**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of nine sampled residents (Resident 1 and Resident 2), who were assessed at risk for elopement (the act of leaving a facility unsupervised and without prior authorization), received supervision to prevent elopement from the facility. These deficient practices resulted in Resident 1 and Resident 2 eloping from the facility on 5/18/2025 at approximately 12 p.m. without staff awareness. Resident 1 and Resident 2 were located by Resident 1's Family Member (FM) 1 approximately 20 miles from the facility on 5/19/2025 at approximately 3 p.m. (approximately 27 hours after they were believed to have eloped from the facility). Both residents were transported to a General Acute Care Hospital (GACH) for evaluation and treatment, where they remained for four days. Resident 1 was admitted to the GACH with altered mental status (a change from a person's normal mental state) and Resident 2 was assessed and treated for a urinary tract infection ([UTI] an infection in the bladder/urinary tract). These deficient practices placed Resident 1 and Resident 2 at risk of exposure to inclement weather (unpleasant or severe weather conditions that can disrupt activities, create hazardous situations, or pose risks to safety), vehicular accident and injury, harm by other individuals and death, and placed 144 residents, who resided in the facility, and who were assessed as high risk for wandering/elopement, at risk for elopement from the facility. On 5/20/2025 at 7:03 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to identify Resident 1 and Resident 2 prior to allowing them entry into the facility's lobby from a locked unit and permitting them to elope the building through the facility's front door. On 5/23/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 5/23/2025 at 3:06 p.m., in the presence of the facility's DON and ADM. The facility's IJRP included the following immediate actions: On 5/19/2025 - 5/20/2025 a review 228 residents' medical records was conducted by the DON and IDT members to ensure each resident had an updated Elopement/Wandering Risk assessment and care plan. 144 residents were identified at risk for elopement/wandering. 10 of the 144 at risk residents were identified with no elopement risk/wandering care plans, their care plans were updated to reflect interventions to ensure residents were free from elopement episodes and free from any injuries if wandering. An Elopement binder located at the receptionist desk and in Point Care Click ([PCC] a healthcare management platform designed to simplify resident care and improve efficiency in senior care facilities) Special Instructions (a mechanism in PCC to identify if a resident is at risk for elopement/wandering) were updated on 5/20/2025 to reflect residents' appropriate risk for elopement/wandering. On 5/18/2025, the Infection Preventionist Nurse (IPN) Nurse Manager and Regional Director of Clinical Services (RDCS) initiated an in-service for the licensed nursing staff regarding the facility's policy and procedure on elopements, and emergency procedure when a resident is missing/has eloped. On 5/19/2025 an In-service was initiated by the DSD for facility staff regarding residents at risk for elopement, identifying wandering and exit seeking behaviors, interventions for wandering and exit seeking behaviors, new visitor screening process for visitors/outside providers, new staff entrance/exit process, staff/visitor/outside providers' badges are visible and any individuals without proper badge/identification will not be permitted entry or exit through the locked doors, when opening locked doors ensure residents are not following them, vigilance in noticing surroundings when entering or leaving locked doors. Staff are no longer permitted to enter or exit through the front doors to lessen crowding and increase visibility. Staff will begin utilizing the metal doors located East of the front entrance at the front of the facility. A sign has been placed on the front door directing staff to the new entrance location. All staff will enter the facility through an alternative entrance on the day and evening shifts, and after hours, staff entering the building will press a button and staff inside the building, after viewing a camera, will let them in. Two receptionists are currently assigned to screen visitors from 7 a.m. - 7 p.m., at the front lobby daily Monday through Sunday. During lunch breaks, the two receptionist will relieve each other, there will be only one receptionist during lunch breaks. On 5/20/2025 the facility upgraded entrance doors with a magnetic security/closure function in addition to a keypad entry that was installed. On 5/19/2025 the Receptionist and CNA involved were placed on leave pending the outcome of the investigation. The Receptionist and CNA's termination will be processed effective 5/23/2025. The DSD/designee will conduct hallway rounds three times per week to ensure residents are supervised and redirected to appropriate units. Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a type of schizophrenia [a mental illness that affects a person's thoughts, feelings and behaviors] marked primarily by distrust of others, and false beliefs of being persecuted, harmed, or spied upon) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/1/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills (problems with a person's ability to think, learn, remember, use judgement, and make decisions) for daily decision making and required supervision (helper provides verbal cues and/or touching /steadying to complete the activity) to complete activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Wandering Risk Observation/assessment dated [DATE], the Wandering Risk Observation/Assessment indicated a score of nine indicating Resident 1 was at risk for wandering. During a review of Resident 1's untitled Care Plan dated 4/23/2025, the Care Plan indicated Resident 1 was an elopement risk/wanderer related to her attempts to leave the facility unattended. Under this Care Plan, the goal was that Resident 1 would not leave the facility unattended through the review date of 6/23/2025. The Care Plan's interventions included distracting Resident 1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books, monitoring Resident 1's location every two hours and document wandering behavior and attempted diversional interventions in the behavior log. During a review of Resident 1's Change of Condition (COC) form dated 5/18/2025, the COC indicated on 5/18/2025 at approximately 5:41 p.m., Resident 1 could not be located anywhere in the facility and Code Black was initiated. The COC indicated at 5:41 p.m., the DON, ADM, local police and Resident 1's Responsible Party (RP) were notified of Resident 1's disappearance. During a review of Resident 1's Nursing Progress Note dated 5/19/2025 and timed at 2:56 p.m., Family Member (FM) 1 reported he located Resident 1 near his residence. The Nursing Progress Note indicated Resident 1 was transported to a GACH by the facility's ADM and SSW for assessment and clearance. During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the GACH on 5/19/2025. During a review of the GACH's Emergency Department (ED) Progress Note dated 5/19/2025, the ED Progress Note indicated Resident 1 was admitted with a diagnosis of altered mental status. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of dementia. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had impaired cognitive skills for daily decision making and required partial/moderate assistance (helpers does less than half the effort) to complete ADLs. During a review of Resident 2's Wandering Risk Observation/assessment dated [DATE] the Wandering Risk Observation/Assessment indicated a score of eleven indicating Resident 2 was a high risk for wandering. During a review of Resident 2's untitled Care Plan dated 9/5/2024, the Care Plan indicated Resident 2 was an elopement risk/wanderer related to disorientation to place and impaired safety awareness. The care plan indicated Resident 2 wandered aimlessly and significantly intruded on the privacy or activities of others. Under this Care Plan, the goal was that Resident 2 would not leave the facility unattended through the review date of 12/04/2024. The Care Plan's interventions included monitoring Resident 2's location, documenting wandering behavior and attempted diversional interventions in the behavior log. During a review of Resident 2's COC dated 5/18/2025, the COC indicated on 5/18/2025 at approximately 5:41 p.m., Resident 1 could not be located anywhere in the facility and Code Black was initiated. The COC indicated at 5:41 p.m., the DON, ADM, local police and Resident 2's RP were notified of Resident 2's disappearance. During a review of Resident 2's Nursing Progress Note dated 5/19/2025 and timed at 2:56 p.m., the Nursing Progress Note indicated FM 1 reported he located Resident 2 near his residence. The Nursing Progress Note indicated Resident 2 was transported to a GACH by the facility's ADM and SSW worker for assessment and clearance. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the GACH on 5/19/2025. During a review of the GACH's ED Progress Note dated 5/19/2025, the ED Progress Note indicated Resident 2 was admitted to the GACH with a diagnosis of urinary tract infection, and diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar [b/s] control and poor wound healing). During an interview on 5/20/2025 at 10:56 a.m., and a subsequent interview at 12:42 p.m., RCP 1 stated on 5/18/2025 at approximately 12:10 p.m. to 12:15 p.m., CNA 1 rang the doorbell from inside the facility's locked area alerting her (RCP 1) to unlock the door, which led to the facility's lobby area, so that the visitors (Resident 1 and Resident 2) could be allowed out. RCP 1 stated she unlocked the door, and Resident 1 and Resident 2 entered the lobby and continued out the facility's front entrance. RCP 1 stated Resident 1 and Resident 2 did not have on green visitors stickers, but she stated that was not uncommon because visitors entered the facility through a different entrance when she was on her lunch break. RCP 1 stated she found out later that evening, those visitors were residents. RCP 1 stated she was not familiar with the residents in the facility, and she did not recognize the visitors were actually residents. RCP 1 stated there was no process to check out visitors when they left the facility, she just told Resident 1 and Resident 2 goodbye and have a nice day when they left out of the building through the facility's front door. During an interview on 5/20/2025 at 11:48 a.m., CNA 1 stated on 5/18/2025 at approximately lunchtime she was passing by the locked doors that led to the facility's lobby area and saw two ladies that did not look like residents near the doors. CNA 1 stated she pressed the button (doorbell) to signal for RCP 1 to unlock the doors, which she (RCP 1) did, and the two ladies proceeded into the lobby area. CNA 1 stated she saw one of the two ladies wearing a green visitor sticker which was given to visitors when they enter the facility. During an interview on 5/20/2025 at 2:42 p.m., CNA 4 stated on 5/18/2025 at approximately lunchtime, she did not see Resident 1 or Resident 2 when she delivered lunch trays to their shared room. CNA 4 stated she does rounds on her assigned residents every two hours, during her rounds on 5/18/2025, she did not see Resident 1 and Resident 2 after delivering their lunch trays and did not look for them because she assumed they were on the facility's patio. CNA 4 stated she did notice their lunch trays were still in the resident's room and were untouched. CNA 4 stated she found out later that night, Resident 1 and Resident 2 were missing from the facility. During an interview on 5/20/2025 at 2:15 p.m., CNA 5 stated when she started her shift at 3 p.m., on 5/18/2025 she noticed Resident 1 and Resident 2's lunch trays were still in their room untouched. CNA 5 stated she asked staff members if they had seen the residents, but nobody had seen them. CNA 5 stated prior to dinner time (unsure of the exact time), she asked other staff to help her look for Resident 1 and Resident 2 and they (her and the other staff) continued looking for them through dinner time. CNA 5 stated she found out the residents had eloped when she heard Code Black (an alert to facility staff to initiate a search of the building and premises for a resident who left the facility without authorization), being activated. During an interview on 5/20/2025 at 3:04 p.m., the DON stated Resident 1 and Resident 2's whereabouts in the facility should have been monitored every two hours because they were high risk for wandering/elopement. The DON stated staff should have confirmed if the two ladies (Resident 1 and Resident 2) were actual visitors prior to allowing them into the facility's lobby area and then allowing them to exit through the facility's front door. The DON stated the facility had no check out process for visitors and none was utilized by RCP 1 prior to Resident 1 and Resident 2 eloping from the facility. The DON stated the residents' elopement placed them at risk for harm by car accident and/or injury by other individuals, missed medications, no access to food or water, and exposure to different weather conditions. During a review of the facility's undated Policy and Procedure (P/P) titled Wandering Residents and Elopements the P/P indicated the facility maintains a process to assess residents for elopement risk, or who are at risk of unsafe wandering and will implement risk reduction strategies. The P/P indicated interventions that may be used for residents identified as high risk for elopement include but may not be limited to the physical plant is secured to minimize the risk of elopement through safety locks or keypad entry that restrict access to dangerous areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident, who was diagnosed with atrial fibrillation ([Afib] abnormally fast heartbeat that may lead to blood clots) and received Warfarin (a medication used to prevent blood clots from forming) was free from significant medication errors for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1's Warfarin was administered as ordered by Resident 1's physician's Nurse Practitioner (NP). 2. Ensure licensed nurses did not administer multiple orders of duplicate therapy of Warfarin to Resident 1 on 11/21/2024, 11/22/2024, 11/23/2024, 11/25/2024 11/29/2024, 11/30/2024, 12/1/2024, 12/2/2024, 12/9/2024 and 12/10/2024 that included a dose of Warfarin that should have been discontinued on 11/19/2024. 3. Ensure licensed nurses monitored medication administration times and critical (values that are significantly outside the normal range) laboratory values to prevent and detect medication errors. These failures resulted in Resident 1's transfer to a General Acute Hospital (GACH) on 12/27/2024 where he was diagnosed with a subdural hematoma ([SDH] a collection of blood on the surface of the brain) measuring 12 millimeters ([mm] a metric unit of measurement, used for medication dosage and/or amount). Resident 1 upon admission to the GACH was intubated (insertion of a tube either through the mouth or nose and into the airway to aid in breathing) and administered Andexxa (a medication given to patients who are on anticoagulant medication [a class of drugs that help prevent blood clots and dissolve existing ones] to treat life-threatening or uncontrolled bleeding. On 1/4/2025 at 5:59 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to administer and monitor Resident 1's Warfarin medication according to the prescriber's order. On 1/5/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After an onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 1/5/2025 at 6:45 p.m., in the presence of the facility's DON and ADM. The facility's IJRP included the following immediate actions: a. On 1/4/2025, a comprehensive three-way audit of 13 medication carts was initiated with an expected completion date of 1/5/2025. This audit was conducted collaboratively by the Pharmacy and facility staff to ensure the following objectives were met; medications were administered correctly based on supply availability, medications availability, match of the medication blister pack/medication container to the physician orders, proper documentation, and medications that were revised previous orders were discontinued. Any issues identified were immediately corrected by the auditing nurse and communicated to the DON for review. b. On 1/5/2025, one on one education was provided to the Consulting Pharmacist ([CP] a licensed pharmacist who provides expert advice on the safe use and administration of medication), by the Pharmacy Regional Director of Operations (PRD). The session focused on the CP's role in conducting monthly drug regimen reviews for residents receiving anticoagulant medications. The key topics included the importance of monitoring medication administration times, critical lab values, and the pharmacist's collaborative role as part of the Interdisciplinary Team ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals. c. On 1/5/2025, the Pharmacy Consultant conducted a Drug Regimen Review for 23 current residents who were receiving anticoagulant medication. Recommendations were communicated to the resident's physicians by the facility nursing staff and addressed accordingly. d. On 1/4/2025, a facility wide audit was conducted by the facility nursing staff for all residents utilizing the Anticoagulant Audit tool to ensure current residents receiving anticoagulant medication had orders to monitor for signs and symptoms (s/s) of bleeding every shift such as but not limited to: bleeding, discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy (a state of being drowsy and dull, listless, and unenergetic, indifferent and lazy, sluggish and inactive), bruising, sudden changes in mental status and/or vital signs (v/s), shortness of breath (SOB), or nose bleeds. The audit identified all current residents receiving anticoagulant therapy had routine monitoring of anticoagulant side effects. e. On 1/4/2025, a facility wide audit was conducted by the nursing staff to ensure proper administration of anticoagulant medications utilizing the Anticoagulant Audit tool The audit confirmed that all current residents who were prescribed anticoagulant medications were accurately identified, and no other residents were receiving those medications inappropriately. f. On 1/4/2025, the Assistant Regional Director of Clinical Services conducted a thorough chart review for 23 residents currently receiving anticoagulant medications. The review was undertaken to ensure the accuracy of medication orders, accurate monitoring of side effects with recommended frequency and to verify there were no instances of incorrect duplicate medications. g. On 1/4/2025 an in-service was initiated to licensed nurses by the DON focusing on the Anticoagulation Therapy Clinical Protocol including Warfarin's dosage, side-effects, significance of laboratory tests, and International Normalized Ratio ([INR] a blood test that measures how long it takes for blood to clot) therapeutic levels (level of medication in the blood to achieve its desired effect). h. On 1/4/2025, the DON initiated an in-service for licensed nurses to address key medication management objectives. The training aimed to ensure the following: medications were administered correctly based on the available supply, availability of medication was verified, the medication blister packs or containers matched physician orders, proper documentation was maintained, and any medication changes were accompanied by the discontinuation of previous orders. The expected completion date for the in-service is January 5, 2025. Nurses who were unable to attend the session were instructed to report to the DON/designee during their next scheduled shift to receive the in-service. 