff and/or medication tech and documented in the electronic medical record on the treatment administration record (TAR) and/or the medication administration record (MAR). 17. The Maintenance Department and/or Manager on Duty would test exit doors and wander guard system daily. The Maintenance Director and/or the Administrator would change the door alarm codes monthly. 18. Wanderguard books were reviewed on 09/17/2023 by the SSD and were found to be up to date. Medical Records would be responsible for updating the Wanderguard books as needed. 19. Elopement drills would be conducted by the Maintenance Director or Maintenance Assistant 5 days per week, across all shifts and including weekends times 2 weeks, then 3 days per week, across all shifts and including weekends x 4 weeks; and then monthly times 3 months and then quarterly thereafter and will be documented on elopement drill sign-in sheets. 20. Any identified non-compliance with facility policy and procedure would result in 1:1 re-education with staff and repeat non-compliance resulting in progressive disciplinary action per facility policy. 21. The Door Code and elopement drills audit would be brought to QAPI by the Maintenance Director. They would be reviewed weekly for four (4) weeks and then monthly for five (5) months in the QAPI meeting by the Administrator and Director of Nursing (DON). ****The State Survey Agency validated the facility had taken the following actions: 1. During an interview with the Assistant Director of Nursing (ADON) on 09/22/2023 at 11:39 AM, she stated when staff escorted Resident #1 into the facility after his/her elopement on 09/17/2023, she assessed the resident for injuries. The ADON stated Resident #1 had no injuries and was appropriately dressed. 2. During an interview with the Social Services Director (SSD) on 09/22/2023 at 4:40 PM, she stated on 09/17/2023, after staff were informed that Resident #1 had eloped, she and other staff completed a full head count of facility residents. The SSD stated all residents were accounted for. 3. During an interview with the Maintenance Director on 09/27/2023 at 9:57 AM, he revealed when he was made aware of Resident #1's elopement he went to the facility and checked to ensure all facility doors were secure and functioning. Observations with the Maintenance Director on 09/27/2023 at 10:00 AM revealed all facility exit doors were checked and were in operating order. The Unit Manager checked 6 (six) current residents who had an order for wanderguards for placement and functioning with other alarmed doors. No issues were noted. 4. In an interview with the Unit Manager and Director of Nursing (DON) on 10/05/2023 at 3:38 PM, they stated they had performed checks on the six residents currently wearing wanderguards and found they were functioning properly. 5. Record review revealed Resident #1 was placed on fifteen (15) minute checks after the elopement. In interviews with Certified Nurse Aide (CNA) #3 on 09/27/2023 at 9:45 AM, Unit Manager #1 on 09/26/2023 at 3:46 PM, and Licensed Practical Nurse (LPN) #2 on 09/26/2023 at 1:43 PM, they stated 15-minute observation checks were conducted on Resident #1. 6. Review of a Progress Note dated 09/17/2023 at 3:00 PM, revealed Unit Manager #1 notified Resident #1's guardian and the resident's physician of the elopement. In an interview with Unit Manager #1 on 09/26/2023 at 3:46 PM, she stated she notified Resident #1's guardian and physician about the elopement on 09/17/2023. In an interview with Resident #1's physician/facility Medical Director, on 10/13/2023 at 2:03 PM, he stated he was notified of Resident #1's elopement by facility staff and provided with updates on the investigation by DON. In interviews with the Administrator on 09/22/2023 at 4:00 PM and the DON on 10/05/2023 at 3:38 PM, both stated they provided the Medical Director with updates on Resident #1 and the facility investigation. They further stated Resident #1's care plan had been reviewed and updated by the Interdisciplinary Team (IDT) to reflect his/her increased supervision. 7. In an interview with the Maintenance Director on 09/27/2023 at 9:57 AM, he stated that he observed the SSD check the doors on the morning of 09/17/2023, prior to the elopement. He further stated he performed checks on the doors on 09/17/2023, after Resident #1's elopement to ensure all doors were functioning properly. Review of the facility's door log on 09/27/2023 at 11:16 AM, revealed the SSD had signed off on all the door checks for 09/17/2023 at 9:00 AM. 8. Review of the Quality Assurance Performance Improvement (QAPI) meeting minutes dated 09/19/2023, revealed the door code audits were completed by maintenance were reviewed and discussed, with no concerns noted. Further review of the meeting minutes revealed the facility identified the Root Cause Analysis to be not responding properly to the door alarm and visitors knowing the door code. 9. Review of the QAPI minutes dated 09/17/2023, revealed the Administrator, Director of Nursing (DON), and the Medical Director attended the meeting. The QAPI team discussed Resident #'1's elopement, the root cause of the incident, elopement policy and procedure, and elopement drill scheduling for all shifts. In an interview with the Administrator on 09/22/2023 at 4:00 PM he stated a QAPI meeting was held on 09/17/2023 with himself, the DON, and Medical Director to discuss Resident #1's elopement. He stated the team further discussed the root cause of the elopement and the next steps to ensure all staff were educated on the elopement policy and procedure. The Administrator stated they have continued to have weekly meetings to discuss the events. In an interview with the facility Medical Director on 10/13/2023 at 2:03 PM, he stated they had a QAPI meeting by telephone. In an interview with the DON on 10/12/2023 at 5:23 PM, he stated he, the Administrator held a QAPI meeting after the elopement with the Medical Director by telephone. 10. In an interview with the Social Services Director (SSD) on 09/22/2023 at 4:40 PM, she stated she reviewed care plans for residents at risk for increased/unsafe wandering. She stated the reviews were comprehensive to ensure the residents care plans accurately reflected the residents needs. In an interview with Minimum Data Set (MDS) Nurse on 09/28/2023 at 10:52 AM, she stated she reviewed care plans for residents at risk for increased/unsafe wandering and updated them if needed. 11. In an interview with the Director of Nursing (DON) on 10/05/2023 at 3:38 PM, he stated he performed a review of all current residents to ensure their current Elopement Risk Assessments and care plans were accurate. He further stated if they were not he would update them at that time. 12. In an interview with the Assistant Director of Nursing (ADON) on 09/22/2023 at 11:39 AM, she stated she checked residents' wanderguard bracelets for placement and function. The ADON further stated care plans were reviewed and revised if needed. In an interview with the DON on 10/14/2023 at 10:24 AM, he stated care plans for identified residents were reviewed and revised to reflect the current status of those residents. He stated he checked those residents with wanderguard bracelets for placement and function. 13. In an interview with the DON on 10/14/2023 at 10:24 AM, he stated he and the ADON reviewed the facility assessment and verified the number of residents with unsafe wandering was correct. He stated this would be updated if concerns were noted with a resident having new wandering behaviors. 14. Review of staff education including post-tests and sign-in sheets revealed all staff disciplines had been educated by DON, ADON, and SDC. The education topics included policy & procedure for elopement prevention and management and the checking of the immediate surrounding area when responding to an alarm, and notification of the Licensed Nurse, DON & the Administrator. Interviews with Registered Nurse (RN) #1 on 10/02/2023 at 8:58 AM, Licensed Practical Nurse (LPN) #5 on 10/02/2023 at 8:56 AM, and Certified Nurse Aide (CNA) #3 on 09/27/2023 at 9:45 AM, revealed they received education on elopement from the SDC and took post-tests to demonstrate understanding of the information. In interviews with Cook #1 on 10/02/2023 at 4:45 PM, Environmental Services Manager on 10/02/2023 at 4:29 PM, and the Business Office Manager on 10/06/2023 at 10:19 AM, they all stated that they had received education on Elopement and took a post-test from the Staff Development Coordinator. In an interview with the Staff Development Coordinator on 10/02/2023 at 4:20 PM, she stated that she provided education to therapy, environmental services, and dietary services on elopement. 15. Observation of the front entrance on 09/21/2023 at 11:55 AM, revealed signage in place informing visitors to not assist residents in exiting the facility. Further observations revealed additional signage was posted on front exit doors of the main lobby of the facility. Additionally, signage informing visitors to not assist residents in exiting the facility was verified to be in place at the front door on 09/17/2023 by the Director of Nursing (DON) and the Administrator. 16. Review of Treatment Administration Records (TARs) of residents at risk for elopement revealed wanderguards were checked by nursing staff and documented. In an interview with Unit Manager #1 on 09/26/2023 at 3:46 PM, she stated she, along with the unit nurses, checked the placement of the residents' wanderguard bracelets every shift. 17. In an interview with the Maintenance Director on 09/27/2023 at 9:57 AM, he stated he was responsible for completing daily wanderguard system checks on all exit doors. If he were not working, the assigned manager on duty would complete the checks. He further stated he changes the door codes monthly to ensure visitors do have the door codes. 18. In an interview with the Social Services Director (SSD) on 09/22/2023 at 4:40 PM, she stated she reviewed the Wanderguard books and ensured they were up to date. She stated if any resident were newly assessed to be a wanderer the book would be updated immediately. 19. Record review of the Elopement drill logs and sign-in sheets on 09/27/2023 at 3:00 PM, revealed staff members participated in elopement drills given by the facility maintenance director. Observation of an elopement drill conducted by the Maintenance Director, on 09/29/2023 at 3:15 PM, revealed no concerns. Facility staff responded appropriately by calling alarms and providing prompt responses to door alarms. Staff were observed to have followed facility policy and procedure on a resident elopement event. Staff were observed walking the building perimeter and an all-clear was given on 09/29/2023 at 3:18 PM. 20. In an interview with the Director of Nursing (DON) on 09/26/2023 at 10:40 AM, he stated facility staff were educated on no longer giving out the door codes to vendors, and visitors. He stated the vendors and visitors have been educated by facility staff as they come to the facility. They were informed that they would now be let in and out of the facility by staff members because the door code would no longer be given out. The DON stated any staff member who violates this practice would face disciplinary action. 21. Review of the Quality Assurance Performance Improvement (QAPI) meeting minutes dated 09/22/2023, revealed the Administrator, DON, ADON, Area Director of Clinical Services, Maintenance Director, and Medical Director attended. The members discussed the elopement situation, the door codes, and the audits of elopement drills. In an interview with the Administrator on 10/14/2023 at 11:15 AM, he stated the door audits and elopement drills have been reviewed during weekly QAPI meetings and there have been no identified issues. He stated all interventions remained in place and seemed to be effective. In an interview with the DON on 10/14/2023 at 10:24 AM he stated that they were still discussing the Elopement in QAPI and evaluating to see if it was going well.

