**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that one (#1) of eight residents out of 16 sample residents remained as free from accidents as possible. Resident #1, severely cognitively impaired and with a history of elopement on 6/8/24 and frequent exit-seeking behaviors in January 2025 and February 2025, left the facility without staff knowledge on 2/5/25 between 9:30 p.m. and 10:30 p.m. He was not located until approximately 8:00 a.m. the next day. The facility's failures in responding to his elopements created a reasonable expectation, absent immediate correction, that an adverse outcome resulting in serious harm, impairment, or death would occur. Record review revealed that on 6/8/24, Resident #1 eloped from the facility and was found across the street later that day. On 6/11/24, the resident was evaluated as being at risk for future elopement. His care plan was updated the same day with interventions that read, in part, to allow the resident to wander in safe areas, to encourage attendance and participation in activities, to attempt to refocus when exhibiting behavior, and for staff to complete the elopement risk evaluation (assessment) per facility policy. -The update did not note that the resident had eloped 6/8/24, did not identify specific concerns/behaviors that might precipitate an elopement or provide individualized interventions to minimize his risk factors (independence with ambulation, his verbalized desire to go home, and his attempts to open doors), identified on the elopement assessment 6/11/24. Further, there was no plan to increase his level of supervision. Record review revealed that on 2/5/25, Resident #1 eloped from the facility a second time. He was last seen at approximately 9:30 p.m. in the building and was noted as missing by a certified nurse aide (CNA) at approximately 10:30 p.m. The time of elopement was uncertain. On 2/6/25 at approximately 8:00 a.m., facility staff located Resident #1 approximately one mile from the facility, outside an establishment with his wheelchair, wearing a coat, pants, and shoes. His vital signs were stable, but he was very cold and shivering. -Record review revealed a quarterly elopement assessment completed 12/26/24 per care plan directive (see above), failed to take into account all the resident's risks from medication, diagnoses, and his prior elopement. -Record review revealed no further care plan updates or an increase in the resident's supervision level after 6/11/24, even though the resident's medication and treatment administration record from January 2025 documented that Resident #1 had exit-seeking behaviors where he was difficult to redirect 22 out of a possible 31 days. And, the medication and treatment record from February 2025 documented that Resident #1 had exit-seeking behaviors on four out of the five days leading up to his elopement on 2/5/25. -Record review revealed the facility's investigation of Resident #1's elopement on 2/5/25 failed to identify root causes to prevent a recurrence or consider lapses in the facility's response. Interviews revealed delays in implementing the facility's policy/protocol once it was determined that Resident #1 was missing. Further interviews revealed that despite documentation and knowledge of Resident #1's behavior on 2/5/25, staff had a conflicting understanding of Resident #1's elopement risk and the resident's exit-seeking behaviors. On 2/25/25 at 12:45 p.m., an Immediate Jeopardy was identified based on the facility failures above that created a situation of potential serious harm for Resident #1, requiring immediate corrective action. Findings include: IMMEDIATE JEOPARDY I. Immediate Jeopardy A. Findings of Immediate Jeopardy Resident #1, with a brief interview for mental status (BIMS) assessment of three out of 15 (severe cognitive impairment), was admitted on [DATE]. An elopement assessment dated [DATE] revealed that Resident #1 was not at risk for elopement. However, less than three months later, on 6/8/24, Resident #1 eloped from the facility. He was assessed on 6/11/24 as being at risk for future elopement following the incident. His care plan was updated the same day with interventions that read, in part, to allow the resident to wander in safe areas, to encourage attendance and participation in activities, to attempt to refocus when exhibiting behavior, and for staff to complete the elopement risk assessment per facility policy. -However, the update did not note that the resident had eloped 6/8/24, did not identify specific concerns/behaviors that might precipitate an elopement or provide individualized interventions to minimize his risk factors (independence with ambulation, his verbalized desire to go home, and his attempts to open doors), identified on the elopement assessment 6/11/24. Further, there was no plan to increase his level of supervision. Record review revealed an inaccurate assessment of the resident's elopement risk on 12/26/24, and no care plan updates or an increase in the resident's supervision level after 6/11/24, even