Based on observations, interviews, record reviews, review of a facility policy titled, Resident Environmental Quality, a facility policy document titled, Resident Rights, a facility document used for weekly testing of fire door exits, and the State Agency's Online Incident Reporting System Report, the facility failed to ensure residents were safe and their property was protected by failing to provide a safe environment. The facility failed to repair a broken, unsecured door in the facility, allowing anyone to gain access to the facility, unauthorized and without staff knowledge. Also, the facility failed to ensure unauthorized person (i.e., former employees) did not have the active door entry code to gain access to resident care areas. The facility confirmed the code to the door entry keypad had not been changed for an undetermined amount of time. On 05/04/2023 at approximately 3:00 AM, two perpetrators, were able to enter the facility through a broken, unsecured exterior door, known by the facility to be broken for over a year. Both perpetrators, armed with handguns and wearing ski masks, entered this exterior door, input the code to a keypad on the interior door, and walked down the hallway on the second floor of the facility. The facility confirmed 45 residents resided on this floor but were asleep during the time of unauthorized entry. One perpetrator, later identified as a former employee, Employee Identifier (EI) #11, who was terminated on 03/13/2023, placed a gun to a male employee's back and guided him down the hallway to the unit charge nurse. The second perpetrator, identified as a Certified Nursing Assistant (CNA) and Medication Assistant Certified (MAC), EI #10, had been terminated on 03/13/2023 for theft of stock medications. EI #10 demanded the unit charge nurse surrender the keys to the two locked medication carts. EI #10 searched the medication carts after obtaining the keys from the unit charge nurse. The controlled narcotic medications for 26 residents and the cellular phone of the one employee was stolen before the perpetrators exited the facility. On 05/04/2023, after the incident, the facility changed one of the two door codes, but failed to change the master door code until 05/16/2023, after the survey team entered the facility. Further, the exterior door used by the perpetrators to enter the facility remained broken and unsecured when the survey team entered the facility. These deficient practices affected 26 residents, who had their controlled medication stolen and placed all 87 residents, who resided in the facility at the time of the incident, in immediate jeopardy, as an unauthorized armed robbery was likely to result in serious injury, serious harm, serious impairment or death. On 05/19/2023 at 2:58 PM, EI #21 Regional Administrator , EI #1 Administrator, EI #2 Interim Director of Nursing Services, EI #20 Director of Nursing Services, and EI #22 Regional Nurse Consultant were provided a copy of the immediate jeopardy templates and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Resident Rights, at F584 - Safe, Clean/Comfortable /Homelike Environment. The immediate jeopardy began 05/04/2023 and continued until 05/19/2023, when the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence. Cross Reference F835. Findings included: A facility policy titled, Resident Environmental Quality with an effective date of 03/10/2014 revealed, . PURPOSE: The facility should be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. STANDARD: According to federal regulation, the facility must: . Maintain all essential mechanical, . equipment in safe operating condition. PROCESS: a) Preventive maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. An undated document provided to residents upon admission revealed, Residents - These are YOUR Rights: YOU have the right to be treated with dignity, privacy, respect, and to live in a safe, . environment. A facility document identified by the facility as the tool used for weekly testing of Fire Door exits revealed: Instructions (name of the facility) . Steps: . 5. Door inspection Inspect all Egress and Exterior doors. Make repairs as needed . The Alabama Department of Public Health received a report of this incident on 05/04/2023. The Online Incident Reporting System Report documented two armed unknown people came in through stairwell to second floor, held staff at gunpoint, and took cart keys away from the nurse. Suspects went through cart and left with unknown items/medications from cart. A facility document titled Verification of Investigation which was signed on 05/10/2023 documented . SUMMARY AND OUTCOME OF INVESTIGATION . on 5/4/23, two unknown individuals entered the facility through a back stairwell, the entry point from the laundry shed to the building. They went straight up the stairs to the second floor . Both individuals were armed with 1 (one) handgun each . The female individual took the keys. She took all narcotics out of the locked narcotic boxes on each