1. On 1/4/2025, the DON initiated an in-service for licensed nurses focused on ensuring the accuracy of medication orders, proper monitoring of side effects at the recommended frequency, and verifying the absence of incorrect or duplicate medications. The in-service is expected to be completed by 1/5/2025. Nurses unable to attend the in-service were instructed to report to the DON/designee during their next scheduled shift to receive the in-service. j. On 1/4/2025, an in-service was provided initiated to licensed nurses by DON regarding policy and procedure on Medication Administration to ensure medications are administered per physician's order, orders are clarified if not available/not matching with supply at hand, and medications that were changed and have ongoing previous orders are clarified and discontinued. k. The Medical Director (MD) was notified of the IJ on 1/4/2025 at 6:45pm by the ADM. l. An Ad Hoc (when necessary or needed) Quality Assessment and Assurance ([QA&A] a group that ensures the quality of care and life in a facility by identifying and fixing quality issues) Committee meeting was scheduled for 1/5/2025, to discuss the IJRP. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of Afib. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 11/10/2024, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity) on facility staff to complete his activities of daily of living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's undated Care Plan, the Care Plan indicated Resident 1 was at risk for bleeding and bruising secondary to anticoagulant therapy related to the use of Warfarin. The Care Plan indicated labs should be completed as ordered and abnormal results should be reported to the physician. During a review of Resident 1's Physician's Order dated 11/5/2024, the Physician's order indicated Resident 1's Prothrombin ([PT] a factor in the blood that helps it clot properly)/INR was to be drawn on 11/7/2024 one time only. During a review of Resident 1's Physician's Order Summary Report dated 11/7/2024, the Physician's Order Summary Report indicated to administer Warfarin 4.5 milligrams ([mg] unit of measurement) one time a day (9 a.m.) for Afib. During a review of Resident 1's Physician Order dated 11/7/2024, the Physician order indicated to draw Resident 1's INR on 11/10/2024. During a review of Resident 1's laboratory results dated [DATE], the Laboratory results indicated Resident 1's INR was 4.27 (INR range 2.0-3.0) and was flagged as critical. During a review of Resident 1's Change in Condition (COC) Note dated 11/13/2024, the COC note indicated Resident 1's INR was reported as 4.27 to Resident 1's physician, who ordered Vitamin K (a vitamin that plays a role in helping blood clot) 10 mg subcutaneous (beneath the skin) injection one time only, hold warfarin dose for two days, and repeat the INR test on 11/14/2024. During a review of the Laboratory Services Patient Care Log, the Laboratory Services Log indicated Resident 1 refused to have his blood drawn for his INR level on 11/14/2024 and 11/15/2024. During a review of Resident 1's laboratory results dated [DATE], the Laboratory results indicated Resident 1's INR was 1.18 and was flagged as abnormal (below the INR normal range of 2.0-3.0). During a review of Resident 1's Physician's Order Summary Report dated 11/2024, the Physician's Order Summary Report indicated the following: 1. On 11/19/2024 - Administer Warfarin 4.5 mg in the afternoon every Tuesday, Thursday, and Saturday for Afib, monitor for s/s of bleeding. 2. On 11/19/2024 - Resident 1 may have PT and INR levels drawn every Tuesday and Thursday. 3. On 11/20/2024 - Administer Warfarin 4 mg, give one tablet in the afternoon every Monday, Wednesday, Friday, and Sunday for Afib, monitor for s/s of bleeding. During a review of Resident 1's laboratory results dated [DATE], the Laboratory results indicated Resident 1's INR was 1.12 and was flagged as abnormal. During a review of Resident 1's Nursing Note, dated 11/22/2024 and timed at 8:59 p.m., the Nursing Note indicated Resident 1's laboratory results dated [DATE] were sent to Resident 1's physician. The Nursing Note indicated there was no response from the physician. During a review of Resident 1's Nursing Note dated 11/23/2024 and timed at 7:41 a.m., the Nursing Note indicated the facility refaxed Resident 1's INR results to Resident 1's Physician. The Nursing Note indicated there was no new order, the facility staff endorsed this to the next shift. During a review of Resident 1's Medication Administration Record (MAR) dated 11/2024, the MAR indicated Resident 1's administration of Warfarin as follows: The 9 a.m., dose of Warfarin should have been discontinued, per Resident 1's Physician's NP. 1. On 11/21/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m. and 5 p.m. (a total of 9 mg). 2. On 11/22/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 3. On 11/23/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 5 p.m. (a total of 9 mg). 4. On 11/25/2024 Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 5. On 11/29/2024 Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 6. On 11/30/2024 Warfarin 4.5 mg was administered to Resident 1 at 9 a.m. and 5 p.m. (a total of 9 mg). During a review of Resident 1's laboratory results dated [DATE], the Laboratory results indicated Resident 1's INR was 6.19 and was flagged as critical. During a review of Resident 1's Progress Note dated 12/2/2024, and timed at 9:38 p.m., the Progress Note indicated Resident 1's INR results of 6.19 were received and sent to Resident 1's physician and the facility was awaiting orders. Resident 1's lab results and the physician's pending response were endorsed to the next shift. There was no physician response. During a review of Resident 1's laboratory results dated [DATE] and timed at 6:58 p.m., the Laboratory results indicated Resident 1's INR was 5.83 and was flagged as critical. During a review of Resident 1's Progress Note dated 12/6/2024 and timed at 4:35 a.m., the Progress Note indicated Resident 1's INR results of 5.83 was relayed to Resident 1's physician, and the staff were waiting for a response. During a review of Resident 1's MAR dated 12/2024, the MAR indicated Warfarin was administered to Resident 1 as follows: The 9 a.m., dose of Warfarin should have been discontinued, per Resident 1's Physician's NP. 1. On 12/1/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg of Warfarin was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 2. On 12/2/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg of Warfarin was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 3. On 12/9/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg of Warfarin was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 4. On 12/10/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 5 p.m. (a total of 9 mg). During a review of Resident 1's Physician's Orders dated 12/11/2024, the Physician's Orders indicated to discontinue administration of Warfarin. During a review of the Resident 1's Physician's Order dated 12/13/2024, the Physician's Order indicated to administer Eliquis (an oral anticoagulant that helps prevent and treat blood clots) 5 mg two times a day for DVT ([deep vein thrombosis] occurs when a blood clot forms in one or more of the deep veins in the body, usually in the legs) prophylaxis (preventative treatment against disease). During a review of Resident 1's MAR dated 12/2024, the MAR indicated Resident 1 received Eliquis as ordered from 12/13/2024 thru 12/27/2024. During a review of Resident 1's Nurse's Note dated 12/27/2024, the Nurse's Note indicated Certified Nursing Assistant 1 (CNA 1) observed Resident 1 sitting in a wheelchair, not talking. The Nurse's Note indicated Resident 1 was assessed and 911 emergency services was called. The Nurse's Note indicated Resident 1 was transferred to the GACH for further intervention and assessment. During a review of Resident 1's Physician's Orders dated 12/27/2024, the Physician's Orders indicated to transfer Resident 1 to the nearest GACH via 911 due to unresponsiveness. During a review of the GACH's Emergency Physician's note dated 12/27/2024, the Emergency Physician's note indicated Resident 1 was brought to the GACH via ambulance with a chief complaint of a SDH that measured 12 millimeters ([mm] a unit of measurement). The Emergency Physician's note indicated Resident 1 was intubated and administered Andexxa for reversal of Eliquis. During an interview on 1/2/2025 at 2:04 p.m., and a subsequent