**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to identify, assess, and evaluate the nursing staff's knowledge, skill level, and ability to provide emergent care in life threating situations or maintain and utilize available emergency medical equipment when reviewed for competently skilled nursing services. The findings include: A review of the facility's Facility Assessment updated [DATE] and last reviewed with the QAA (Quality Assessment & Assurance)/QAPI (Quality Assurance & Performance Improvement) committee [DATE], revealed, the persons identified in completing the assessment were the Senior Director of Healthcare Services, the Administrator, the Director of Nursing, and the Medical Director. Part 1: Our Resident Profile- The intent was to identify common diagnoses in the resident population in order to identify the types of human and material resources necessary to meet the needs of the resident's living with these conditions or a combination of these conditions. Heart/Circulatory System identified diagnoses included Congestive Heart Failure (CHF) and hypertension. Respiratory identified diagnosis included Chronic Obstructive Pulmonary Disease (COPD) and respiratory failure. Part 2: Services and Care We Offer Based on Our Residents' Needs- Assessment, early identification of problems/deterioration, management of medical symptoms and conditions of heart failure and chronic obstructive pulmonary disease (COPD). Part 3: Facility Resources Needed to Provide Competent Support and Care for Our Resident Population Every Day and During Emergencies- Identify the type of staff members, other health care professionals, and medical practitioners that are needed to provide support and care for residents. Potential data sources include staffing records and organization charts. Staffing Plan: Evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff is available to meet each resident's needs. Evaluation of residents' needs and overall acuity levels revealed the total number of staff needed were 2-4 licensed nurses providing care and 4-12 nurses' aides depending on the shift. Individual staff assignment: Staffing strategically planned based on acuity levels on halls. Staff training/education and competencies: Licensed, CPR is done annually or when expired. All onboarding employees receive orientation and a list to be checked off due within one month of hire. The facility performed skills check offs at least annually and upon I&As (Incidents & Accidents). The nursing department has competency forms filled out and checked upon new hire and annually. No plan to identify or evaluate the competency of staff in medical emergency situations was assessed by the facility. A review of the facility's Education Calendar 2025 provided by the Administrator on [DATE], revealed no scheduled CPR [Cardiopulmonary Resuscitation] or BLS [Basic Life Support] training, no mock codes, or medical equipment training. A review of the facility's Nurse Skills Checklist, LPN [Licensed Practical Nurse] or RN [Registered Nurse] revised [DATE], revealed no section for medical emergencies, no section for emergency medical equipment, and no section to indicate CPR/BLS certification. A review of the facility's 2024 Skills and Competency Fair sheet for nurses' and CNAs [Certified Nursing Assistants] revealed no competency check off was indicated for medical emergency equipment or required certifications. A review of a facility policy titled, Advanced Directives, revised [DATE], indicated, Advanced Directives will be respected in accordance with state law and facility policy. A review of a facility policy titled, Emergency Procedures-Cardiopulmonary Resuscitation, revised February 2018, indicated, Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. Victims of cardiac arrest may initially have gasping respirations or may appear to be having a seizure. Training in BLS includes recognizing presentation of SCA [Sudden Cardiac Arrest]. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. Early delivery of a chock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiated CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g., rigor mortis). If the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives. Preparation for Cardiopulmonary Resuscitation included, Obtain and/or maintain American red Cross or American Heart Association certification in Basic Life Support (BLS/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. The facility's procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. Provide Mock Codes (simulations of an actual cardiac arrest) for training purposes. Select and identify a CPR team for each shift in the case of an actual cardiac arrest. