Regency Center

F-F656; and 42 CFR 483.25 Quality of Care, F 689 at a Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was also identified at 42 CFR 483.25 Quality of Care,

F-F689 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.25. The IJ was determined to exist

on 09/08/2022 when the facility discovered Resident R259 had eloped from the building.

The facility provided an acceptable plan for the removal of the IJ on 07/29/2024. This plan alleged the IJ was removed, and the deficient practice was corrected on 01/30/2023, prior to the initiation of the investigation.

The plan provided by the facility alleged the following:

1. On 09/08/2022, Resident R259 remained in the visual site of a CNA who was outside the facility when the resident went out until further staff arrived, and she was assisted back into the facility. Immediately following the elopement event, the Unit Manager completed a head-to-toe skin assessment, and pain evaluation, with no injuries or pain noted. The wander guard was noted to be in place at that time. Resident 259's Physician and family/Responsible party were notified of the event. In addition, on 09/08/2022, the Maintenance Director inspected the wander guard door system and noted that it was non-functioning due to disconnected wires caused by accidental contact with the transmitter. The Maintenance Director immediately repaired the door system. Following the repair, the system was checked for function and determined to be functioning properly. Additionally, on 09/08/2022, the Maintenance Director moved the door sensor to prevent another accidental bumping from a wheelchair. Signage was in place on both entrance doors for notice and education to those entering and exiting the center to be aware of tailgating (look behind). On 09/08/2022, the Vendor acknowledged understanding of notice/education at that time. A prior inspection of the wander guard door system had been completed on 09/07/2022, and the system was noted to be functioning. Following the events on 09/08/2022, a one-time reassessment was completed on residents assessed at risk for elopement and change in condition, and no new residents were noted to be at risk for elopement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 17 185290 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185290 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Regency Nursing and Rehabilitation Center 1550 Raydale Drive Louisville, KY 40219

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 2. On 10/27/2022, Resident R82 was noted to be outside the facility entrance and was assisted back into the facility and placed on increased monitoring. The wander guard system was fully functioning as designed and Level of Harm - Immediate intended. Immediately following the event of Resident R82's elopement on 10/27/2022, a change in condition was jeopardy to resident health or completed, and the resident's guardian and physician were notified. In addition, a skin assessment and a safety pain assessment were completed on 10/27/2022; no injuries or pain noted. Additionally, Resident R82 was reassessed for elopement on 10/27/2022 and based on this assessment, the resident was an elopement Residents Affected - Few risk, and a wander guard was placed on the resident immediately following the assessment. Following the events on 10/27/2022, a one-time reassessment was completed on residents assessed at risk for elopement and change in condition, and no new residents were noted to be at risk for elopement. The Maintenance Director inspected the wander guard system on 10/27/2022 and found the system fully functional and operating properly as intended.

3. On 01/02/2023, Resident R82 was assisted back into the facility and was immediately placed on one-to-one monitoring. Immediately, following the events on 01/02/2023, a skin assessment and pain assessment were completed, with no injuries or pain noted. Resident R82's wander guard was noted to be in place and functioning at that time. Also, on 01/02/2023, a one-time assessment was completed on residents assessed at risk for elopement and change in condition, and no new residents were noted to be at risk for elopement by a licensed nurse. The resident's guardian and physician were notified on 01/02/2023 of the elopement event.

In addition, on 01/02/2023, the Maintenance Director checked the wander guard system's functioning, and it was determined to be functioning properly as intended and designed. Additionally, on 01/03/2023, Resident R82 was re-assessed for elopement, and her care plan was reviewed, developed, implemented, and updated to reflect increased supervision. On 01/05/2023, a technologies Healthcare system inspected the wander guard system on all doors and noted that they were functioning properly; adjustments were made at that time to increase sensor range for maximum potential. Residents at risk for elopement and those with changes in condition were reviewed in the daily clinical meetings by the interdisciplinary care plan teams for events, orders, progress notes, behaviors, labs, clinical and any additional needs identified were addressed, and care plans were developed and implemented, and Kardex were updated as necessary.

