**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, the facility neglected to maintain the physical safety of one resident (#1) out of 11 residents at risk for elopement regarding not providing services to prevent a resident with known exit-seeking behaviors and desire to leave the facility from falling down a flight of stairs and sustaining multiple life threatening injuries. The facility failed to prevent the resident from accessing the East stairwell on the second floor by not providing a system to prevent access to 4 exit doors on the floor despite having residents at risk for elopement who could reach the doors and residents who required frequent redirection away from the doors. The facility neglected to ensure the safety of Resident #1; on 4/13/2023 at approximately 1:15 PM, Resident #1 propelled herself in her wheelchair from the unit nurses' station, down the East Hall, passing by three staff offices, and approximately 141 feet to the East Hall emergency exit fire door. Resident #1 pushed on the handle to the East Hall emergency exit fire door, equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked), for approximately 15 seconds while a steady, audible beeping alarm sounded until the door opened. Resident #1 accessed the stairwell unsupervised and without staff knowledge and fell in her wheelchair down nine stairs to a landing between the 2nd and 1st floors of the building. This failure created a situation that resulted in serious injury and or the likelihood of death to Resident #1 and resulted in the determination of Immediate Jeopardy on 4/13/2023. The findings of Immediate Jeopardy were determined to be removed on 4/20/2023 and the severity and scope was reduced to a D. Findings included: A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), unspecified anxiety disorder, severe unspecified dementia with other behavioral disturbance, and major depressive disorder. Review of Resident #1's medical record revealed Resident #1 was discharged from the facility on 4/13/2023 to a higher level of care and had not returned to the facility as of 4/20/2023. A review of Resident #1's physician's orders for April 2023 revealed the following: - An order dated 12/10/2021 for an alert bracelet changed every 90 days and as needed. - An order dated 12/10/2021 for a functional check of the alert bracelet every day on the 11 PM to 7 AM shift. - An order dated 10/27/2020 for a check for placement of the alert bracelet on the left ankle, every shift. A review of Resident #1's care plan, revealed an undated, except for a listed admission date of 2/27/2019, Focus that (Resident #1) is at risk for behavior symptoms related to dementia, resistance to care at times, attempting to exit the facility, packs clothes and belongings on wheelchair and will attempt to push chair to the elevator and go home. Interventions included providing comfort by taking time with patient, reinforce positive behavior, redirect the patient, and use consistent approaches when giving care. In addition, Resident #1's care plan, revealed an undated, except for a listed admission date of 2/27/2019 Focus that (Resident #1) is exit seeking related to cognitive impairments, diagnosis of dementia, and wanting to drive home to Ohio. Interventions included an alert bracelet, calmly redirect to an appropriate area, check alert bracelet placement every shift, and check functioning of alert bracelet every day. Resident #1's care plan, also revealed an undated, except for a listed admission date of 2/27/2019 Focus that (Resident #1) is at risk for falls due to impaired cognition with poor safety awareness, impulsiveness, history of falls, risk for impaired balance, fluctuations of gait, risk for low blood sugar, and potential adverse reactions to medications. Patient ambulates independently into the halls and in her room. Interventions included encouraging transfers and position changes slowly, reinforce need to call for assistance, and help with transfers and ambulation as needed. In addition, Resident #1's care plan, revealed an undated, except for a listed admission date of 2/27/2019 Focus that (Resident #1) enjoys activities such as the daily perk and current events, attending activities like bingo, cooking class, arts and crafts, ice cream social, happy hour, live entertainment, reminiscing, and much more. She likes hanging out in the hall, talking with her peers, and visiting her friends up and down the unit. She likes watching movies on movie and snack night or she likes to just hang out in her room watching her TV. She has the notion to pack up all her things and head to the elevator saying she is going to the parking lot as her mother is waiting for her and then the nursing staff re-directs her. For the most part she is independent with use of her leisure time and chooses the group activities she attends. Interventions include activities (staff) will deliver a newspaper and daily perk to room for independent reading, encourage participation in independent activities such as current events, movies on television, music, reading, word games, group activities, and television, and provide supplies/materials for leisure activities as needed and requested. A review of Resident #1's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 4/6/2023 revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 6, which indicated severely impaired cognition. Resident #1's MDS assessment revealed under Section E - Behavior, that Resident #1 did not display behaviors of wandering. Section G - Functional Status revealed Resident #1 required supervision and one person physical assistance with locomotion on the unit and used a walker and a wheelchair for mobility devices. Resident #1's MDS assessment revealed under Section P - Restraints and Alarms showed a wander/elopement alarm was used daily. A review of a Social Services Progress note dated 4/8/2023 signed by Staff L, revealed, Resident is being assessed for an annual review. Her (representative) is local and active in her care. Resident is up daily and is able to self-propel throughout the unit. Patient wears glasses and has adequate hearing. Patient continues to require 24-hour care and supervision. There is no plan for discharge at this time. A review of Resident #1's progress notes dated 4/13/2023 at 1:30 PM and authored by Staff B, Licensed Practical Nurse (LPN), revealed the following: Alarm to elevator and side exit to stairs going off. Checked elevator and side fire stairwell all clear. Checked west exit door and all clear. Checked east hall fire stairwell and CNA found [Resident #1] laying at bottom of stairs laying on left side with [wheelchair] over on side. Noted extensive amount of blood on floor around [Resident #1] and noted blood dripping from forehead. [Resident #1] was alert and talking and no [respiratory] distress noted. Other nurses and CNA [certified nursing assistant] at site and this writer left and called 911 and completed paper transfer sheet and showed [Resident #1] to EMS [emergency medical services] when they arrived. This writer called [Resident #1's family member] and informed of above and that [Resident #1] was transferred to [the hospital]. A telephone interview was conducted with Resident #1's representative (RR). The RR stated they were informed by the facility Resident #1 was rushed to the emergency room after opening a door, accessing a stairwell, and falling down several flights of stairs. The RR stated Resident #1 had suffered from a brain bleed, a fractured neck, something with her carotid artery, 8 staples on the side of her head, and 16 staples up from her nose to her forehead because of the fall. A review of Resident #1's hospital records, dated 4/13/2023 at 3:49 PM revealed Resident #1 was admitted from the emergency room to the Intensive Care Unit (ICU) critically ill with multiple lacerations