Based on interview, record review, and facility policy review, it was determined the facility failed to review and revise the resident's Person-Centered Comprehensive Care Plan for one (1) of six (6) sampled residents reviewed for elopement (Resident #1). Interviews with facility staff revealed Resident #1 frequently searched for and asked staff about the whereabouts of family members. However, this behavior was not reflected in Resident #1's care plan. Additionally, the Administrator stated the resident frequently left the facility with his/her family, which was a trigger for the resident to leave the facility unsupervised; however, the resident's care plan was not revised to reflect the Administrator's concerns. On 09/17/2023, while ambulating throughout the facility independently, Resident #1 exited the facility without staff's knowledge. The facility's failure to have an effective system to ensure residents' care plans were revised to reflect the residents' healthcare needs, has caused or is likely to cause serious injury, serious harm or death to residents. Immediate Jeopardy (IJ) was identified on 09/29/2023 and was determined to exist on 09/17/2023, with deficiencies cited at 42 CFR 483.21, Comprehensive Resident Centered Care Plans, (F657); and 42 CFR 483.25, Quality of Care, (F689); both at a Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25, Quality of Care, (F689). The facility was notified of the Immediate Jeopardy on 09/29/2023. An acceptable IJ Removal Plan was received on 10/12/2023, which alleged removal of the Immediate Jeopardy on 10/01/2023. The State Survey Agency (SSA) validated the removal of the IJ, as alleged, on 10/14/2023, prior to exit on 10/14/2023. IJ was removed at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, (657); and 42 CFR 483.25, Quality of Care, (F689); both were lowered to a S/S of a D, while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. (Refer to F689) The findings include: Review of the facility's policy, Comprehensive Care Plans revised 08/25/2023, revealed the facility would develop and implement a comprehensive, person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframe to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the resident's comprehensive assessment. The care planning process would include an assessment of the resident's strengths and needs and would incorporate the resident's personal and cultural preferences in developing goals of care. The comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Further review of the policy revealed the comprehensive care plan objectives would be utilized to monitor the resident's progress. Alternative interventions would be documented as needed. Qualified staff responsible for carrying out interventions specified in the care plan would be notified of their roles and responsibilities for carrying out interventions specified in the care plan initially and when changes were made. Review of the facility's policy, Elopement and Wandering Residents, revised 01/02/2023, revealed the facility would ensure that residents who exhibited wandering behavior and/or are at risk for elopement receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility should establish and utilize a systematic approach to monitoring and managing residents at risks for elopement or unsafe wandering to include identifying and assessing residents of risk, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness, and modifying interventions when necessary. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or minimize risks associated with hazards would be added to the resident's care plan and communicated to appropriate staff. Closed record review revealed the facility admitted Resident #1, on 11/01/2021 with diagnoses which included: Unspecified Dementia, Generalized Anxiety Disorder, and Major Depressive Disorder. Further review of the record revealed Resident #1 was discharged home with family on 09/20/2023. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 08/22/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating the resident was severely cognitively impaired. Review of Resident #1's Elopement Assessment Risk dated 08/22/2023, revealed the facility assessed Resident #1 as being at risk for elopement based on him/her being ambulatory, cognitively impaired, having poor decision-making skills, and history of wandering. Review of the Facility's Investigation, completed by the Administrator and Director of Nursing on 09/20/2023, revealed on 09/17/2023 at 2:40 PM, a caller notified facility staff that Resident #1 was found outside the facility approximately six hundred (600) feet from the front entrance. Resident #1 was escorted back into the facility by two (2) staff members at 2:45 PM. Review of Resident #1's elopement care plan revealed Resident #1 was care planned for interventions which included Resident #1's room was decorated with items from his/her home with pictures of his/her family so when he/she wandered, he/she would see something familiar. Additional interventions included to check the placement and functioning of his/her safety monitoring device every shift and distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. Further review of the care plan revealed staff were to identify patterns of wandering based on whether the wandering was purposeful or aimless and if the resident was looking for something. Staff would intervene as appropriate, observe for fatigue and weight loss, and for his/her wander alert device. Review of the facility's in-coming call log, revealed Caller #1 had called the facility on 09/17/2023 at 2:46 PM, to inform staff that Resident #1 was outside the facility. In an interview with Certified Nurse Aide (CNA) #12 on 10/05/2023 at 10:32 AM, she stated she was familiar with Resident #1 and he/she would walk the halls constantly. She stated Resident #1 would be looking for his/her family members. CNA #12 stated she would usually tell Resident #1 his/her family members had left for the day and other times she would just redirect Resident to an activity in the dining room. She stated these diversions seemed to help distract the resident. In an interview with CNA #2 on 09/23/2023 at 7:14 PM, he stated Resident #1 was a wanderer and would often wander the facility asking where certain family members were. He stated staff would redirect the resident by offering snacks or an activity. CNA #2 stated that these interventions were effective for him when caring for Resident #1. In an interview with CNA #3 on 09/27/2023 at 8:06 PM she stated Resident #1 was a wanderer and would constantly look for his/her family members. She stated that when Resident #1 would display this behavior she would divert the resident by offering a snack, toileting him/her, taking the resident back to his/her room, or by taking the resident to an activity if one was being held at that time. CNA #3 stated most times these interventions were effective. In an interview with Certified Nurse Aide (CNA) #5 on 09/27/2023 at 9:07 AM, she stated Resident #1 always walked the facility and would ask where his/her family was. In an interview with Licensed Practical Nurse ( LPN) #2 on 09/26/2023 at 1:43 PM, she stated it was normal behavior for Resident #1 to wander the facility. She stated on 09/17/2023 she witnessed Resident #1 walking towards the nurse's station on the East Hall, holding a baby doll and asking, Where's momma? then turned and began walking towards the living room area. Per the interview, LPN #2 stated she let Resident #1 continue to walk towards the living room area, as requesting for the resident's family members was normal behavior for Resident #1. She further stated she did not feel anything needed to be added to Resident #1's care plan at that time. She stated after Resident #1 eloped she assumed the Social Services Director (SSD) may have updated the care plan because she was the manager on duty. In an interview with the Social Services Director (SSD) on 09/22/2023 at 4:40 PM, she stated after Resident #1 eloped on 09/17/2023 his/her care plan was updated to reflect the intervention of fifteen (15) minute checks for seventy-two (72) hours and initiated a psychosocial assessment. She stated the next day she completed the psychosocial assessment on Resident #1 to see how the elopement had affected him/her afterward and there were no changes. The SSD stated nursing would update the care plan for interventions related to the elopement because the resident had already been assessed to be at risk for elopement. She further stated she didn't add any new interventions for mood or behaviors because Resident #1 was assessed to be unaffected by the event. During additional interviews with the SSD on 09/28/2023 at 11:53 AM and 2:10 PM, she stated it was normal everyday behavior for Resident #1 to ask where his/her momma was and that he/she would also ask where his/her sisters and brother were as well. When this behavior occurred, staff would always redirect Resident #1 with an activity. If church services were being offered, staff would take Resident #1 to the church service because he/she liked music and singing. The SSD further stated because this was normal everyday behavior for Resident #1 that it should have been added to the resident's care plan as an intervention, so all staff was aware that it was not a new behavior. The SSD stated the resident's wandering behavior and request for his/her family was such a constant behavior, that staff knew how to intervene when he/she displayed the behavior. She stated staff were basically informed of the resident's behavior by word of mouth, but it would have been nice if it was added to his/her care plan. In an interview with the Minimum Data Set (MDS) Nurse on 09/28/2023 at 10:52 AM, she stated she added the fifteen (15) minute checks to Resident #1's care plan after the elopement. She stated Resident #1 was discharged from the facility shortly afterward because the resident's family was going to be providing his/her care. The MDS Nurse stated after an event they would re-evaluate the residents' care plans and revise them as needed. During an additional interview with the MDS Nurse, on 09/28/2023 at 12:19 PM, she stated that potentially a resident seeking a family member could become agitated and potentially violent if they were left unsupervised and ended up not finding their family member. She stated Resident #1's care plan was not updated because all his/her current interventions seemed to be adequately working and staff reported the resident was easily redirected when seeking family members. The MDS Nurse further stated that they were open to feedback from staff about any resident behaviors so the care plan could be reviewed and revised if needed. In an interview with the Assistant Director of Nursing (ADON) on 09/22/2023 at 11:39 AM, she stated during morning meetings the interdisciplinary team (IDT) and Administrator reviewed resident care plans. She stated the MDS Nurse was ultimately responsible for updating resident care plans based on staff's feedback and assessments. She further stated that if staff were to observe something at a specific time they could add it to the care plan and notify the MDS Nurse for review. In an interview with the Director of Nursing (DON) on 10/05/2023 at 3:38 PM, he stated all resident care plans were updated with changes and any pertinent information that staff needs to be aware of. He stated he felt the interventions on Resident #1's care plan were sufficient enough regardless of the resident calling out and looking for his/her momma or daddy. In an interview with the Administrator on 10/04/2023 at 4:14 PM, he stated updating a resident's care plan was a team approach and not just the responsibility of one person. He stated he did not feel that Resident #1's care plan needed to be updated because he/she said a lot of things. The Administrator stated Resident #1 went out of the facility with family at least three (3) to four (4) times a week and was used to going out the front door frequently. He stated visitors knowing the door code and holding the door open for others were the root cause of why Resident #1 eloped from the facility on 09/17/2023. He further stated that Resident #1's care plan interventions would not change because he/she was already care planned for wandering, and he had mentioned the frequent trips out of the facility being a trigger for wandering with family in previous care conferences. However, a review of the resident's care plan revealed no revised interventions to address the resident's trigger for wandering due to frequent trips outside of the facility with his/her family. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 10/12/2023 that alleged removal of the Immediate Jeopardy (IJ) on 10/01//2023 as follows: 1. Resident #1 was discharged home on 09/20/2023. 2. On 09/17/2023 and 09/18/2023, the Assistance Director of Nursing (ADON), DON, Unit Managers, Staff Development Coordinator, and SDC, conducted a one-time 100% record review for residents who may have increased/unsafe wandering behaviors and/or were increased elopement risk for the past thirty (30) days. The record reviews included but were not limited to physician's orders, care plans, and treatment administration records (TAR). Plans of care for identified residents were reviewed and revised as needed to reflect the resident's status. 3. On 09/19/2023 the DON and ADON reviewed residents' physician orders, progress notes, plans of care, and Elopement Risk Assessments to ensure care plans were accurate. 4. On 09/19/2023 the DON and ADON reviewed residents with wander alert bracelets to ensure proper placement and function, with no concerns noted. Additionally, care plans for identified residents were reviewed and revised as needed to reflect the resident's status. 5. Further corrective action on 09/19/2023 included, the DON and ADON reviewed the Facility Assessment to ensure the number of residents at risk for unsafe wandering/elopement was accurate. 6. The Administrator, Assistant Director of Nursing, Social Services Director, and Staff Development Coordinator were educated on documentation of behaviors and care planning with effective interventions by the Area Director of Clinical Services. The Director of Nursing would be educated upon return from vacation. 7. On 09/29/2023 the Staff Development Coordinator educated all current Registered Nurses, Licensed Practical Nurses, and all nursing assistants to include PRN (as needed) staff. The education was on documenting resident behaviors that included increased wandering/ elopement and repetitive verbalizations in the nurse's notes and point of care. 8. On 09/29/2023 the Staff Development Coordinator (SDC)and Assistant Director of Nursing (ADON) educated all non-nursing staff on reporting observations of resident behaviors such as increased wandering and repetitive verbalizations, and to notify a licensed nurse immediately. During education, the Elopement Risk Assessment and plans of care for any residents reported by staff as exit-seeking or having repeated verbalizations, not already identified by the IDT, were reviewed and revised as needed. All staff voiced understanding of the material presented as well as a post-test with an overall score of 100%. Beginning 09/30/2023 the education would be included in the orientation of newly hired staff. 9. Starting on 09/30/2023 the Director of Nursing (DON) and Assistant Director of Nursing (ADON) would audit nurse progress notes daily seven (7) days a week for documentation of residents who have behaviors including increased wandering/elopement risk and repetitive verbalizations. If identified the DON/ADON would ensure the resident's care plan was up to date with personalized interventions. This process would occur Monday through Friday in the daily clinical meeting ongoing and would be done every Saturday and Sunday for twelve (12) weeks by the DON/ADON. 10. Starting on 09/30/2023 the Social Services Director or Social Services Assistant would audit Point of Care documentation with the DON/ADON daily x 7 days per week for documentation of residents who have behaviors including increased wandering/elopement risk and repetitive verbalizations. The process would occur Monday through Friday and was ongoing in the daily clinical meeting. On Saturday and Sunday, this would done for twelve weeks by the DON/ADON/SDC. 11. Starting on 09/30/2023 the Administrator/DON/ADON/UM/SS would interview five random staff members a week on various shifts to ask if any resident had behaviors including increased wandering/elopement and or repetitive verbalizations for twelve weeks, then monthly for three (3) months. 12. Starting on 09/30/2023 the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers, and Social Services would review all residents identified as at risk for elopement to ensure personalized care plan interventions were in place to prevent elopement daily for twelve (12) weeks then once per month for three (3) months. 13. A Quality Assurance meeting was held on 09/29/2023 to discuss. The Administrator, Assistant Director of Nursing, Area Director of Clinical Services, and Medical Director were in attendance. ***The State Survey Agency validated the facility had taken the following actions: 1. Closed record review revealed Resident #1 was discharged from the facility to home with family on 09/20/2023. In an interview with the Administrator on 09/22/2023 at 4:00 PM, he stated Resident #1 was discharged on [DATE] and the family wished to provide care for the resident. 2. In an interview with the Social Services Director (SSD) on 09/22/2023 at 4:40 PM, she stated she reviewed care plans for residents at risk for increased/unsafe wandering. She stated the reviews were comprehensive to ensure the residents' care plans accurately reflected the residents' needs. In an interview with the Minimum Data Set (MDS) Nurse on 09/28/2023 at 10:52 AM, she stated she reviewed care plans for residents at risk for increased/unsafe wandering and updated them if needed. 3. In an interview with the Director of Nursing (DON) on 10/05/2023 at 3:38 PM, he stated he performed a review of all current residents to ensure their current Elopement Risk Assessments and care plans were accurate. He further stated if they were not he would update them at that time. In an interview with the Assistant Director of Nursing (ADON) on 09/22/2023 at 11:39 AM, she stated she checked residents' wanderguard bracelets for placement and function. The ADON further stated care plans were reviewed and revised if needed. 4. In an interview with the Assistant Director of Nursing (ADON) on 09/22/2023 at 11:39 AM, she stated she reviewed the wanderguard orders for the at-risk residents and assisted with checking their placement and function. In an interview with the Director of Nursing (DON) on 10/14/2023 at 10:24 AM, he stated care plans for identified residents were reviewed and revised by himself and the ADON to reflect the status of those residents. 5. In an interview with the DON on 10/14/2023 at 10:24 AM, he stated he and the ADON reviewed the facility assessment and verified the number of residents with unsafe wandering was correct. 6. In an interview with the Area Director of Clinical Services on 10/13/2023 at 5:02 PM, she stated she provided education to the Administrator, Assistant Director of Nursing, Social Services Director, and Staff Development Coordinator on documentation of behaviors and care planning with effective interventions and that she educated the DON upon his return from vacation. Review of the Staff Education/In-service Document, dated 09/29/2023, revealed ADON, SSD, and SDC were educated on documentation of behaviors and care planning with effective interventions. 7. In an interview with the Staff Development Coordinator (SDC) on 10/12/2023 at 3:55 PM, she stated she educated all current RN's and LPN's including PRN's on documenting resident behaviors to include increased wandering/elopement and repetitive verbalizations in the nurse's notes. During an interview with the Staff Development Coordinator on 10/13/2023 at 3:52 PM, she stated besides administering a post-test to staff after they received their education, she typed a syllabus and then reads it to staff. She stated she then asked if they understood, and had staff recite specific parts of the education given, like the names of the residents. In interviews with Licensed Practical Nurse (LPN) #8 on 10/13/2023 at 4:36 PM, LPN #2 on 10/13/2023 at 4:45 PM, LPN #9 on 10/09/2023 at 4:43 PM, and LPN #6 on 10/03/2023 at 2:26 PM, they stated they were educated by the SDC on documentation of resident behaviors to include increased wandering/elopement and repetitive verbalizations and took a post-test. In an interview with the Staff Development Coordinator (SDC) on 10/12/2023 at 3:55 PM, she stated she educated all current nursing assistants including PRN (as needed) staff on documenting resident's behaviors that included increased wandering/elopement and repetitive verbalizations in Point of Care. In an interview with the Staff Development Coordinator (SDC) on 10/12/2023 at 3:55 PM, she stated she educated all current nursing assistants including PRN (as needed) staff and gave post tests on documenting resident behaviors that included increased wandering/elopement and repetitive verbalizations in Point of Care. In interviews with Certified Nurse Aides (CNAs) #5 on 10/09/2023 at 2:49 PM, CNA #16 on 10/09/2023 at 3:35 PM, they stated the SDC provided education documenting resident behaviors to include increased wandering/elopement and repetitive verbalizations in Point of Care. CNA #5 further stated, on 10/09/2023 at 2:49 PM, in her interview that the Administration would randomly quiz them while they were out on the floor from time to time. 8. In an interview with the Staff Development Coordinator (SDC) on 10/12/2023 at 3:55 PM, she stated she educated all current non-nursing staff to notify a licensed nurse immediately if they had observed a resident with behaviors including increased wandering and repetitive verbalizations. In an interview with the Director of Rehabilitation Services on 10/05/2023 at 9:57 AM, she stated she received education from the SDC about when to notify licensed nursing staff if she observed any increased wandering or repetitive behaviors in a resident. During an interview with the Activities Director on 10/13/2023 at 3:28 PM, she stated she received education from the SDC about when to notify licensed nursing staff if she observed any behaviors in residents such as an increase in wandering or repetitive behaviors. In an interview with Certified Nurse Aide (CNA) #11 on 10/03/2023 at 3:24 PM, he stated he had been employed at the facility for approximately two weeks (2). He stated he received education and training during his orientation on elopement and documentation of resident behaviors in Point of Care from the Staff Development Coordinator (SDC). 9. Review of audits dated 09/30/2023 and completed by the ADON and DON, revealed audits of nurse progress notes and review of resident care plans were completed. In an interview with DON on 10/14/2023 at 10:24 AM, he stated that he along with the ADON had been reviewing the resident's care plan to ensure they included personalized interventions and were up to date. 10 In an interview with the Director of Nursing (DON) on 10/14/2023 at 10:24 AM, he stated that he along with the ADON and SSD, had been reviewing the Point of Care documentation to ensure they were up to date with personalized interventions. 11. In an interview with the DON on 10/14/2023 at 10:24 AM, he stated that he along with the ADON were conducting interviews with five (5) random staff members a week on various shifts and asked if any resident has had behaviors including increased wandering/elopement and or repetitive verbalizations. In an interview with Certified Nurse Aide (CNA) #6 on 10/10/2023 at 1:29 PM, she stated she had been interviewed by the ADON regarding resident behaviors. CNA #5 on 10/09/2023 at 2:49 PM, stated the Administration would randomly quiz them while they were out on the floor from time to time. In an interview with the ADON on 10/12/2023 at 5:07 PM, she stated she performed random audits on behaviors with staff. 12. In an interview with the Director of Nursing (DON) on 10/14/2023 at 10:24 AM, he stated he and other disciplines were reviewing care plans for those residents identified as at risk for elopement weekly and the reviews would continue. He stated these reviews were to ensure the residents had appropriate and personalized interventions in place to prevent elopement. In an interview with the ADON on 10/12/2023 at 5:07 PM, she stated she reviewed care plans for those residents identified as at risk for elopement. 13. Review of the Quality Assurance Performance Improvement (QAPI) meeting minutes dated 09/29/2023, revealed the results of on-going audit results of nurse progress note, Point of Care documentation of. and employee interviews were being discussed. In an interview with the Administrator on 10/14/2023 at 11:15 AM, he stated the committee was going over the documentation of the audits and employee interviews in QAPI. The team has also been addressing these topics items in the daily morning meetings in an effort to prevent further non-compliance. In an interview with the Area Director of Clinical Services on 10/13/2023 at 5:02 PM, she stated that documentation of the audits and employee interviews had been brought to QAPI and was being discussed. A review of the facility's Allegation of Correction on 10/12/2023 revealed documentation of QAPI meetings that occurred on 09/29/2023 included the audits and employee interviews.