interview on 1/3/2025 at 12:15 p.m., Licensed Vocational Nurse (LVN ) 1 stated Resident 1 received multiple doses of Warfarin that overlapped beginning on 11/19/2024. LVN 1 stated when Resident 1's laboratory results indicated his INR level was critically high on 12/2/2024, the results were sent to the physician but there was no follow up by facility's staff when Resident 1's physician did not respond to the fax. LVN 1 stated the staff should have followed up with the physician to determine if the laboratory results were received because the INR values were critically high, and Resident 1 was at risk for bleeding. During an interview on 1/2/2025 at 4:18 p.m., LVN 2 stated all lab results should be reported to the physician and a response from the physician was expected by the end of the shift. LVN 2 stated, if there was no response from the physician by the end of the shift, the lab results should be reported to the MD. During an interview on 1/2/2025 at 4:41 p.m., the NP stated when she revised the Warfarin order to indicate it should be administered to Resident 1 on alternating days of the week (11/19/2024), she instructed LVN 2 to discontinue the order for Warfarin 4.5 mg daily. The NP stated she was not aware Warfarin 4.5 mg daily order was still active. The NP stated Warfarin had a very narrow therapeutic range and Resident 1's INR level could be affected if Warfarin was not administered as ordered and closely monitored. During an interview on 1/4/2025 at 1:18 p.m., the MD stated he had no knowledge that Resident 1's physician had not responded to a report of critical INR levels and was only aware of Resident 1's condition on 12/30/2024, when the GACH reported that Resident 1 sustained an SDH. The MD stated Warfarin was a complicated medication to administer because it involved constant monitoring, blood tests, dose adjustments, and daily monitoring for side effects such as bleeding and bruising. The MD stated if a resident's INR was low, there was a risk that the resident could develop blood clots and if the INR was too high, there was a risk that the resident could develop bleeding. During an interview on 1/4/2025 at 2:08 p.m., the DON stated when administering Warfarin, INR levels should be monitored because if the levels were out of the therapeutic range, residents could be at risk for bleeding or clotting. The DON stated licensed staff should report abnormal lab results to the physician within 24 hours, and critical lab results should be reported to the physician within 4 hours. The DON stated if there was no response from the physician, the MD should be contacted. The DON stated Resident 1's Warfarin 4.5 mg daily order should have been discontinued on 11/19/2024 when the revised Warfarin order was received. During an interview on 1/4/2025 at 2:47 p.m., the ADM stated the licensed nurses documented they administered Warfarin 4.5 mg daily (9 a.m.) in error and they did not administer Warfarin to Resident 1, so Resident 1 could not have received extra doses of Warfarin. During a review of the facility's Policy and Procedure (P/P), titled Administering Medications dated 2001, the P/P indicated medications were administered in accordance with the prescriber's orders, including any required time frame. During a review of the facility's P/P titled Critical Labs of Tests and Diagnostic Procedures-Reporting of dated 1/2/2024, the P/P indicated the response including any new orders/interventions related to the critical results of tests and diagnostic procedures must occur within four (4) hours of reporting of results. The P/P indicated if the Licensed Independent Practitioner ([LIP] a health care provider who is legally permitted to provide care without direct supervision) and or clinician responsible for the resident is not available and that LIP's alternate cannot be reached or is unavailable, the medical director under which the LIP is privileged shall be notified of the critical result.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, a resident, who lacked the capacity to understand and make decisions, was not discharged from the facility against medical advice ([AMA] choosing to leave the hospital before the treating physician recommends discharge) for one of 141 residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was competent to make a decision to leave the facility and sign out AMA. 2. Ensure Resident 1 had a valid Out On Pass ([OOP] temporary permission given to a resident to leave the facility for a specified amount of time) and AMA order on 4/19/2024, the day Resident 1 wanted to leave. 3. Assess Resident 1's ability to understand his medication regimen in order to safely take his prescribed Haldol (medication for treating schizophrenia [a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others]) for paranoid delusion (profound fear and anxiety [Intense, excessive, and persistent worry and fear about everyday situations] along with the loss of the ability to tell what's real and what's not real) before providing Resident 1 with a total of 41 tablets of Haldol 10 milligrams ([ mg] a unit of measurement of weight) at the time of discharge AMA on 4/19/2024. 4. Ensure there was a referral (preadmission arrangements) made to the shelter before allowing Resident 1 to leave the facility AMA, placing him into a ride-share (a service or network through which ride-sharing trips are arranged) vehicle and sending him to the shelter. 5. Prior to discharge, notify Resident 1's Responsible Party (RP) that Resident 1 was going to sign out of the facility AMA and would be going to a shelter on 4/19/2024. These deficient practices resulted in Resident 1 leaving the facility without prior arrangements, to the shelter of his choice. Resident 1 was not accepted by the shelter upon Resident 1's arrival to the shelter and is now missing. Resident 1's whereabouts are currently unknown. These failures placed Resident 1 at a high risk for exposure to harsh environmental conditions, possible motor vehicle accidents, and medical complications due to taking antipsychotic medications (medications work by altering brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disordered thinking) inappropriately, or overdosing (too much of a drug taken or given at one time), malnutrition (lack of proper nutrition), heart failure, chronic kidney disease complications, dehydration (body doesn't have as much fluid as it needs), and possible death. On 4/26/2024 at 3:02 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation caused, or was likely to cause serious injury, harm, impairment, or death to a resident) related to failure to safely discharge a psychiatric resident (Resident 1) with a 20-days supply of medications without assessing the resident's ability to self-administer his prescribed antipsychotic (medication that affects the brain) medication was called in the presence of the Administrator, the Director of Nursing (DON) and two outside Resource Registered Nurses. The facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed on 5/1/2024 at 8:41 a.m., in the presence of the temporary manager and Assistant Director of Nursing (ADON). The IJRP included the following: 1.On 4/26/2024 the Medical Director reviewed and approved the updated changes to the Policy and Procedure for Out on Pass, to include, residents' discharge, and measures to take if a resident is out on pass and refuses to return to the facility on April 27, 2024. 2.The Medical Director approved the updated changes to the Policy and Procedure for Discharging a Resident Without a Physician's approval (Against Medical Advice-AMA) on April 30, 2024. 3.The facility began In-service (education) training for Social Services and Licensed Nurses on Policies and Procedures for the following; Out On Pass, Safe Discharge AMA, beginning on April 30, 2024, by the Director of Nursing/Designee to be completed when employees return to work according to their schedule. 4.At the time of admission, the physician will make the decision regarding the capacity (ability of the resident to make decisions). The results of the capacity determination will identify if the resident is responsible for decision making. The facility will ascertain if the resident has a responsible party or not, prior to admission. A new policy and procedure will be implemented for capacity. The admission Packet includes the resident's capacity for making decisions and the responsible party who signs on behalf of the resident. 5.Physicians will be asked to reassess their residents' capacity status as needed. 6.The Out On Pass Policy was updated to state that if a resident is refusing to return to the facility from out on pass activity, residents' responsible party, primary MD and Psychiatrist will be notified. 7.Every effort will be made by the staff to assist the resident to return to the facility. They will have a conversation with the resident on why they do not want to return to the facility. Social Services, the Administrator and Director of Nursing will be notified. 8.If the resident is suspected to be a danger to self or others appropriate authorities will be notified to determine if a 5150 hold (an involuntary hold of a person who is deemed to be a danger to themself, a danger to others, or gravely disabled, as a result of a mental disorder, for psychiatric evaluation, assessment, and/or treatment) will be placed and the resident will be transferred to a psychiatric (mental illness) acute (sudden) care hospital for further evaluation. If the resident is determined not to be a danger to self or others, he/she will be educated on the risks and benefits of leaving the facility against medical advice (AMA). As, it is the Residents Right to leave the facility AMA, the staff will follow guidelines of AMA policy and procedure. 