to the head and face. A C1 (first cervical vertebrae) fracture, a small pseudoaneurysm (damage to a blood vessel wall causing blood to leak out into the surrounding tissue) on the left internal carotid artery at the level of the injury, a small intraparenchymal (into the functional tissue of the brain) bleed as well as what is read as a small 4 millimeter (mm) right cavernous carotid artery aneurysm, a nasal fracture, and a right temporal subarachnoid hemorrhage (bleeding in the space that surrounds the brain) were discovered following Resident #1's admission to the hospital. The physician who performed the initial critical care assessment wrote Patient has multiple issues that could be potentially life threatening. Complications in the management of C1 fractures range from minor discomfort to death. Jun 29, 2016, C1 fractures: a review of diagnoses, management options, and outcomes, nih.gov https://www.ncbi.nlm.nih.gov > articles > PMC4958388 A tour of the facility's second floor was conducted on 4/17/2023 at 1:00 PM. The unit nurses' station is in the middle of the unit with two long hallways (East and West) and two short hallways (North and South). An emergency fire exit door is located at the end of each hallway on the unit. An observation of the East Hall revealed an emergency fire exit door at the end of the hallway. A piece of paper with a printed out stop sign on it was observed on the emergency fire exit door. The emergency fire exit door was observed to be locked with an electromagnetic lock, which could be opened after holding the door handle for 15 seconds according to the red lettering affixed to the door Emergency exit only. Security alarm will sound if door is opened. Push until alarm sounds. Door can be opened in 15 seconds. An additional exit door alarm was observed affixed to the upper portion of the door, which had white lettering Stop alarm will sound. The East emergency fire exit door was observed locked and secured. Observations of the North, South, and [NAME] hallway emergency fire exit doors on the unit revealed all doors had printed out stop signs, red lettering indicating Emergency exit only. Security alarm will sound if door is opened. Push until alarm sounds. Door can be opened in 15 seconds, and additional exit door alarms affixed to the upper portion of the door. The 4 exit doors on the unit were observed to be secured in the same way. An interview was conducted with Staff A, LPN Unit Manager (UM). Staff A, LPN UM stated the facility's second floor is designated as the Long Term Care (LTC) unit. Staff A, LPN UM stated the unit had an elevator which could be accessed by residents that were not a risk for elopement. Any residents with an alert bracelet would trigger the elevator alarm. A functional test and observation was conducted on the second floor of the facility on 4/17/2023 at 1:21 PM of the East hallway's emergency fire exit door with Staff A, LPN UM. Upon pressing on the handle of the emergency fire exit door, a repetitive beep sound can be heard for approximately 15 seconds and the door remains locked by the activated electromagnetic lock. After 15 seconds of pressing on the handle, the electromagnetic lock releases, and a loud, steady tone is heard. Upon opening the emergency fire exit door, the additional exit door alarm also activated, and a loud and steady screech noise could be heard from the alarm. Opening the door also activated a flashing white light on top of the exit door alarm. After testing the alarm functioning, Staff A, LPN UM deactivated the emergency fire door alarm and the exit door alarm. An interview was conducted with Staff A, LPN UM following the door alarm test. Staff A, LPN UM stated the facility installed additional exit door alarms, which were referred to as screechers to all the emergency fire exits doors on the unit following Resident #1's fall down the East stairwell. Staff A, LPN UM stated on 4/13/2023 she was in her office, located in the East hallway, when she heard an alarm sound around 1:30 PM. Staff A, LPN UM immediately went to the nurses' station to visually check all the emergency fire exit doors on the unit and the elevator and ensure staff were responding to the alarms. Staff A, LPN UM stated the elopement alarm at the elevator and the fire exit alarm were going off at the same time during the incident. Staff A, LPN UM stated she first responded to the unit elevator and South emergency fire exit door and did not see any residents by the doors. Staff A, LPN UM observed the red colored light on the door's electromagnetic lock was illuminated, indicating the door was still locked and secured. Staff A, LPN UM heard Staff G, CNA yell from the East hallway emergency fire exit door asking for assistance. Staff A, LPN UM responded to the East hallway emergency fire exit door at the end of the hallway and observed Resident #1 on the right side of the landing at the bottom of the first flight of stairs between the first and second floor of the building. Resident #1 was lying on the floor on her left side with her head toward the beginning of the second flight of stairs with her wheelchair folded up behind her on the left side of the landing. Staff A, LPN UM assessed Resident #1 to ensure she was still breathing. Staff A, LPN UM stated Staff E, CNA responded from the second floor shortly after she observed Resident #1. After verifying Resident #1 was breathing and had an open airway, Staff A, LPN UM went to the first floor emergency fire exit door, yelled out for assistance, and instructed staff to call 911. Staff F, LPN and Staff K, LPN responded to the East stairwell from the first floor and remained with Resident #1 while Staff A, LPN UM went down to the first floor and gathered Resident #1's paperwork in preparation for arrival of EMS personnel and transfer to the hospital. Staff A, LPN UM stated the facility's Medical Director (MD) was at the facility and observed Resident #1 before the resident was transferred to the hospital. Staff A, LPN UM stated Resident #1 had visible injuries, including lots and lots of blood and probably a fractured nose, but was alert and verbal when EMS arrived at the facility. EMS personnel entered the stairwell from the first floor and transported Resident #1 to the hospital. Staff A, LPN UM stated Resident #1 was exit seeking and would attempt to exit the unit by using the elevator but did not attempt to open the emergency fire exit doors on the unit. An observation was conducted on 4/17/2023 at 1:38 PM of the East stairwell on the second floor of the facility with Staff A, LPN UM. The East emergency fire exit door on the second floor opens to a landing, approximately 10 feet in length and 8 feet wide, leading to a flight of nine brown rubber coated stairs. The stairs lead to a landing, approximately 8 feet in length and 4 feet in width. The landing leads to another set of nine brown rubber coated stairs, leading to the first floor of the facility. Three small, jagged, black colored pieces of plastic were observed on the left corner of the landing between the first and second floor. Staff A, LPN UM stated the plastic pieces were from the side panel of Resident #1's wheelchair and had broken off. A small, one foot section of exposed concrete between the first and second staircase appeared stained with red colored liquid. (Photographic Evidence Obtained) At this time, Staff A, LPN UM stated the red colored staining to the exposed concrete was from Resident #1's blood and was not able to be cleaned. A tour of the second floor of the facility was again conducted on 4/19/2023 at 11:20 AM. The unit nurses' station is observed when exiting the elevator located in the South hallway. The unit nurses' station is a large octagon shaped desk situated in the middle of the unit. The North, South, East, and [NAME] emergency fire exit doors and unit elevator