Based on observation, interview, record review, review of the facility's policies, and review of the Police Report it was determined the facility failed to protect residents from abuse related to misappropriation of resident property for one (1) of forty-one (41) sampled residents (Resident #9). On 06/28/2023, Resident #9 reported that she/he was missing her/his debit card and cash from her/his wallet. Resident #9's daughter discovered a debit card that was in Resident #9's wallet was potentially used by a staff member. She reported this to the facility on [DATE] or 06/27/2023. The police investigation discovered the debit card was used by one of the facility's staff members. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 08/30/2022, revealed the facility would protect the rights of each resident from misappropriation of property. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility would provide ongoing oversight and supervision of staff in order to assure that its policies were implemented as written. Potential employees would be screened for a history of abuse, neglect, exploitation, or misappropriation of residents' property. Back ground, reference, and credential checks shall be conducted on potential employees. Addressing features of the physical environment that may make misappropriation of resident property more likely to occur. Review of Resident #9's medical record revealed the facility admitted the resident, on 05/18/2023. The facility discharged the resident on 07/14/2023. Further record review revealed Resident #9's diagnoses included: fracture of the right leg, psychotic disturbance, Chronic Obstructive Pulmonary Disease (COPD), and heart failure. Review of Resident #9's Admission Minimum Data Set (MDS), dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score was fifteen (15) of fifteen (15). This score indicated the resident was cognitively intact. Further review revealed the resident was independent with activities of daily living. Review of the facility's Grievance Log revealed Resident #9 reported a missing debit card (bank card) on 06/28/2023. The Assistant Director of Nursing (ADON) and Social Service Director (SSD) investigated the incident. The disposition of the grievance on the form stated the issue had been resolved. However, the column indicating the written decision was blank. Review of the Police Report dated 06/28/2023, revealed at approximately 11:44 AM, the Police Officer called Resident #9's Daughter, who had reported that sometime between 05/11/2023 and 06/28/2023, Resident #9's card had gone missing. Further review revealed she reported that five (5) unauthorized transactions had occurred totaling $256.86. She also reported that her parent was missing a $100.00 bill along with $66.00 in other bills from her/his wallet. The Daughter reported that the total theft was $422.86. Continued review of the Police Report revealed the Officer had viewed the video footage of a transaction at a gas station and had taken still shots of the suspect. He then contacted Licensed Piratical Nurse (LPN) #6, who worked at the facility. When he showed LPN #6 the photograph, she immediately identified the suspect as Certified Nurse Aide (CNA) #10. LPN #6 confirmed that CNA #10 was an employee at the facility and would have access to Resident #9's room. The Police Officer ended the report with I will be seeking a warrant for CNA #10 for Fraudulent Use of a Credit Card under $500.00. During telephone interview with Resident #9's Daughter on 10/04/2023 at 2:43 PM, she stated she checked her parent's checking account at the end of June to pay the July rent, and it was in the negative. She stated she called the bank Monday 06/26/2023 or Tuesday 06/27/2023. Resident #9's Daughter stated the bank informed that the card was suspended. She stated she searched to see if her parent had lost the card or put it somewhere. She then went to the bank and got a copy of the transactions. The Resident's Daughter stated something did not seem right. During forward interview, she stated she called the fraud department, and they said the card was not hacked as it had been used. She stated they asked if it was possible that the card had been given to someone and she told them her parent would not give the card to someone. Continued interview revealed she suspected a visitor or a staff at the facility had token the card and money. She then called the facility and reported the missing card on Monday 06/26/2023 or Tuesday 06/27/2023. After she called the facility, she called the bank. The bank reimbursed the amount used on the debit card. However, the facility did not reimbursed the one hundred sixty dollars ($166.00). She stated her parent was very upset about the loss of the money but, was not having any lasting emotional problems. She said that she and her sister were more upset that someone would go in a resident's wallet and take money. During telephone interview with Resident #9 on 10/11/2023 at 3:09 PM, resident stated she/he had a hundred-dollar ($100) bill and might have some twenties (20 dollar bills). Resident #9 stated she/he went home for a little while and fell again. The resident stated she/he had to go to another facility and she/he did not want to go back to the facility. Resident #9 stated she/he was upset that someone took the wallet. Review of the facility's Investigation Report, dated 07/20/2023, revealed, on 07/17/2023, Resident #9's daughter contacted the Social Service Director (SSD) to notify her that the Sheriff Department was able to confirm that a suspected employee was noted using the resident's missing debit card at multiple locations. On 07/17/2023, the Director of Nursing (DON) contacted the Deputy who confirmed the identity of the individual observed using the debit card. Further review revealed the Deputy advised that the card was used at multiple locations that included amounts of two hundred fifty-two dollars ($252) and one hundred fifty-six dollars ($156). The staff member was immediately suspended pending investigation. Review of the Social Service Director's statement, dated 06/28/2023, revealed she spoke with Resident #9's daughter on the phone regarding the resident's bank card being stolen. During interview with the Police Officer on 10/06/2023 at 12:56 he reported the daughter had contacted him on 06/28/2023 about her parent's lost debit card. He stated he reviewed his record and reported Resident #9's card had been used at several locations. He stated he contacted the businesses and obtained a video of CNA #10 using Resident #9's card. He obtained a picture and brought it to the facility and asked LPN #6 to identify the person in the picture. LPN #6 was able to identify that the picture was of CNA #10. During interview with LPN #6 on 10/05/2023 at 10:57 AM, she stated the police called and then came to the facility in the afternoon, she did not remember the date. LPN #10 stated the Officer came to the facility with a picture of CNA #10, and she identified that CNA #10 was the person in the photograph. During interview with the Assistant Director of Nursing (ADON) on 10/04/2023 at 3:10 PM, she stated Resident #9's daughter called to let the facility know her parent's debit card was misplaced. However, she did not remember the date or what she did after she received the call. During interview with the Director of Nursing (DON) on 10/10/2023 at 4:44 PM he stated a resident's family member notified the facility about a missing debit card. The DON stated the family member was not sure if the card was stolen or misplaced. Continued interview revealed the facility would follow up if there was any other information. The DON stated the Daughter notified the facility that the card was stolen and used by an employee. Further interview revealed the staff member was terminated. During interview with the current Administrator on 10/05/2023 at 4:35 PM he stated the bank reimbursed Resident #9 for the charges placed on the debit card. The Administrator stated the facility did not reimburse Resident #9 for the cash that was allegedly taken.

Based on interviews, record review, and review of the facility's policy, it was determined the facility failed to ensure its abuse policy was implemented for one (1) of forty-one (41) sampled residents (Resident #9). On 06/28/2023, Resident #9 and his/her family member informed staff he/she was missing his/her debit card. The facility failed to implement its policy by identifying, correcting, and intervening in situations where misappropriation of the resident's property was likely to occur. Further, the facility failed to ensure the allegations were thoroughly investigated when the allegations of misappropriation were reported on 06/28/2023. The facility's failure to protect and prevent further acts of misappropriation allowed staff to steal over $500.00 from Resident #9 and potentially other residents. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 08/30/2022 revealed it was the policy of the facility to provide protection for residents by developing and implementing written policies and procedures that prohibit and prevent misappropriation of resident's property. Further review of the policy revealed the facility would identify, correct, and intervene in situations in which misappropriation of the resident's property was more likely to occur. A continued review revealed an immediate investigation was warranted when suspicion of abuse or reports of abuse occurred. The policy further revealed staff were to identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Review of Resident #9's medical record revealed the facility admitted the resident, on 05/18/2023 and discharged the resident on 07/14/2023. The resident's diagnoses included a fracture of the right leg, psychotic disturbance, Chronic Obstructive Pulmonary Disease, and Heart Failure. Review of Resident #9's Admission Minimum Data Set (MDS), date 05/25/2023 revealed the Brief Interview for Mental Status (BIMS) score was fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Resident was independent with activities of daily living. Review of Resident #9's Inventory of Personal Property, dated 05/18/2023, revealed that upon admission, the resident had a purse and wallet. There was; however, no documentation of what was in the resident's wallet. A review of Resident #9's Grievance Form, dated 06/28/2023, revealed Resident #9 stated his/her card was missing. Further review revealed the Assistant Director of Nursing (ADON) and Social Service Director (SSD) were to investigate the incident. Continued review of the form revealed the Disposition of the resident's Grievance had been resolved; however, there was no date provided for the written decision and no documentation to support the facility thoroughly investigated the allegations. Review of the Police Report, dated 06/28/2023, revealed the estimated date and time the incident occurred was between 05/11/2023 at 8:00 AM to 06/08/2023 at 11:00 PM. A continued review of the report revealed the police officer contacted Resident #9's family member on 06/28/2023 at approximately 11:44 AM. Per the review, the resident's family member reported the resident's {debit}card had gone missing. Further, the family member reported five (5) unauthorized transactions totaled in the amount of $256.86 had occurred. The family member stated the resident was also missing a $100.00 bill along with $66.00 in other bills from her/his wallet. The report revealed the total theft was in the amount of $422.86. A continued review of the Police Report revealed the police officer reviewed the video footage of the transaction that took place at a local gas station and took still shots of the suspect. The officer contacted Licensed Practical Nurse (LPN) #6 (date not mentioned) who worked at the facility and showed her a photograph of the suspect. The LPN identified the suspect as Certified Nurse Aide (CNA) #10 and confirmed that the CNA was employed at the facility. The officer ended the report with, I will be seeking a warrant for CNA #10 for Fraudulent Use of a Credit Card under $500.00. Review of CNA #10's employment file revealed the facility employed CNA #10 on 10/03/2022. Continued review revealed the facility did not complete the employee's Criminal Record Check until 05/05/2023, approximately seven (7) months after CNA #10 was hired. During a telephone interview with Resident #9's family member, on 10/04/2023 at 2:43 PM, she stated she checked Resident #9's checking account at the end of June to pay the resident's July rent and noticed the resident's account had a negative balance. She stated she called the bank Monday 06/26/2023 or Tuesday 06/27/2023 and had the resident's debit card suspended. Per the interview, she stated she contacted the fraud department and was informed the card was not hacked but was used by someone. The family member stated she suspected a visitor or a staff at the facility had taken the card and the resident's money. She stated she called the facility and reported the missing card on Monday 06/26/2023 or Tuesday 06/27/2023. Resident #9's family member stated the bank reimbursed the resident's funds; however, the facility had not reimbursed the one-hundred and sixty-six dollars ($166) that was stolen from the resident. During a telephone interview with Resident #9, on 10/11/2023 at 3:09 PM, the resident stated she/he had a hundred-dollar ($100) bill and some twenty (20) dollar bills that turned up missing while he/she resided in the facility. The resident stated he/she was upset that someone took his/her wallet but stated he/she had not had any loss of appetite, trouble sleeping, or feelings of not being safe. During an interview with Licensed Practical Nurse (LPN) #6, on 10/05/2023 at 11:02 AM, she stated she filled out Resident #9's inventory of Personal Property for Resident #9, she stated she did not know why she did not document the contents in the resident's wallet. In an additional interview with LPN #6, on 10/05/2023 at 10:57 AM, she stated the police officer called her and then came to the facility in the afternoon; however, could not recall the date the office came to see her. Per the interview, she stated the officer showed her the picture of the alleged suspect and she identified the person in the photograph as Certified Nurse Aide (CNA) #10. During a telephone interview with the police officer, on 10/06/2023 at 12:56 PM, he stated Resident #9's family member contacted him on 06/28/2023 about the resident's lost debit card. Per the interview, the officer stated Resident #9's card had been used at several locations. He further stated he contacted the businesses in which the suspect made transactions and obtained a video of CNA #10 using Resident #9's card. He stated he had taken a picture of the suspect and brought it to the facility. Further, he stated he asked LPN #6 to identify the person in the picture and she identified CNA #10 as the suspect in the pictures. During an interview on 10/06/2023 at 10:19 AM with the Business office manager (BOM), she stated there was a safe that residents could use to store their wallets or other things. She stated Resident #9 had reported his/her card was missing and the Social Service Director (SSD) asked her to look in the safe on 06/28/2023 when Resident #9 reported the missing card. During an interview with the SSD on 10/12/2023 at 2:52 PM she stated the process of reporting a lost debit card was to report it to the administrator who was the abuse coordinator. The SSD stated the administrator was on vacation, and the Director of Nursing (DON) usually covered as the abuse coordinator when the Administrator was on vacation. Per the interview, the SSD stated the DON; however, was also on vacation, so the Assistant Director of Nursing (ADON) was covering at the time of Resident #9's lost debit card. The SSD stated she reported the lost debit card to the ADON. During an interview with the Assistant Director of Nursing (ADON), on 10/04/2023 at 3:10 PM, she stated Resident #9's family member reported the loss of the resident's debit card; however, she stated she could not recall the date the family member reported the card missing. The ADON stated she believed there was an investigation of the concern. Further, the ADON stated misappropriation was abuse and it should be reported to the Director of Nursing (DON) and the Administrator. During a telephone interview, on 10/05/2023 at 3:39 PM with the Director of Nursing (DON) he stated he was notified that Resident #9's debit card was missing during the months of July or August, however, stated he could not recall the date. He stated the resident's family member notified the facility that the resident's card was missing. The DON stated the SSD reported the resident's concerns to him. The DON stated the process of investigating misappropriation would be that when he was notified, he would verify the incident occurred. He stated he would then report his findings to the Administrator who would take over the investigation and come up with appropriate actions to resolve the issue. During an interview with the Interim Administrator, on 10/13/2023 at 10:58 AM, who was the Administrator from 05/27/2023 through 07/13/2023, she stated during her interim as administrator she was not notified of Resident #9's missing card. During an interview with the current Administrator on 10/05/2023 at 4:35 PM he stated he does not have a facility investigation file for the 06/28/2023 grievance on the June 2023 Grievance Log concerning the resident's missing debit card. Further, he stated the bank reimbursed Resident #9 for the charges placed on the debit card. The Administrator stated the facility did not reimburse Resident #9 for the cash that was allegedly taken from the resident.