4. Education: Starting on 09/09/2022 and ending on 09/20/2022, the Regional clinical market team lead educated the Administrator and Director of Nursing on Elopement policy and procedure, talking points and posttest. Starting on 09/09/2022 and ending on 09/20/2022, a Licensed Nurse or the Administrator, educated facility staff, including Agency staff on elopement education, exit-seeking behavior, care plan revision, developments and updates, elopement assessments, status changes, and notifications for condition changes. Any new staff, including Agency staff would receive an education during on boarding and orientation. In addition, starting on 10/28/2022 and completed on 11/02/2022, facility staff including Agency staff were educated by a Licensed Nurse or the Administrator on resident safety, elopement, care plan development, and updates, and changes in resident behaviors. Any new hires, including Agency staff would receive elopement education during on boarding and orientation. Additionally, starting on 01/02/2023 and completed on 01/23/2023, facility staff including Agency staff were also educated by a Licensed Nurse or the Administrator on resident safety, elopement, care plan development and updates, and changes in resident behaviors. Any new hires including Agency staff would receive elopement education during on boarding and orientation. No further incidents of elopement had occurred since 01/02/2023, and the education and training were provided during that time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 17 185290 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185290 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Regency Nursing and Rehabilitation Center 1550 Raydale Drive Louisville, KY 40219

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 5. Audits: Starting on 01/03/2023 through 01/26/2023, daily elopement drills were completed on various shifts by a License Nurse or Maintenance Director/Assistant. This continued weekly for two (2) more weeks, Level of Harm - Immediate then decreased to monthly for two (2) months and ongoing. Audits would be reviewed in Quality Assurance jeopardy to resident health or Performance Improvement (QAPI) meetings. Then, starting on 02/08/2023, elopement drills were decreased safety monthly. In addition, starting 01/27/2023, the Maintenance Director or Assistant completed the testing of doors, locks, and alarms four (4) times monthly. This would continue weekly for two (2) more weeks, then Residents Affected - Few decrease to monthly for two (2) months and ongoing. Audits would continue to be reviewed in QAPI meetings.

4. QAPI: On 01/03/2023 an ad-hoc QAPI meeting was held with the Administrator, DON, Nurse Educator, Infection Preventionist, and Medical Director, who participated by phone. The Administrator presented information regarding the elopement incidents and the created plan. The Medical Director had no further recommendations. An additional QAPI meeting was held on 01/20/2023, the QAPI committee members, and

the Administrator presented the information at the meeting. The Medical Director had no further recommendations. Starting on 01/20/2023, the QAPI meeting would be held Monthly/Quarterly thereafter.

The Administrator/Director of Nursing would present the information at the QAPI meetings. The QAPI committee would increase the frequency of meetings as needed. The Administrator/Director of Nursing would be responsible for ensuring the plan was carried out. In addition, as part of the ongoing QAPI process of systems the following review was completed when ownership changed last fall (2022) by new ownership/clinical team. Therefore, on 11/08/2023, a review of facility elopement events from prior ownership was initiated. Residents at risk for elopement or those that had a change in condition, or as needed in the facility were to be reassessed for elopement. Five previously identified residents were noted to remain at risk for elopement, and no additional residents were determined to be at risk. On 11/08/2023, residents identified as at risk for elopement were noted to have their picture in the elopement book and to have an order in place for wander guard device monitoring for placement and function. Also, on 11/08/2023, residents noted at risk for elopement had a one-time review of their care plan addressing development, elopement risk, including interventions and updated/updates made as necessary. Additionally, on 11/15/2023, the Maintenance Director and/or Maintenance Assistant assessed all doors for proper functioning and safeguards. Further, the volume of the door alarm annunciator was adjusted.

An Extended Survey and IJ Removal validation was conducted 07/30/2024 - 08/02/2024, and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on 08/02/2024. The SSA validated the immediacy of the IJ had been removed on 01/30/2023, as alleged.

The findings include:

Review of the facility's policy, Safety and Supervision of Residents, revised 07/01/2017, revealed the facility was to strive to make the (residents') environment as free from accident hazards as possible which was a facility-wide priority. Continued review revealed the safety risks and environmental hazards were identified

on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. Further review revealed the safety risks and environmental hazards were also identified on an ongoing basis through the Quality Assurance and Performance Improvement (QAPI) reviews of safety and incident/accident data, and a facility-wide commitment to safety at all levels of the organization.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 17 185290 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185290 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Regency Nursing and Rehabilitation Center 1550 Raydale Drive Louisville, KY 40219

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Continued review of the policy, revised 07/01/2017, revealed individualized, resident-centered care was a core component of the facility's systems approach to safety, and the type and frequency of resident Level of Harm - Immediate supervision was determined by each resident's assessed individualized needs. The Interdisciplinary Care jeopardy to resident health or Team analyzed information obtained from assessments and observations to identify any specific risks for safety individual residents and shall target interventions to reduce related hazards in the environment, including adequate supervision. Further, review revealed the individualized, resident centered approach to safety Residents Affected - Few included implementing interventions to reduce accident risks and hazards that included communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, ensuring interventions are implemented and documenting and monitoring the effectiveness of the interventions.