are visible from the unit nurses' station. The distance from the middle of the unit nurses' station to the entrance of the East hallway is approximately 16 feet. The East hallway contains 18 total rooms, including 13 resident rooms, Staff A, LPN UM's office, a Social Services office, an additional staff office, a soiled utility room, and a treatment room. The length of the hallway to the emergency fire exit door is approximately 125 feet in length. The emergency fire exit door opens to a landing, which is approximately 15 feet in length from the door to the first stair of the staircase. The total distance from the middle of the unit nurses' station to the first step of the East stairwell is approximately 156 feet. A review of the facility's staffing assignment sheet for the second floor dated 4/13/2023 on the 7 AM to 3 PM shift revealed two licensed nurses and five CNAs were assigned to the 62 residents on the unit. Eleven of the 62 residents were assessed to be at risk for elopement. An interview was conducted on 4/17/2023 at 2:38 PM with Staff B, LPN. Staff B, LPN stated she was Resident #1's assigned nurse on 4/13/2023 and was familiar with Resident #1. Staff B, LPN stated Resident #1 was alert and oriented, but confused and had days where she was agitated and exit seeking. Resident #1 would normally go to the unit elevator if she wanted to exit the unit, but the elevator alarm would sound right away due to Resident #1 having an alert bracelet. Staff B, LPN stated Resident #1 attempted to open the emergency fire exit doors in the past, but staff would respond and redirect her before she was able to open the emergency fire exit door. Staff B, LPN stated Resident #1 did not seem agitated on 4/13/2023 and did not express a desire to leave the facility. Staff B, LPN stated other residents were attempting to seek exit from the unit on the night of 4/13/2023 and the doors were being monitored frequently throughout the day. Staff B, LPN stated at approximately 1:15 PM on 4/13/2023, she was at the unit nurses' station charting when an alarm sounded. Staff B, LPN stated the alarms for the alert bracelets and the emergency fire exit doors sounded similar and were hard to distinguish, so they must physically and visually check all the doors on the unit when an alarm is triggered. Staff B, LPN stated that approximately eight to ten people, including residents, were near the activity room between the unit elevator and the South emergency fire exit door when the alarm sounded, and she responded to the area to see if any residents approached either door. Staff B, LPN then hollered down the [NAME] hall from the unit nurses' station and instructed the CNA staff to check for any residents near the [NAME] emergency fire exit door or in the west stairwell. The CNA staff told Staff B, LPN the [NAME] emergency fire exit door was secure, and no residents were observed in the [NAME] stairwell. Staff B, LPN heard a voice shout from the East hallway get down here quick, it's bad. Staff B, LPN and Staff A, LPN UM responded to the East stairwell and observed Resident #1 lying on her left side on the landing at the bottom of the staircase between the first and second floor. Staff B, LPN stated Resident #1's wheelchair was laying on it's side behind Resident #1 as if she flipped out of it and immediately noticed a pool of blood around Resident #1's head. Staff B, LPN stated Resident #1 was alert, talking, and stated to staff I really did it this time. Staff B, LPN observed Resident #1 had a head laceration and blood dripping from her nose and instructed staff to not touch the resident. Staff B, LPN stated after other staff responded to the stairwell, whom she could not remember, she left the stairwell and went to the first floor to call 911. Once EMS arrived at the facility, Staff B, LPN escorted them to Resident #1's location in the East stairwell and Resident #1 was taken to the hospital. Staff B, LPN stated she normally works on the weekends on the second floor and a resident would trigger the door alarms at least once during the weekend. The elevator alarm triggers the most because if any resident with an alert bracelet approaches the elevator, the alarm will trigger. Staff B, LPN stated the screecher alarms were added to the emergency fire exit doors after Resident #1's fall. Staff B, LPN stated no staff on the second floor witnessed Resident #1 pushing on the East emergency fire exit door handle or witnessed Resident #1 exiting the unit. Staff B, LPN stated residents were setting the elevator alarm off several times on 4/13/2023 because there were several near the activity room between the elevator and the South emergency fire exit door and the elevator alarm was sounding at the same time the emergency fire exit door on the East hall was sounding. An interview was conducted on 4/17/2023 at 3:18 PM with Staff C, CNA. Staff C, CNA stated he worked on the second floor on the 7 AM to 3 PM shift on 4/13/2023 and was familiar with Resident #1. Staff C, CNA stated Resident #1 had periods of confusion and would place her belongings into her wheelchair and ambulate toward the elevator because she wanted to leave the facility. Staff C, CNA stated Resident #1 did not express a desire to leave the facility on 4/13/2023 and was not observed near the exit doors on that day. Staff C, CNA stated he and Staff I, CNA were in a [NAME] hall resident room transferring another resident using a non-weight bearing lift into the resident's wheelchair shortly before they heard an alarm sounding. Staff B, LPN shouted down the [NAME] hallway and instructed Staff C, CNA and Staff I, CNA to visually observe the [NAME] hall stairwell. Staff C, CNA and Staff I, CNA opened the emergency fire exit door at the end of the [NAME] hallway and did not see any residents in the stairwell. Staff C, CNA reset the alarm on the [NAME] emergency fire exit door and returned to a resident room to assist another resident with a shower. Staff C, CNA stated on 4/13/2023, three different residents were witnessed approaching the stairwell doors on the [NAME] hallway throughout the shift and were redirected away from the doors before they could attempt to open them. Staff C, CNA stated when a resident approaches the emergency fire exit doors or attempts to push on the handle, staff on the floor will attempt to re-direct the resident and reset the alarm if needed. An interview was conducted on 4/17/2023 at 3:31 PM with Staff D, Registered Nurse (RN). Staff D, RN stated she was not assigned to Resident #1 on 4/13/2023 but was working on the second floor. Resident #1 would often sit by the unit nurses' station and would interact pleasantly with staff. Staff D, RN stated she did not witness Resident #1 display any exit seeking behaviors in the past and did not witness Resident #1 near exit doors on the unit. Staff D, RN stated she was returning to the unit following her lunch break when she witnessed EMS assisting the resident in the East stairwell and observed Resident #1 lying on the landing between the first and second floor surrounded by blood. Resident #1 was observed by Staff D, RN to have an injury to her scalp and a cracked nose. Staff D, RN observed Resident #1's wheelchair on the landing of the stairwell near Resident #1. Staff D, RN stated a staff member was assigned to observe the emergency fire exit doors for the rest of the shift following Resident #1's fall and additional alarms were installed on the doors. Staff D, RN stated all staff are to respond to alarms and they are normally able to re-direct residents on the unit before they can approach the emergency fire exit doors. An interview was conducted on 4/17/2023 at 3:40 PM with Staff E, CNA. Staff E, CNA stated she was familiar with Resident #1 and had taken care of the resident before. Staff E, CNA stated she had never heard Resident #1 