9. The facility began In-service training for Social Services staff and Licensed Nurses on Policies and Procedures for the following; Out On Pass, Safe Discharge AMA, beginning on April 30, 2024, by the Director of Nursing/Designee to be completed as employees return to work according to their schedule. 10. A facility wide Capacity/Responsible Party (a person that would make decisions for Residents that cannot safely make their own decisions) audit was conducted on April 26, 2024, to determine if there were any other residents found to have unknown responsibility status. At this time all residents have capacity identified and the Responsible Party identified. An audit was conducted by Social Services for other residents if they have fluctuating capacity (a person whose decision-making ability varies). 18 residents were identified with fluctuating capacity. Out of the 18 identified, six residents did not have capacity status (to make decisions); they were referred to the public guardian (a public official that is responsible for the care of individuals who are no longer able to make decisions or care for themselves). Four of those are still being processed and two have been processed and will move forward through the public guardian appointing process. Their physicians will be notified to reassess if they have capacity to make decisions on a quarterly basis. 11. The care plans for those residents with fluctuating or no capacity will be revised to reflect the residents' capacity by Friday May 3rd, 2024. 12.The resident's physician will be notified of the request for AMA discharge. The physician will determine the need to release the resident AMA with or without medications. If the resident does not have capacity, they will not be sent with medications unless there is a Responsible Party present to take responsibility for the medication. If the resident is released with medications and it is expected that they will self-administer those medications, an assessment of the resident, will be conducted by the nursing staff to assure they have the ability to accurately self-administer those medications. 13. Any resident who discharges AMA will be trained on self- administration of medications before they leave the facility. A Discharge Summary will be given to the resident with the directions for taking the medications. The resident will sign the Discharge Summary indicating that they have received self-medication administration training and understand the risks and benefits of taking the medications correctly. The facility staff will also sign the Discharge Summary, witnessing the resident's signature. The progress note will include all steps taken to foster the resident's highest practicable wellbeing because of the resident going out of the facility AMA. 14. Licensed nurses will be in-serviced on the policy and procedure for self-administration of medications, training on self-administration of medications and disposition of remaining medications beginning on April 30, 2024, by the Director of Nursing/Designee using the teach back method by May 3rd, 2024, or upon their next scheduled shift. Medications not given to the resident upon AMA discharge will be disposed of according to State and Federal regulations. 15. The facility will ensure that any resident who leaves the facility AMA is given the best chance possible of succeeding outside of the facility by notifying the receiving facility, including shelters, the resident has requested to move to and that the shelter would be able to meet their needs. Social Services and licensed nurses will be in-serviced on notifying the intended location, assuring availability and capability to meet resident needs. Social Services will be responsible for notifying any shelter of the resident's request. Social Services will be in-serviced on Discharging a Resident Without a Physician's approval (Against Medical Advice-AMA) beginning on April 30, 2024, by the Director of Nursing/Designee to be completed by May 3rd, 2024. 16. Social Services will be responsible for follow-up on any resident who went AMA to see if they arrived at their intended location, where practicable. Social Services and Licensed nurses will be in-serviced beginning on April 30, 2024, by the Director of Nursing/Designee to be completed by May 3rd, 2024. 17. The facility has begun an audit of all residents with the inability to make decisions. Conservators (a person who looks after and is legally responsible for someone who is unable to manage their own affairs)/Responsible Party will be notified if one of their residents tries to seek a discharge (AMA). That is the conservator's/ Responsible Party's responsibility to make that decision. The facility will follow the conservators' decisions. The facility will follow its' policies and procedures for AMA Discharge and notification of Responsible Parties pending AMA discharge. 18. Action Plans to manage reoccurrences of leaving the facility against medical advice (AMA) will be implemented in the Quality Assurance and Performance Improvement Committee ([QAPI] a facility committee consisting of department heads, the medical director, physicians and key staff that identifies system failures by data gathering and analysis and implements measure to improve the overall quality of life and quality of care and services delivered to nursing home residents.) on April 29, 2024. Findings: During a review of Resident 1's General Acute Care Hospital (GACH 1) Behavioral Health Progress Note dated 2/25/2024, the Behavioral Health Progress Note indicated, Resident 1 exhibited signs of paranoia (unjustified suspicion and mistrust of other people and/or their actions) and was brought to GACH 1 from a jail, with disorganized thoughts, and poor insight. The Behavioral Health Progress Note indicated Resident 1 was a poor historian, unkempt (having an untidy appearance), malodorous (an unpleasant or offensive odor), and with disorganized speech, and on a 5150 hold. The Behavioral Health Progress Note indicated Resident 1 had two recent psychiatric evaluations in the past two months and ongoing intractable (not easily controlled or directed) psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). During a review of Resident 1's Order Summary Report (OSR), from the SNF, dated 4/24/2024, the OSR indicated, to admit Resident 1 to the facility on 3/4/2024. During a review of Resident 1's Skilled Nursing Facility (SNF) admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paranoid schizophrenia, congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), myocardial infarction ([heart attack] when the heart muscle begins to die because it isn't getting enough blood flow), anxiety disorder, obstructive sleep apnea (a disorder in which a person frequently stops breathing during his or her sleep), and essential hypertension ([HTN] abnormally high blood pressure that's not the result of a medical condition). During a review of Resident 1's History and Physical (H&P), dated 3/15/2024, the H&P indicated, Resident 1 had a fluctuating capacity to make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/20/2024, the MDS indicated Resident 1 required assistance (helper does all of the effort) from one staff for toilet use, hygiene, lower body dressing, putting on/taking off footwear, bed mobility, and transfers. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) from one staff for personal hygiene, moderate assistance (helper does less than half the effort) from one staff for upper body dressing, oral hygiene, rolling from left to right, and supervised touch assistance (helper provides verbal cues/touching/steadying/contact guard assistance) from one staff for eating and showering. During a review of Resident 1's Change in Condition Evaluation/Change of Condition (COC) dated 3/4/2024 and timed at 6 p.m., the COC indicated, upon admission Resident 1 was verbally aggressive and attempted to strike at staff and was requesting to leave the facility. The COC indicated a physician's order was obtained to transfer Resident 1 on a 5150 hold to GACH 2 for further evaluation. During a review of Resident 1's Order Summary Report dated 4/24/2024, the OSR indicated, a physician's order dated 3/4/2024 to transfer Resident 1 to GACH 2 for evaluation and treatment related to paranoid delusion. During a review of Resident 1's GACH 2 H&P, dated 3/5/2024, the H&P indicated, Resident 1 was brought to GACH 2's emergency department (ED) on a 5150 hold for further treatment, after developing acute agitation and striking out at staff members. During a review of Resident 1's Order Summary Report, from the SNF, dated 4/24/2024, the Order Summary Report indicated, a physician's order dated 3/13/2024 to admit Resident 1 to the facility. During a review of Resident 1's Summary of Neurobehavioral and Cognitive (an assessment of a wide range of mental functions, including behavior, to see how well the brain works) consult, dated 4/12/2024, the Neurobehavioral Summary indicated Resident 1 was partially oriented (he did not know the month and the year), with partial awareness of his location, and was unable to express himself verbally. The Summary Neurobehavioral Consult note indicated Resident 1 had difficulty making complex decisions and the help of a designated decision-maker was recommended. During a review of Resident 1's Interdisciplinary Team [([IDT] - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the resident) Conference Notes, dated 3/13/2024, the IDT Conference Notes indicated, Resident 1 was to remain in the facility at this time. The IDT Conference Notes indicated Resident 1 wished to transition back to community and he would be referred to ancillary (supportive or diagnostic measures that supplement and support a primary healthcare provider in treating a patient) services and psychology for follow up. During a review of Resident 1's Order Summary Report dated, 4/24/2024, the Order Summary Report indicated a physicians' order dated 3/13/2024 to give Haldol 10 mg, one tablet by mouth, two times a day for schizophrenia manifested by paranoid delusions. During a review of Resident 1's Order Summary Report dated, 4/24/2024, the Order Summary Report indicated a physician's order dated 3/31/2024 to give Ativan one mg, one tablet by mouth, every six hours as needed for anxiety disorder for 14 days as manifested by the inability to relax. During a review of Resident 1's Medication Administration Record (MAR), the MAR indicated Resident 1 received Ativan 1 mg for anxiety on the following days: 1. 