**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility's policies and procedures, and staff interviews, the facility failed to protect each Residents' right to be free from abuse and neglect when they failed to accurately evaluate the risk for elopement and develop a individualized care plan to address wandering behaviors for Resident #53, and failed to immediately investigate an incident of staff to resident verbal abuse for Resident #5. Resident #53 was admitted to the facility on [DATE] and exhibited behaviors such as yelling out, combativeness and disrobing in the hallways. Resident #53 required continuous use of oxygen for Chronic Obstructive Pulmonary Disease (COPD). Staff interviews revealed Resident #53 was confused, constantly wandered and required close supervision. On 5/2/25, sometime between 6:00 p.m., and 6:55 p.m., Resident #53, who was cognitively impaired, with a history of dementia, unsafe wandering behaviors, and oxygen dependent, was able to exit the building unsupervised and without staff knowledge. The resident crossed a busy four lane highway, to a gas station that was approximately 0.1 miles from the facility. When the resident was located she was being tended to by Emergency Medical Services. She was brought back to the facility-by-facility staff. Staff were unable to determine the exact time of the resident ' s return but report it was sometime after 7:00 p.m. Resident #53 crossed a busy four lane road to get to the gas station located on a major eight lane highway creating a likelihood for serious injury, serious harm or death. Resident #53 could have sustained a fall traveling uneven ground or could have been hit by a car while crossing the busy four lane road. Resident #53 could have sustained life-threatening complications from the lack of necessary supplemental oxygen, such as low blood oxygen and respiratory failure. This failure resulted in the determination of Immediate Jeopardy. The findings included: Cross Reference to F689 and F835. 1. Review of the facility's policy titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI), revised 3/2025 revealed, Neglect . means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Review of the clinical record revealed Resident #53 was admitted to the facility from a local hospital on 4/26/25. Diagnoses included but were not limited to acute respiratory failure with hypoxia (lack of sufficient oxygen in the tissues), Chronic Obstructive Pulmonary Disease (COPD), Dementia, symptoms and signs involving cognitive functions and awareness. Review of the hospital Discharge summary dated [DATE] revealed the main problem during the hospital stay had been active delirium, agitation. The discharge summary noted, We do suspect this patient has Alzheimer dementia. She was treated with Seroquel [antipsychotic] while here, at discharge she will be on Seroquel 12.5 mg [milligrams] 3 times daily . I do not think this patient can go back to her independent living facility. She will need constant supervision from now on . She is going today to SNF [Skilled Nursing Facility] . Review of the physician's orders dated 4/26/25 revealed to encourage and assist the resident to use oxygen at 4 liters via nasal cannula continuously for COPD. Review of the admission Nursing Evaluation dated 4/26/25 revealed an elopement risk evaluation was completed. The nurse completing the evaluation entered No for the questions: Resident has cognitive status impairment (i.e. short term memory loss, BIMS score, diagnosis, etc.), Does the resident have the ability to ambulate independently (with or without use of assistive device/wheelchair)?, Does the resident exhibit exit-seeking behavior (e.g. walk towards exits, manipulate doors, handles etc.). The elopement evaluation determined Resident #53 was not at risk for elopement. The interventions included: Increased staff observation. Review of the progress notes revealed on 4/27/25 at 6:37 a.m., Resident #53 was sitting on the floor next to her bed. Her oxygen was off. Resident #53 was yelling at the nurse, You're trying to murder me, you're in love with my husband, you're having an affair with him. The nurse documented the resident was very confused and became more lucid with the oxygen on at 3 liters. On 4/29/25 at 1:27 a.m., a nursing progress note documented Resident #53 was standing naked in the hallway yelling, calling this nurse a witch and refusing to put O2 (oxygen) on. On 4/29/25 at 2:30 a.m., a nursing progress note documented the resident continued to yell at staff; sat on the floor from the wheelchair trying to hit and kick staff. The resident kicked and scratched the nurse. When the oxygen was put on, the resident became calmer. On 4/30/25 at 6:22 a.m., a Social Service progress note documented the resident's son did not feel she could return to independent living and was looking into memory care. The son shared his mother has had paranoid behaviors for some time now. On 5/1/25, an initial psychiatric evaluation noted the resident scored 05 on the Brief Interview for Mental Status, which