Review of the facility's policy, Wandering and Elopements, revised 03/01/2019, revealed the facility identified residents who were at risk of unsafe wandering and strove to prevent harm while maintaining the least restrictive environment for those residents. Continued review revealed if a resident was identified as at risk for wandering, elopement, or other safety issues, the resident's care plan was to include strategies and interventions to maintain the resident's safety. The policy also noted if a resident was missing, the facility was to initiate the elopement/missing resident emergency procedure and upon returning to the facility, the resident was to be examined for injuries by the Director of Nursing Services (DNS) or charge nurse. Staff were to notify the attending physician and report the findings and condition of the resident; notify the resident's legal representative; notify search teams that the resident had been located; complete and file an incident report; and document relevant information in the resident's medical record.

Review of the facility's operations policies and procedures manual titled Elopement of Patient dated 2022, revealed residents would be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the clinical assessment process. Those residents determined to be at risk received appropriate interventions to reduce risk and minimize injury. The procedures manual defined Elopement as any situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary.

Review of the facility's Elopement Binder revealed four (4) residents listed who were noted to be at risk for elopement. Resident 259 no longer resided at the facility.

1.Closed record review of an Admission Sheet revealed the facility admitted Resident R259 on 07/18/2022, with diagnoses to include depression, anxiety disorder, bipolar disorder, unspecified dementia, alcohol abuse, aphasia (communication disorder), and dysarthria (difficulty speaking).

Review of Resident R259's Admission Minimum Data Set (MDS) assessment dated [DATE REDACTED], revealed the facility assessed Resident R259 to have a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated severe cognitive impairment. Further review of the MDS Assessment revealed the facility assessed Resident R259 to require a wheelchair for mobility.

Review of Resident R259's Elopement Assessment Risk dated 08/15/2022 at 10:39 AM, revealed the facility assessed

the resident as being at risk for elopement based on her ability to self-propel in a wheelchair independently; history of hovering near exits and pushing on front doors.

Review of Resident R259's Order Summary dated 08/15/2022 at 11:29 AM, revealed a written physician order for a wander guard (security bracelet) to left ankle.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 17 185290 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185290 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Regency Nursing and Rehabilitation Center 1550 Raydale Drive Louisville, KY 40219

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Review of the facility's investigation dated 09/13/2022, revealed on 09/08/2022 at approximately 10:30 AM, Resident 259 exited the facility with a vendor, as he thought resident was a visitor. The vendor stated he Level of Harm - Immediate observed resident propelling fast in her wheelchair towards the left side of the facility parking lot. jeopardy to resident health or Approximately two to three minutes later, after putting his equipment inside the van, the vendor then went to safety alert staff of his suspicion that he let a resident out of the facility. Per the facility's investigation, Resident R259 wore a security bracelet (wander guard) to her ankle; however, the security alarm (wander guard) did not sound Residents Affected - Few when the resident exited the facility. Upon the Maintenance Director's investigation, it was revealed the sensor on the left side of the entrance/exit door was not connected. Continued review of the facility's investigation revealed after Resident R259 went missing and was later located in the facility's parking lot unsupervised, she was redirected back into the facility per staff assistance.

Further review of the facility's investigation revealed due to Resident R259's difficult time communicating related to her aphasia, the facility conducted another Brief Interview for Mental Status (BIMS) score of the resident on 09/08/2022, at which time resident scored an 11 out of 15, which indicated the resident had moderate cognitive impairment. However, review of Resident R259's Admission MDS assessment dated [DATE REDACTED], revealed the facility assessed resident to have a BIMS score of two out of 15, which indicated severe cognitive impairment. In addition, review of Resident R259's Quarterly MDS assessment dated [DATE REDACTED], three (3) months after

the resident went missing revealed the facility assessed resident to have a BIMS score of five out of 15, which also indicated severe cognitive impairment.

Review of the internet weather history for 09/08/2022 at 10:30 AM for the facility's location, revealed it had been sunny with passing clouds and the temperature was 74 degrees Fahrenheit (F).