Based on observations, interviews, record reviews, and review of the facility's policy it was determined the facility failed to protect residents from abuse for one (1) of forty-one (41) sampled residents (Resident #33). On 10/10/2023 at 6:25 PM, Resident #32 was sitting in a wheelchair at the East Nurses' Station and motioned for Resident #33 to come over. Resident #32 then touched Resident #33's breast above his/her clothes. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 08/30/2022, revealed it was the facility's policy to provide protection for the health, welfare and rights of each resident. This would be done by developing and implementing policies that prohibited and prevented abuse, neglect, exploitation, and misappropriation of resident's property. Training on misappropriation included training for new and existing staff on activities that constituted abuse, neglect, misappropriation of resident's property, reporting procedures, resident abuse prevention and establish coordination with the Quality Assurance Performance Improvement (QAPI) program. Review of the Progress Notes, revealed Resident #32 was noted to have touched staff members inappropriately on 06/24/2023, and 08/31/2023. Review of the Admission record revealed the facility admitted Resident #32 on 03/02/2021 with diagnoses that included pneumonia, dementia, and hypertension. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine out of fifteen which indicated the resident was moderately cognitively impaired. Review of Resident #32's care plan dated 10/01/2023, revealed the care plan was updated with interventions regarding his/her sexual behaviors on 09/29/2023. Interventions included redirect Resident #32 during care; let Resident #32 know that it was not appropriate to grope and grab at staff; and use the assistance of two (2) staff members to assist with distraction when was provided. Review of the resident's Admission record revealed the facility admitted Resident #33 on 02/21/2023 with diagnoses that included Alzheimer's and mood disorder. Review of the MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of three (3) of fifteen (15) which indicated the resident had severe cognitive impairment. Observation of Resident #33 on 10/13/2023 at 10:00 AM revealed he/she was clean and very pleasant. Resident #33 was alert to name only. Observation of Resident #32 on 10/13/2023 at 10:05 AM revealed she/he was clean and calm. Further observation revealed the resident was sitting in a wheelchair. Resident #32 was alert to name only. Observation of Resident #33 on 10/14/2023 at 9:57 AM revealed the resident was in his/her wheelchair sitting in the living area with staff members and other residents. Observation of Resident #32 on 10/14/2023 at 10:00 AM revealed Resident #32 asleep in bed at this time. Review of the facility's investigation revealed on 10/10/2023 at 6:25 PM, Resident #32 was sitting in a wheelchair at the East Nurses' Station and motioned for Resident #33 to come over. Licensed Practical Nurse (LPN) #9 witnessed Resident #32 touch Resident #33's breast above her/his clothes. Further review revealed Resident #33 did not appear to notice the touch. The residents were immediately separated; Resident #32 was escorted to his/her room. Resident #33 stayed at the Nurses's Station. During interview with LPN #9 on 10/13/2023 at 12:07 PM, she stated she and Certified Nurse Aide (CNA) #7 were charting at the East Side nurse's station on 10/10/2023 in the evening. She stated she saw Resident #32 sitting in a w/c (wheelchair) and waved for Resident #33 to come over. LPN #9 stated Resident #33 walked over to Resident #32 and touched her/him on the breast. The LPN stated Resident #33 did not appear upset. He/she had the same behavior and facial expressions as before she/he was touched. She stated she came around the desk and redirected Resident #33 to sit down in her/his chair. LPN #9 stated she then took Resident #32 to her/his room. The LPN stated she immediately told the ADON (Assistant Director of Nursing), the Director of Nursing (DON), and Administrator, as they were all in the Administrator's office. During interview with CNA #7 on 10/13/2023 at 1:59 PM, she stated she was sitting at the nurses' station charting. CNA #7 stated Resident #32's facial expression did not change or her/his behavior after the incident with Resident #33. The CNA stated Resident #32 had also grabbed her breast; she just asked him/her to stop. During interview with Resident #33's Daughter, on 10/13/2023 at 4:06 PM, she stated she was very upset about the incident that occurred. She stated she was not happy with the way the situation was handled. During the interview she stated they first told her they called the police then told her everything was OK. Resident #33's Daughter stated that they took Resident #32 to her/his room. During interview with LPN #10, on 10/13/2023 at 2:17 PM, she stated she knew Resident #33. LPN #10 stated Resident #33 was happy and wandered around the unit. She stated Resident #33 had not had any change in his/her behavior after the incident. She stated Resident #32 was very slow in her/his movements, so she was able to get away before he/she could touch her. The LPN stated Resident #33 had tried to grab her multiple times, more than three times. During interview with CNA #16 on 10/13/2023 at 3:25 PM she stated she had worked at the facility about three (3) months. She stated she had worked with Residents #32 and #33. CNA #16 stated Resident #33 was sociable, tried to help everyone and was usually quiet. The CNA stated Resident #32 had tried to touch her breast when she changed her/his brief. During an interview with the Director of Nursing (DON) on 10/13/2023 at 3:36 PM, he stated he was at the facility when the incident occurred. The DON stated he was in the administrator's office when LPN #9 reported the incident. He stated LPN #9 reported that Resident #32 was sitting in the w/c (wheelchair) and Resident #33 walked up to him/her. He stated Resident #32 touched Resident #33's right breast over his/her clothes. The DON stated Resident #32 had had recent behaviors of attempting to grab staffs' breasts. He stated Resident #32 was easy to redirect. The DON stated he did not believe any staff was afraid to report abuse. During additional interview with the Director of Nursing (DON) on 10/14/2023 at 10:24 AM, he stated a psych consult was ordered for Resident #32 and new orders were received for medication to help combat the sexual behaviors. The DON stated Resident #32 was heavily dependent on staff for care and was not concerned with him/her entering other residents' rooms because he/she was dependent on staff for locomotion as well. He also stated that the Interdisciplinary Team (IDT) looked at increasing supervision for Resident #32, but they declined to do so because of his/her dependence on staff; and during the time period he/she was on 15 minute checks he/she did not display any behaviors. The DON stated they made observations of the resident after he/she was started on his/her new medications. He stated Resident #32 had already begun to show a decrease in his/her sexual behaviors. The DON further stated the facility provided education to staff on interventions and behaviors for Resident #32 and updated Resident #32's care plan as well. During an interview with the Administrator on 10/13/2023 at 4:17 PM, he stated he was involved in abuse investigations and was involved in this case. The Administrator stated he tried to prevent abuse through education, monitoring and listening. The Administrator stated that he did not lead in such a way that staff were afraid to report abuse. During additional interview with the Administrator on 10/14/2023 at 11:15 AM, he stated the facility had put training in place to train staff regarding Residents #32 and #33 and their behaviors. He stated that at this time he was looking for alternative placement for Resident #33 due to his/her cognitive decline and continued progression of illness.

Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure residents' grievances were thoroughly investigated to include a statement of findings with corrective actions taken for one (1) of forty-one (41) sampled residents (Resident #9). On 06/28/2023, Resident #9 and his/her family member filed a grievance reporting concerns that the resident's debit card and his/her money were missing. The facility failed to thoroughly investigate the resident's grievance and did not resolve or provide corrective action related to the resident's concerns until 07/17/2023, when the Certified Nurse Aide (CNA) #10, was identified by local police, as the person who made unauthorized transactions using the resident's debit card. The findings include: Review of the facility's policy, Resident and Family Grievances, dated 01/02/2023 revealed the Grievance Official was responsible for overseeing the grievance process; receiving, and tracking grievances through to its conclusion. The staff member receiving the grievance would record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member in completing the form. The staff member receiving the grievance would report any allegations involving neglect, abuse, injuries of unknown source, and/or misappropriation of resident property immediately to the administrator and follow procedures for those allegations. Further, the policy revealed the Grievance Official would take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. A review of Resident #9's Grievance Form, dated 06/28/2023, completed by the Social Service Director (SSD)/Grievance Official, revealed the resident stated his/her bank card and $166.00 in cash were missing. Further review of the form revealed the date the debit card was determined missing was unknown; however, the SSD noted she became aware of the resident's missing money on 06/28/2023 between the times of 11 AM to 7 PM. Further review of the Grievance Form revealed Resident #9 had signed her/his name. Additionally, the SSD documented the resolution to the resident's grievance was dated 07/06/2023, with the note that the resident's family member was working with the deputy with no updates. Continued review of the Grievance Form revealed the form had not been signed by the SSD. Review of the Facility's Grievance Log, dated 06/28/2023, revealed Resident #9 informed staff his/her debit card was missing. Continued review of the log revealed the Assistant Director of Nursing (ADON) and Social Service Director (SSD) investigated the resident's grievance and determined the resident's concern had been resolved; however, there was no documentation to support actions that were taken to resolve the resident's grievance, as stated in the facility's policy. Review of the Facility's Investigation Report, dated 07/20/2023, completed by the interim Administrator, revealed Resident #9's daughter contacted the Social Service Director (SSD) on 07/17/2023 to inform her the police had completed their investigation and confirmed that CNA #10 had used Resident #9's debit card without the resident's consent. The facility interviewed all staff who were working Resident #9's unit, on 07/17/2023, and all staff denied seeing the resident with his/her debit card. Further review of the Report revealed CNA #10 was suspended pending the investigation. Review of Certified Nurse Aide (CNA) #10''s Personnel file revealed her last working day in the facility was 07/17/2023. Closed record review revealed the facility admitted Resident #9 on 05/18/2023 and discharged the resident on 07/14/2023, with diagnoses which included: Chronic Obstructive Pulmonary Disease and Heart Failure. Review of Resident #9's Admission Minimum Data Set (MDS) Assessment, dated 05/25/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), which indicated he/she was cognitively intact. During a telephone interview with Resident #9's Family Member, on 10/04/2023 at 2:43 PM, she stated the resident's checking account had a negative balance at the end of June. She stated she called the bank on 06/26/2023 or 06/27/2023 (she could not recall the date) and had the card suspended. Further, she stated she called the fraud department and was informed the resident's debit card was not hacked but was used. Resident #9's Family member stated she had suspected a visitor or a facility staff member had taken the resident's card and money. She stated she called the facility and reported the missing debit card the same day she suspended the resident's debit card. Per the interview, the resident's family member stated she could not recall who she reported the resident's missing card to, but stated the bank reimbursed the resident for the amount used on the debit card. The resident's family member stated, however, the resident was not reimbursed for the $166.00 dollars that was stolen from the resident's wallet. During a telephone interview with Resident #9 on 10/11/2023 at 3:09 PM, he/she stated his/her debit card and about $160.00 was missing from his/her wallet. He/she stated this upset him/her and the bank refunded his/her money. In a further interview with Resident #9, he/she stated his/her family member had reported the card missing to facility staff. The resident stated he/she was not satisfied with the results of the facility's investigation and believed his/her concern had not been resolved. The State Survey Agency (SSA) surveyor attempted a telephone interview with CNA #10 on 10/03/2023 at 2:00 PM; however, when the CNA heard who the caller was, she hung up on the surveyor. During an interview with the Business Office Manager (BOM), on 10/06/2023 at 10:19 AM, she stated Resident #9 had reported his/her debit card was missing. She stated the Social Services Director (SSD) asked her to look in the safe, located in the business office, for the resident's missing card, on 06/28/2023; however, the resident's debit card was not found in the safe. During an interview with the Social Service Director (SSD), on 10/12/2023 at 5:12 PM she stated the process for investigating a grievance was that after the grievance form was completed, staff would give the form to her. She stated she would review the form and give it to the appropriate department/person to address the concern identified in the grievance. Further, she stated that when she received a resolution she would then discuss the resolution with the resident who had the grievance. The SSD stated she started the grievance process when Resident #9 made the allegation of misappropriation. She stated, however, she did not report the allegation of the missing card to the abuse coordinator, the Administrator, but should have. She stated it was a mistake. During a telephone interview with the Interim Administrator, who was the Administrator between 07/14/2023 and 08/18/2023, on 10/13/2023 at 10:58 AM, she stated that when a grievance was identified, the nurse on the unit should complete a grievance form and then take it to the SSD, and this would begin the investigation. She stated Resident #9's grievance occurred prior to her position as the Administrator; however, the SSD was the gatekeeper of the grievance process and should have followed up with the resident for a resolution to his/her concern. During a telephone interview on 10/05/2023 at 3:39 PM with the Director of Nursing (DON), he stated the Social Service Director (SSD) reported to him that Resident #9's family member reported the resident's debit card was missing. Per the interview, he stated this occurred around July or August; however, could not recall the date. In a continued interview with the DON, he stated he and the Administrator would take over the investigation to resolve the grievance; however, he was on vacation during the time of this grievance and did not know the details. During an interview with the current Administrator on 10/05/2023 at 4:35 PM, he stated he did not have a facility investigation on file for the 06/28/2023 grievance regarding the missing debit card. Further, the Administrator stated he was not the Administrator during the time the resident filed his/her grievance; however, it was his expectation that the investigation would have been conducted.