expressing a desire to exit the facility, but the resident would sometimes gather her belongings and put them in her wheelchair. Staff E, CNA stated Resident #1 was able to be re-directed and enjoyed participating in activities. Staff E, CNA stated on 4/13/2023 she was on the elevator taking resident lunch trays down to the kitchen area following lunch on the unit when she heard an alarm. When she got off the elevator and stepped into the second floor unit, Staff A, LPN UM was already in the area near the elevator looking by the South emergency fire exit door. Staff E, CNA stated she went down the East hallway to see if any residents were observed near the doors at the end of the hallway when she observed Staff G, CNA open the East emergency fire exit door and requested her to come to the door. Staff E, CNA then turned around and yelled for assistance from Staff A, LPN UM and went through the East emergency fire exit door with Staff G, CNA. Staff E, CNA observed Resident #1 lying on the right side of the landing between the first and second floors of the building in a pool of blood with her wheelchair behind her on the left side of the landing. Staff E, CNA stated she tried to observe where the blood was coming from but Resident #1's face was covered in blood, so it was difficult to tell. Resident #1 requested Staff E, CNA to assist her to her feet but Staff E, CNA did not touch the resident. Staff E, CNA stated her and Staff G, CNA remained with Resident #1 until EMS personnel arrived and took the resident to the hospital. An interview was conducted on 4/18/2023 at 10:36 AM with Staff F, LPN. Staff F, LPN stated Resident #1 was normally confused and would occasionally pack up her belongings and place them in her wheelchair wanting to go home. Staff F, LPN would sometimes witness Resident #1 going to the elevator on the second floor and wait for the elevator to open so she could get into it, but not toward the emergency fire exit doors. Staff F, LPN stated when Resident #1 would attempt to enter the elevator, an alarm would beep because Resident #1 had an alert bracelet and was known to wander on the unit. Staff F, LPN stated she was by the nurses' station on the first floor of the facility when she was informed by Staff B, LPN Resident #1 had fallen down the stairs on the east side of the facility. Staff F, LPN responded to the East stairwell from the first floor and witnessed Resident #1 lying on the landing between the first and second floor of the facility on her stomach with her left arm behind her and her right arm out in front of her. Resident #1 was observed with her head lying on the left and resting on the floor with her wheelchair on the left side of the landing. Staff E, CNA and another CNA were in the stairwell with Resident #1 at the time. Staff F, LPN sat down next to Resident #1 and attempted to speak with the resident. Resident #1 was observed to have a skin tear on her right arm and had blood everywhere. Staff F, LPN attempted to wipe blood off Resident #1's nose several times as it was filled up with blood. Resident #1 stated to Staff F, LPN get me up, I got to get up, my head hurts but Staff F, LPN encouraged Resident #1 to remain still and reassured the resident. Staff F, LPN stated Staff H, LPN, Staff A, LPN UM and a bunch of other people entered the stairwell to assist. When EMS personnel arrived, Staff F, LPN exited the stairwell and Resident #1 was taken to the hospital. An interview was conducted on 4/18/2023 at 10:55 AM with the facility's Maintenance Director. The Maintenance Director stated the emergency fire exit doors on the second floor are equipped with electromagnetic locks and alarms. The alarm activates when the handle to the door is pressed, and the door can be opened after 15 seconds due to fire safety reasons. The alarm has a steady loud beep tone and does not stop until it is reset using the keypad next to the door. The Maintenance Director stated the elevator on the unit was equipped with an alarm for residents at risk for elopement. When a resident with an alert bracelet approaches the elevator, a separate alarm with an electromagnetic sound will trigger and the elevator will not be functional until the alarm is reset. The Maintenance Director stated staff would be able to distinguish the elevator door alarm from the emergency fire exit alarms. The Maintenance Director stated additional alarms, which he referred to screamers, were installed on the emergency fire exit doors following Resident #1's fall. The Maintenance Director stated the emergency fire exit doors were not equipped with a separate alarm for residents at risk for elopement and would be opened after holding the handle for 15 seconds. An interview was conducted on 4/18/2023 at 11:06 AM with Staff G, CNA. Staff G, CNA stated she occasionally assisted staff on the second floor and was familiar with Resident #1. Staff G, CNA stated Resident #1 was known to wander the unit and required frequent re-direction. Resident #1 would notify staff she needed to get her car and take care of her mom and would try to approach the elevator. Resident #1 was able to be re-directed and enjoyed sitting in her office eating snacks. Staff G, CNA stated Resident #1 would occasionally approach the emergency fire exit doors but was re-directed before she could attempt to open them. Staff G, CNA stated she was in her office on the second floor scheduling another resident for a procedure when she heard an alarm. Staff G, CNA hung up the call she was on and responded to the East hall of the unit. When she was partially down the East hall Staff G, CNA noticed the indicator light on the electromagnetic lock of the East emergency fire exit door was green, indicating the door was open. Staff G, CNA ran to the door with Staff E, CNA following behind her. Staff G, CNA entered the East stairwell and saw Resident #1 at the bottom of the stairs on the landing below. Staff G, CNA opened the East emergency fire exit door and shouted down the hallway for help. Staff G, CNA stated she walked about halfway down the stairs and saw Resident #1 lying flat on her stomach on the right side of the landing in a puddle of blood with her wheelchair behind her on the left side of the landing. Staff A, LPN UM and Staff F, LPN responded to the stairwell to aid Resident #1. Staff G, CNA returned to her office and notified the Nursing Home Administrator (NHA) and Director of Nursing (DON) of Resident #1's fall. Staff G, CNA returned to the East stairwell and remained there until EMS personnel arrived to take Resident #1 to the hospital. Staff G, CNA stated Staff H, LPN, Staff D, RN, the facility's MD, and the NHA were all present at the time. Staff G, CNA stated she would often see residents on the second floor wandering toward the emergency fire exit doors but had never witnessed a resident attempt to open the doors. An interview was conducted on 4/18/2023 at 1:07 PM with Staff H, LPN. Staff H, LPN stated he was working on the second floor as a CNA on 4/13/2023 due to CNA call offs. Staff H, LPN stated Resident #1 was able to propel herself in her wheelchair around the unit and had an alert bracelet, but never recalled the resident expressing a desire to leave the facility. Staff H, LPN stated he went on his lunch break around 12:50 PM on 4/13/2023 and saw Resident #1 sitting in her wheelchair by the unit nurses' station. When he returned from his lunch break Staff H, LPN responded to the East stairwell with a treatment cart from the first floor because he was told a resident fell in the stairwell. Staff H, LPN observed Resident #1 lying face down on the landing between the first and second floor. Staff H, LPN stated he provided gauze to Staff F, LPN, who was trying to control the resident's profuse bleeding from her head. Staff H, LPN assisted the staff already tending to Resident #1 by opening [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, the facility failed to ensure one resident (#1) of 11 residents at risk for elopement, was provided with supervision and services related to the resident's known exit-seeking behaviors and desire to exit the facility. The facility nursing staff failed to ensure the safety of Resident #1; on 4/13/2023 at approximately 1:15 PM, Resident #1 propelled herself in her wheelchair from the unit nurses' station, down the East Hall, passed by three staff offices, and approximately 141 feet to the East Hall emergency exit fire door. Resident #1 pushed on the handle to the East Hall emergency exit fire door, equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked), for approximately 15 seconds while a steady, audible beeping alarm sounded until the door opened. Resident #1 accessed the stairwell unsupervised and without staff knowledge and fell in her wheelchair down nine stairs to a landing between the 2nd and 1st floors of the building. The facility failed to take action to prevent the resident from accessing the stairwell on the second floor by not providing supervision for the resident and not responding to the audible alarm on the emergency fire exit door before the resident was able to open the door, access the stairwell and fall down the stairs. Resident #1 was discovered by a Certified Nursing Assistant (CNA) on the right side of the landing lying flat on her stomach in a puddle of blood with her wheelchair on the left side of the landing. Emergency Medical Services (EMS) was called and arrived approximately 10 minutes later and took Resident #1 to the hospital and was discovered to have a right temporal lobe subarachnoid hemorrhage, C1 ring fracture (fracture of the first cervical vertebra), suspect vessel injury with vessel wall irregularity and small pseudoaneurysm of the left cervical Internal Carotid Artery (ICA) at the level of the C1-C2 fractures, nasal bone fracture, facial laceration, and scalp laceration. This failure created a situation that resulted in a serious injury and the likelihood of death to Resident #1 and resulted in the determination of Immediate Jeopardy on 4/13/2023. The findings of Immediate Jeopardy were determined to be removed on 4/20/2023 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: A review of Resident #1's progress notes dated 4/13/2023 at 1:30 PM and authored by Staff B, Licensed Practical Nurse (LPN), revealed the following: Alarm to elevator and side exit to stairs going off. Checked elevator and side fire stairwell all clear. Checked west exit door and all clear. Checked east hall fire stairwell and CNA found [Resident #1] laying at bottom of stairs laying on left side with [wheelchair] over on side. Noted extensive amount of blood on floor around [Resident #1] and noted blood dripping from forehead. [Resident #1] was alert and talking and no [respiratory] distress noted. Other nurses and CNA [certified nursing assistant] at site and this writer left and called 911 and completed paper transfer sheet and showed [Resident #1] to EMS [emergency medical services] when they arrived. This writer called [Resident #1's family member] and informed of above and that [Resident #1] was transferred to [the hospital]. A telephone interview was conducted with Resident #1's representative (RR). The RR stated they were informed by the facility Resident #1 was rushed to the emergency room after opening a door, accessing a stairwell, and falling down several flights of stairs. The RR stated Resident #1 had suffered from a brain bleed, a fractured neck, something with her carotid artery, 8 staples on the side of her head, and 16 staples up from her nose to her forehead because of the fall. A review of Resident #1's hospital records, dated 4/13/2023 at 3:49 PM revealed Resident #1 was admitted from the emergency room to the Intensive Care Unit (ICU) critically ill with multiple lacerations to the head and face. A C1 (first cervical vertebrae) fracture, a small pseudoaneurysm (damage to a blood vessel wall causing blood to leak out into the surrounding tissue) on the left internal carotid artery at the level of the injury, a small intraparenchymal (into the functional tissue of the brain) bleed as well as what is read as a small 4 millimeter (mm) right cavernous carotid artery aneurysm, a nasal fracture, and a right temporal subarachnoid hemorrhage (bleeding in the space that surrounds the brain) were discovered following Resident #1's admission to the hospital. The physician who performed the initial critical care assessment wrote Patient has multiple issues that could be potentially life threatening. Complications in the management of C1 fractures range from minor discomfort to death. Jun 29, 2016, C1 fractures: a review of diagnoses, management options, and outcomes, nih.gov https://www.ncbi.nlm.nih.gov > articles > PMC4958388 A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), unspecified anxiety disorder, severe unspecified dementia with other behavioral disturbance, and major depressive disorder. Review of Resident #1's medical record revealed Resident #1 was discharged from the facility on 4/13/2023 to a highter level of care and had not returned to the facility as of 4/20/2023. A review of Resident #1's physician's orders for April 2023 revealed the following: - An order dated 12/10/2021 for an alert bracelet changed every 90 days and as needed. - An order dated 12/10/2021 for a functional check of the alert bracelet every day on the 11 PM to 7 AM shift. - An order dated 10/27/2020 for a check for placement of the alert bracelet on the left ankle, every shift. A review of Resident #1's care plan, revealed an undated, except for a listed admission date of 2/27/2019, Focus that (Resident #1) is at risk for behavior symptoms related to dementia, resistance to care at times, attempting to exit the facility, packs clothes and belongings on wheelchair and will attempt to push chair to the elevator and go home. Interventions included providing comfort by taking time with patient, reinforce positive behavior, redirect the patient, and use consistent approaches when giving care. In addition, Resident #1's care plan, revealed an undated, except for a listed admission date of 2/27/2019 Focus that (Resident #1) is exit seeking related to cognitive impairments, diagnosis of dementia, and wanting to drive home to Ohio. Interventions included an alert bracelet, calmly redirect to an appropriate area, check alert bracelet placement every shift, and check functioning of alert bracelet every day. Resident #1's care plan, also revealed an undated, except for a listed admission date of 2/27/2019 Focus that (Resident #1) is at risk for falls due to impaired cognition with poor safety awareness, impulsiveness, history of falls, risk for impaired balance, fluctuations of gait, risk for low blood sugar, and potential adverse reactions to medications. Patient ambulates independently into the halls and in her room. Interventions included encouraging transfers and position changes slowly, reinforce need to call for assistance, and help with transfers and ambulation as needed. In addition, Resident #1's care plan, revealed an undated, except for a listed admission date of 2/27/2019 Focus that (Resident #1) enjoys activities such as the daily perk and current events, attending activities like bingo, cooking class, arts and crafts, ice cream social, happy hour, live entertainment, reminiscing, and much more. She likes hanging out in the hall, talking with her peers, and visiting her friends up and down the unit. She likes watching movies on movie and snack night or she likes to just hang out in her room watching her TV. She has the notion to pack up all her things and head to the elevator saying she is going to the parking lot as her mother is waiting for her and then the