In an interview with the Maintenance Director on 07/20/2024 at 9:00 AM , he stated the security (wander guard) alarm system would sound an alarm when the entrance/exit door handles were pressed on, of which had a slow beep sound and once it recognized the wander guard alarm the beeping would speed up, and if

the door handle continued to be pressed on, the fire egress system would initiate and the door would automatically unlock and open in 15 seconds as long as the door handle itself was still being pressed on. He stated maintenance performed mandatory tests on the exit doors twice a week on Mondays and Fridays and may perform an additional test during the week as needed. The Maintenance Director further stated the facility had eight (8) doors that had the security (wander guard) alarm system. He stated with the elopement that occurred in September of 2022, his investigation revealed the antennas on the door sensor were knocked loose and he repaired that immediately. He stated he also had the alarm company come out and check the system as well to ensure that it was functioning properly. In addition, the facility also put in strobe lights and loud decibel alarms to get staff's attention and improve staff's response to the alarm. He further stated he did not recall any other resident making it outside of the building besides Resident R82. He stated she was

the only resident to cross the threshold, others got close but to his knowledge, residents never made it out of

the building and the only door the facility ever had issues with was the front door.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 17 185290 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185290 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Regency Nursing and Rehabilitation Center 1550 Raydale Drive Louisville, KY 40219

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 In an interview with the Vendor on 07/24/2024 at 4:33 PM, he stated he was making a routine delivery to replace oxygen tanks at the facility on 09/08/2022 and commented, you must be buzzed in and out of the Level of Harm - Immediate facility. He stated at about 10:30 AM, late morning, in the middle of his rounds he noticed a lady in a jeopardy to resident health or wheelchair (Resident R259), going room to room and up and down the halls. The Vendor stated shortly after 10:30 safety AM, as he finished up all his rounds and went back to the entrance, he asked to be buzzed out and a maintenance man came and asked if he was ready to go out. The vendor stated Resident R259 was behind him the Residents Affected - Few whole time, and when he was permitted to exit, Resident R259 followed and came out too. He further stated, as he walked to his truck, he observed Resident R259 propel towards the left side of the parking lot, rolling fast. However,

the Vendor stated he noticed Resident R259 was headed quickly towards the exit area of the parking lot and; therefore, he thought something might be wrong and went back in the facility to alert staff. He added this was all within an approximate three to five minute time frame.

In an interview with the facility's Scheduler on 07/25/2024 at 4:20 PM, she stated she started as a central supply staff member in November 2021 and then in May 2022, moved into the scheduler position and worked that position until April 2024. The Scheduler stated she remembered the elopement incident of Resident R259

on 09/08/2022, as Resident R259 followed a vendor out the entrance door. The scheduler stated a staff member, Certified Nursing Assistant (CNA14), was sitting in their car, and a woman's voice called the front desk and asked if Resident R259 was supposed to be outside alone. Shortly after, she remembered someone rolled Resident R259 back into the facility. The scheduler recalled the Administrator, and the DON were present in the front area when

this occurred. She further stated there was an elopement binder kept at the front desk and at each nurse's stations that list residents at risk of elopement with a picture of the residents at risk of wandering. However,

the scheduler did not know if Resident R259 had been care planned for wandering and elopement but she knew Resident R259 wore a security alarm (wander guard) for monitoring.

In an interview with CNA13 on 07/20/2024 at 12:10 PM, she stated a wandering resident would have a wander guard in place, and staff must supervise and monitor those residents because if you do not watch them, on any given moment they could be exit seeking. CNA13 further stated, there were elopement binders at each nurse's station and at the front desk with the receptionist, that included those residents' identity, photo, and elopement risk information.

In an interview with CNA14 on 07/25/2024 at 9:50 AM, she stated when the elopement occurred in September 2022 with Resident R259, she was sitting in her truck in the parking lot at work, eating her lunch and looking on her phone at approximately 10:40 AM. She happened to look up as Resident R259 was going through the parking lot in her wheelchair. CNA14 stated she then called the Scheduler and asked if Resident R259 was to be outside and the Scheduler told her No. Therefore, CNA14 jumped out of her truck and ran to Resident R259, who had rolled herself all the way down the road and was about three houses from the main road. She stated she asked Resident R259 where she was going, and the resident told her she was going home. At that time, CNA14 stated

she rolled resident back into the facility in her wheelchair. Further, she observed the Administrator and the Maintenance Director checking the wander guard sensor wires on the front entrance doors.