though staff documented in January 2025, Resident #1 had exit-seeking behaviors where he was difficult to redirect 22 out of a possible 31 days and in February 2025, had exit-seeking behaviors on four out of the five days leading up to an elopement on 2/5/25. On 2/5/25, Resident #1 eloped from the building a second time. He was last seen at approximately 9:30 p.m. and was noted as missing by a CNA at approximately 10:30 p.m. The time of elopement was uncertain. Facility staff began looking for the resident in the building, at the neighboring nursing facility, and in the neighborhood. The director of nursing (DON), nursing home administrator (NHA), and police were not notified until 3:00 a.m. on 2/6/25, after facility staff were unable to locate the resident. On 2/6/25 at approximately 8:00 a.m., facility staff located Resident #1 approximately one mile from the facility with his wheelchair, wearing a coat, pants, and shoes. His vital signs were stable, but he was very cold and shivering. Resident #1 was taken back to the facility and was placed on one-to-one staff supervision for the initial 72 hours and then on 15-minute checks. Resident #1 was also monitored for exit-seeking behaviors every shift, although the behaviors remained unspecified on his care plan. On 2/24/25 (during the survey), the facility completed a COC (change of condition) assessment for Resident #1. The revised COC assessment revealed the resident's score for elopement was 32, indicating a high risk for elopement. As of 2/25/25, the facility had not identified specific behaviors/concerns or identified new interventions to address Resident #1's high risk for elopement. Interviews with staff on 2/24/25 and 2/25/25 revealed that the director of nursing (DON) was not aware of Resident #1's ongoing exit-seeking behaviors, although staff reported the resident wandered, especially in the evening and at night, pushed on doors, and talked about going outside often. The facility failures above created a situation of Immediate Jeopardy for serious harm for Resident #1 that required immediate corrective action. On 2/25/25 at 12:45 p.m., the DON, the nursing home administrator (NHA), and the nurse consultant (NC) were notified of the Immediate Jeopardy situation. B. Facility plan to remove the Immediate Jeopardy On 2/25/25 at 6:51 p.m., the NHA provided a plan to remove the Immediate Jeopardy situation. The removal plan read: The facility will reassess all residents for elopement risk and identify triggers or predictive behaviors. The IDT (interdisciplinary) team will review and update care plans for residents at risk of elopement with individual resident centered approaches/strategies. The DON or designee will educate all staff on strategies and interventions for preventing elopement. The DON or designee will educate all staff on supervision, monitoring and reporting residents who are exit seeking. The DON or designee will educate nursing staff on notifying the NHA/DON of residents who are exit seeking, behaviors/triggers to monitor and strategies/interventions. The NHA or designee will educate all staff on the missing person policy, including timely required notifications at shift change. The education was to be completed prior to the first shift for new hires and agency staff. The DON or designee will review the behavior tracking five times per week for exit seeking behavior Residents and family will be educated regarding not assisting other residents to leave the facility and the process for signing in and out when leaving the facility by the NHA or designee. All staff on all shifts received education on the process for the front doors, wandering, elopement policy to include predictive behaviours and elopement prevention strategies, elopement binder missing persons policy and residents safety by the DON or designee. Any staff on leave received education on their next scheduled work day. An elopement risk assessment will be completed on admission and quarterly by the IDT team. Residents determined at risk by the IDT team will have a care plan in place to prevent elopement. The DON or designee will audit new admissions for elopement risk, determine if the facility can meet the resident's needs and ensure a care plan with appropriate interventions is in place if appropriate. New hires will receive education on wandering, elopement policy and elopement binder, and resident safety by the DON, director of social services or designee(s). A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAPI meeting for a minimum of three months or until the pattern of compliance is maintained. C. Removal of Immediate Jeopardy The NHA and the NC were notified on 2/26/25 at 12:17 p.m. after the implementation of the plan (see above) was verified by the surveyors onsite (see below) that the removal plan was accepted, and the Immediate Jeopardy was removed. After the removal of Immediate Jeopardy, the deficient practice remained at a scope/severity level D, isolated with no actual harm. The facility provided the following on 