nursing staff re-directs her. For the most part she is independent with use of her leisure time and chooses the group activities she attends. Interventions include activities (staff) will deliver a newspaper and daily perk to room for independent reading, encourage participation in independent activities such as current events, movies on television, music, reading, word games, group activities, and television, and provide supplies/materials for leisure activities as needed and requested. A review of Resident #1's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 4/6/2023 revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 6, which indicated severely impaired cognition. Resident #1's MDS assessment revealed under Section E - Behavior, that Resident #1 did not display behaviors of wandering. Section G - Functional Status revealed Resident #1 required supervision and one person physical assistance with locomotion on the unit and used a walker and a wheelchair for mobility devices. Resident #1's MDS assessment revealed under Section P - Restraints and Alarms showed a wander/elopement alarm was used daily. A tour of the facility's second floor was conducted on 4/17/2023 at 1:00 PM. The unit nurses' station is in the middle of the unit with two long hallways (East and West) and two short hallways (North and South). An emergency fire exit door is located at the end of each hallway on the unit. An observation of the East Hall revealed an emergency fire exit door at the end of the hallway. A piece of paper with a printed out stop sign on it was observed on the emergency fire exit door. The emergency fire exit door was observed to be locked with an electromagnetic lock, which could be opened after holding the door handle for 15 seconds according to the red lettering affixed to the door Emergency exit only. Security alarm will sound if door is opened. Push until alarm sounds. Door can be opened in 15 seconds. An additional exit door alarm was observed affixed to the upper portion of the door, which had white lettering Stop alarm will sound. The East emergency fire exit door was observed locked and secured. Observations of the North, South, and [NAME] hallway emergency fire exit doors on the unit revealed all doors had printed out stop signs, red lettering indicating Emergency exit only. Security alarm will sound if door is opened. Push until alarm sounds. Door can be opened in 15 seconds, and additional exit door alarms affixed to the upper portion of the door. The 4 exit doors on the unit were observed to be secured in the same way. An interview was conducted with Staff A, LPN Unit Manager (UM). Staff A, LPN UM stated the facility's second floor is designated as the Long Term Care (LTC) unit. Staff A, LPN UM stated the unit had an elevator which could be accessed by residents that were not a risk for elopement. Any residents with an alert bracelet would trigger the elevator alarm. A functional test and observation was conducted on the second floor of the facility on 4/17/2023 at 1:21 PM of the East hallway's emergency fire exit door with Staff A, LPN UM. Upon pressing on the handle of the emergency fire exit door, a repetitive beep sound could be heard for approximately 15 seconds and the door remained locked by the activated electromagnetic lock. After 15 seconds of pressing on the handle, the electromagnetic lock released, and a loud, steady tone was heard. Upon opening the emergency fire exit door, the additional exit door alarm activated, and a loud and steady screech noise could be heard from the alarm. Opening the door also activated a flashing white light on top of the exit door alarm. After testing the alarm functioning, Staff A, LPN UM deactivated the emergency fire door alarm and the exit door alarm. An interview was conducted with Staff A, LPN UM following the door alarm test. Staff A, LPN UM stated the facility installed additional exit door alarms, which were referred to as screechers to all the emergency fire exits doors on the unit following Resident #1's fall down the East stairwell. Staff A, LPN UM stated on 4/13/2023 she was in her office, located in the East hallway, when she heard an alarm sound around 1:30 PM. Staff A, LPN UM immediately went to the nurses' station to visually check all the emergency fire exit doors on the unit and the elevator and ensure staff were responding to the alarms. Staff A, LPN UM stated the elopement alarm at the elevator and the fire exit alarm were going off at the same time during the incident. Staff A, LPN UM stated she first responded to the unit elevator and South emergency fire exit door and did not see any residents by the doors. Staff A, LPN UM observed the red colored light on the door's electromagnetic lock was illuminated, indicating the door was still locked and secured. Staff A, LPN UM heard Staff G, CNA yell from the East hallway emergency fire exit door asking for assistance. Staff A, LPN UM responded to the East hallway emergency fire exit door at the end of the hallway and observed Resident #1 on the right side of the landing at the bottom of the first flight of stairs between the first and second floor of the building. Resident #1 was lying on the floor on her left side with her head toward the beginning of the second flight of stairs with her wheelchair folded up behind her on the left side of the landing. Staff A, LPN UM assessed Resident #1 to ensure she was still breathing. Staff A, LPN UM stated Staff E, CNA responded from the second floor shortly after she observed Resident #1. After verifying Resident #1 was breathing and had an open airway, Staff A, LPN UM went to the first floor emergency fire exit door, yelled out for assistance, and instructed staff to call 911. Staff F, LPN and Staff K, LPN responded to the East stairwell from the first floor and remained with Resident #1 while Staff A, LPN UM went down to the first floor and gathered Resident #1's paperwork in preparation for arrival of EMS personnel and transfer to the hospital. Staff A, LPN UM stated the facility's Medical Director (MD) was at the facility and observed Resident #1 before the resident was transferred to the hospital. Staff A, LPN UM stated Resident #1 had visible injuries, including lots and lots of blood and probably a fractured nose, but was alert and verbal when EMS arrived at the facility. EMS personnel entered the stairwell from the first floor and transported Resident #1 to the hospital. Staff A, LPN UM stated Resident #1 was exit seeking and would attempt to exit the unit by using the elevator but did not attempt to open the emergency fire exit doors on the unit. An observation was conducted on 4/17/2023 at 1:38 PM of the East stairwell on the second floor of the facility with Staff A, LPN UM. The East emergency fire exit door on the second floor opened to a landing, approximately 15 feet in length and 8 feet wide, leading to a flight of nine brown rubber coated stairs. The stairs lead to a landing, approximately 8 feet in length and 4 feet in width. The landing leads to another set of nine brown rubber coated stairs, leading to the first floor of the facility. Three small, jagged, black colored pieces of plastic were observed on the left corner of the landing between the first and second floor. Staff A, LPN UM stated the plastic pieces were from the side panel of Resident #1's wheelchair and had broken off. A small, one foot section of exposed concrete between the first and second staircase appeared stained with red colored liquid. (Photographic Evidence Obtained) Staff A, LPN UM stated the red colored staining to the exposed concrete was from Resident #1's blood and was not able to be cleaned. A tour of the second floor of the facility was again conducted on 4/19/2023 at 11:20 AM. The unit nurses' station is visible when exiting the elevator located in the South hallway. The unit