med (medication) cart including the STAT (emergency medication) box . The suspects knew the door codes as they were the same as the time of their termination, and as such were able to get into the building unabated. The summary also indicated the facility was able to use narcotic logs to order all stolen medications from the pharmacy. The prescriptions written on 05/04/2023 to replace the stolen medications for 26 residents were reviewed and included Hydrocodone-APAP (Acetaminophen) 5-325 MG (milligram), Hydrocodone-APAP 7.5-325 MG, Hydrocodone-APAP 10-325 MG, Diazepam 5 MG, Tramadol HCL (hydrochloride) 50 MG, Oxycodone 2.5-325 MG, Oxycodone HCL 5 MG, Oxycodone-APAP 10-325 MG, Oxycodone HCL 15 MG, Morphine Sulfate ER (extended release) 30 MG, Pregabalin 200 MG, Lorazepam 0.5 MG, Gabapentin 100 MG, Gabapentin 300 MG, Gabapentin 800 MG, Lacosamide 150 MG, and Locosamide 200 MG. An interview was conducted on 05/17/2023 at 8:55 AM with EI #14, a CNA on duty at the time of the robbery. EI #14 said about 2:00 AM he was coming out of a room and a male robber came toward him with a gun pointed at him. EI #14 stated by the sound of the robber's voice it sounded like a male's voice. EI #14 stated it scared him to death. EI #14 said the robber told him to come here and took his (EI #14's) cell phone. EI #14 stated the robber asked him who else was on the floor and he stated his nurse and another aide. EI #14 said they went to the nurses' station where EI #15, the nurse on duty at the time of the robbery, was sitting. EI #14 stated the robber pointed his gun at EI #15 and told her to get up. EI #14 said he heard a woman's voice say to EI #15, Give me the keys. EI #14 stated he did not see the other robber but could hear a female's voice. EI #14 said the male robber told him and EI #15 to go to the Director of Nursing's office door, lay on their belly, and don't move. He stated he could hear noises by the medication carts that sounded like the doors were opening and closing. EI #13, another CNA, came up later and the male robber instructed EI #13 to lay on the floor with us. EI #14 said he did not look around because he did not want to get shot. EI #14 said he just started praying and thinking about his family. He stated later the floor technician came over toward them and he told him they had been robbed. He stated he asked the floor technician if anyone was on the first floor and was informed, they were all working. EI #14 stated they paged the first floor and staff came up and they started checking the residents. EI #14 stated the door code he used was the Master Code that could be used on all the doors. EI #14 said that he had been there for 23 years and that had been the universal code for years. EI #14 said it was last changed on May 16th because he tried to use it when he came in to work (and it did not work). EI #14 was asked how armed robbers gained access to the keypad. EI #14 said the back door did not work and would not lock. EI #14 was asked if the codes had been changed prior to May 4th, how the armed persons could have entered the building. He answered they would not have been able to get in the building. EI #14 was asked what should have been in place to ensure the safety of staff and residents. He answered the exterior door should have been closed and locked. He added the codes should be changed. EI #14 was asked what the potential concern of armed persons on the hall was where residents reside. He answered their safety, the residents could have been hurt. A phone interview was conducted on 05/17/2023 at 9:52 AM, with EI #15, LPN (Licensed Practical Nurse). EI #15 stated she saw EI #14 being led down the hall toward the nurses' station by a person dressed in all black and wearing a ski mask. EI #15 said she saw EI #14's eyes and realized he could not talk. EI #15 stated the person behind EI #14 asked her if she was the nurse and she stated, yes. EI #15 said one of masked individuals asked her, Where are the keys? EI #15 stated she reached in her jacket pocket and gave them a set of keys. EI #15 stated the voice was a female's voice and she said, No, the other set of keys. EI #15 stated she got the other key ring and the male robber led EI #14 over towards the DON's office and had him on the floor. EI #15 stated the male robber told her to get on the floor face down, do not say anything, and do not move. After that she heard the carts were being opened and closed. EI #15 stated she could hear the female say, son bag and he responded, Oh, okay. EI #15 said after a while the rambling noises stopped and it got quiet. EI #15 stated they stayed down like they were told. EI #15 said she recognized the male by how he stood. EI #15 was asked how the armed persons would have gained access to the keypad to the second floor from the stair well. She answered from the outside door by the laundry because it never locked. EI #15 was asked if the door had been locked, how would the robbers have entered the stairwell and accessed the code