Based on interview, record review and facility policy review, it was determined the facility failed to ensure a resident with pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one (1) of three (3) sampled residents (Residents #1). Record review revealed there was no documented evidence skin assessments were completed routinely for Resident #1. The findings include: Review of the facility's policy titled, Prevention of Pressure Ulcers/Injuries, last revised 07/2017, revealed skin assessments are to be repeated weekly and upon any change in condom. Review of the facility's policy titled, Skin assessment, dated 06/19/20, revealed a full body skin assessment should be performed as part a systematic approach to pressure injury prevention and management. Further review of the policy revealed a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, weekly, and as needed. Continued review of the policy revealed documentation of skin assessment shall include documented date and time of the assessment, name and position title of the assessor, observations including skin conditions, toleration of procedure by resident, type of wound, measurements, and if refused. Closed record review revealed the facility admitted Resident #1 on 11/10/2020 and discharged on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Admission Minimum Data Set (MDS) assessment, dated 11/13/20, revealed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of five (5) which indicated the resident was not interviewable. Review of Resident #1's Comprehensive Care Plan revealed the resident was at risk/actual skin breakdown related to a pressure ulcer to the right heel, dated 11/11/20, with an intervention to assess skin weekly and as needed. Review of Admission /Re-Admission Observation note dated 11/11/2020, revealed Resident #1 had a suspected deep tissue injury to his/her right heel. Review of Resident #1's Weekly Skin Reports, revealed no documented evidence Resident #1 had a skin assessment from 11/19/20 through 12/29/20. Interview with Licensed Practical Nurse (LPN) #10 on 05/14/21 at 9:40 AM, revealed skin assessments should be documented in the computer weekly for each resident. Interview with LPN #8 on 05/14/21 at 11:03 AM, revealed skin assessments should be documented in the computer weekly for each resident. She further stated the assessment should be documented in the residents progress notes as well. Interview with the Administrator on 05/14/21 at 2:10 PM, revealed he expected nursing to complete weekly skin assessments per policy. He further stated he expected the Unit Managers to follow up to ensure completion of care and duties provided to the residents.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the residents environment remains as free of accident hazards as is possible for one (1) of three (3) sampled residents (Resident #3). Observation on 05/14/21 at 10:45 AM, revealed Resident #3 up in his/her Broda chair with no Dycem on his/her wheelchair seat cushion. The findings include: Review of facility's policy titled, Accidents and Supervision, last revised 03/15/2020, revealed each resident receives adequate supervision and assist devices to prevent accidents this includes: identifying hazards and risks, evaluate and analyze hazards and risks, implement interventions to reduce hazards and risks, and to monitor for effectiveness and modifying interventions when necessary. All staff are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. Review of facility's policy titled, Falls Management Program Guidelines, last revised 12/01/2018, revealed the corporation strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. Further review of the policy revealed care plan interventions should be implemented that address the residents risk factors. Record review revealed the facility admitted Resident #3 on 10/29/20, with diagnoses to include Alzheimer's Disease and [CONDITION(S)] with Behavioral Disturbance. Review of Quarterly Minimum Data Set (MDS) assessment, dated 02/02/21, revealed Resident #3's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of Physician Orders dated 03/23/21 and 04/03/21, revealed an order for Dycem to top of wheelchair cushion and Dycem mat under wheelchair cushion and verify placement every day and night shift. Review of Treatment Administration Record (TAR) dated 05/14/21, revealed Registered Nurse (RN) #3 had documented the Dycem to Resident #3's wheelchair seat cushion was in place. Review of the CNA Kardex (care plan for CNA's) Report dated 04/26/21, revealed Resident #3's fall interventions included a Dycem mat to the bottom of his/her wheelchair seat cushion. Interview and observation on 05/14/21 at 10:45 AM, with UM #1, revealed Resident #3 up in his/her wheelchair and no Dycem was not in Resident #3's Broda wheelchair seat cushion or under the seat cushion. UM #1 stated the Dycem should and there was no Dycem under the wheelchair cushion but they was on care plan to be there. Additionally, UM #1 stated she would have expected the Dycem to be in place. She further stated the Dycem was a fall intervention put in place for Resident #3. Interview with Certified Nursing Assistants (CNA) #11 and CNA #12 on 05/14/21 at 10:55 AM, revealed they had attended to Resident #3 and the care plan is so staff will know what care is for the resident, and everyone is to follow the care plan for the residents. Interviews with Registered Nurse (RN) #3 on 05/14/21 at 11:00 AM and Licensed Practical Nurse (LPN) #8 at 11:05 AM, revealed they had provided care to Resident #3 and failed to notice Dycem was not on the resident's wheelchair seat cushion. RN #3 and LPN #8 both stated the Dycem was a fall intervention for Resident #3 and should have been in place. Interview with Director of Nursing on 05/14/21 at 11:22 AM, revealed he expected fall interventions to be implemented for residents. He further stated all nursing staff were responsible for monitoring and ensuring the interventions were in place. Interview with the Administrator on 05/14/21 at 2:10 PM, revealed nursing staff are responsible for ensuring interventions are implemented. The Administrator further stated the Unit Managers conduct daily rounds to observe and ensure the CNA's are following resident care plans.

Based on interview and record review, it was determined that the facility failed to maintain medical records on each resident that are complete and accurately documented for one (1) of three (3) sampled residents (Resident #4). The facility failed to maintain narcotic count sheets from date of Resident #4's admission of 09/18/2020 through 09/30/2020. The findings include: Interview with the Director of Nursing (DON) on 05/14/21 at 11:26 AM, revealed the facility had no specific policy related to the retention of narcotic count sheets. She further stated the facility follows Federal and State regulations related to narcotic documentation logs. Record review revealed the facility admitted Resident #4 on 09/18/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Medical Records on 05/13/2021 at 9:37 AM, revealed she receives the narcotic sheets from the nurses and stores them in a binder in the medical records office. She further stated she could not locate narcotic sheets for Resident #4. Interview with the DON on 05/14/2021 at 11:26 AM, revealed narcotic sheets for all residents should be retained but was not sure how long they would be retained. He further stated the narcotic sheets for Resident #4's medications could not be located. The Administrator stated he expected the nursing staff to turn the narcotic sheets over to medical records once completed. Interview with the Administrator on 05/14/21 at 2:13 PM, revealed he would expect narcotic sheets to be accounted for. He further revealed he expected all facility policies to be followed and resident records to be maintained.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to implement interventions for two (2) of three (3) sampled residents (Residents #1 and #3). Resident #1 was care planned for weekly skin assessments and Resident #3 was care planned for fall interventions; however, there was no documented evidence skin assessments were completed routinely for Resident #1. Observation on 05/14/21 at 10:45 AM, revealed Resident #3 up in his/her Broda chair with no Dycem on the wheelchair seat cushion. The findings include: Review of facility's policy titled, Care Plans, Comprehensive Person-Centered, last revised 12/2016, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Further review of the policy revealed the comprehensive, person-centered care plan will incorporate identified problem areas, incorporate risk factors associated with identified problems, reflect currently recognized standards of practice for problem areas and conditions. And areas of concern will be identified before interventions are placed on the care plan, used to identify problem areas and their causes, and for developing interventions that are targeted and meaningful to the resident is the endpoint of an interdisciplinary process. 1. Closed record review revealed the facility admitted Resident #1 on 11/10/2020 and discharged on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Admission Minimum Data Set (MDS) assessment, dated 11/13/20, revealed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of five (5) which indicated the resident was not interviewable. Review of Resident #1's Comprehensive Care Plan revealed the resident was at risk/actual skin breakdown related to a pressure ulcer to the right heel, dated 11/11/20, with an intervention to assess skin weekly and as needed. Review of Resident #1's Weekly Skin Reports, revealed no documented evidence Resident #1 had a skin assessment from 11/19/20 through 12/29/20. Interview with the Unit Manager (UM) #1 on 05/14/20 at 10:44 AM, revealed Resident #1's last documented skin assessment was noted on 11/19/20. Interview with Registered Nurse (RN) #1 on 06/11/2020 at 8:26 AM, revealed she failed to initial Resident #1's 05/27/2020 wound care on the TAR. She stated she thought she did the dressing change to Resident #1's coccyx but could not recall what the wound looked like or what treatment she applied. RN #1 further revealed if the TAR was not initialed someone could assume the care was not provided. She stated she should have followed Resident #1's care plan related to wound care orders. Interview with Certified Nursing Assistant (CNA) #2 on 05/12/21 at 2:30 PM, revealed staff should follow resident care plans because they outline individualized care for each resident. Interview with Registered Nurse (RN) #2 on 05/12/21 at 4:30 PM, revealed the residents care plans are located in their rooms and staff should review it upon entry. RN #2 further stated that the care plan is the guideline to maintain safety, general guideline how to provide care for each resident. 2. Record review revealed the facility admitted Resident #3 on 10/29/20, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Quarterly Minimum Data Set (MDS) assessment, dated 02/02/21, revealed Resident #3's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of Resident #3's Comprehensive Care Plan revealed the resident was at risk for falls related to Alzheimer's Disease. Further review of the care plan revealed interventions dated 03/23/21 and 04/03/21, included Dycem to wheelchair cushion and Dycem mat to the bottom of wheel chair cushion. Review of the CNA Kardex (care plan for CNA's) Report dated 04/26/21, revealed Resident #3's fall interventions included a Dycem mat to the bottom of his/her wheelchair seat cushion. Observation on 05/14/21 at 10:45 AM, revealed Resident #3 sitting up in his/her Broda chair with no Dycem in place on the wheelchair seat cushion. Interview with the UM #1 on 05/14/21 at 10:45 AM, Resident #3 was care planned for Dycem to the wheelchair seat cushion. She further stated staff should follow the care plan interventions to ensure proper care of each resident. Interview with Certified Nursing Assistants (CNA's) #11 and #12 on 05/14/21 at 10:55 AM, revealed they were responsible for Resident #3's care and Dycem should have been placed on the wheelchair seat cushion. CNA's #11 and #12 further stated resident care plans are used to inform staff of the care needs for each resident and should be followed to ensure proper care is provided. Interviews with RN #3 and Licensed Practical Nurse (LPN) #8 on 05/14/21 at 11:00 AM, revealed when toileting Resident #3 they had failed to notice if the Dycem had been in place to his/her wheelchair seat cushion. RN #3 and LPN #8 further stated care plan interventions should be followed by staff providing resident care. Interview with the Director of Nursing (DON) on 05/14/21 at 11:22 AM, revealed he would have expected the fall interventions to be in place and followed by all staff when providing care to the residents. He further stated the interventions to be monitored by all staff to ensure the residents receive proper care per the care plan. Interview with the Administrator on 05/14/21 at 2:10 PM, revealed nursing staff are responsible for ensuring care plan interventions are in place and being followed. The Administrator further stated staff should be familiar with the residents care plans in order to meet the resident care needs. Further interview revealed Unit Managers conduct daily rounds to ensure interventions are implemented by staff providing care.

Based on observations, interviews, record reviews and facility policy it was determined the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for (1) one resident (Resident #1 related to being a [MEDICAL TREATMENT] patient that went in/out of the facility to dailysis (3) three times a week); in a sample size of three (3) residents. The findings include:

Based on observation, interview, and review of the facility's policy, it was determined the facility failed store food in accordance with professional standards for food service safety related to failing to date a pan of pudding and a pitcher of tomato juice when refrigerated per facility policy. Review of the Census and Condition, dated 07/16/19 revealed eighty-six (86) of eighty-eight (88) residents receive their meals from the kitchen. The findings include: Review of the facility's policy and procedure titled, Proper Storage of Leftovers (Perishable and Non-Perishable), dated 2010, revealed leftovers may have several meanings such as unused ingredients after opening a container, production leftovers, and food remaining after a meal service. A. Storage of perishable leftovers 1. Cover, and label with name, date stored and the date it must be used by or discard by. Observation of the kitchen refrigerators, on 07/16/19 at 10:44 AM, revealed a pan of pudding and a jug of tomato juice not dated when placed in the refrigerator. Interviews on 07/18/19 with the Dietary Manager at 10:14 AM, the Dietary Cook at 10:16 AM, and the Administrator at 10:30 AM, revealed any food or food item should have been dated and labeled when it was put in the refrigerator and anything outdated should be discarded.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure one (1) of nineteen (19) sampled residents received an accurate assessment, reflective of the resident's status at the time of the assessment (Residents #86). The facility failed to code the Minimum Data Set (MDS) assessment accurately for Resident #86 related to receiving Hospice Services. The findings include: Review of the RAI Version 3.0 User Manual, dated (MONTH) (YEAR), for Coding instructions for Section O0100 Special Treatments, Procedures, and Programs, Column 2 instructs to check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14 (fourteen)-day look-back period. Record review revealed the facility admitted Resident #86 on 10/05/18, with [DIAGNOSES REDACTED]. Review of Resident #86's physician's orders [REDACTED].#86's Quarterly MDS Assessment, dated 06/28/19, revealed the facility failed to check the Hospice Care O0100K box Column 2 Section O0100 Special Treatments, Procedures, and Programs, to indicate the resident received hospice services. Interview with the MDS Coordinator on 07/19/19 at 9:40 AM, revealed she was responsible for completing Section O for Resident #86. She stated she knew Resident #86 received hospice services; however, she overlooked it and failed to accurately code it on the Quarterly MDS Interview with the Assistant Director of Nursing (ADON) on 07/19/19 at 11:15 AM, revealed she expected the MDS to be coded accurately to reflect the hospice status of Resident #86.