indicated severely impaired cognition. The evaluation noted the resident was difficult to redirect, and verbally inappropriate making the assessment difficult. On 5/1/25, a statement signed by the attending physician noted in his opinion, Resident #53 no longer had the capacity to make knowing health care decisions for herself or provide informed consent after a sufficient explanation without coercion or undue influence. On 5/12/25 at 12:08 p.m., in an interview, Licensed Practical Nurse (LPN) Staff A said on 5/2/25 she was assigned to Resident #53. She said historically Resident #53 was confused and often had extreme behaviors including fighting, pulling off her oxygen, and not staying in one spot. LPN Staff A said on 5/2/25, Resident #53 got out of the building and was found at the gas station across the street. LPN Staff A said she usually kept a close eye on Resident #53, as she liked to wander. Staff A said on 5/2/25 she had been with a different resident when she noticed Resident #53 was gone. Staff A said they looked for the resident all around the building. Resident #53 was eventually located at the gas station across the street. Staff A said when they found Resident #53, she said she didn't want to be there, and she hated her son. Staff A said Resident #53 explained how she went out the back door and pushed the egress bar for 15 seconds to be let out. LPN Staff A said the door alarm did go off. Staff A said she notified the Director of Nursing (DON), the Administrator, and called the family. LPN Staff A verified the lack of documentation of Resident #53's wandering behavior and elopement incident in the clinical record. LPN Staff A said she had no explanation for the lack of documentation. She said, It was all just verbal. On 5/12/25 at 12:40 p.m., in an interview, LPN Staff B said she was on duty on 5/2/25 but was not directly working with Resident #53 when the resident left the building. LPN Staff B said she was on a different hallway. Someone said an Emergency Medical Services (EMS)/deputy was at the front door. She went to the front door. EMS told her they found someone at the gas station down the street and were trying to find where the person belonged. Staff B said EMS provided a last name that was different than Resident #53's last name. She said apparently Resident #53 had given EMS her [NAME] name. LPN Staff A looked in the computer and couldn't find a resident with the last name given by EMS. EMS left since they did not recognize the last name. LPN Staff B said a little after that LPN Staff A was going down the hall looking for Resident #53. When she told her the resident's last name, LPN Staff B said the resident that could not be located was probably the lady at the gas station EMS enquired about. She said she and Staff A went to the gas station. They asked EMS if the lady was still there so they could look at her and identify her. LPN Staff B said, I recognized her, I had seen her in the building. LPN Staff A said yes, that was who we were looking for. Resident #53 was a bit resistant to coming back. They called Resident #53's son from the gas station. He was able to persuade her to go back to the facility. LPN Staff B said Resident #53 was sitting on a milk crate at the gas station and didn't appear to have any harm. LPN Staff B said the Director of Nursing (DON) knew about the incident. The DON and the Administrator showed up to help. When asked about documentation of the incident, LPN Staff B said she wrote a witness statement. She did not do an incident report as she was not assigned to the resident. Staff B said she assumed LPN Staff A completed the incident report. LPN Staff B said earlier that day, before they knew Resident #53 was gone, she had heard the alarm by room [ROOM NUMBER] and 332 go off. LPN Staff A said it was one of her visually impaired residents who had pushed on the door causing it to alarm. She shut the alarm off. EMS showed up at the facility 20 to 30 minutes after she heard the door alarm to see if they had a missing resident. She said they noticed Resident #53 was missing at around 6:55 p.m., since she printed the face sheet at that time. Further review of Resident #53's clinical record failed to reveal documentation of the resident's elopement, assessment for injuries upon return to the facility, physician, DON, Administrator and legal representative notification. There was no documentation, the care plan was updated and supervision implemented to prevent further incident of unsafe wandering and elopement. On 5/12/25 at 12:32 p.m., in an interview, the interim DON said Resident #53 went out the back door on 5/2/25. The interim DON said Resident #53 was alert and oriented and wanted to go to the store. She said they did a reenactment with the resident. Resident #53 was able to describe it all, including walking to the door, reading the sign that says the door will release after 15 seconds, went out, looked both ways, crossed the street and walked to the gas station on the corner. The interim DON said staff had been up front dealing