pad. She said they would have had to have a key. EI #15 was asked if the codes had been changed prior to May 4th, how could the armed persons have entered the building. She answered they could not have. She added you cannot get in without the code. EI #15 was asked what should have been in place to ensure the safety of staff and residents. She said security, change the codes often, and have secured doors. EI #15 was asked what was the potential concern of armed persons on the hall where residents reside. She answered the residents getting hurt and their safety. An interview was conducted on 05/17/2023 at 7:56 AM with EI #13, CNA. EI #13 said that she went into a resident's room to get a tray. Then she went back toward the nurses' station and saw a man dressed in black with a hoodie and a mask with only his eyes uncovered. She was told to get on the floor with EI #14 and EI #15. EI #13 was asked how armed persons would have gained access to the keypad to the second floor from the stair well. She responded that the laundry door was always open because it did not lock or work. EI #13 was asked if both codes had been changed, how could the armed persons have gotten in the building. She responded they could not without a code that worked. EI #13 was asked what should have been in place to ensure the safety of staff and residents. She answered that back door should have been closed and locked. EI #13 was asked what was the potential concern of armed persons on the hall where residents resided. She answered it could have scared them or they could have been hurt. On 05/18/2023 at 11:09 AM, the local detective assigned to the robbery was interviewed. The detective stated the perpetrators, who entered the facility, the day of the incident, were able to enter the building because they were former employees and knew the door code. An observation was made of all exterior doors to the building during the initial tour on 05/16/2023 at 11:31 AM with EI #4, the Maintenance Supervisor. All the exterior doors were observed to be secured except for the door to the stairwell on the back of the East Wing which was opened and not secured. EI #4 demonstrated that it was propped open, and it did not work. EI #4 stated this was the doorway that was used by the robbers to gain entry to the stairwell on 05/04/2023. He stated the robbers went up to the second floor after entering that door. EI #4 said the door would close but not latch when shut. EI #4 demonstrated by closing and opening the door. It was observed that the exterior door handle, that should have been horizontal, was broken and dangled downward. EI #4 stated the door had not been in working order and secured since before he came to the facility approximately six weeks earlier. EI #4 stated, nothing had changed to the condition of the door since the robbery. EI #4 said he had requested funds for the door to be fixed by a door contractor. A follow-up interview was conducted on 05/16/2023 at 5:58 PM with EI #4. EI #4 reported he identified the exterior door used by the robbers to gain entry to the stairwell was not in working around the end of April 2023. During a walk-through his third week on the job, he identified the door and frame were warped. He added the door handle did not work because it would not shut and latch closed. When EI #4 was asked what he saw that made him believe the door was not secured, he responded the door was open and would not close. EI #4 added there was no magnetic lock on the door. EI #4 said the Master Code had been changed on 05/16/2023 at 5:30 PM. EI #4 said before the Master Code was changed anyone with the code could have accessed the stairwell on the first floor through the broken door in the back of the East Wing. EI #4 was asked who all knew the Master Code before it was changed. He said facility staff and pharmacy delivery staff, and apparently, it had been in use for a while because numerous people knew it. EI #4 acknowledged former employees could have known the Master Code. EI #4 said he did not know when the access code, intended for staff to use was changed, but it was before he started working at the facility on 03/27/2023. A third interview was conducted on 05/18/2023 at 2:38 PM with EI #4. EI #4 was asked what was the likelihood of the robbers entering the building if that door had been secured. EI #4 said, a lot less likely. EI #4 said he did not know how robbers could have entered the building if that door had been secured. An interview was conducted on 05/17/2023 at 2:33 PM with EI #5, the Housekeeping/Laundry Supervisor. EI #5 had worked at the facility for 33 years and the last eleven or twelve years at her current position. EI #5 said the East Wing exterior stairwell had been broken and unsecured for approximately a year ago. An interview was conducted on 05/18/2023 at 8:23 AM with EI #1, the Administrator. EI #1 was asked what he observed regarding the East Wing exterior stairwell door. He said it had sign indicating it was a fire door and to keep