3/15/2024 at 4:15 p.m. 2. 3/16/2024 at 6:00 p.m. 3. 3/17/2024 at 9:56 p.m. and 6:00 p.m. 4. 3/18/2024 at 10:01a.m. and 6:05 p.m. 5. 3/20/2024 at 5:15 p.m. 6. 3/21/2024 at 5:20 p.m. 7. 3/22/2024 at 5:30 p.m. 8. 3/23/2024 at 6:00 p.m. 9. 3/24/2024 at 5:03 p.m. 10. 3/27/2024 at 5:00 p.m. 10. 4/2/2024 at 4:27 p.m. 11. 4/5/2024 at 4:27 p.m. 12. 4/11/2024 at 9:28 p.m. During a review of Resident 1's Self-Administration of Medication observation form, dated 3/13/2024, the Self-Administration of Medication Observation form indicated, Resident 1 did not want to self-administer medication. During a review of Resident 1's OOP order, created by the Assistant Director of Nurses (ADON) on 4/19/2024 and a back -date (to date the order earlier than it was actually given) of 3/20/2024, the OOP order indicated Resident 1 could leave the facility on a therapeutic pass, in the company of a facility staff member for safety and supervision. During a review of Resident 1's AMA order, created by the Director of Nursing (DON) on 4/22/2024 (back-dated three days after Resident 1 left the facility AMA), the AMA order indicated Resident 1 may be discharged from the facility AMA on 4/19/2024. During a review of Resident 1's clinical record, the clinical record indicated there was no OOP order on 4/19/2024 (the day Resident 1 was accompanied by facility staff OOP). During a review of Resident 1's Ride-Share receipt, dated 4/19/2024, the Ride Share receipt indicated Resident 1 was picked up at the bus stop near the sidewalk of the fast-food restaurant at 1:52 p.m., and arrived at the destination (shelter) at 2:10 p.m. During a review of Resident 1's Social Service Notes (SSN), dated 4/23/2024 and timed 9:50 p.m., the SSN indicated, the Social Service Director (SSD) contacted the shelter Resident 1 was sent to, and spoke to the shelter coordinator. The SSN indicated the shelter coordinator stated there was no record of Resident 1 checking in to the shelter as of 4/19/2024. During an interview on 4/23/2024, at 3:40 p.m., the SSD stated he was not informed that Resident 1 signed out of the facility AMA until after the incident. The SSD stated, many shelters required a referral due to limited space and had he known Resident 1 was being discharged from the facility he could have assisted him to find a place to transfer to. The SSD stated he should have followed up with the shelter Resident 1 was transferred to, to make sure Resident 1 arrived and was admitted there. The SSD stated, some shelters could assist residents with limited medical care, he did not know if the shelter that Resident 1 was sent to could accommodate Resident 1's medical needs or if they would administer Resident 1's medications. The SSD stated there was no discharge plan for Resident 1 because Resident 1 had been transferred in and out of the facility to the GACH on a 5150 hold because of behavioral issues. During an interview on 4/23/2024, at 4:03 p.m., Licensed Vocational Nurse (LVN 1) stated Resident 1 was usually quiet and cooperative, but there were times when he became verbally aggressive and paranoid. LVN 1 stated that was why Resident 1 was on routine (scheduled) Haldol and as needed Ativan. LVN 1 stated, Resident 1 had a history of noncompliance with taking his medication, and his daily medications were administered by the licensed nurses at the facility and Resident 1 never expressed a desire to self-administer his medications. During an interview on 4/23/2024, at 4:41 p.m., Registered Nurse Supervisor 1 (RNS 1) stated, Resident 1 was transferred to GACH 2 on 3/4/2024 because of aggressive behavior and was readmitted to the facility on [DATE] to a secured unit (a unit in a nursing home that restricts a resident's ability to freely move in and out of ) for behavior monitoring, but was transferred from the secured unit to a skilled nursing unit (non-secured unit with less intense monitoring for behavior issues and focuses on medical and rehabilitation treatment) on 4/16/2024. RNS 1 stated Resident 1 had a fluctuating mental capacity, and he might not understand the risks of AMA and stated she was not sure if Resident 1 was safe to leave the facility AMA. During a telephone interview on 4/24/2024, at 8:46 a.m., Family Member (FM 1) stated, no one at the facility called to notify her that Resident 1 wanted to leave the facility or that Resident 1 left the facility AMA. FM 1 stated, Resident 1 was not in his right mind, and she could not understand how the facility let Resident 1 leave the facility even if he wanted to go, or how the sheriff, who were not medical professionals, could assess someone's mental capacity. During an interview on 4/24/2024, at 10:49 a.m., the ADON stated he took Resident 1 OOP on 4/19/2024 to a fast-food restaurant across the street from the facility. The ADON stated, after Resident 1 ordered and got some food Resident 1 started walking outside of the fast-food restaurant and refused to go back to the facility. The ADON stated, he notified the DON, the Administrator (ADM), and a Registered Nurse that worked with a temporary management team (TMRN 1) that was contracted with and stationed at the facility. The ADON stated TMRN 1 instructed him to call the local sheriff department to evaluate Resident 1 for a 5150 hold, to notify Resident 1's psychiatric (Psychiatrists are trained physicians who specialize in evaluating, diagnosing and treating mental disorders) doctor and follow whatever the psychiatrist asked him to do. During an interview on 4/24/2024, at 11:00 a.m., the ADON stated, he spoke to Resident 1's psychiatrist via the telephone and received an order from him to sign Resident 1 out AMA if the sheriff did not place Resident 1 on a 5150 hold. The ADON stated, the sheriff reported that Resident 1 did not meet the criteria for a 5150 hold, so he (ADON) believed Resident 1 was safe to be discharged AMA, as instructed by Resident 1's psychiatrist. The ADON stated, there was an order in place on 4/16/2024 which indicated Resident 1 could go out to the courtyard (which was an outside common area on facility grounds surrounded by the facility buildings) for therapeutic services. The ADON stated, the fast-food restaurant was across the street from the facility, so he took Resident 1 to the fast-food restaurant. The ADON stated he did not assess Resident 1's behavior prior to taking him across the street to the fast-food restaurant to determine if it was safe for him to go OOP that day. During an interview on 4/24/2024, at 11:15 a.m., the ADON stated, he did not know the shelter (Resident 1 chose to go to) required a referral and thought anyone could just walk in and get accepted, nor did he follow up with the shelter to see if Resident 1 arrived there safely. The ADON stated he should have consulted with the SSD for Resident 1's placement, but he did not, and he did not call FM 1 or FM 2 during the process prior to Resident 1 leaving AMA, he only left a message with FM 1 after Resident 1 had already left the facility AMA. The ADON stated he did not notify FM 1 or FM 2 that Resident 1 was not accepted at the shelter or that Resident 1's current location was unknown because he did not follow up with the shelter and did not know Resident 1 was not there. During a telephone interview on 4/24/2024, at 11:29 a.m., Resident 1's psychiatrist stated, he did not think Resident 1 had the capacity to make decisions, but it did not matter whether he had capacity or not, it was his right to leave AMA if the sheriff did not place him on a 5150 hold. Resident 1's psychiatrist stated he told the facility to give Resident 1 a 10 day-supply of Haldol 10 mg tablets because he did not want Resident 1's medication to be stopped abruptly to prevent relapse (reoccurrence) of psychosis (a severe mental condition in which thoughts and emotions are so affected and contact is lost with reality). Resident 1's psychiatrist stated there was the risk of overdose if Resident 1 took to many Haldol tablets, which could lead to arrythmia (a condition in which the heart beats with an irregular or abnormal rhythm which may increase the risk for a serious heart condition). During an interview on 4/24/2024, at 11:44 a.m., LVN 3 stated, she received a