2/26/25: -Shift report training and expectations with a roster showing which nursing staff completed the training as of 2/26/25. -Spreadsheet showing the audit conducted on 2/26/25, the reassessment of risk, and the new interventions implemented for the residents whose assessment had changed. -Elopement binder and the facility policy on elopement was updated on all nurses stations by 2/26/25. -Documentation of Resident #1's care plan with updated behaviors updated by 2/26/25. -A spreadsheet of residents with completed and updated wandering assessments with an updated IDT note and updated care plan interventions if needed dated 2/25/25. -Communication of education and updated door locking policy provided to facility residents, family members, and staff on 2/25/25 and 2/26/25. -The elopement policy with education, including when to notify the IDT team if a resident was suspected missing, including education sign in sheets to show which staff had received training on 2/25/25 and 2/26/25. -Education sign in sheets were provided to show which staff had received the training on 2/25/25 and 2/26/25. On 2/26/25 between 9:30 a.m. and 12:00 p.m. the following staff were interviewed and confirmed they had received elopement training and how to use the elopement binder: dietary manager, housekeeping, ADON (assistant director of nursing), receptionist, CNA #4, licensed practical nurse (LPN) #5, human resources, maintenance, receptionist, and activity aide. II. Facility policy The Elopements and Wandering Residents policy, 2023, was provided by the NHA on 2/24/25 at 12:33 p.m. The policy read in pertinent part, The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary team. The IDT team will evaluate the unique factors contributing to risk in order to develop a person centered care plan. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize the risks associated with hazards will be added to the resident's care plan and communicated to the appropriate staff. Adequate supervision will be provided to help prevent accidents or elopements. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol. The designated facility staff will look for the resident. If the resident is not located in the building or on the grounds, the NHA or designee will notify the policy department and serve as the designated liaison between the facility and the police department. Post-elopement, staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. III. Resident #1 A. Resident status Resident #1, age less than 80, was admitted to the facility on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included dementia, depression, and type 2 diabetes. The 12/27/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The resident required partial assistance with showering and toileting. He required supervision for transfers and walking. He was independent with his wheelchair. An elopement assessment, dated 3/22/24, revealed that Resident #1 was not at risk for elopement. Resident #1 was interviewed on 2/24/25 at 10:00 a.m. He said he went outside every day. He said he loved going outside. B. First elopement - Facility failures in response 1. Elopement 6/8/24 On 6/8/24 at 2:26 p.m., a nursing note documented that around 8:00 a.m. on 6/8/24, a CNA told the nurse that Resident #1 was not in his room. The nurse checked the smoking area and other empty rooms in the building. They started searching outside the building. Resident #1 was found 30 minutes later near a daycare across the street from the facility. The NHA and the DON were notified. An elopement evaluation (assessment), completed on 6/11/24, indicated that Resident #1 was at risk for elopement based on his diagnosis of dementia, independent ambulation with a wheelchair, had wandering behaviors as part of his past, was cognitively impaired, had verbalized desire to go home or attempting to open doors, and he had a change in status or routine. A care plan for elopement risk, initiated on 6/11/24, revealed Resident #1 was at risk for elopement/exit-seeking/wandering related to dementia and intermittent delusions and that he was redirectable without agitation. Interventions included allow wandering in safe areas, approach in calm manner, assess for pain and medicate as needed, attempt to refocus, document and notify physician if behavior interferes with daily functioning, educate on facility protocol for check in/out logs, educate on potential risks and the facility protocol for leaving the facility, elopement risk assessment, encourage participation in activities of choice and encourage expression of feelings. 