it shut. EI #1 said the door would not lock. EI #1 was asked on the morning of 05/04/2023, how did two masked and armed perpetrators enter the second-floor hall. EI #1 replied they came in the stairwell that was next to the laundry shed, went up to the second floor and let themselves in using the keypad code. EI #1 said the perpetrators took the keys from the nurse to both east and west medication carts which included the narcotic boxes. EI #1 said the facility's root cause analysis determined the root cause was that the perpetrators knew the door code. EI #1 was asked why the Master Code was not changed on 05/04/2023. He said he did not know why. EI #1 said residents were not provided a safe environment and were placed at risk when the exterior door was unsecured, and the door codes were not changed. ************************************************************************ After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F584 was lowered to a F level on 05/19/2023, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on observations, interviews, review of the Administrator's Job Description, facility policies titled, Resident Environmental Quality and Resident Rights, and the State Agency's Online Incident Reporting System Report, the facility administrator, who was responsible for day-to-day operations, failed to ensure the physical environment of the facility was safe and secure for residents' and staffs' safety. The Administrator, Employee Identifier (EI) #1, admitted to knowing an exterior door, leading to the inside of facility, needed to be repaired for approximately one year before the facility was robbed of residents' narcotic medications and an employee cellular phone on 05/04/2023. On 05/04/2023 at approximately 3:00 AM, two perpetrators, entered the facility through the broken, unsecured exterior door, known by the Administrator to be broken for over a year. Both perpetrators, armed with handguns and wearing ski masks, entered the broken exterior door, input the code to a keypad on the interior door, and walked down the hallway on the second floor of the facility. The facility confirmed 45 residents resided on this floor but were asleep during the time of unauthorized entry. One perpetrator, later identified as a former employee, EI #11, who was terminated on 03/13/2023, placed a gun to a male employee's back and guided him down the hallway to the unit charge nurse. The second perpetrator, also a former employee and identified as a Certified Nursing Assistant (CNA) and Medication Assistant Certified (MAC), EI #10, had been terminated on 03/13/2023 for theft of stock medications. EI #10 demanded the unit charge nurse surrender the keys to the two locked medication carts. EI #10 searched the medication carts after obtaining the keys from the unit charge nurse. The controlled narcotic medications for 26 residents and the cellular phone of the one employee was stolen before the perpetrators exited the facility. Further, according to staff interviews, the broken exterior door leads to an interior door that can be accessed with a security code. Several staff revealed in interviews that they would use the Master Code, that opened all doors, to enter doors. Staff revealed the secondary access security code and the master security code, were not changed often allowing anyone, including former employees, who knew the code to a gain access into the facility. However, after this incident, the Administrator ensured the facility changed the secondary door code but failed to ensure the Master Code was changed until 05/16/2023 at 5:30 PM. These deficient practices affected 26 residents, who had their controlled medication stolen and placed all 87 residents, who resided in the facility at the time of the incident, in immediate jeopardy, it was likely to result in serious injury, serious harm, serious impairment or death. On 05/19/2023 at 2:58 PM, EI #21 Regional Administrator, EI #1 Administrator, EI #2 Interim Director of Nursing Services, EI #20 Director of Nursing Services, and EI #22 Regional Nurse Consultant were provided a copy of the immediate jeopardy templates and notified of the findings at immediate jeopardy level in the area of Administration F835 - Administration. The immediate jeopardy began 05/04/2023 and continued until 05/19/2023, when the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence. Cross Reference F584. Findings included: A review of the Administrator's job description that he signed on 10/11/2021 revealed, . Job Title: Administrator Department: . To direct the day-to-day functions of the facility in accordance with current Federal, State, and local standards governing long-term care facilities to ensure that the highest practicable level of care is provided to the residents. Standard Requirements . 2. Knowledgeable of resident rights and ensures an atmosphere, which allows for . well-being of all residents in a safe, secure environment. 