In an interview with CNA15 on 07/23/2024 at 4:00 PM, she stated she remembered Resident R259 being in a wheelchair, and moving up and down the halls a lot in her wheelchair. CNA15 stated Resident R259 would sit up front around the entrance and was considered a risk for elopement. CNA15 stated Resident R259 did not ever elope while

she was working that she was aware; however, resident was a wanderer and noted to be exit seeking.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 185290 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185290 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Regency Nursing and Rehabilitation Center 1550 Raydale Drive Louisville, KY 40219

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 In an interview with the former Minimum Data Set (MDS) Coordinator on 07/24/2024 at 11:40 AM, she stated

she recalled Resident R259's placement of a security bracelet (wander guard) and the facility care planned Resident R259 for Level of Harm - Immediate elopement risk. MDS Coordinator remembered Resident R259, and the resident did not recall nor communicate a lot jeopardy to resident health or during the interview, indicating a low BIMS score. safety

In an interview with the former Director of Nursing (DON) on 07/25/2024 at 1:38 PM, she stated she recalled Residents Affected - Few Resident R259 exitting the facility with the oxygen vendor as the vendor let her go out with him. She stated after this incident she did a lot of education with staff and vendors on elopement and educated them on which residents were at risk for eloping. She stated she remembered Resident R259 was a younger resident who could easily be mistaken as a visitor. She stated she made sure her education focused on that concern and making sure someone was at the front desk and that they stayed well informed of who came and went out of

the building. She stated she believed before Resident R259's incident they knew about her exit seeking behavior, but

it was not until after the resident had eloped that they placed her as a one-on-one (1:1) with staff. She stated Resident R259 used to be very easy to redirect, up until the elopement then afterwards she was always 1:1 supervision because she continued to attempt to elope.

The former DON, on 07/25/2024 at 1:38 PM, also stated she tried to stress to staff the importance of responding to the door alarm as soon as it sounded; however, she learned during the re-education process that some of the staff were not aware of the process of what to do when the alarm went off, some of the CNAs stated to her that they did not realize they were to respond, but thought other staff members were responsible for checking the doors. The former DON further stated at the time that the elopement incident occurred, she felt it had to do with how the staff responded because one of the incidents occurred during shift change. Since the elopement, former DON stated the facility tried to ensure someone was always up front watching the front entrance by having the Administrator's office up front, extending the receptionist hours at the desk, and to have another staff member cover the desk if she had to go to the restroom or on break. She stated the goal was to always have somebody up front watching the front entrance. In addition,

the former DON stated she provided an extensive amount of education and the facility had only three of their own staff members at the time of Resident R259's elopement and all the rest were agency. The DON added the facility increased the length of orientation to one full week and dedicated one-half day of orientation to customer satisfaction education and the other half of the day to customer escalation techniques. Futher, the former DON stated she ultimately had to follow up with the staff that was refusing to participate in the elopement drills by enforcing the discipline process, giving verbal warnings to staff that she knew she had already educated but were not being active in participation because she felt any elopement was important and must be addressed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 185290 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185290 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Regency Nursing and Rehabilitation Center 1550 Raydale Drive Louisville, KY 40219

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 In an interview with the former Administrator on 07/20/2024 at 2:00 PM, she stated she was the former Administrator during Resident R259's elopement on 09/08/2022. She stated she remembered, Resident R259 and stated the Level of Harm - Immediate resident was admitted to the facility due to a stroke; therefore, required a wheelchair and was assessed as jeopardy to resident health or difficulties with communication. The Former Administrator further stated that on the day Resident R259's exited the safety facility unsupervised, she was in her office when she and the Maintenance Director heard the alarm. She stated she observed the vendor coming back in the front entrance as the agency CNA (CNA14) was coming Residents Affected - Few back inside the facility with Resident R259 without any injuries or concerns and resident was placed on one-on-one supervision at that time. The former Administrator stated all the doors were checked and ensured Resident R259's wander guard bracelet was on properly and activated. She stated she was informed that after the Maintenance Director's inspection, he revealed the sensor was knocked to the side and was not working properly; therefore, the sensors were repaired immediately. In addition, the Maintenance Director preformed checks on all the doors daily and Resident R259 was listed in the binder as an elopement risk. The former Administrator could not recall if the receptionist was at the front entrance or not during the incident. She stated Resident R259 experienced no injuries, nor psychosocial issues. Additionally, facility wide drills, door checks, staff re-education and trainings were initiated and implemented immediately.