2. Failures in facility response The resident's care plan update did not note that he had eloped on 6/8/24, did not identify specific concerns/behaviors that might precipitate an elopement or provide individualized interventions to minimize his risk factors (independence with ambulation, his verbalized desire to go home, and his attempts to open doors), identified on the elopement assessment 6/11/24. Further, there was no plan to increase his level of supervision. C. Continuing failures after 6/8/24 1. A quarterly elopement assessment, completed on 12/26/24, indicated that Resident #1 was independent in his wheelchair, wandered without a sense of purpose, had a diagnosis that may have impacted cognition, took one medication that could increase restlessness of agitation, had not expressed desire to leave the facility, exhibited unsafe wandering or elopement attempts but was easily redirectable. It documented that Resident #1 did not wander out of the facility but wandered into different rooms. Based on the assessment completed, resident #1 scored a 12. (The facility did not provide a scoring tool, however, lower scores indicated lower risk.) Consistent with the quarterly assessment above, Resident #1's 12/27/24 MDS assessment documented that the resident did not have wandering behaviors. -However, the 12/26/24 elopement assessment was inaccurate. Resident #1 took two medications that could increase restlessness or agitation, had two medical diagnoses that may have impacted his cognition, and had one elopement in the prior year. See also interviews below; staff reported the resident wandered, especially in the evenings and at night, and pushed on doors. 2. A review of Resident #1's medication and treatment administration record from January 2025 documented that Resident #1 had exit-seeking behaviors where he was difficult to redirect 22 out of a possible 31 days. The medication and treatment record from February 2025 documented that Resident #1 had exit-seeking behaviors on four out of the five days leading up to his elopement on 2/5/25. Record review revealed no care plan updates describing Resident #1's exit-seeking behavior and how staff might respond or a plan to increase the resident's supervision level, despite the documentation on the medication and treatment administration records for January 2025 and February 2025, and staff documentation the resident was now difficult to redirect. D. Second elopement - Failures in facility response 1. Elopement 2/5/25 On 2/6/25 at 7:27 a.m., a nursing note by LPN #3 documented that Resident #1 was missing. The note read that during the dinner time medication pass (2/5/25), Resident #1 was in his room eating and carrying his guitar. After dinner, the nurse requested the two CNAs working on his side of the hall to collect meal trays from all the rooms. At that time, the nurse did not see Resident #1 in his room and asked the CNA in charge of his daily care to look for him. -The CNA came back to the nurse later and stated that Resident #1 was on the Capital side of the building. At night, after the nurse's lunch, he started passing medication and did not see Resident #1 in his room. He asked the CNA to look for Resident #1. At the same time, the nurse went to check on another resident who was not feeling well. The CNA returned and stated that Resident #1 was still wandering in the Capital side of the building. -At 10:45 p.m., the CNAs working the graveyard shift (10:00 p.m. to 6:00 a.m.) had come in, and the new CNA in charge of Resident #1's care stated that Resident #1 was not in his room. She reported that the resident was not seen during shift change. The nurse instructed the CNA to look for the resident. -After a few hours of looking for him, Resident #1 was not found in the building or neighborhood. The DON was notified, and a report was given about the situation. On 2/6/25 at 7:35 a.m., a late entry nursing note by LPN #3 documented that on 2/5/25, Resident #1 went missing from the property around 10:45 p.m. All staff on shift started looking for him in each room within the facility and around the neighborhood. The DON and police were notified. Resident #1 was found on 2/6/25 between 8:00 a.m. and 9:00 a.m. All vital signs were stable, labs were done, skin was intact and cold on touch, no frostbite noted, and no signs of pain or discomfort noted. Resident #1 was placed on one one-on-one monitoring with a one-to-one sitter and 72-hour charting. On 2/6/25 at 8:40 a.m., a nursing note documented that after a long search, Resident #1 was found a few blocks away from the facility. Resident #1 appeared very cold and was shivering. He was brought back to the facility, where warm blankets awaited him. His vital signs were stable. A head-to-toe assessment revealed no sign of injury. One-on-one care was provided to Resident #1 immediately. The provider ordered lab work, a urine test, and an electrocardiogram (EKG). A review of the facility investigation of Resident #1's elopement 2/5/25 to 2/6/25 revealed the investigation was initiated on 2/6/25. It read that Resident #1 was noted missing by staff around 11:40 p.m. on 2/5/25. He was last seen by staff around 9:30 p.m. on 2/5/25. He was found by the DON and the NHA around 8:00 a.m. on 2/6/25, a few minutes away from the facility, in front of a business. He was brought back to the facility and assessed. CNA #1 was interviewed by the DON (no date or time). CNA #1 was in charge of Resident #1's care and reported she did her rounds when