6. Support, cooperate with, and implement specific procedures and programs for: a. Safety, including standard precautions and safe work practices, established fire/safety/disaster plans, risk management, and security, report and/or correct unsafe working conditions, equipment repair and maintenance needs.7. g. Follow up as appropriate with supervisor, co-workers or residents regarding reported complaints, problems, and concerns. A review of the facility policy titled, Resident Environmental Quality dated 03/01/2010 revealed, . PURPOSE: The facility should be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public PROCESS: a) Preventive maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. An undated document provided to residents upon admission revealed, Residents - These are YOUR Rights: YOU have the right to be treated with dignity, privacy, respect, and to live in a safe, . environment. The Alabama Department of Public Health received a report of this incident on 05/04/2023. The Online Incident Reporting System Report documented two armed unknown people entered through the stairwell to the second floor, held staff at gunpoint, and took cart keys away from the nurse. Suspects went through cart and left with unknown items/medications from cart. A facility document titled Verification of Investigation which was signed on 05/10/2023 documented . SUMMARY AND OUTCOME OF INVESTIGATION . on 5/4/23, two unknown individuals entered the facility through a back stairwell, the entry point from the laundry shed to the building. They went straight up the stairs to the second floor . Both individuals were armed with 1 (one) handgun each . The female individual took the keys. She took all narcotics out of the locked narcotic boxes on each med (medication) cart including the STAT (emergency medication) box . The suspects knew the door codes as they were the same as the time of their termination, and as such were able to get into the building unabated. An interview was conducted on 05/17/2023 at 2:33 PM with EI #5, the Housekeeping/Laundry Supervisor. EI #5 had worked at the facility for 33 years and the last eleven or twelve years at her current position. EI #5 said the East Wing exterior door, the entry point from the laundry shed to the building, had been broken and unsecured for approximately a year. EI #5 reported the door started dragging on the bottom across the concrete and the door handle kept getting stuck and it would no longer stay closed. EI #5 said she reported to EI #1 that the door handle was getting stuck, and it would not stay shut. When asked if anyone else was present when she made EI #1 aware that the door would not stay shut, she responded she mentioned it in a morning meeting a while ago but did not recall exactly when. EI #5 was asked what was the concern of an exterior door not closing or locking. EI #5 answered the residents could be harmed and it was a danger to residents and staff. EI #5 said anybody that had the door code could have entered the halls. EI #5 stated the condition of the door worsened and there was no response from the Administrator. EI #5 said nothing was done after the robbery to prevent unauthorized persons from entering that door. EI #5 knew the Master Code. She could not remember when the other code was changed before the robbery, but it had been a long time, maybe years. EI #5 was asked if the back door would not close and lock, and anyone entered the Master Code on the keypad, could they enter the resident hallways. EI #5 replied yes. An interview was conducted on 05/17/2023 at 6:02 PM with EI #18, MDS (Minimum Data Set) Coordinator. EI #18 recalled during a morning meeting approximately one year ago, the Laundry Supervisor brought to the attention of all present that the exterior door would not shut and lock. EI #18 confirmed knowing the Master Code. EI #18 could not recall the last time the codes had been changed. EI #18 said employees and former employees would also have known both codes. When asked who had access to a Master Code, EI #18 answered everyone she knew had it. EI #18 was asked if the fire doors were supposed to stay closed and she said yes. A review of an email sent to EI #1 on 03/08/2023 revealed a quote for the replacement of a fire door. During an interview on 05/18/2023 at 11:55 AM with EI #1 regarding the request for funding for the door, EI #1 provided the surveyor with an emailed quote dated 03/08/2023 for the door to be replaced. EI #1 said he did not request for it to be funded, because it was a lot of money. A review of the quote provided by EI #4, the Maintenance Supervisor, revealed a quote for replacement of a fire door on 04/26/2023. An interview was conducted on 05/17/2023 at 8:55 AM with EI #14, the other CNA on duty at the time of the robbery. EI #14 was asked what door code he used for the stairwell or other doors. EI #14 provided the number of the Master Code, saying that code worked on all of the doors. EI #14 stated he worked at the facility for 23 years, and it had been the universal code (Master Code) for