Based on interview, record review, and review of the facility's investigation it was determined the facility failed to ensure one of three sampled residents (Resident #1) received adequate supervision to prevent accidents. On 12/05/12 at 6:50 AM, Certified Nursing Assistant (CNA) #1 was providing incontinent care to Resident #1 without assistance and instructed Resident #1 to turn to the opposite side of the bed. The resident turned and was unable to grab the grab bar attached to the bed. Resident #1 rolled off the bed, onto the floor, and landed on his/her left side. Resident #1 was assessed and care planned for the assistance of two staff for bed mobility and incontinent care. CNA #1 failed to have the required number of staff present while providing care to Resident #1, resulting in the resident falling from his/her bed. (Refer to F282) The resident was transferred to the hospital for further evaluation and was diagnosed with [REDACTED]. The findings include: Review of the facility's investigation of Resident #1's fall revealed the facility determined the cause of Resident #1's fall was CNA #1 provided care to the resident by herself and did not review the resident's care plan prior to assisting the resident. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the significant change Minimum Data Set (MDS) assessment, dated 10/12/12, revealed the facility assessed the resident as severely impaired in his/her cognition and required extensive assistance of two staff with bed mobility, transfers and toilet use. A review of the comprehensive care plan, dated 10/15/12, revealed Resident #1 required the assistance of two staff for incontinent care and turning and repositioning. A review of the Nurse Aide Data Sheet dated 10/15/12 revealed the resident required the assistance of two staff for turning every two hours and for toileting. A review of the nurse's notes, dated 12/05/12 at 7:30 AM, revealed the nurse tech changed the resident's brief in bed and the resident rolled from the bed to the floor. The resident sustained [REDACTED]. The resident was sent to the hospital emergency room , the family was notified and a fax was sent to the physician. A review of the Diagnostic Imaging Report dated 12/05/12 revealed there was an impacted fracture in the proximal left femur, in the subcapital region. An interview with CNA #1, on 12/11/12 at 11:34 AM, revealed she was the aide in the room with Resident #1 on 12/05/12. She entered the room around 6:50 AM to get the resident up for breakfast when the resident reported having a bowel movement. CNA #1 walked to the left side of the bed, unfastened the resident's brief on the right side, and instructed the resident to roll toward her (to the left side). She tucked the brief underneath the resident and directed him/her to roll to the right side and to reach for the bar. As Resident #1 reached for the bar he/she missed the bar and went over the side of the bed. CNA #1 tried to stop the resident but she was unable to stop him/her. She ran to the other side of the bed and knelt down beside him/her to check to make sure the resident was okay, then left the room and yelled for the nurse. CNA #1 went back into the room and Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 came into the room along with two other aides. The nurses checked Resident #1 and he/she had a skin tear to his/her right arm. The nurses cleaned the skin tear and completed incontinent care on the resident. The resident was transferred back to the bed with the assistance of staff. Per interview, CNA #1 revealed she did not know how many staff was needed to provide the resident's incontinent care and she did not look at Resident #1's care plan before she started his/her care. An interview with RN #1, on 12/11/14 at 10:42 AM, revealed she was at the desk on 12/05/12 when CNA #1 yelled for a nurse. She reported when she entered Resident #1's room, she saw the resident on the floor on his/her left side with CNA #1 knelt down beside him/her. RN #1 assessed the resident and Resident #1 complained of his/her head and left arm hurting. They provided incontinent care to the resident and LPN #1 took care of the skin tear on the resident's arm. One of the aides pulled out a draw sheet and they placed the resident on it and transferred him/her back to the bed. She explained to the resident, she was going to send him/her out to be evaluated at the hospital and that she would contact his/her family as well the physician. When the emergency medical services arrived to transport Resident #1 to the hospital, Resident #1 verbalized complaints of head, arm, and spine hurting. RN #1 stated that Resident #1 required extensive assistance of two staff with his/her activities of daily living (ADL's) such as transfers, bed mobility and incontinent care. An interview with LPN #1, on 12/11/12 at 2:14 PM, revealed it was about 6:50 AM on 12/05/12 when CNA #1 came out of Resident #1's room and she heard her say "I need a nurse". Both she and RN #1 responded. When she walked into the room, she observed CNA #1 kneeling down by Resident #1 on the floor. The resident was lying on his/her left side and there was blood on the floor. Resident #1 said he/she was hurting and "I'm on the floor, I need help, get me up". RN #1 assessed the resident and the resident had a skin tear to the right forearm. LPN #1 cleaned the skin tear, applied a pad, and wrapped the arm in Kerlix. Staff put a lift pad under Resident #1 and transferred the resident back to the bed. An interview with the Director of Nursing (DON), on 12/12/12 at 12:14 PM, revealed it was about 7:30 AM when someone told her about the fall and she immediately went to the resident's room. When she arrived, the ambulance staff was in the room with Resident #1. The resident was complaining of pain in the head, arm and spine and was transported to the hospital for further evaluation. She reviewed Resident #l's care plan which revealed the resident was assist of two for changing his/her brief. The DON talked to CNA #1 and asked her if she knew the resident was assist of two and CNA #1 said "no". The DON stated staff was expected to follow the resident's care plan when providing care.

Based on interview, record review and policy review it was determined the facility failed to ensure care was provided in accordance with the resident's plan of care for one of three sampled residents (Resident #1). Resident #1 was assessed and care planned for the assistance of two staff for bed mobility and incontinent care. On 12/05/12 at 6:50 AM, Certified Nursing Assistant (CNA) #1 was providing incontinent care to Resident #1 without assistance and instructed Resident #1 to turn to the opposite side of the bed. The resident turned and was unable to grab the grab bar attached to the bed. Resident #1 rolled off the bed, onto the floor, and landed on his/her left side. The resident was transferred to the hospital for further evaluation and was diagnosed with [REDACTED]. The findings include: A review of the facility's policy entitled "Comprehensive Care Plans" dated 01/01/07 and revised 06/14/11 revealed residents would have a plan of care for assessed needs. Care plan approaches would be communicated to staff for use in providing direction in care. The plan of care would clearly state and identify the resident's problem, have measurable goals to be achieved, which include timetables to meet resident's needs, and the interventions to be followed by staff in providing the resident care. Each approach would identify the discipline responsible for the care delivery. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the significant change Minimum Data Set (MDS) assessment, dated 10/12/12, revealed the facility assessed the resident as severely impaired in his/her cognition and required extensive assistance of two staff with bed mobility, transfers and toilet use. A review of the comprehensive care plan, dated 10/15/12, revealed Resident #1 required the assistance of two staff for incontinent care and turning and repositioning. A review of the Nurse Aide Data Sheet dated 10/15/12 revealed the resident required the assistance of two staff for turning every two hours and for toileting. A review of the nurse's notes, dated 12/05/12 at 7:30 AM, revealed documentation of the nurse tech changing the resident's brief in bed and the resident rolled from the bed to the floor. The resident sustained [REDACTED]. The resident was sent to the hospital emergency room , the family was notified and a fax was sent to the physician. An interview with CNA #1, on 12/11/12 at 11:34 AM, revealed she provided care to Resident #1 previously. She did not review Resident #1's care plan prior to providing care to the resident and did not know how much assistance the resident required. Additionally, she did not have another staff member to aide her in completing the incontinent care or turning the resident. She revealed the resident turned to the opposite side of her and rolled off the bed. An interview with Registered Nurse (RN) #1, on 12/11/12 at 10:42 AM, revealed she was at the desk the morning of 12/05/12, when CNA #1 came up the hall to get the attention of the nurses. She entered Resident #1's room and observed CNA #1 beside the resident who was lying on the floor. She asked the CNA #1 what happened and she explained the resident rolled off the bed while turning to the opposite side. RN #1 revealed she was aware the resident required extensive assistance of two staff for turning and incontinent care which was provided in the bed. She revealed the CNA did not provide care according to the resident's plan of care. She could not explain why the CNA wasn't following the plan of care but it resulted in the resident having a [MEDICAL CONDITION]. An interview with the Director of Nursing (DON), on 12/12/12 at 12:14 PM, revealed she came in the morning of 12/5/12 and was informed of the resident falling. She reviewed the resident's care plan and saw the resident required the assistance of two staff for repositioning and incontinent care. She talked to CNA #1 and asked her if she knew the resident required the assistance of two staff for incontinent care. The DON reported CNA #1 informed her she did not know the resident required the assistance of two staff for incontinent care. Per interview, the staff did not follow the care plan and it resulted in the resident falling from his/her bed.

Based on interview, record review, and Clinical Practice Guideline review, it was determined the facility failed to ensure care was provided in accordance with the plan of care, for one resident (#1), of a selected sample of nine residents, related to behaviors of wandering and exit seeking. The facility failed to ensure care plan interventions utilized were functioning properly to alert staff to address a resident's wandering behaviors in an effort to provide adequate supervision. The facility failed to follow the care plan for Resident #1 when staff observed this resident on 03/25/12 prior to 9:00 PM wandering the perimeter of the interior of the facility without staff intervention to "inquire to the reason for wandering and to attempt to meet that need." Resident #1, who the facility had assessed as at risk for elopement, exited the facility without staff knowledge on 03/25/12 sometime after 9:00 PM. Sometime after 9:00 PM, the facility's wanderguard alarm was activated; however, nursing staff was unable to address the alert immediately as they were providing care to other residents and could not hear the alarm in residents' rooms or throughout the facility. Once staff heard the alarm and identified the front door of the facility was alarming, they initiated the elopement procedures identifying that Resident #1 was missing. The facility found the resident off the facility campus, down the street, sitting in the driver's seat of a parked car. The facility assessed the resident as having no injuries noted. The facility's failure to ensure care plan interventions were followed and devices were functioning properly in order to provide adequate supervision of residents the facility had identified as having wandering behaviors and/or at risk for elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/29/12 and determined to exist on 03/25/12. The Immediate Jeopardy was determined removed on 03/30/12 lowering the scope and severity to a "D", as the facility had not completed the Quality Assurance (QA) initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the Plan of Correction (POC) to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance. (Refer to F323) Findings include: Review of the "Exit Seeking Residents with Elopement Risk Clinical Practice Guideline," dated 02/15/10, revealed "7. In the event the wandering alarm system is activated, the following response will occur: a) staff will immediately respond to the area in which the alarm was activated." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/02/12, the facility developed and initiated the initial admission care plan detailing Resident #1 has exhibited indicators of wandering inside to inappropriate places, making statements that they are leaving or exit seeking, displays behaviors and/or body language indicating an elopement may be forthcoming, attempts to exit the building, and is cognitively impaired. The facility detailed staff would provide basic needs, evaluate the reason for the resident's wandering/exit seeking and attempt to meet the resident's need, apply the wander alert safety bracelet to the resident, engage in diversional conversation with the resident, take the resident for a short walk, take the resident to an activity as possible, validate concerns and offer alternatives, engage family in diversional activities. On 02/05/12, the facility revised the care plan to reflect staff would conduct every 15 minute checks. An admission Minimum Data Set (MDS) assessment, dated 02/07/12, revealed the facility assessed the resident as having impaired decision making and requiring the assistance of one for activities of daily living. He/she was ambulatory with a steady gait and ambulated about the facility per self. Review of the comprehensive care plan titled Wandering/Elopement, dated 02/10/12, revealed the goal as "Resident will respond to being re-directed from wandering and attempts to exit the building". Interventions included "inquire of the reason for wandering/exit seeking and attempt to meet that need, if possible; wanderguard to right ankle; assess and provide basic needs (hunger, thirst, toileting needs,pain) when resident shows signs of wandering; and resident is on every 15 minute checks. Review of the Nurse Aide Data Sheet, dated 02/14/12, revealed nurse aides were to ensure the safety device (wanderguard) was secure to the resident's right ankle; behavioral interventions detailed to offer to talk on the phone with family, remind of upcoming events, call him/her by a specific name, see activity preference; special instructions included the resident is on 15 minute checks. An interview with RN #2, on 03/28/12 at 11:25 AM, revealed Resident #1 walked around the inside of the building and fifteen minute checks were documented. On 03/25/12, she had seen, prior to 9:00 PM, Resident #1 walking on the West short hall (resided on East), but thought nothing of it because he/she would pass through the West side of the building multiple times going through the dining room and on into the East side of the building. RN #2 did not intervene as the resident's behavior was to continuously wander throughout the building. An interview with RN #1, on 03/28/12 at 12:26 PM, revealed Resident #1 walked constantly. On 03/25/12 prior to 9:00 PM, RN #1 observed the resident attempting to enter the nursing station and lead him/her to his/her room without difficulty. No other intervention was attempted. Resident #1 usually wandered throughout the facility and nurses documented fifteen minute checks. The facility investigation regarding an incident involving Resident #1 occurring on 03/25/12, and interviews with: RN #2, on 03/28/12 at 11:25 AM; CNA #2, on 03/28/12 at 11:50 AM; CNA #1, on 03/28/12 at 12:08 PM and on 03/29/12 at 9:40 AM; RN #1, on 03/28/12 at 12:26 PM and on 03/29/12 at 2:00 PM; CNA #3, on 03/29/12 at 10:20 AM; and CNA #5, on 03/29/12 at 9:10 AM, revealed West Side RN #2 stated she had exited a resident's room on the long hall and as she approached the nursing station she heard a door alarm sounding sometime after 9:00 PM. After going in another direction she realized that the alarm was coming from the front door of the facility. RN #2 went out the front door and looked in every direction but did not see anyone and then went to the East hall to inform RN #1 they should have staff start a search. CNA #1 stated she was working on the West hall at the time and did not know the alarm was sounding . CNA #5 stated she was assisting another resident in his/her room and did not hear the alarm. RN #1 stated she was providing a treatment for [REDACTED].