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. The CPR team in this facility shall include at least one nurse, one LPN [Licensed Practical Nurse]/LVN [Licensed Vocational Nurse] and two CNAs [Certified Nursing Assistants], all of whom have received training and certification in CPR/BLS. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. Provide information on CRP/BLS policies and advance directives to each resident/representative upon admission. Emergency Procedures-Cardiopulmonary Resuscitation included, If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac death is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct staff members to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events. Airway: Tilt head back and lift chin to clear airway. When the AED arrives, assess for need and follow AED protocol as indicated. Continue with CPR/BLS until emergency medical personnel arrive. A review of an in-service titled, CPR Training, dated [DATE], revealed 9 staff members who attended CPR training, 8 are still active employees, and 7 are bedside staff. A review of the Registered Nurse & Licensed Practical Nurse, Job Description, revealed that no CPR certification/training was listed under qualifications. A review of the list Code Status, provided by the DON [Director of Nursing] on [DATE] at 2:02 PM, revealed 14 of the 50 residents in the facility selected full code meaning the 14 identified residents wished to have CPR for life sustaining intervention if they were to require it. A review of the Resident Summary, indicated on [DATE] the facility admitted Resident #4 with diagnoses which included acute on chronic congestive heart failure, acute kidney failure, emphysema, type 2 diabetes, anemia, COPD [chronic obstructive pulmonary disease], hyperlipidemia, hypertension, and atrial fibrillation. The admission Minimum Data Set (MDS) was never completed for Resident #4 prior to the resident's death on [DATE]. A review of Resident #4's Care Plan, dated [DATE], revealed the resident was admitted for continuing care of an unstable condition. Interventions included monitoring respiratory, circulation, and cardiac status: lung sounds, vital signs, oxygenation status, skin color and turgor, nailbed color, activity tolerance. Note presence of lethargy, mottling, confusion, change in mood or demeanor. A review of Resident #4's facility Advanced Directive form signed [DATE], by Resident #4's family representative and witnessed by LPN #3 indicated, Resident #4 ' s wish to be a full code by marking the line stating, Yes, I DO WANT the staff to begin CPR and call 911 with the intention of providing resuscitation and other emergent life-saving measures. A review of Physician Orders, revealed Resident #4 ' s order stated, DNR Form: no; CPR-CODE entered by LPN #4 on [DATE] at 4:06 PM. An order for Oxygen 3L (Liters) via NC (Nasal Cannula) continuously for SOB (Shortness of Breath)/COPD Exacerbation. A review of Resident #4's internal investigation documentation revealed: 1.The facility submitted a report to the OLTC (Office of Long-Term Care) Incident and Accident Report (I&A) on [DATE] at 8:44 AM, a summary of Incident indicating, Resident #4 reported SOB at 11:40 PM om [DATE]. Resident #4 was addressed by LPN #1 as SOB and using accessory muscles to assist in breathing. LPN #4 exchanged Resident #4's oxygen delivery system from NC to a mask related to the resident's breathing technique. A medicated inhaler was administered at 11:50 PM per LPN #1 without relieving the SOB. LPN #1 left the resident and phoned the on-call provider. While LPN #1 was on the phone a CNA reported Resident #4 was found on the floor and bleeding for a head injury. The provider gave an order to transfer the resident to the hospital for evaluation and treatment. 911 was called at 12:04 AM on [DATE]. After calling 911, LPN #1 went to Resident #4's room and observed the resident lying flat on the floor stomach down. LPN #2 was applying pressure to Resident #4's forehead for a laceration which was bleeding and did not move the resident due to a head injury. Resident #4 had agonal respirations and was not responding to verbal commands. The pulse oximeter showed no reading, but a manual pulse check was 68. 