2 a). Review of the facility's investigation dated 11/02/2022, revealed on 10/27/2022 at approximately 7:58 PM, a gentleman showed up at the facility front entrance and stated he thought one the facility's residents was at his home. Continued review of the facility's investigation revealed Resident R82 was observed on video exiting

the facility around 7:47 PM, and two staff members went to the gentleman's home to retrieve the resident and brought the resident back to the facility without incident or injury.

Record review revealed Resident R82 was admitted on [DATE REDACTED] with diagnoses to include, anoxic brain damage, dementia in other diseases classified elsewhere, and impulse disorder.

Review of Resident R82's Quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED], revealed a Brief Interview for Mental Status (BIMS) score of seven out of fifteen, which indicated the resident had severe cognitive impairment.

The State Survey Agency (SSA) surveyor attempted an interview with Certified Nursing Assistant (CNA) 7 on 07/17/2024 at 6:40 PM. The SSA surveyor left a voicemail message; however, did not receive a return phone call and the staff member was no longer employed at the facility.

The SSA surveyor attempted an interview with CNA8 on 07/17/2024 at 6:42 PM and a voicemail was left; however, the SSA surveyor did not receive a return phone call and the staff member. The staff member was no longer employed at the facility.

In an interview with Resident R82's State Guardian on 07/18/2024 at 10:00 AM, she stated she was notified by the facility regarding Resident R82's elopement incidents. She stated she was made aware that Resident R82 would be placed on one-on-one monitoring.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 185290 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185290 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Regency Nursing and Rehabilitation Center 1550 Raydale Drive Louisville, KY 40219

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 In an interview with Neighbor 1 on 07/18/2024 at 12:44 PM, he stated he had to notify the facility on two separate occasions of when a resident showed up at his house. He stated the first time it happened, the Level of Harm - Immediate resident came to his house in the evening. The second time was during the day. Per the interview, he stated jeopardy to resident health or could not recall the dates of either incident. He stated Resident R82 asked him for a ride. He stated it was obvious she safety was suffering from some sort of memory problem. Further, he stated the resident appeared very confused. Neighbor 1 stated the resident then asked him to call people so she could get a ride. He stated the resident Residents Affected - Few would provide him with a non-working telephone number or the wrong number. He stated he kept calling the facility to get a hold of someone to come get her but could not get anyone to answer the phone. He stated he finally left his home and walked to the facility and saw some people there and he asked if they knew her. He stated someone from the facility came to his home and they were able to talk Resident R82 into returning to the facility with them. He stated she was wearing a shirt, pants and a pair of socks with grips on bottom of the socks. He further stated Resident R82 did not have on a coat and he brought out a blanket for her because she was chilly.

In an interview with Licensed Practical Nurse (LPN) 2 on 07/18/2024 at 10:38 AM, she stated she was the nurse working the day the resident exited the facility. She stated she had been watching Resident R82 because the resident was able to ambulate even though she utlized a wheelchair. She stated she always felt that the resident was an elopement risk. On the day the resident exited the faciltiy, unsupervised, she stated the resident was running all over the place. She stated that around 4:00 PM or later, she had assisted Resident R82 to bed. Per the interview, she stated she had stepped outside for about 10 minutes for a break and she had a nurse on the floor watching the resident in her absence. LPN2 stated when she came back from her break, another resident's family member, that could not speak English, pointed to the door and that was when she realized that the resident had exited the facility. She stated the family member showed her which house the resident was located. She stated she and the Certified Medication Technician (CMT) 13 went to the house and found the resident sitting on the neighbor's couch.

In an interview with Certified Medication Technician (CMT) 13 on 07/19/2024 at 1:43 PM, she stated she accompanied LPN2 to retrieve the resident. She stated they were alerted by another resident's mother that

the resident was outside of the facility. She stated she could not recall what the resident was wearing, but stated she remembered it was cold outside. She stated she did not recall if the resident said anything to them and they found the resident sitting on the couch at the neighbor's residence. She stated the nurse assessed the resident and made sure she was ok. She stated just a few minutes before she eloped, the resident was put in bed by nursing staff and she last saw the resident in bed prior to the elopement.

2 b). Review of the facility's investigation dated 01/06/2023 revealed on 01/02/2023 at approximately 4:45 PM, Resident R82 eloped from the front entrance of the building and was returned to the building by two staff member [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 185290