she came in and noted the resident was not in his room between 10:30 p.m. and 10:45 p.m. CNA #1 reported she let the nurse know at the time, and they began searching for the resident. This concluded all interviews provided in the facility's investigation. Resident #1's care plan was updated on 2/6/25 to add a one-to-one sitter, and nursing notes indicated he had the sitter from 2/6/25 until 2/9/25 at 11:30 p.m., with the nurse and staff monitoring him the rest of the night. On 2/9/25, the care plan read 15-minute checks were added and sometime later, removed from the care plan. 2. Failures in facility response a. Record review See the facility investigation above. The facility failed to conduct a comprehensive investigation to identify root causes to prevent a recurrence or consider lapses in the facility's response. See care plan additions above. As of 2/25/25 (during survey) Resident #1's care plan still lacked specific concerns/behaviors that might precipitate an elopement or provide individualized interventions to minimize his risk factors (independence with ambulation, his verbalized desire to go home, and his attempts to open doors), in addition to failing to document either of his elopements. Further, there was no evidence an elopement assessment was conducted after 2/6/25 until 2/24/25, during the survey. E. Interviews 1. Staff interview Staff interviews revealed that Resident #1 was known to wander, especially in the evening and at night, pushed on doors, and talked about going outside often. a. CNA #3 was interviewed on 2/24/25 at 1:10 p.m. CNA #3 said the staff did not do shift reports at this facility. She said facility staff would leave without giving a report. She said she walked around to lay eyes on all her residents at the beginning of her shift. She said she worked with Resident #1. She said she had noticed a decline in his cognition. She said he used to be able to go outside to smoke and find his way back to his room by himself. She said that now, he wandered more aimlessly, so she made the effort to take him out to smoke when he wanted to. She said if nobody was with him or reminded him, he would wander everywhere. b. CNA #2 was interviewed on 2/24/25 at 2:55 p.m. CNA #2 said Resident #1 was very fast in his wheelchair. She said he refused care and staff had to approach him in another way, and he would usually let her do his care. She said he was very forgetful and did not call for help. She said he could walk but was not supposed to. She said he wandered around the building a lot, especially in the evenings and at night. She said he talked about going outside often. CNA #2 said she worked with Resident #1 the night he eloped. She said she was working from 2:00 p.m. to 10:00 p.m. She said he ate dinner in the dining room around 5:00 p.m. on 2/5/25. She said she brought him to the nursing station at the Cherry Creek hallway (where he lived) after dinner for a snack. She said she last saw him around 9:00 p.m. at the nursing station. She said she left at 10:00 p.m. She said that the CNA taking over for Resident #1's portion of the hall was not there yet, so she gave a report to the other CNA who was taking over the other part of the hall. She said she got a call from the DON in the middle of the night asking when was the last time she had seen Resident #1. c. LPN #1 was interviewed on 2/25/25 at 9:30 a.m. LPN #1 said Resident #1 was an elopement risk. She said he was independent with pedaling in his wheelchair and was very fast. She said his cognition had declined in the last few months, and he seemed more forgetful. She said that on every shift, she documented his exit-seeking behavior. She said his exit-seeking behavior was pedaling around the facility in his wheelchair and pushing at doors. She said that sometimes he was redirectable with a snack or activity, and other times, he would get agitated when a staff member tried to redirect him. She said the nurses used a report sheet to indicate he was on elopement precautions. She said this included documenting exit-seeking behaviors and extra monitoring. She said he was on frequent checks, meaning every 15 minutes, and she parked the cart outside his room to keep an eye on him throughout her shift. d. LPN #3 was contacted by phone. A message was left to return the call on 2/25/25 at 4:25 p.m. However, LPN #3 did not return the call. 2. Management interview Management (NHA, DON, and nurse consultant/NC) interviews revealed the DON was not aware of Resident #1's exit-seeking behaviors before his elopement on 2/5/25 to 2/6/25. The interviews further revealed staff conducted a search on foot and by car in the surrounding neighborhood once the resident was discovered missing. Finally, interview revealed there had been a delay, contrary to facility expectations, in contacting management about Resident #1's elopement. a. The NHA, the DON, and the NC were interviewed together on 2/24/25 at 5:00 p.m. Contrary to the treatment and medication records for January 2025 and February 2025 (see above), the DON said