911 arrived at the facility at 12:12 AM. Resident #4 was placed on a stretcher by Emergency Medical Services (EMS) and coded at 12:18 AM. 2.LPN #2 wrote a witness statement at 11:30 AM on [DATE], stated resident laying headfirst on ground-breathing became apneic. EMT arrives-CPR started. A review of Resident #4's Ambulance Run Record dated [DATE], indicated the EMS team was on scene at 12:12:35 AM, and reached the resident at 12:15:30. EMS narrative reported, upon arrival the patient was found unresponsive, lying prone [on stomach] on the floor with [pronoun] head slightly looking to the left, and [facility name] staff applying pressure dressing to [pronoun] forehead. The patient had weak, agonal respirations with an extremely slow, faint pulse. The patient was found unresponsive with a GCS [Glasgow Coma Scale] of 3. A slow, faint, thready carotid pulse was palpated initially. [Pronoun] airway was open and patent with no vomit or secretions noted in or around [pronoun] mouth or nose. Trachea appeared midline and there was no JVD [Jugular Vein Distention] noted. [Pronoun] had shallow, agonal respirations at 8 breaths/min. with no visual chest rise or fall. Cyanosis [bluish tint to the skin or nail beds indicating a lack of oxygen in the blood] was noted to [pronoun] face and peripheral extremities, but [pronoun] skin was otherwise warm and mottled. The patient's pupils [were] equal and sluggish to respond. During an interview on [DATE] at 1:00 PM, LPN #1 stated, she and LPN #2 did not want to move the resident related to trauma but turned Resident #4's head to the side so the resident's face was not in the pillow. During an interview on [DATE] at 1:27 PM, LPN #5 stated she was new, but not aware of any emergency equipment or where it was kept. LPN #5 asked LPN #6 for assistance in locating the emergency equipment. LPN #6 stated that the facility had oxygen, but did not think they had an Ambu bag [a medical tool which forces air into the lungs of patients who have either ceased breathing completely or who are struggling to breathe properly]. LPN #5, LPN #6, then joined by LPN #4 all entered the medication room. No Ambu bag was located. LPN #4 stated that she had seen one on another unit and it might be in the treatment cart. Given Resident #4's scenario, LPN #6 stated agonal breathing would be considered a respiratory code and stated if an Ambu bag was available it should be utilized in a respiratory code. LPN #5 and LPN #6 stated they were CPR certified, LPN #4 stated she had let her certification lapse. During a concurrent observation and interview on [DATE] at 1:40 PM, the DON stated the facility had an AED [automated external defibrillator], and a mask was kept with it. The facility had oxygen tanks, oxygen concentrators, and she was 99% sure of an Ambu bag. The DON stated during a medical emergency, 911 should be called, then the AED and Ambu bag or mask should be taken to the resident's room. The DON stated, all nurses currently working in the facility are not CPR certified, but it will be required. The facility is looking for someone to help with that. The DON stated that semi-Fowlers would be ideal for someone in respiratory distress and lying on their stomach would compromise their breathing more. At 1:46 PM, the DON took this surveyor to the medication room; an empty plastic bag was hanging on a metal shelfing unit which was where the Ambu bag was to be kept. No Ambu bag was located and the DON stated only one at a time was kept in the facility. This surveyor indicated LPN #4 thought one was located on a treatment cart. At 1:49 PM, an Ambu bag was located inside the treatment cart of a medication room on a back unit. At 1:52 PM, the DON took this surveyor to the front common area close to the dining room where an AED was in a box on the wall. Inside the box was a one-way valve mask for rescue breathing. A tag with monthly check going back over a year was attached to the AED. The DON stated nursing did not check the AED, it was the maintenance department. During an interview on [DATE] at 2:19 PM, the Medical Director stated he believed all the nursing staff had to have BLS certification, but was unaware of what emergency equipment was available in the facility. He thought there was an AED but was unaware of its location. When questioned about Resident #4's medical emergency the Medical Director stated, breathing takes priority over any trauma. The staff should have intervened to assist with breathing. Resident #4 should have been repositioned supine (on back) and bagged with the agonal breathing. During an interview on [DATE] at 4:03 PM, the RN Educator stated the facility did not have any CPR reference cards available to the nurses for quick access instructions. She stated the facility was working on CPR training for everyone. During a follow-up interview on [DATE] at 1:02 PM, LPN #1, stated she had worked here about a year and did not feel she was properly trained for an emergency in the facility setting and had never been part of a mock code for training purposes. She stated she was CPR certified, but no assignments were made each shift to identify a charge nurse or code team. LPN #1 was aware an AED was available in the facility but was not aware of a one-way valve mask or an Ambu bag to provide respirations to a resident. LPN #1 stated, if she had access to an Ambu bag the night Resident #4 required emergency services, she would have used it with the resident. During an interview on [DATE] at 3:25 PM, LPN #7 stated in a code situation she would start