years and had not been changed. EI #14 was asked how armed persons gained access inside the building. RI #14 stated the back door did not work and that is it was never locked. EI #14 stated they (armed persons) would not have been able to get in the building if door was locked. EI #14 was asked what should have been in place to ensure the safety of staff and residents. EI #14 stated the exterior door should have been locked and codes should be changed. A phone interview was conducted on 05/17/2023 at 9:52 AM with EI #15, an LPN (Licensed Practical Nurse), the nurse on duty at the time of the robbery. EI #15 was asked how armed persons would have gained access to the keypad to the second floor from the stair well. She answered from the outside door by the laundry because the door was never locked. EI #15 was asked if the codes had been changed prior to May 4th, could the armed persons have gotten in the building. She answered they could not because you cannot get inside the facility without the code. EI #15 was asked what should have been in place to ensure the safety of staff and residents. She said security, changing the codes often, and having secured doors. An interview was conducted on 05/17/2023 at 7:56 AM with EI #13, one of the CNAs on duty at the time of the robbery. EI #13 confirmed knowing the Master Code to the door's keypad. EI #13 said everybody that went in and out to take the linen out knew the Master Code. EI #13 was asked how did the armed persons gain access inside the building. EI #13 responded that the door was always open because it did not lock or work. EI #13 was asked what should have been in place to ensure the safety of staff and residents. She answered that back door should have been closed and locked. On 05/16/2023 at 3:20 PM, EI #23, a CNA was able to name one of the two door codes as the Master Code and admitted she knew it was the Master Code. On 05/16/2023 at 3:29 PM, EI #24, a member of the housekeeping staff reported one of the keypad codes had been changed. EI #24 was able to provide the Master Code to the surveyor. EI #24 stated she heard about the Master Code from other random employees about a year ago. She said the staff have access to both codes and former employees could know the Master Code. On 05/16/2023 at 3:40 PM, EI #25, LPN (Licensed Practical Nurse), confirmed knowing both codes, one being the Master Code. EI #25 said staff have access to both codes. On 05/16/2023 at 3:45 PM, EI #26, Medication Assistant Certified (MAC) confirmed knowing two codes, including the Master Code, that would unlock the doors that have a keypad. EI #26 stated staff and administration have access to both codes. When EI #26 was asked if any former employees could have the Master Code, she said probably. On 05/16/2023 at 4:56 PM, EI #27, CNA reported she had worked at the facility for 22 years. EI #27 was able to name the codes, including the Master Code. EI #27 stated currently there were two codes that would unlock stairwell doors and one of the codes was the Master Code. EI #27 stated she has known the Master Code for about a year. When asked if any former employees could have the Master Code, she said possibly. During an interview on 05/17/2023 at 4:21 PM it was determined EI #29, a CNA who worked the first and second floor knew the Master Code. EI #29 could not recall when the code was changed before the robbery. She added that she did not realize after they changed codes on 05/04/2023, the number she gave that was the Master Code was still going to work. When EI #29 was asked who all had access to both codes, she replied everyone that worked there and the people that robbed the place. EI #29 voiced she thought that when somebody got fired, they were supposed to change the codes. EI #29 said any former employees could have the Master Code. EI #29 said everybody that worked at the facility had access to the Master Code. An observation was made during the initial tour on 05/16/2023 at 11:31 AM with EI #4, the Maintenance Supervisor, of all exterior doors to the building. It was observed that all the exterior doors were secured except for the door to the stairwell on the back of the East Wing. This door observed to be open. The exterior door handle dangled downwards and was broken. EI #4 stated the door had not been in working order and secured since before he came to the facility approximately six weeks earlier. He states nothing had changed to the condition since the robbery. EI #4 stated he had requested funds for the door to be fixed by a door contractor. An observation was made on 05/16/2023 at 5:12 PM that the Master Code allowed access to hallways inside the facility from the stairwell on the back of the East Wing. An interview was conducted on 05/16/2023 at 5:58 PM with EI #4, the Maintenance Supervisor. EI #4 reported he identified the exterior door used by the robbers to gain entry to the stairwell was not working around the end of April. EI #4 stated, during a walk-through his third week on the