nurses' station is a large octagon shaped desk situated in the middle of the unit. The North, South, East, and [NAME] emergency fire exit doors and unit elevator are visible from the unit nurses' station. The distance from the middle of the unit nurses' station to the entrance of the East hallway is approximately 16 feet. The East hallway contains 18 total rooms, including 13 resident rooms, Staff A, LPN UM's office, a Social Services office, an additional staff office, a soiled utility room, and a treatment room. The length of the hallway to the emergency fire exit door is approximately 125 feet in length. The emergency fire exit door opens to a landing, which is approximately 15 feet in length from the door to the first stair of the staircase. The total distance from the middle of the unit nurses' station to the first step of the East stairwell is approximately 156 feet. A review of the facility's staffing assignment sheet for the second floor dated 4/13/2023 on the 7 AM to 3 PM shift revealed two licensed nurses and five CNAs were assigned to the 62 residents on the unit. Eleven of the 62 residents were assessed to be at risk for elopement. An interview was conducted on 4/17/2023 at 2:38 PM with Staff B, LPN. Staff B, LPN stated she was Resident #1's assigned nurse on 4/13/2023 and was familiar with Resident #1. Staff B, LPN stated Resident #1 was alert and oriented, but confused and had days where she was agitated and exit seeking. Resident #1 would normally go to the unit elevator if she wanted to exit the unit, but the elevator alarm would sound right away due to Resident #1 having an alert bracelet. Staff B, LPN stated Resident #1 attempted to open the emergency fire exit doors in the past, but staff would respond and redirect her before she was able to open the emergency fire exit door. Staff B, LPN stated Resident #1 did not seem agitated on 4/13/2023 and did not express a desire to leave the facility. Staff B, LPN stated other residents were attempting to seek exit from the unit on the night of 4/13/2023 and the doors were being monitored frequently throughout the day. Staff B, LPN stated at approximately 1:15 PM on 4/13/2023, she was at the unit nurses' station charting when an alarm sounded. Staff B, LPN stated the alarms for the alert bracelets and the emergency fire exit doors sounded similar and were hard to distinguish, so they must physically and visually check all the doors on the unit when an alarm is triggered. Staff B, LPN stated that approximately eight to ten people, including residents, were near the activity room between the unit elevator and the South emergency fire exit door when the alarm sounded, and she responded to the area to see if any residents approached either door. Staff B, LPN then hollered down the [NAME] hall from the unit nurses' station and instructed the CNA staff to check for any residents near the [NAME] emergency fire exit door or in the [NAME] stairwell. The CNA staff told Staff B, LPN the [NAME] emergency fire exit door was secure, and no residents were observed in the [NAME] stairwell. Staff B, LPN heard a voice shout from the East hallway get down here quick, it's bad. Staff B, LPN and Staff A, LPN UM responded to the East stairwell and observed Resident #1 lying on her left side on the landing at the bottom of the staircase between the first and second floor. Staff B, LPN stated Resident #1's wheelchair was laying on it's side behind Resident #1 as if she flipped out of it and immediately noticed a pool of blood around Resident #1's head. Staff B, LPN stated Resident #1 was alert, talking, and stated to staff I really did it this time. Staff B, LPN observed Resident #1 had a head laceration and blood dripping from her nose and instructed staff to not touch the resident. Staff B, LPN stated after other staff responded to the stairwell, whom she could not remember, she left the stairwell and went to the first floor to call 911. Once EMS arrived at the facility, Staff B, LPN escorted them to Resident #1's location in the East stairwell and Resident #1 was taken to the hospital. Staff B, LPN stated she normally works on the weekends on the second floor and a resident would trigger the door alarms at least once during the weekend. The elevator alarm triggers the most because if any resident with an alert bracelet approaches the elevator, the alarm will trigger. Staff B, LPN stated the screecher alarms were added to the emergency fire exit doors after Resident #1's fall. Staff B, LPN stated no staff on the second floor witnessed Resident #1 pushing on the East emergency fire exit door handle or witnessed Resident #1 exiting the unit. Staff B, LPN stated residents were setting the elevator alarm off several times on 4/13/2023 because there were several near the activity room between the elevator and the South emergency fire exit door and the elevator alarm was sounding at the same time the emergency fire exit door on the East hall was sounding. An interview was conducted on 4/17/2023 at 3:18 PM with Staff C, CNA. Staff C, CNA stated he worked on the second floor on the 7 AM to 3 PM shift on 4/13/2023 and was familiar with Resident #1. Staff C, CNA stated Resident #1 had periods of confusion and would place her belongings into her wheelchair and ambulate toward the elevator because she wanted to leave the facility. Staff C, CNA stated Resident #1 did not express a desire to leave the facility on 4/13/2023 and was not observed near the exit doors on that day. Staff C, CNA stated he and Staff I, CNA were in a [NAME] hall resident room transferring another resident using a non-weight bearing lift into the resident's wheelchair shortly before they heard an alarm sounding. Staff B, LPN shouted down the [NAME] hallway and instructed Staff C, CNA and Staff I, CNA to visually observe the [NAME] hall stairwell. Staff C, CNA and Staff I, CNA opened the emergency fire exit door at the end of the [NAME] hallway and did not see any residents in the stairwell. Staff C, CNA reset the alarm on the [NAME] emergency fire exit door and returned to a resident room to assist another resident with a shower. Staff C, CNA stated on 4/13/2023, three different residents were witnessed approaching the stairwell doors on the [NAME] hallway throughout the shift and were redirected away from the doors before they could attempt to open them. Staff C, CNA stated when a resident approaches the emergency fire exit doors or attempts to push on the handle, staff on the floor will attempt to re-direct the resident and reset the alarm if needed. An interview was conducted on 4/17/2023 at 3:31 PM with Staff D, Registered Nurse (RN). Staff D, RN stated she was not assigned to Resident #1 on 4/13/2023 but was working on the second floor. Resident #1 would often sit by the unit nurses' station and would interact pleasantly with staff. Staff D, RN stated she did not witness Resident #1 display any exit seeking behaviors in the past and did not witness Resident #1 near exit doors on the unit. Staff D, RN stated she was returning to the unit following her lunch break when she witnessed EMS assisting the resident in the East stairwell and observed Resident #1 lying on the landing between the first and second floor surrounded by blood. Resident #1 was observed by Staff D, RN to have an injury to her scalp and a cracked nose. Staff D, RN observed Resident #1's wheelchair on the landing of the stairwell near Resident #1. Staff D, RN stated a staff member was assigned to observe the emergency fire exit doors for the rest of the shift following Resident #1's fall and additional alarms were installed on the doors. Staff D, RN stated all staff are to respond to alarms and they are normally able to re-direct residents on the unit before they can approach the emergency fire exit doors. An interview was conducted on 4/17/2023 at 3:40 PM with Staff