#2 told her the alarm was sounding and someone was missing. RN #1 was not aware the alarm was sounding. The facility initiated a room search and determined Resident #1 could not be located. The facility staff searched outside and located Resident #1 down the street, sitting in the driver's seat of a car, off the facility's campus. The resident told the Night Shift Supervisor that he/she was going home. RN #1 assessed Resident #1 when he was assisted back into the facility and no injuries were found. Interviews with facility staff revealed that while the Resident had the wanderguard bracelet on and they were conducting 15 minute checks, no staff observed or was knowledgeable to this resident's successful attempt to leave the building. No staff observed this resident going to the door and no staff was providing supervision at the time of the incident. The staff was providing care to other residents and could not hear the wanderguard alarm and could not state when the alarm began sounding. An interview conducted with the Administrator, on 03/27/12 at 8:30 AM, revealed Resident #1 was very active and could "walk the entire building in about two minutes". The resident had a wanderguard. He stated the alarm is designed to provide an audible alert that a person wearing the wanderguard bracelet is nearing an exit door and requires redirection. He stated the wanderguard had been tested and verified working and the door alarm had sounded and staff responded as expected. However, the facility was unable to provide evidence that staff was supervising Resident #1 at the time he/she exited the building to prevent elopement. Furthermore, on 03/29/12 at 8:45 AM, an observation with the DON was conducted in a resident room at the end of the long hall on the East unit. The door was closed and a maintenance staff triggered the front door alarm. The alarm was not audible. Upon exiting the room once the door was opened the alarm was barely detectable. The DON stated the alarm was not as loud as the call light tones but was a "different type of sound". Further observation revealed that when the wanderguard is activated the audible alarm can be heard at the door that has been activated and at the panel at the nursing station. Interview with staff revealed that the panel will light up to specify when a door alarm is activated and an audible alarm will sound at the panel. While the facility, had initiated one to one supervision of Resident #1 during awake hours, placed a bed alarm on Resident #1's bed after the incident, they had not identified through their investigation that the alarm was not audible throughout the building to alert staff to address the exit door and wanderguard system to ensure adequate supervision of wandering residents. The State Agency verified the following action taken by the facility to remove Immediate Jeopardy as of 03/30/12: Review of the facility's documentation revealed the facility held an Emergent Quality Assurance Meeting on 03/26/12 at 10:00 AM. The facility had sixteen staff attend which included key Administrative staff such as the Administrator, Director of Nursing, MDS Nurse, Social Services Director, Nursing Unit Manager, etc. The Quality Assurance Meeting Minutes detailed the topic discussed was a resident leaving the facility. The Committee Recommended the following: 1. to discuss discharge potential, inviting the family for care plan meeting with a follow-up on 03/29/12 at 10:30 AM; 2. Educate staff on wandering elopement, elopement policy, location of elopement books and to conduct ongoing in-servicing until all nursing staff have been trained; 3. Reviewed all potential elopement residents for accuracy and assessments, reviewed all fifteen elopement potential residents to ensure accuracy of assessment, care plans and wanderguards; 4. Validated wanderguards are working properly, conducting daily checks with the use of the Secure Care Tester; 5. Review all exit doors, testing all exit doors for alarm sounding and review on 03/26/12. Review of the in-service documentation verified the facility trained nursing staff, social services and admissions on 03/26/12 related wanderguards, elopement, resident assessment upon admission, wanderguard placement, wanderguard book location, picture on facesheet, wanderguard checked daily by staff, alarm panel at each nurses desk. The in-service was provided by the facility's Director of Nursing. Interviews on 03/30/12 with CNA #6, at 12:08 PM; LPN #1 at 12:15 PM; LPN #2 at 12:00 PM, Social Services at 12:05 PM, RN/MDS at 11:42 AM; RN #3 at 11:55 AM; CNA #7 at 11:25 AM; CNA #8 at 11:40 AM revealed all these staff had attended the training and validated their understanding of the facility's new system related responding to the audible wanderguard alarm, the door panel, elopement procedures, elopement books, etc. Interview with the Administrator on 03/30/12, revealed the facility initiated a staff person to monitor the nursing station panel for the wanderguard which started on 03/29/12. These staff have been trained to make an announcement of which door is alarming so staff can respond timely, until the new annunciator can be installed to ensure the alarm can be audible throughout the building. Observation at this time revealed a staff person was at the nursing station monitoring the panel. The surveyor observed timely response by staff to the wanderguard alarming on this date 03/30/12. Further observation revealed Resident #1 was being supervised by staff on one to one supervision. Based on the above interviews, observation and record reviews, it was determined the Immediate Jeopardy was removed, effective 03/30/12, with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance.

Based on observation, interview, record review, Clinical Practice Guideline and Policy and Procedure reviews, it was determined the facility failed to ensure one resident (#1), in the selected sample of nine residents, received adequate supervision to prevent accidents. The facility failed to follow their Missing Resident/Resident Elopement policy. The facility failed to ensure care plan interventions utilized were functioning properly to alert staff to address Resident #1's wandering behaviors in an effort to provide adequate supervision. Additionally, the facility failed to follow the care plan for Resident #1 when staff observed this resident, on 03/25/12 prior to 9:00 PM, wandering the perimeter of the interior of the facility without staff intervention to "inquire to the reason for wandering and to attempt to meet that need." The facility's system for supervision utilizing, the wanderguard assistive device for residents identified as wandering risk, was ineffective to ensure the safety of these residents. The facility had identified, assessed and care planned fifteen residents with wandering behaviors. On 03/25/12 after 9:00 PM, Resident #1, who the facility had identified, assessed and care planned as having wandering behaviors, exited the facility without staff knowledge. The facility found Resident #1 off the facility campus sitting in an unknown car in the driver's seat, asleep after 9:30 PM. Facility staff documented last seeing Resident #1 at 9:00 PM on 03/25/12. The facility had identified that staff was to utilize the wanderguard and conduct every fifteen minutes checks of Resident #1. Facility staff interviews identified that Resident #1 could walk through the facility very quickly within approximately two minutes and had a history of [REDACTED].#1 exited the building without staff knowledge. This failure to ensure adequate staff supervision of Resident #1 and the facility's failure to ensure the assistive device functioned adequately and effectively, prevented the facility from identifying Resident #1 was exit seeking on 03/25/12 in order to redirect him/her to safety. The facility's failure to ensure adequate supervision of residents the facility had identified as having wandering behaviors and/or at risk for elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/29/12 and determined to exist on 03/25/12 and Substandard Quality of Care was identified at 483.25. The Immediate Jeopardy was determined removed on 03/30/12 lowering the scope and severity to a "D", as the facility had not completed the Quality Assurance (QA) initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the Plan of Correction (POC) to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance. Findings include: A review of the facility policy and procedure titled MISSING RESIDENT/RESIDENT ELOPEMENT, dated 01/01/07 and revised 02/15/10, included: 1. Residents who exhibit exit seeking behaviors or elopement potential will be identified. 2. Residents who exhibit exit seeking behaviors or elopement potential will be evaluated by the interdisciplinary team and an individualized care plan will be developed to address the elopement risk. 3. Resident's response to interventions will be monitored, and revisions will be made as indicated. 4. In the event a resident exits the building or the wandering alarm system is activated, staff will respond. Review of the Exit Seeking Residents with Elopement Risk Clinical Practice Guideline, dated 02/15/10 revealed "7. In the event the wandering alarm system is activated, the following response will occur: a) staff will immediately respond to the area in which the alarm was activated." Review of the "Checking Electronic Wandering Transmitting Devices Clinical Practice Guideline", dated 08/30/07, revealed "4. The designated individual will check the equipment and follow the manufacturer's instructions for the following: proper use, proper tone and volume, battery replacement, appropriate placement." The facility admitted Resident #1 on 01/31/12 with [DIAGNOSES REDACTED]. The facility developed and initiated the initial admission care plan, on 02/02/12, detailing Resident #1 has exhibited indicators of wandering inside to inappropriate places, making statements that they are leaving or exit seeking, displays behaviors and/or body language indicating an elopement may be forthcoming, attempts to exit the building, and is cognitively impaired. The facility detailed intervention that staff would provide basic needs, evaluate the reason for the resident's wandering/exit seeking and attempt to meet the resident's need, apply the wander alert safety bracelet to the resident, engage in diversional conversation with the resident, take resident for a short walk, take to an activity as possible, validate concerns and offer alternatives, engage family in diversional activities. The facility revised the care plan to reflect staff would conduct every 15 minute checks on 02/05/12. An admission Minimum Data Set (MDS) assessment, dated 02/07/12, revealed the facility assessed Resident #1 as having impaired decision making and required the assistance of one for activities of daily living. He/she was ambulatory with a steady gait and ambulated about the facility per self. Review of the comprehensive care plan, dated 02/10/12, revealed the facility implemented the following interventions to address Resident #1's Wandering/Elopement risk: wandeguard device: secure bracelet to resident's right ankle, name on wander alert log, check wandergaurd to evaluate operating status; approach the resident by a specific name; assess and provide basic needs; engage in diversional conversation with resident; provide diversional activity; validate concerns and offer alternatives; "inquire of the reason for wandering/exit seeking and attempt to meet that need, if possible"; and resident is on every 15 minutes checks. An interview with Certified Nursing Assistant (CNA) #5, on 03/29/12 at 9:10 AM, revealed Resident #1 walks the hall of the East and West units and that he/she would try to open exit doors at the ends of the halls and then walk back up the hall. Interview with CNA #2, on 03/28/12 at 11:50 AM, revealed Resident #1 walked all the time, usually around the facility in a circle and went door to door at times. An interview with Registered Nurse (RN) #1, on 03/28/12 at 12:26 PM and on 03/29/12 at 2:00 PM, revealed Resident #1 did not normally say much and was "usually in (his/her) zone" and that he/she went door to door at times. A review of the facility Compressed Behavior Report, dated 01/31/12 through 03/25/12, revealed only one entry for wandering altered was documented for 02/13/12. A review of the facility's Behavior Management 15 Minute Monitoring Form, dated March 25, 2012, revealed RN #1 documented seeing Resident #1 at 9:00 PM. Review of nursing notes, dated 03/25/12 at 9:15 PM, revealed Registered Nurse #1 documented "front door alarm sounding, began search for Resident #1. Checked each resident's room, bathroom, dining area, fine dining area, breakroom, lobby and throughout building". Further review of the Behavior Management 15 Minute Monitoring Form, dated March 25, 2012, revealed RN #1 had documented "missing" for 9:15 PM and 9:30 PM. Review of the nursing notes, on 03/25/12 at 9:30 PM, RN #1 documented "resident found outside of building, sitting in the driver's seat of a vehicle, sleeping, by Night Shift Supervisor. When asked resident what he/she was doing he/she stated "trying to get home. Resident was then escorted back to facility". A review of the facility's investigation of the 03/25/12 event, and interviews with: RN #2, on 03/28/12 at 11:25 AM; CNA #2, on 03/28/12 at 11:50 AM; CNA #1,on 03/28/12 at 12:08 PM and on 03/29/12 at 9:40 AM; RN #1, on 03/28/12 at 12:26 PM and on 03/29/12 at 2:00 PM; CNA #3, on 03/29/12 at 10:20 AM; and CNA #5, on 03/29/12 at 9:10 AM, revealed West Side RN #2 stated she exited a resident's room on the long hall and as she approached the nursing station she heard a door alarm sounding sometime after 9:00 PM. She realized after going in another direction that the alarm was coming from the front door of the facility. RN #2 went out the front door and looked in every direction but did not see anyone. She then went to the East hall to inform RN #1 they should have staff start a search. CNA #1 stated she did not know the alarm was sounding as she was working on the West Hall at the time of the incident. CNA #5 stated she was assisting another resident in his/her room and did not hear the alarm. RN #1 stated she was performing a treatment for [REDACTED]. After exiting the resident's room, RN #1 stated RN #2 told her the alarm was sounding and someone was missing. RN #1 was not aware the alarm was sounding. The facility initiated a room search and determined Resident #1 could not be located. The facility staff searched outside and located Resident #1 down the street, sitting in the driver's seat of a car, off the facility's campus. The resident told the Night Shift Supervisor that he/she was going home. RN #1 assessed Resident #1 when he/she was assisted back into the facility and no injuries were found. Observation of Resident #1, on 03/28/12 at 11:15 AM, revealed the resident ambulated with a steady, slow gait, had a blank expression and answered only "yes" to questions. The resident continued to ambulate from one side of the building through the dining room to the other side completing a circle. The resident was observed at 11:30 AM, 11:45 AM, 12:02 PM, 12:10 PM, and 12:30 PM, walking the same circular path through the building. A staff member was within arm's reach at all times as the facility had initiated one to one monitoring while awake since 03/25/12. An interview conducted with the Administrator, on 03/27/12 at 8:30 AM, revealed Resident #1 was very active and could "walk the entire building in about two minutes". The resident had a wanderguard. He stated the wanderguard alarm is designed to provide an audible alert to staff that a person wearing the wanderguard bracelet is nearing an exit door and requires redirection. Resident #1 was determined missing about 9:00 PM on 03/25/12 and was found sleeping in a car down the street a few minutes later. The resident was returned to the facility, had no injury and the facility had initiated one to one supervision. The wanderguard had been tested and verified working and the door alarm had sounded and staff responded as expected. However, the facility was unable to provide evidence that staff was supervising Resident #1 at the time he/she exited the building to prevent elopement. On 03/29/12 at 8:45 AM, an observation with the DON was conducted in a resident room at the end of the long hall on the East unit. The resident room door was closed and a maintenance staff triggered the front door alarm. The alarm was not audible while in the resident's room. Upon exiting the room, once the door was opened, the alarm was barely detectable. The DON stated the alarm was not as loud as the call light tones but was a "different type of sound". Further observation revealed that when the wanderguard is activated the audible alarm can be heard at the door that has been activated and at the panel at the nursing station. Interview with these staff revealed that the panel will light up to specify when a door alarm is activated and an audible alarm will sound at the panel. While the facility, had initiated one to one supervision of Resident #1 during awake hours, placed a bed alarm on Resident #1's bed, they had not identified through their investigation that the alarm was not audible throughout the building to alert staff to address residents wandering near the exit doors. This failure prevented the facility from ensuring assistive devices used to adequately supervise wandering residents was functioning effectively to alert staff to address the needs of wandering residents. The State Agency verified the following action taken by the facility to remove Immediate Jeopardy as of 03/30/12: Review of the facility's documentation revealed the facility held an Emergent Quality Assurance Meeting on 03/26/12 at 10:00 AM. The facility had sixteen staff attend which included key Administrative staff such as the Administrator, Director of Nursing, MDS Nurse, Social Services Director, Nursing Unit Manager, etc. The Quality Assurance Meeting Minutes detailed the topic discussed was a resident leaving the facility. The Committee Recommended the following: 1. to discuss discharge potential, inviting the family for care plan meeting with a follow-up on 03/29/12 at 10:30 AM; 2. Educate staff on wandering elopement, elopement policy, location of elopement books and to conduct ongoing in-servicing until all nursing staff have been trained; 3. Reviewed all potential elopement residents for accuracy and assessments, reviewed all fifteen elopement potential residents to ensure accuracy of assessment, care plans and wanderguards; 4. Validated wanderguards are working properly, conducting daily checks with the use of the Secure Care Tester; 5. Review all exit doors, testing all exit doors for alarm sounding and review on 03/26/12. Review of the in-service documentation verified the facility trained nursing staff, social services and admissions on 03/26/12 related wanderguards, elopement, resident assessment upon admission, wanderguard placement, wanderguard book location, picture on facesheet, wanderguard checked daily by staff, alarm panel at each nurses desk. The in-service was provided by the facility's Director of Nursing. Interviews on 03/30/12 with CNA #6, at 12:08 PM; LPN #1 at 12:15 PM; LPN #2 at 12:00 PM, Social Services at 12:05 PM, RN/MDS at 11:42 AM; RN #3 at 11:55 AM; CNA #7 at 11:25 AM; CNA #8 at 11:40 AM revealed all these staff had attended the training and validated their understanding of the facility's new system related responding to the audible wanderguard alarm, the door panel, elopement procedures, elopement books, etc. Interview with the Administrator on 03/30/12 at approximately 8:00 AM, revealed the facility initiated a staff person to monitor the nursing station panel for the wanderguard which started on 03/29/12. These staff have been trained to make an announcement of which door is alarming so staff can respond timely, until the new annunciator can be installed to ensure the alarm can be audible throughout the building. Observation at this time revealed a staff person was at the nursing station monitoring the panel. The surveyor observed timely response by staff to the wanderguard alarming on this date 03/30/12. Further observation revealed Resident #1 was being supervised by staff on one to one supervision. Based on the above interviews and record reviews, it was determined the Immediate Jeopardy was removed, effective 03/30/12, with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance.