CPR, but no staff members were designated to any code team during each shift. She was aware of the AED and its location, but stated the facility did not have an Ambu bag. She felt she was trained, but stated the staff did not do it very often and it was a high stress situation. During an interview on [DATE] at 3:36 PM, the Administrator stated, staff were not required to have CPR certification but thought they had it from nursing school. He stated the human resources department, nor the DON tracked which staff members in the facility were certified. The previous DON had a list, and they were looking for it. The facility did not in-service on their CPR protocol but had an outside instructor in the facility who held a CPR class in April of 2024. No charge nurse was specified during a shift and no code team assignments were made. Nurses had radios they could use to call for assistance from other staff. The facility was working towards getting everyone CPR certified. During an interview on [DATE] at 3:42 PM, the DON stated that the CPR policy was not given out to employees at hire, but it would be good moving forward. There was a policy binder located at the front nurses' station, and the policy was located inside it. There were no code team duties assigned for each shift, the emergency equipment was not easily accessible, and there were no mock codes done for training. The DON stated until this surveyor brought it to her attention, she was unaware how inaccessible the equipment was. The CPR policy was part of the nurses ' training but moving forward the DON planned to elaborate more. The DON stated there were two (2) types of codes, a cardiac and respiratory. Resident #4 was likely having a respiratory code and should have been rolled over on [pronoun] back, an Ambu bag used to rescue breathing, and the AED applied to analyze the resident's rhythm. During an interview on [DATE] at 2:02 PM, the Administrator stated the facility was aware of one (1) CNA employed who had their CPR certification. The only nursing staff they were aware of who had their BLS certification were those who signed into the [DATE] BLS class at the facility. The facility kept no list of CPR certification. During an interview on [DATE] at 3:00 PM, the DON stated, she felt like she had received the proper training for medical emergencies and the equipment, but she could not speak for every employee in the facility. Related to Resident #4's situation the DON stated, a bad decision was made by the first nurse on the scene and the staff did not understand what equipment was available to assist them in the situation. During an interview on [DATE] at 3:10 PM, the Administrator stated he felt the staff were trained and competent to handle medical emergencies quickly. He stated maybe we need more in-service and return demonstration. The facility did not have a checkoff for emergency care or CPR qualifications, and he did not believe the DON did either. They are licensed I would assume CPR is nursing 101. No facility competencies are measured or recorded.

Based on interviews, record review, facility document review, facility policy review, it was determined that the facility failed to a resident was free from a significant medication error for 1 (Resident #1) of 3 residents reviewed for medication administration. Findings include: A review of a facility policy titled, Documentation of Medication Administration, revised in April 2007, indicated, all medications administered to a resident should be documented on the resident's Medication Administration Record (MAR) immediately after (never before) it is given with the signature and title of the person administering the medication. A review of a facility policy Medication Record for 08/2024, revealed Resident #1 had an order for an anticonvulsant to be given at 8:00 AM and 6:00 PM which was started on 12/18/2022. The 08/25/2024 8:00 AM dose was signed off by Licensed Practical Nurse (LPN) #3. The 08/27/2024 6:00 PM dose was not signed of as administered. A review of Resident #1's anticonvulsant medication's page in the facility's narcotic book revealed, on 08/25/2024 no medication was signed out by LPN #3. A review of a Progress Note dated 08/29/2024 at 10:43 AM, revealed Resident #1 had seizure like activity in the dining room and Emergency Medical Services (EMS) were called. A review of Resident #1 ' s hospital records revealed, Resident #1 was diagnosed with a seizure. Written education provided by the hospital stated common causes of seizures were fever, infection, brain tumors, head injuries, bleeding in the brain and low levels of sugar or salt. Resident #1 ' s temperature was 97.2 º Fahrenheit, no elevated white blood cell count indicating an infection, Resident #1 Computed Tomography (CT) of the head and neck was negative for any