E, CNA. Staff E, CNA stated she was familiar with Resident #1 and had taken care of the resident before. Staff E, CNA stated she had never heard Resident #1 expressing a desire to exit the facility, but the resident would sometimes gather her belongings and put them in her wheelchair. Staff E, CNA stated Resident #1 was able to be re-directed and enjoyed participating in activities. Staff E, CNA stated on 4/13/2023 she was on the elevator taking resident lunch trays down to the kitchen area following lunch on the unit when she heard an alarm. When she got off the elevator and stepped into the second floor unit, Staff A, LPN UM was already in the area near the elevator looking by the South emergency fire exit door. Staff E, CNA stated she went down the East hallway to see if any residents were observed near the doors at the end of the hallway when she observed Staff G, CNA open the East emergency fire exit door and requested her to come to the door. Staff E, CNA then turned around and yelled for assistance from Staff A, LPN UM and went through the East emergency fire exit door with Staff G, CNA. Staff E, CNA observed Resident #1 lying on the right side of the landing between the first and second floors of the building in a pool of blood with her wheelchair behind her on the left side of the landing. Staff E, CNA stated she tried to observe where the blood was coming from but Resident #1's face was covered in blood, so it was difficult to tell. Resident #1 requested Staff E, CNA to assist her to her feet but Staff E, CNA did not touch the resident. Staff E, CNA stated her and Staff G, CNA remained with Resident #1 until EMS personnel arrived and took the resident to the hospital. An interview was conducted on 4/18/2023 at 10:36 AM with Staff F, LPN. Staff F, LPN stated Resident #1 was normally confused and would occasionally pack up her belongings and place them in her wheelchair wanting to go home. Staff F, LPN would sometimes witness Resident #1 going to the elevator on the second floor and wait for the elevator to open so she could get into it, but not toward the emergency fire exit doors. Staff F, LPN stated when Resident #1 would attempt to enter the elevator, an alarm would beep because Resident #1 had an alert bracelet and was known to wander on the unit. Staff F, LPN stated she was by the nurses' station on the first floor of the facility when she was informed by Staff B, LPN Resident #1 had fallen down the stairs on the east side of the facility. Staff F, LPN responded to the East stairwell from the first floor and witnessed Resident #1 lying on the landing between the first and second floor of the facility on her stomach with her left arm behind her and her right arm out in front of her. Resident #1 was observed with her head lying on the left and resting on the floor with her wheelchair on the left side of the landing. Staff E, CNA and another CNA were in the stairwell with Resident #1 at the time. Staff F, LPN sat down next to Resident #1 and attempted to speak with the resident. Resident #1 was observed to have a skin tear on her right arm and had blood everywhere. Staff F, LPN attempted to wipe blood off Resident #1's nose several times as it was filled up with blood. Resident #1 stated to Staff F, LPN get me up, I got to get up, my head hurts but Staff F, LPN encouraged Resident #1 to remain still and reassured the resident. Staff F, LPN stated Staff H, LPN, Staff A, LPN UM and a bunch of other people entered the stairwell to assist. When EMS personnel arrived, Staff F, LPN exited the stairwell and Resident #1 was taken to the hospital. An interview was conducted on 4/18/2023 at 10:55 AM with the facility's Maintenance Director. The Maintenance Director stated the emergency fire exit doors on the second floor are equipped with electromagnetic locks and alarms. The alarm activates when the handle to the door is pressed, and the door can be opened after 15 seconds due to fire safety reasons. The alarm has a steady loud beep tone and does not stop until it is reset using the keypad next to the door. The Maintenance Director stated the elevator on the unit was equipped with an alarm for residents at risk for elopement. When a resident with an alert bracelet approaches the elevator, a separate alarm with an electromagnetic sound will trigger and the elevator will not be functional until the alarm is reset. The Maintenance Director stated staff would be able to distinguish the elevator door alarm from the emergency fire exit alarms. The Maintenance Director stated additional alarms, which he referred to screamers, were installed on the emergency fire exit doors following Resident #1's fall. The Maintenance Director stated the emergency fire exit doors were not equipped with a separate alarm for residents at risk for elopement and would be opened after holding the handle for 15 seconds. An interview was conducted on 4/18/2023 at 11:06 AM with Staff G, CNA. Staff G, CNA stated she occasionally assisted staff on the second floor and was familiar with Resident #1. Staff G, CNA stated Resident #1 was known to wander the unit and required frequent re-direction. Resident #1 would notify staff she needed to get her car and take care of her mom and would try to approach the elevator. Resident #1 was able to be re-directed and enjoyed sitting in her office eating snacks. Staff G, CNA stated Resident #1 would occasionally approach the emergency fire exit doors but was re-directed before she could attempt to open them. Staff G, CNA stated she was in her office on the second floor scheduling another resident for a procedure when she heard an alarm. Staff G, CNA hung up the call she was on and responded to the East hall of the unit. When she was partially down the East hall Staff G, CNA noticed the indicator light on the electromagnetic lock of the East emergency fire exit door was green, indicating the door was open. Staff G, CNA ran to the door with Staff E, CNA following behind her. Staff G, CNA entered the East stairwell and saw Resident #1 at the bottom of the stairs on the landing below. Staff G, CNA opened the East emergency fire exit door and shouted down the hallway for help. Staff G, CNA stated she walked about halfway down the stairs and saw Resident #1 lying flat on her stomach on the right side of the landing in a puddle of blood with her wheelchair behind her on the left side of the landing. Staff A, LPN UM and Staff F, LPN responded to the stairwell to aid Resident #1. Staff G, CNA returned to her office and notified the Nursing Home Administrator (NHA) and Director of Nursing (DON) of Resident #1's fall. Staff G, CNA returned to the East stairwell and remained there until EMS personnel arrived to take Resident #1 to the hospital. Staff G, CNA stated Staff H, LPN, Staff D, RN, the facility's MD, and the NHA were all present at the time. Staff G, CNA stated she would often see residents on the second floor wandering toward the emergency fire exit doors but had never witnessed a resident attempt to open the doors. An interview was conducted on 4/18/2023 at 1:07 PM with Staff H, LPN. Staff H, LPN stated he was working on the second floor as a CNA on 4/13/2023 due to CNA call offs. Staff H, LPN stated Resident #1 was able to propel herself in her wheelchair around the unit and had an alert bracelet, but never recalled the resident expressing a desire to leave the facility. Staff H, LPN stated he went on his lunch break around 12:50 PM on 4/13/2023 and saw Resident #1 sitting in her wheelchair by the unit nurses' station. When he returned from his lunch break Staff H, LPN responded to the East stairwell with a treatment cart from the first floor because he was told a resident fell in the stairwell. Staff H, LPN observed Resident #1 lying face down on the landing between the first and second floor. Staff H, LPN stated he provided [TRUNCATED]