Resident #1 wandered in circles but was not exit-seeking. She said he did not wander into other residents' rooms. She said there was nothing about him that seemed unsafe. She said the residents became unsafe if they were heading towards the door, and he did not do that. Also, contrary to the treatment and medication records for January 2025 and February 2025 (see above), the DON said staff redirected him with snacks or activities. She said she was unable to have any meaningful conversations with Resident #1 due to his low BIMS score and cognition. The NHA said facility exit doors opened and were then alarmed if the egress bar was pushed for 15 seconds. The NHA said he went to the facility on 2/6/25 at 4:00 a.m. The NHA said the staff that worked the overnight shift on the evening of Resident #1's elopement looked for the resident in the surrounding neighborhood on foot and in their cars. The NHA said the facility was unable to determine if Resident #1 left after a family member walked out the front door or what exactly happened. The NHA said the staff members working that evening (2:00 p.m. to 10:00 p.m.) said they did not see anyone leave behind them. The NHA said staff parking was in the back of the building and staff came in the side door or through the front door, and family members parked in the street in front of the facility. The NHA said one of the facility doors had since been made inactive to enter after Resident #1's elopement. The DON said the facility cameras were not working the night Resident #1 eloped. The DON said staff checked all the side doors after his elopement and confirmed all the doors worked correctly. The DON said Resident #1 was found outside near a local business, wearing a coat, a hat, and shoes the facility thought belonged to the resident. The DON said a CNA reported that the last time she saw Resident #1, he was wearing house slippers and provided the description of Resident #1 to the police. The DON said the facility identified one CNA scheduled to relieve the day shift staff at 10:00 p.m. had arrived late to the floor (on 2/5/25), but she was not aware how late the CNA had arrived. The DON said that the facility investigation had not included checking to see if all staff came in at 10:00 p.m. as scheduled. The DON said the staff reported to her that they did their walking rounds as they came into the facility at 10:00 p.m. The DON said she came to the facility immediately upon being notified around 3:00 a.m. on 2/6/25 that Resident #1 was missing, and the NHA called 911 while he was en route to the facility and told a nurse to call the hospital. The DON then arrived at the facility, where the police met her and started their own surveillance. The DON said she got in a car with the assistant director of nursing (ADON) and tried to find the resident. The DON said if a CNA thought a resident was missing, the CNA should notify the nurse they could not find a resident. The nurse should broaden the search and look in every room, every shower room, and ask all the other staff to help search. The DON said that after searching for 20 minutes maximum, the staff should call the DON, and the DON should call the NHA. The DON said she should have been notified by midnight, at the very latest, that Resident #1 was missing. The DON said that after finding Resident #1, the resident did not articulate where he went and willingly got in the car. He said only that he left to get coffee and did not answer any other questions. The DON said she updated the medical director about the resident's elopement. She said a family member might have exited the facility unaware that Resident #1 was behind them. The DON said some of the staff would have been pulled off the floor to look for Resident #1 when they identified he was missing. The DON said the front double doors to the facility door locked at 6:00 p.m., preventing people from both leaving and entering. The DON said it was an automatic lock and was not locked manually. The DON said a person had to push on the front door for 15 seconds as it had an egress handle or enter a code on the keypad. The DON said the staff reported the door was locked at the time they exited to look for Resident #1. The DON said the staff could enter the facility by entering a code into the keypad. The DON said the facility updated Resident #1's care plan with interventions following the elopement that occurred in June 2024, and the expectation was to have a complete resident record to provide the best care for the resident. The DON said this was to ensure the facility staff could do the best work they could and provide the best care for the resident even with staff turnover. b. The NHA, the DON, and the NC were interviewed together again on 2/27/25 at 11:31 a.m. The NC said Resident #1 used his wheelchair and walked behind his wheelchair, using it like a walker. The NC said the medication administration times and care task completion records for Resident #1 were reviewed post-investigation to determine a timeline of Re[TRUNCATED]