abnormalities, Resident #1's glucose level was elevated at 172 and Sodium level was within normal range at 138. Resident #1's seizure was controlled with an anticonvulsant medication. During an interview on 11/19/2024 at 1:41 PM, LPN #1 stated, Resident #1 had not had a seizure in the previous years they had worked here. During an interview on 11/20/2024 at 11:55 AM, Director of Nursing (DON) stated, on 08/25/2024 LPN #3 probably documented the 8:00 AM dose on the MAR prior to retrieving the dose and forgot to go back and do it or documented the 8:00 AM dose for another nurse who never gave it. DON stated there were no discrepancies reported during the narcotic count, so the tablet had not been pulled. If the tablet had been pulled without being signed out a discrepancy would have been noted during the narcotic count. The result was no dose was administered to Resident #1 on 08/25/2024 at 8:00 AM. The DON stated no dose was documented and administered on 08/27/2024 at 6:00 PM. The DON explained when a second nurse comes to help administer medications the nurses pull and sign out medications for each other, this results in nurses forgetting to administer medications or documenting them. The DON agreed Resident #1 most likely did not receive two doses of the anticonvulsant medication. During an interview on 11/20/2024 at 12:27 PM, LPN #3 stated he did not remember the exact occurrence, but they most likely documented the medication and never gave it. LPN #3 stated there were no issues with a discrepancy in the narcotic counts that week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to identify the risk of side rail entrapment which resulted in actual harm for 1 (Resident #7) of 37 (Residents #1, #2, #3, #4, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #25, #26, #27, #29, #30, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #43 and #96) sampled residents who had side rails on their bed as documented on a list provided by Administrator on 05/27/23 at 7:45 AM, and failed to identify risk and respond to multiple elopements for 2 (Residents #13 and #40) of 4 (Residents #13, #38, #40 and #43) sampled residents who were at risk for wandering as documented on a list provided by Administrator on 05/27/23 at 7:45 AM. The findings are: 1. Resident #7 had diagnoses of Unspecified Dementia, Unspecified Severity, without Behaviors and Aphasia following a Cerebral Infarction. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of two plus persons for bed mobility and did not use bed rails. a. A Care Plan with a start date of 10/27/22 documented, .May use top two rails in bed for positioning . b. An Office of Long Term Care (OLTC) Witness Statement Form dated 05/08/23 completed by the Director of Nursing (DON), provided by the DON on 05/23/23 at 4:15 PM documented, .This nurse [DON] advised by CNA [Certified Nursing Assistant (CNA) #2] that resident had turned sideways & [and] managed to get her upper leg under the siderail. This nurse escorted him to resident's room & assessed patient & found no redness or s/s [signs/symptoms] of injury to BLE [bilateral lower extremities], ROM [range of motion] was WNL [within normal limits] for this resident . advised CNA to obtain extra pillow or pillows as necessary to position for comfort . c. An Office of Long Term Care (OLTC) Witness Statements dated 05/08/23 at 7:30 PM completed by CNA #1 provided by the Treatment Nurse on 05/22/23 at 3:10 PM documented, When I entered room [Resident #7's room number], I found her between the bed and bed rail trapped from hitting the floor. Her feet were touching the floor. She had threw up, she was pale. The bed sheets where almost off the bed with her. I called for help via yelling and on the walkie. Got her back into the bed and Nurse [Registered Nurse (RN) #1] helped me get her feeling better. Changed the bed covers, new night gown, washed the throw up off her and got V/S [vital signs]. Resident was feeling better . d. An email dated 05/09/23 at 4:08 PM from the Assistant Director of Nursing (ADON) to Registered Nurse (RN) #1 provided by the Treatment Nurse on 05/22/23 at 3:10 PM documented, .My concern is that there is no documentation in [Electronic Medical Record] regarding this, will you please start an I/A [Incident and Accident Report] for this incident as a near fall, just document as a late entry and enter your assessment for 5/8/23. She does have some new bruises from this event so if you will measure and document those when completing I/A that would be appreciated . e. The Incident Log-Fall/Skin/General did not contain Resident #7's incident dated 05/08/23. f. On 05/22/23 at 3:45 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1 about the side rail incident with Resident #7. CNA #1 stated, The door was closed to Room [Resident #7's room number] and when I went in, I saw her