Based on interview, record review, review of the Job Description for Facility Administrator, and review of Clinical Practice Guidelines and Policies and Procedures, it was determined the facility failed to be administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for one resident (#1), in a selected sample of nine residents. The facility failed to ensure adequate supervision to prevent accidents was provided for one resident (#1). Resident #1, who the facility had assessed as having wandering/exit seeking behaviors and determined was an elopement risk, exited the facility on 03/25/12 without staff knowledge and was found in a parked car on the street off the facility campus. The facility had assessed and identified fifteen residents with wandering behaviors and had implemented wanderguard devices as an intervention. The facility failed to ensure Resident #1 was supervised adequately to prevent elopement. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. The facility developed and implemented a care plan for elopement initiating the use of the wanderguard device and staff checks every fifteen minutes due to wandering behaviors. On 03/25/12 sometime after 9:00 PM, Resident #1 exited the building through the front door without staff knowledge. At 9:30 PM, the facility found the resident down the street in the driver's seat of a car off the facility's campus. The resident was missing approximately thirty minutes based on the facility's medical record documentation. Interview with five facility staff revealed they did not hear the Secure Care Alarm System sounding, on the evening of 03/25/12, which prevented staff from addressing the resident's wandering behavior in an effort to redirect him/her to safety. The facility failed to identify through their investigation, staff's failure to follow the care plan interventions and the inability for staff to hear the wanderguard audible alarm throughout the facility while providing care. However, the facility staff, on the evening of 03/25/12, were unable to hear the Secure Care audible alarm while providing care to other residents, which prevented them from immediately responding to the alarm, per the facility's policy. This prevented the facility from providing necessary supervision to Resident #1 who was successful in eloping from the facility without staff knowledge. The facility's failure to ensure adequate supervision of residents the facility had identified as having wandering behaviors and/or at risk for elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/29/12 and determined to exist on 03/25/12 and Substandard Quality of Care was identified at 483.25. The Immediate Jeopardy was determined removed on 03/30/12 lowering the scope and severity to a "D", as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the Plan of Correction (POC) to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance. (Refer to F282 and F323) The findings include: A review of the facility Job Description-Facility Administrator, no date, revealed the Job Summary: Oversees patient/resident care, manages overall operation, employee management, fiscal management, and ensure compliance with State and Federal regulations. Job Responsibilities included: Provision of quality patient services consistent with the philosophy; and standards of the company by means of adequately trained personnel and implementation of company procedures. Insure that the facility is free of any unsafe conditions and participate in monthly safety meetings. Responsible for overseeing risk management activities that focus on risk reduction and preventative strategies for residents, visitors and staff. Reviews, monitors and follows-up on incident reports, adverse incidents, resident grievances, and deficiencies cited by the agency. Develops plans of action to correct and respond to identified quality and risk issues. A review of the facility policy and procedure titled MISSING RESIDENT/RESIDENT ELOPEMENT, dated 01/01/07 and revised 02/15/10, included: 1. Residents who exhibit exit seeking behaviors or elopement potential will be identified. 2. Residents who exhibit exit seeking behaviors or elopement potential will be evaluated by the interdisciplinary team and an individualized care plan will be developed to address the elopement risk. 3. Resident's response to interventions will be monitored, and revisions will be made as indicated. 4. In the event a resident exits the building or the wandering alarm system is activated, staff will respond. Review of the Exit Seeking Residents with Elopement Risk Clinical Practice Guideline, dated 02/15/10 revealed "7. In the event the wandering alarm system is activated, the following response will occur: a) staff will immediately respond to the area in which the alarm was activated." Review of the "Checking Electronic Wandering Transmitting Devices Clinical Practice Guideline", dated 08/30/07, revealed "4. The designated individual will check the equipment and follow the manufacturer's instructions for the following: proper use, proper tone and volume, battery replacement, appropriate placement." A review of Resident #1's record revealed he/she was admitted to the facility 01/31/12 with [DIAGNOSES REDACTED]. The facility assessed and identified Resident #1 as having wandering behaviors and at risk for elopement on 02/02/12 per the facility's admission wander/elopement at risk care plan. An interview with RN #1 on 03/28/12 at 12:26 PM, and with RN #2, on 03/28/12 at 11:25 AM, revealed Resident #1 walked constantly around the inside of the building and fifteen minute checks were documented. RN#1 stated, that on 03/25/12 prior to 9:00 PM, she observed the resident attempting to enter the nursing station and led him/her to his/her room without difficulty. No other intervention was attempted. RN #2 stated, that on 03/25/12 prior to 9:00 PM, she had seen Resident #1 walking on the West short hall (resided on East), but thought nothing of it because he/she would pass through the West side of the building multiple times going through the dining room and on into the East side of the building. RN #2 did not intervene as the resident's behavior was to continuously wander throughout the building. Per the facility's investigation, on 03/25/12 sometime after 9:00 PM, Resident #1 exited the building without staff knowledge. The facility staff initiated elopement procedures once they heard the wanderguard alarm. Facility staff conducted a search outside and found the resident off the facility campus, sitting in the driver's seat of a parked car. The facility assessed Resident #1 with no injury identified. Review of the facility's investigation revealed the facility had not identified that the wanderguard alarm was not audible when staff was in resident's rooms with the door shut. Interviews with: RN #2, on 03/28/12 at 11:25 AM; CNA #2 on 03/28/12 at 11:50 AM; CNA #1,on 03/28/12 at 12:08 PM and on 03/29/12 at 9:40 AM; RN #1, on 03/28/12 at 12:26 PM and on 03/29/12 at 2:00 PM; CNA #3, on 03/29/12 at 10:20 AM; and CNA #5, on 03/29/12 at 9:10 AM revealed West Side RN #2 stated she had exited a resident's room on the long hall and as she approached the nursing station she heard a door alarm sounding sometime after 9:00 PM. CNA #1 stated she was working on the West hall at the time and did not know the alarm was sounding . CNA #5 stated she was assisting another resident in his/her room and did not hear the alarm. RN #1 stated she was providing a treatment for [REDACTED].#2 told her the alarm was sounding and someone was missing. RN #1 was not aware the alarm was sounding. While the facility staff responded appropriately once they heard the alarm, the facility could not provide evidence that they provided adequate supervision to prevent elopement as the assistive device used to aid staff was not audible while staff was providing care in resident rooms. This prevented the facility from addressing Resident #1's wandering behavior in order to prevent elopement. Observation revealed, on 03/29/12, the Secure Care Alarm was not audible in the resident's room with the door shut and could barely be heard when standing in the hallway outside the resident room. The Administrator, on 03/27/12 at 8:30 AM, stated Resident #1 was very active and could "walk the entire building in about two minutes". The resident had a wanderguard. The Administrator detailed the front exit door locked and alarmed when a wanderguard was placed near the exit door; however, when the panic bar of the exit door was compressed for approximately fifteen seconds, the door lock released and the door would open. They stated the system was used to alert staff of wandering residents who were within approximately four feet of the exit door so they could redirect them. The Administrator validated that Resident #1 had successfully eloped at about 9:00 PM on 03/25/12 and was found sleeping in a car down the street a few minutes later. The resident was returned to the facility, had no injury and was now on one to one supervision. The wanderguard had been tested and verified working and the door alarm had sounded and staff responded as expected. However, during testing for the ability to hear the wanderguard alarm, observation of the last East unit resident room, on 03/29/12 at 8:45 AM, revealed that both the State Agency Surveyor and the Director of Nursing (DON), after maintenance staff triggered the front door alarm, could not hear the alarm in the resident's room. Upon exiting the room, once the door was opened, the alarm was barely detectable. Further observation revealed that when the wanderguard is activated, the audible alarm can be heard at the door that has been activated and at the panel at the nursing station. Interview with these staff revealed that the panel will light up to specify when a door alarm is activated and an audible alarm will sound at the panel. While the facility had initiated one to one supervision of Resident #1 during awake hours, placed a bed alarm on Resident #1's bed, they had not identified through their investigation that the alarm was not audible throughout the building to alert staff to address wandering resident's who were nearing an exit door. This failure prevented the facility from ensuring assistive devices used to adequately supervise wandering residents was functioning effectively to alert staff to address the needs of wandering residents. Furthermore, the facility was unable to provide evidence that staff was supervising Resident #1 at the time he/she exited the building to prevent elopement. The State Agency verified the following action taken by the facility to remove Immediate Jeopardy as of 03/30/12: Review of the facility's documentation revealed the facility held an Emergent Quality Assurance Meeting on 03/26/12 at 10:00 AM. The facility had sixteen staff attend which included key Administrative staff such as the Administrator, Director of Nursing, MDS Nurse, Social Services Director, Nursing Unit Manager, etc. The Quality Assurance Meeting Minutes detailed the topic discussed was a resident leaving the facility. The Committee Recommended the following: 1. to discuss discharge potential, inviting the family for care plan meeting with a follow-up on 03/29/12 at 10:30 AM; 2. Educate staff on wandering elopement, elopement policy, location of elopement books and to conduct ongoing in-servicing until all nursing staff have been trained; 3. Reviewed all potential elopement residents for accuracy and assessments, reviewed all fifteen elopement potential residents to ensure accuracy of assessment, care plans and wanderguards; 4. Validated wanderguards are working properly, conducting daily checks with the use of the Secure Care Tester; 5. Review all exit doors, testing all exit doors for alarm sounding and review on 03/26/12. Review of the in-service documentation verified the facility trained nursing staff, social services and admissions on 03/26/12 related wanderguards, elopement, resident assessment upon admission, wanderguard placement, wanderguard book location, picture on facesheet, wanderguard checked daily by staff, alarm panel at each nurses desk. The in-service was provided by the facility's Director of Nursing. Interviews on 03/30/12 with CNA #6, at 12:08 PM; LPN #1 at 12:15 PM; LPN #2 at 12:00 PM, Social Services at 12:05 PM, RN/MDS at 11:42 AM; RN #3 at 11:55 AM; CNA #7 at 11:25 AM; CNA #8 at 11:40 AM revealed all these staff had attended the training and validated their understanding of the facility's new system related responding to the audible wanderguard alarm, the door panel, elopement procedures, elopement books, etc. Interview with the Administrator, on 03/30/12 at approximately 8:00 AM, revealed the facility initiated a staff person to monitor the nursing station panel for the wanderguard which started on 03/29/12. These staff have been trained to make an announcement of which door is alarming so staff can respond timely, until the new annunciator can be installed to ensure the alarm can be audible throughout the building. Observation at this time revealed a staff person was at the nursing station monitoring the panel. The surveyor observed timely response by staff to the wanderguard alarming on this date 03/30/12. Further observation revealed Resident #1 was being supervised by staff on one to one supervision. Based on the above interviews and record reviews, it was determined the Immediate Jeopardy was removed, effective 03/30/12, with the scope and severity lowered to a "D" as the facility had not completed the QA initiative related to staff monitoring, analysis of monitoring audit results and the development and implementation of the POC to ensure interventions are effective and will prevent recurrence, in order to achieve and maintain compliance.