call from the ADON asking her to bring an AMA form and all Resident 1's medications to the sidewalk near the fast-food restaurant. LVN 3 stated she gave all of Resident 1's medications and AMA form for Resident 1 to sign, to the ADON. During a telephone interview on 4/24/2024, at 11:56 a.m., the Referral Agent (RA) at the shelter Resident 1 was sent to stated, Resident 1 showed up at the shelter on 4/19/2024, but they could not admit him because he did not have a referral from the facility, he came from, prior to arriving at the shelter and they only accept walk-ins if they had enough beds available. The RA stated Resident 1 came in after 2 p.m., when available beds had already been assigned by that time. The RA stated Resident 1 left the shelter after he was told he could not check in and he (RA) did not know where Resident 1 went or his whereabouts. During an interview on 4/24/2024, at 1:48 p.m., the DON stated he was not sure if there was an OOP order for Resident 1 prior to 4/19/2024 and he did not create an AMA order until after Resident 1 left the facility (4/22/2024) because he got busy and forgot to do it. The DON stated, he received a call from the ADON on 4/19/2024 regarding Resident 1's refusal to come back to the facility. The DON stated he went with the ADM to the sidewalk of the fast-food restaurant to assist the ADON with discharging Resident 1. The DON stated, he gave Resident 1 a total of 41 tablets of Haldol 10 mg which was a 10-day supply. (According to the Resident 1's physicians' order dated 3/13/2024 to administer Haldol 10 mg, one tablet by mouth, two times a day for schizophrenia manifested by paranoid delusions, the DON gave Resident 1 a 20-day supply of Haldol). During an interview on 4/24/2024, at 2:00 p.m., the DON stated, he did not check Resident 1's Self-Administration of Medication Assessment nor did he give Resident 1 written instructions related to his Haldol. The DON stated Resident 1 responded OK when he showed him the instructions on the Haldol package on how to take his medication. The DON stated, he forgot to document Resident 1's medication order to give Resident 1 a 10-day supply of Haldol on the eMAR (a digital version of the MAR), or in Resident 1's Medication Disposition Log (any medication dispositioned or supplied to the resident should be documented on medication disposition log for record keeping). During an interview on 4/24/2024, at 2:05 p.m., the DON stated, he did not know if anyone at the shelter would supervise Resident 1's Haldol self-administration. The DON stated, Resident 1 could be at risk for overdose if he took to many of the Haldol tablets at one time or his symptoms could worsen if Resident 1 did not take the Haldol. The DON stated, it was not safe to discharge Resident 1 but Resident 1 was the one who made the decision to leave the facility AMA. The DON stated, he did not know the shelter required a referral from the facility for Resident 1 to be admitted , had he known that he would have called the shelter with a referral to have Resident 1 admitted . The DON stated, he was not familiar with the facility's AMA policy for residents with mental illness. During a telephone interview on 4/24/2024, at 6:25 p.m., FM 1 stated, Resident 1 had been suffering from mental illness and other medical conditions for over 23 years and had been in and out of hospitals all of those years for his behaviors. FM 1 stated she received a voice-message from facility staff during the evening of 4/19/2024, when she called back the next morning (4/20/2024) the facility nurse told her Resident 1 left the faciity on 4/19/2024 because he did not want to stay at the facility. FM 1 stated, the facility did not tell her Resident 1 was not accepted to the shelter he was sent to, and that his whereabouts were unknown. FM 1 stated she was scared that Resident 1 would harm himself or someone else, based on her previous experience with him, and she was worried about his safety. During an interview on 4/25/2024, at 4:42 p.m., the ADM stated, he received a call from the ADON that Resident 1 refused to come back to the facility while her and Resident 1 were OOP at a fast-food restaurant across the street from the facility. The ADM stated, they followed the instructions of Resident 1's psychiatrist and TMRN 1 to discharge Resident 1 AMA. The ADM stated, they could have done better, but the situation was very intense at that time, and they did not have all of Resident 1's previous psychiatric history. The ADM stated, they should have contacted the SSD to arrange placement for Resident 1 before discharging him AMA and they should have followed up with the shelter to see if Resident 1 was admitted . The ADM stated their policy was not very clear about the process and requirements for AMA. During a telephone interview on 4/27/2024, at 9:51 a.m., Resident 1's psychologist (a person who specializes in the treatment of mental, emotional, and behavioral disorders without prescribing medications) stated, he was not aware that Resident 1 was released from the facility AMA. Resident 1's psychologist stated Resident 1 could not make complex decisions and he was concerned Resident 1 would become noncompliant with his care and not take his medication as he had done in the past, which would make his condition worse. During a review of the facility's P&P titled, Transfer or Discharge, Emergency, revised 8/2018, the P&P indicated, should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will notify the resident's attending physician, notify the receiving facility that the transfer is being made, notify the representative (sponsor) or other family member. During a review of the facility's P&P titled, Discharging a Resident Without a Physician's Approval, revised 10/2022, the P&P indicated, if a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility will treat this situation similarly to refusal of care, and will discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location, document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed, document that despite being offered other options that could meet the resident's [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide supervision and follow the facility ' s policy and procedure titled, Safety and Supervision of Residents, to ensure one of three sampled residents (Resident 1) did not elope (leaving a secured institution without notice or permission) from a locked unit in the facility. The policy indicated the care team would determine the individuals ' assessed needs for the type and frequency of the resident ' s supervision. Resident 1 was admitted to the facility on [DATE] at 11:30 am., to a locked unit and discovered missing on 3/4/2023 at approximately 10: 45 pm. Resident 1 was in the facility for approximately 11 hours. According to licensed vocational nurse (LVN) 2, all new admissions are closely visually monitored for 72 hours to screen the residents ' behavior. As a result, Resident 1 eloped from the facility on 3/4/2023 and remains missing. This deficient practice resulted in Resident 1 leaving the facility with the potential of being exposed to severe environmental conditions including excessive cold, possible motor vehicle accident, medical complications including malnutrition (health problems that may arise due to lack of nutrients [substances found in food necessary for the body to function normally]), dehydration (abnormally low fluid levels in the body), stroke (injury to brain tissue caused by hypertension [abnormally high blood pressure] ) due to missing routine medications including high blood pressure medication, and mood stabilizer medication. On 3/8/2023 at 4:22 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was identified and called in the presence of Administrator (ADMIN) and the Director of Nursing (DON) due to the facility's failure to have a system in place to prevent a new admission, Resident 1, that was on 72 hour close monitoring, from eloping from the facility ' s locked unit. On 3/9/2023 at 3:56 p.m., the facility submitted an acceptable IJ removal plan (IJRP, interventions to immediately correct the deficient practices). After onsite verification of IJRP implementation, through observation, interviews, and record reviews, the IJ was removed on 3/9/2023 at 4:23 p.m., in the presence of the DON. The IJPR included the following immediate actions: a. In-Service of facility staff on 3/7/23 regarding: - Staff to be more vigilant when opening exit doors to ensure no residents within immediate surroundings, checking the door behind to ensure it is locked/engaged, and any unfamiliar individual not wearing uniforms/name badge will not be allowed to go through exit doors without verification or supervision. - Staff to wear name badges appropriately and should be visible while at workplace. - Licensed nurses will obtain a photograph of every new admission facility-wide in the absence of Activities staff. Activities staff will download pictures of new admissions the next business day. - Residents identified with moderate risk for elopement will be monitored visually, every 2 hours, through a Behavior Mapping Tool in Point of Care (electronic documenting system), under Certified Nurse Assistant (CNA) -Task. CNAs are to report to charge nurses in any new onset or increase episode of wandering behavior. - High risk residents will be monitored hourly utilizing Behavior Mapping Tool. CNAs are to report to charge nurses in any new onset or increased episodes of wandering