between the side rail and bed. There was throw up everywhere. She was stuck above the thigh and under the stomach. The area was red. She was facing the door. Her left side was stuck in the rail. There was abrasion with two little openings. There was thin bruising on the thigh area. They did not change the side rails and there was no cushioning placed between the mattress and side rail. g. On 05/23/23 at 8:44 AM, Resident #7 was in bed with two side rails up. The air mattress was set on normal pressure and there was no cushion between the side rails and the bed. h. On 05/23/23 at 2:51 PM, Resident #7 was lying in bed, the air mattress was inflated. There was no cushion or padding between the side rails and the bed. 2. Resident #13 had diagnoses of Unspecified Dementia, Unspecified Severity without Behavior and Muscle Weakness (Generalized). The Quarterly MDS with an ARD of 05/11/23 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a BIMS and did not exhibit wandering behavior. a. A Physicians Order dated 08/10/22 documented, .Resident needs continued care in nursing home due to the inability to live independently and the need for medical assistance, observation, and planning . b. A Care Plan with a start date of 05/03/23 documented, .Cognitive Loss .Resident has impaired cognition as related to dx [diagnosis] of unspecified dementia without behaviors . c. A Care Plan with a start date of 05/03/23 documented, .Behavior .is at risk for wandering, exit seeking, and leaving the unit unattended. He is easily redirected back to HCC [Health Care Center] . d. Risk of elopement/ wandering review dated 5/03/23. admission date 8/10/22. Summary of review: Resident is at risk for elopement/wandering, as evident by: leaving without notifying staff. e. The Incident Log-Fall/Skin/General did not contain Resident #13 ' s incidents dated 04/26/23 and 05/01/23. f. On 05/23/23 at 10:23 AM, Resident #13 stated he does not go outside by himself. [Family Member] comes and takes him outside when he visits. g. On 05/22/23 at 2:25 PM, the Surveyor was handed a Timeline from the Front Door Receptionist. She stated, We have had three incidents since March 8th, 2023, where we called HCC [Health Care Center] to alert them to a possible problem and the situation was allowed to escalate before anything was done. h. A document provided by the Front Desk Receptionist on 05/22/23 at 2:25 PM documented, .April 26, 2023 [Resident #13] came to the front desk area alone in his wheelchair. He is usually accompanied by someone, so I thought this was unusual. He sat by the front desk for a few minutes and then started to go out the front doors . I tried to call HCC but got no answer. [Resident #13] was outside at this point but we were both watching him. When he started down the sidewalk towards the North atrium door, [IT] went outside to be with him. [IT] said he was going to make sure [Resident #13] got back to HCC. I didn't try to call HCC again since I knew [IT] would take care of it. May 1, 2023 [Resident #13] came to front desk alone in his wheelchair. I immediately called HCC to make sure they knew where he was. All I got in response was an OK, thanks. I don't know who answered the phone. I was keeping a close eye on [Resident #13] because of the incident the previous week. He went outside and turned left. Since that leads to the main driveway, I asked security [name] if he could see him on camera. He couldn't at that moment but assured me that he was probably fine . Although I didn't see this directly, about 15 minutes later I heard that he was found in the main driveway by the cottages. After that [Administrator], [DON] and [Senior Director of Resident Services] came to the security office to watch camera footage to see what happened. In all, it was about 45 minutes from the time I called HCC to the time he was back in his room. In light of these three incidents happening within a short span of time, I believe that there has been a failure on the part of the HCC staff to respond to these incidents in the appropriate way. All three could have been resolved without incident if there had been proper and timely response from them . i. On 05/22/23 at 3:10 PM, the Treatment Nurse stated Resident #13 doesn't know 70% of the time where he is. He would not be able to sign in and out. Resident #13 is one resident we would not want him going out unattended. j. The St. Louis University Mental Status (SLUMS) Examination, an assessment tool for mild cognitive impairment and dementia documented Resident #13 scored 19. A 1 - 20 score indicates Dementia. k. The OLTC Witness Statement Form dated 05/01/23 at 16:00 (4:00 PM) completed by the DON documented, .Security was able to monitor resident on video as he leaves the sidewalk & goes onto the drive & around the building for all but an approximate 