job, he identified the door and frame were warped. He added the door handle did not work because it would not shut, and latch closed. EI #4 explained that he had been trying to figure out how to get the Master Code to the doors changed since the robbery but was unable until 05/16/2023 at 5:30 PM. EI #4 stated, apparently the Master Code had been in use for a while and numerous people knew it. EI #4 acknowledged former employees could have known the Master Code. EI #4 said until 5:30 PM on 05/16/2023 anyone with the code could have accessed the stairwell first floor through the broken door in the back of the East Wing. An interview was conducted on 05/18/2023 at 8:23 AM with EI #1, the Administrator. EI #1 was asked what he observed regarding the East Wing exterior stairwell door. He said that it would not lock and there was no magnetic lock on it. EI #1 was asked on the morning of 05/04/2023, how did two masked and armed perpetrators enter the second-floor hall. EI #1 answered they came in the stairwell that is next to the laundry shed (East Wing), went up to the second floor and let themselves in using the keypad code. EI #1 was asked when the facility changed door codes so that unauthorized persons, like ex-employees, would not have access. EI #1 stated they did not have a policy for that before the robbery. EI #1 said he did not know when either code was changed before the robbery on 05/04/2023. EI #1 was asked when he became aware of the condition of the East Wing exterior door that opens to the stairwell. EI #1 said he did not remember, but a couple of months ago they got an estimate on replacing it. EI #1 was asked if that was that the first time, he was made aware of the condition of that door. He responded no, but he could not recall when it was brought to his attention before. EI #1 said EI #5, the Housekeeping/Laundry Supervisor notified him the first time but did not recall when she notified him. EI #1 was asked what did he do in response to being notified by the Housekeeping/Laundry Supervisor. EI #1 stated he did nothing at that time. EI #1 was asked why would he want the building to be secure. He answered to keep the residents and employees safe. EI #1 stated he could have had a new door installed and added a magnetic lock. EI #1 confirmed nothing was in place to prevent unauthorized persons from entering that stairwell. EI #1 said when entry was gained through that door, a person could enter the stairwell and then have access to the stairs and the keypads to the top and bottom floors. EI #1 was asked if the key codes were not changed routinely and the exterior door was not secured, how could he ensure former employee would not come back to the building. He said he could not. EI #1 was asked who was responsible for ensuring the codes were changed. EI #1 stated he was the responsible person. EI #1 was asked when was the Master Code changed after the robbery. He answered Tuesday, May 16th. EI #1 was asked why was the Master Code was not changed on 05/04/2023 when the other door access was changed. EI #1 stated he forgot about the Master Code and did not think about it. EI #1 stated it was oversight on his part. EI #1 was asked how long he had been aware that staff knew the Master Code. He said he was only made aware on May 16th. EI #1 was asked with the East Wing exterior door not being secured or guarded and the Master Code not being changed until 05/16/2023 at 5:30 PM, who could have accessed the building, staff and residents before the Master Code was changed. He answered any employee or former employee that knew the code. EI #1 was asked who was responsible for ensuring the safety of the facility and residents. He said that would be him. EI #1 said residents were not provided a safe environment and were placed at risk when the exterior door was unsecured, and the door codes were not changed. A final interview was conducted on 05/19/2023 at 10:48 AM with EI #1. EI #1 said he did not make his Regional Administrator aware when he received the quote to replace the exterior door. EI #1 stated it fell by the wayside. EI #1 was asked who else was involved in that decision. EI #1 stated no one. EI #1 said at the time of the robbery that exterior door would not close and latch. EI #1 was asked was what his role as Administrator. He answered to be over the overall operations of the Nursing Facility. EI #1 was asked what was his role regarding safety. He said to ensure the safety of their residents and staff. An interview was conducted with EI #17, Chief Operating Officer on 5/19/23 11:09 AM. EI #17 was asked, what he was told about the condition of the East Wing exterior door. EI #17 said he was not made aware and if he had known about the condition of the door, it would have been handled before. ************************************************************************ After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F835 was lowered to a F level on 05/19/2023, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.