behavior. - Each CNA is assigned to 9-10 residents all throughout the facility to care and monitor to ensure residents are supervised and kept safe. The director of nursing/ director of staff development will review staffing projections (staffing needs assessments) and adjustments will be made as appropriate for high demand/high acuity residents. b. All 4 identified exit doors throughout the facility will be monitored hourly for functionality to ensure exit doors are locking/engaging properly. These exit doors are entrances/exits that employees use as passageways to leave/enter the facility or move between units, namely: Palm Court and Palm Grove (locked unit). These four exit doors are identified as follows: Palm Court Main lobby, Palm Court after-hours entrance/exit door (behind Administrator ' s office), Palm Court East (passage going to Palm Grove/locked unit), and Palm Grove entrance/exit. c. Current staff including those from the registry, administration, dietary, housekeeping, rehab, etc. will be in-serviced (on items a. and b. above) by the director of nursing or designee, and no staff will be allowed to report to work assignments until in-service is completed. Facility will complete 100% staff in-service by 3/10/2023. Staff on per diem status, unavailable or on vacation will receive in-service training through the phone if able, until such will return to work then a face-to-face training will be done. d. During new hire orientation and annual performance evaluation, staff will receive training on facility ' s wandering/elopement policy and procedures, resident ' s safety, monitoring of resident ' s whereabouts and providing adequate supervision. The administrator will randomly review 5 employees' files monthly to audit evidence of training during the next 3 months. e. For pre-admission screening, DON will ensure elopement risk and residents with history of suicidal ideations ' documents are reviewed before a new admission is accepted. A plan will already be in place, discussed with the Interdisciplinary Team (IDT- each resident ' s health care team) if necessary, and communicated to nursing staff (including registry staff) before the resident is transferred to the facility. Any referral for new admission/readmission with active suicidal ideation will be denied placement until a clearance from psychiatrist is obtained. f. Any in-house resident experiencing suicidal ideation will be immediately placed on 1:1 monitoring until transfer to a more appropriate setting is done. g. The Environmental supervisor will check all windows, exit doors, emergency exits, perimeter fence and gates for proper functioning daily. Administrator will review log weekly for the next 3 months. h. Department heads will conduct exit door staff compliance checks to at least 10 random staff members weekly for 3 months to ensure staff entering or exiting locked doors are keeping residents safe and preventing them from eloping - any issues will be communicated to administrator or director of nursing for immediate resolution for the next 3 months. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility ' s locked unit on 3/4/2023 with diagnoses including paranoid schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real), hypertension, anxiety (Feeling nervous, restless or tense, having a sense of impending danger, or panic) and insomnia (sleep disorder that makes it difficult to sleep). During a review of Resident 1 ' s General Acute Care Hospital (GACH - where Resident 1 was transferred) Psychiatric Evaluation (PE) dated 2/7/2023, the PE indicated that Resident 1 had been expressing feelings of helplessness, hopelessness, worthlessness with suicidal thoughts with intent to walk in traffic or overdose. During a review of Resident 1 ' s elopement risk assessment (ERA) dated 3/04/2023, the ERA indicated Resident 1 scored 7 (score of 7 indicated the resident was a moderate risk for elopement). During a review of Resident 1's physician ' s order dated 3/4/2023, the physician ' s order indicated lisinopril (blood pressure medication) 10 milligrams ([mg] unit of measurement), 1 tablet by mouth one time day, divalproex sodium (mood stabilizer medication) 500mg to be given 3 times a day and risperidone (medication for schizoaffective [symptoms including the minds break from realty, and severe mood swings] disorder ) 2mg to be given twice a day manifested by paranoid schizophrenia. During a review of Resident 1 ' s Care plan (C/P) dated 3/4/2023. The C/P indicated Resident 1 was at risk for wandering/elopement with a score of 7- moderate risk. Goals set for Resident 1 indicated Resident 1 will not have episode of seeking exits, resident ' s safety will be maintained through the review date (next assessment date), 3/6/2023 and that the resident will not leave the facility unattended through the review date. Interventions included: clearly identify Residents ' room and bathroom to avoid going to other resident ' s bathroom, engage resident in purposeful activity to keep self-busy and monitor whereabouts closely. During a review of Resident 1 ' s Nursing Progress Note (NPN) dated 3/5/2023 at 2:39 a.m., the NPN indicated that at 10:45 p.m. (on 3/4/2023), Resident 1 was reported missing to the local sheriff department. During an interview on 3/7/2023 at 9:44 a.m., Certified Nursing Assistant (CNA) 3 stated CNAs are assigned an area (each) to monitor, the three areas are the east and west hallways and the patio (areas in the locked units with exits). CNA 3 stated monitoring was done due to the unpredictable behavior (exit seeking, altercations, or accidents) of the residents in the locked unit. During an interview on 3/7/2023 at 10:25 a.m., with the Maintenance Supervisor (MS), the MS stated the exit doors require at least 300-400 pounds of pressure to be opened and that they can be opened in event of emergency. The MS states that all the exit doors require a key to be opened and the only people that have keys are staff members. During an interview on 3/7/2023 at 12:21 p.m., with LVN 2, LVN 2 stated new admissions need to be closely monitored for 72 hours to screen the residents ' behavior and the result of monitoring needed to be documented. LVN 2 stated the purpose of monitoring new admissions was because residents in this (locked) unit can be aggressive and show exit seeking behavior because the residents are in a new and unfamiliar environment. During an interview on 3/7/2023 at 4:06 p.m., with Registered Nurse (RN) 2, RN 2 stated that the locked unit was fully staffed, a CNA was stationed in each hallway and patio, if a resident was able to leave the unit, staff should have been able to see the resident leave. RN 2 also stated there was no picture of Resident 1 in his medical record, and it would have helped identify Resident 1. During a phone interview on 3/7/2023 at 4:37 p.m., with LVN 1, LVN 1 stated Resident 1 was last seen around 8:30 p.m. on 3/4/2023, which was the last smoke break for the evening. LVN 1 stated that Resident 1 ' s elopement put him at risk for getting hurt, hit by a vehicle or can get sick from exposure to extreme weather. During an interview on 3/8/2023 at 9:30 a.m., with the admissions coordinator (AC), the AC stated the admissions staff and the nursing staff collaborated on which unit to place a new resident in. Factors in making that decision are age, medical history, and any other details that nursing receives during report. Resident 1 was placed in the locked unit due to him being young and the resident ' s suicidal history. During a concurrent observation and interview on 3/8/2023 at 1:17 p.m., CNA 4 was observed monitoring the exit door of the locked unit, CNA 4 stated someone should be watching the hallways and exit doors and we (CNAs) cannot leave the area unattended. CNA 4 stated if there was a need to leave an exit unattended, then the charge nurse needs to be notified or one of our colleagues (facility ' s staff). During a concurrent interview and record review on 3/8/2023 at 2:20 p.m., with the DON, the DON stated a staff member should be monitoring the patio, and the east and west hallways at all times. The document titled Nursing Staffing Assignment and Sign In dated for 3/4/2023 indicated that seven CNAs were on shift when Resident 1 eloped from the facility. The DON stated there was more than enough staff to monitor the unit and the staff weren ' t properly monitoring the exits. The DON stated that the safety of all residents is the responsibility of all staff members. According to the Accuweather forecast report for Artesia area from 03/04/2023 to 03/09/2023 https://www.accuweather.com/en/us/artesia/90701/march-weather/332029, the temperature was in the high 50 ' s degree Fahrenheit (°F, referring to temperature) to low 60 ' s °F during the day, and 30 ' s °F to mid 40 ' s °F during the night. During a review of the facility ' s policy and procedure (P/P) titled Safety and Supervision of Residents revised July 2017, the P/P indicated that resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents ' assessed needs. The P/P also indicated the frequency and type of supervision varied per the needs of each resident. During a review of the facility ' s document titled Standard of Certified Nursing Assistant (CNA) Practice, revised 11/2012, the document indicated The CNA is responsible to each resident in the facility and should - together with all staff- attempt to determine and meet resident needs, as possible, according to applicable capabilities and regulations.