50ft [feet] length/time span of 3 minutes where there is no camera. Resident reappears & then goes onto sidewalk & entrance at the performance hall where he re-enters the building . l. The OLTC Witness Statement Form dated 05/01/23 at 3:21 PM completed by the License Social Worker documented, .The security guard called me into his office to view video of [Resident #13], who was outside the building and propelling himself in his wheelchair. He was headed west toward the cottages. When he reached the drive between the main building and the cottages, he turned left heading south and eventually out of range of the camera. The security guard reported that he went to the south side of the Performance Hall (in the main building) and entered there . 3. Resident #40 had diagnoses of Unspecified Dementia, Unspecified Severity, without Behaviors and History of Falling. The Quarterly MDS with an ARD of 04/10/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a BIMS and did not exhibit wandering behavior. a. A Physicians Order dated 01/10/23 documented, .Resident needs continued care in nursing home due to the inability to live independently and the need for medical assistance, observation, and planning . b. A Care Plan with a start date of 01/24/23 documented, .has impaired cognition related to dx [diagnosis] of unspecified dementia without behavioral disturbance . Resident will be able to locate own room . Orient to room and location of personal belongings . Reorient as needed . c. An Interdisciplinary Note dated 04/10/23 at 12:47 PM documented, .Event Date: 03/08/2023 documented, .Approximately 3pm the DON was noptified [notified] resident was not in room & companion was not in HCC.Receptionist @ [at] front lobby called & resident had been there & she turned her back towards HCC . continued to search for resident approx [approximately] 15 minutes when the . social worker found her visiting with her friend on the 3rd floor in her apartment . d. A Care Plan with a start date of 04/12/23 documented, .at risk for wandering, exit seeking, and leaving the unit unattended . all staff to redirect resident if she is leaving HCC without supervision . Secure unit/environment. Utilize check out/in logs at nurses station . e. A document provided by the Front Door Receptionist on 05/22/23 at 2:25 PM documented, In re [regard]: In-service training documents dated May 2 and May 3, 2023.We have had three incidents since March 8th, 2023, where we called HCC to alert them to a possible problem and the situation was allowed to escalate before anything was done. March 8, 2023 [Resident #40] entered the lobby from the exterior door with no one accompanying her at approximately 4:00 pm. I was familiar with [Resident #40 ' s] cognitive issues having dealt with her on a regular basis while she was in Independent Living. Since she was always accompanied by a companion even then, I decided to stay after my shift to make sure she made safely back to HCC. I conversed with her for a few minutes. She was asking for the key to her apartment and said she had lost her fob and needed another one. I reminded her that she didn't have that apartment anymore and that she had a room in HCC (she had been made permanent in HCC in January). I directed her towards HCC and called the nurses' station. There was no answer, so I called the [DON]. We agreed to both head for the commons area to make sure she made it back safely. Even though we both left immediately, she had disappeared by the time [DON], and I met. Security was called and began searching for her on camera while many employees began to search as well. After approximately 55 minutes, it was discovered that she had gone to a friend's apartment. She was then returned to HCC . f. On 05/22/23 at 3:05 PM, the Treatment Nurse stated that Resident #40 was in room [Room Number] and was not on the secured unit at the time she left the facility. She stated that Resident #40 would not know where she was going. g. The Incident Log-Fall/Skin/General did not contain Resident #40's incident dated 03/08/23. 4. A facility Emergency Measures procedure titled, Code Pink - Missing Resident (Elopement), provided by Administrator 05/24/23 documented, If resident is not located, unable to find for any reason please complete the following steps. 1. Ensure the resident has not checked out and away from the facility . 2. Call CODE PINK and resident name 2x [2 times] to alert staff of missing resident. 3. All staff should immediately begin searching and clearing rooms, closets, showers, and all other similar areas. 4. Send staff outside to search exterior of facility. 1 person search left and 1 search right and meet back once exterior has been completed all the way around campus. 5. Once resident has been located, announce the all clear and return to your assigned position .