with another resident who wanted to leave and go to the store. She said LPN Staff A, Resident #53's nurse, was up front assisting with the other resident. She said the alarm sounded; they discovered Resident #53 was not in building. She was found at the gas station on the corner. She said if a resident wants to go to the store, the normal process was to sign out on a leave of absence. She said Resident #53 scored 13 on a Brief Interview for Mental Status she performed upon the resident's return to the facility. (A BIMS score of 13-15 indicates intact cognition). The DON said Resident #53 had been very behavioral and declined when she took her oxygen off. The DON said Resident #53 did not have her oxygen when she was found at the gas station. She said the police were at the gas station, but she did not know if they did a report. The interim DON said Resident #53 was cognitively intact and was able to describe how she left the facility that day and again the next day. Therefore, they did not consider Resident #53 leaving the facility without staff knowledge or supervision an elopement but rather a near miss. On 5/12/25 at 3:10 p.m., in an interview, the Administrator said on 5/2/25 staff called and notified him saying they couldn't find Resident #53 and had called an elopement code. He came to the building and so did the interim DON. He said after the fact, they did a reenactment with Resident #53. He said at first Resident #53 said she didn't do it. Then she walked us through what she did. She was able to do it again the next day. He said they investigated and completed a head to toe assessment. Resident #53 had behaviors, but the interim DON completed a BIMS and the resident scored 13. He said Resident #53 was someone who did what she wanted to do. The Administrator said staff reported that EMS came to the building to enquire about someone, but EMS asked about someone with a last name different then Resident #53's last name. The Administrator said Resident #53 leaving the facility without staff knowledge and supervision was not considered an elopement. He said it was a near miss since the resident was cognitively intact and knew where she was going. The Administrator said Resident #53 had not been incapacitated. When asked about the incapacity statement the attending physician signed and dated 5/1/25, the Administrator said Had I known Resident #53 was incapacitated, I would have considered the incident an elopement without a doubt. On 5/12/25 at 3:32 p.m., in an interview, the interim DON said she did not know on 5/1/25 the attending physician had signed an incapacity statement for Resident #53. She said Definitely, the incident would have been considered an elopement and would have been reported for sure. On 5/13/25 at 1:02 p.m., the Interim DON said all residents were assessed for elopement, on admission, quarterly or with any change in condition. When asked about Resident #53's hospital discharge documentation indicating she needed constant supervision, the interim DON said that didn't mean resident was exit seeking but meant she needed a skilled nursing facility. She said if a resident is exhibiting behaviors, it would have to be exit seeking behavior for an elopement re-screen. She said it all depended on how a resident presented. On 5/13/25 at 2:08 p.m., in an interview the Attending Physician verified on 5/1/25 he signed the letter of incapacity for Resident #53. When asked if it was safe for Resident #53 to be at the gas station on a busy road alone, he said it was a tricky case, as the resident's BIMS fluctuated. He said when she first came, she was more confused, was up and down. Her mentation waxed and waned. He explained when tricky like that, the long-term plan would be further evaluation, maybe to a neuropsychologist. He said with the waxing and waning, bouts of confusion/mentation, it could be confusing, and it was quite a complicated case. 2. Review of the facility's Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) Policy (last revised on 3/2025) revealed, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . Staff are required to report any allegation of ANEMMI to the facility risk manager, direct supervisor, and/or abuse coordinator immediately upon knowledge of the allegation . Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily harm . Review of the facility's policy and procedure titled, Resident Rights last revised on 1/2024 revealed, Employees shall treat all residents with kindness, respect, and dignity. Review of the facility's Abuse Reporting education revealed verbal abuse is, Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend or disability. The education also noted, Any verbal, physical, sexual; neglect; exploitation or injury of unknown source must be reported immediately, and All licensed staff (RN (Registered Nurse), LPN (Licensed Practical Nurse), CNA (Certified Nursing Assistant) ) are REQUIRED by law to report abuse, neglect or exploitation. Record review for Resident #5 revealed diagnoses of depression, generalized anxiety disorder and an unspecified mood disorder. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 4/15/25 revealed Resident #5 scored 15 on the BIMS test, indicating intact cognition. Review of the progress notes revealed a psychology note dated 4/17/2025 which noted, Patient was visible irritable when I approached her in the hallways prior to our session. Patient shared that she had a negative interaction with an aide last night. She reports that she did not threaten the aide in any way, but she did request to speak to her night nurse to express her needs. Patient had a meeting this morning to discuss concerns with the aide's behavior and dissatisfaction with care. Behavior management techniques were used to address and modify patient's behavior. On 5/12/2025 at 12:04 p.m., in an interview, Resident #5 said a couple of weeks ago she was on the phone with her sister. She heard the CNAs arguing in the hallway. Her sister asked what was going on. She told her sister, I think the aides are fighting. Resident #5 said a CNA then came in her room, slammed her meal tray on the table and then slammed the door. She went out in the hallway to confront the CNA. Resident #5 said the CNA falsely accused her of using a racial slur. She said the CNA began cursing at her. It made her angry, so she cursed back at the CNA. The resident said, It was a yelling match in the hall, and they had to be separated. Resident #5 said LPN Staff C witnessed the incident. Resident #5 said the Administrator and Social Services met with her. She was not sure who the CNA was and had not seen her since that day. On 5/12/2025 at 1:57 p.m., in an interview, the Administrator said he and Social Service met with the resident that day. Resident #5 reported the incident and said she had used a racial slur, the N word. The Administrator said Resident #5 curses an awful lot. On 5/12/2025 at 3:33 p.m., in an interview, Resident #5 said Social Services came to talk to her today and asked how long ago the altercation happened. She told the Social Worker, You should know, you were there. Resident #5 said the Administrator and the Social Worker were both there the day of the altercation. They said they would get the CNA's name, but they never did. Resident #5 said there was no investigation done that she knew about. On 5/13/2025 at 11:35 a.m., in a joint interview, the Administrator and Director of Nursing (DON) said there was no prior investigation of the incident. On 5/14/2025 at 3:18 p.m., in an interview, LPN Staff C said he remembered the altercation. Resident #5 was upset that day that a CNA slammed the tray. He could not remember the name of the CNA and said the Administrator and Social Services talked to Resident #5. On 5/14/2025 at 3:21 p.m., in an interview, the Social Worker said the CNA was no longer employed at the facility. She said the incident happened over a month ago. The Social Worker said Resident #5 reported she was on the phone with her sister and went out in the hall after the CNA slammed the tray. The Social Worker said Resident #5 said the CNA called her a white bitch under her breath. On 5/14/2025 at 3:36 p.m., in a follow up interview, LPN Staff C confirmed witnessing the verbal altercation between Resident #5 and the CNA. When asked about reporting the incident and if anyone came to see Resident #5 that day, LPN Staff C replied, I don't know. On 5/14/2025 at 3:33 p.m., in a follow up interview, the Administrator said he was not aware of the verbal altercation. On 5/15/2025 at 11:44 a.m., in an interview, the Administrator said any staff who witnesses an altercation between a resident and staff member immediately separates them. The person who witnesses the altercation notifies the DON who in turn will notify him. The staff member involved in the altercation is immediately suspended pending investigation. The Administrator said a staff member yelling at a resident would be considered abuse and would be reported. The Administrator said, If they witnessed it, they have a licensed obligation to report it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident representative and staff interviews, the facility failed to ensure processes were in place to ensure the safety of cognitively impaired residents at risk for elopement. The facility failed to accurately assess the risk for elopement and adequately supervise to prevent elopement of 1 (Resident #53) of 1 cognitively impaired, mobile and confused resident with known wandering behavior. Resident #53 was a vulnerable adult with severe cognitive impairment, confusion and multiple behaviors such as yelling out, disrobing in the hallway and constant wandering. On 5/2/25 at an unknown time after 6:00 p.m., staff failed to adequately supervise Resident #53. Resident #53 exited the facility without staff knowledge and necessary supervision. Staff were not aware of the resident's exit until 5/2/25 at approximately 7:00 p.m. On 5/2/25 at an unknown time after 7:00 p.m., Resident #53 was found at a gas station located approximately 0.1 mile from the facility. Resident #53 crossed a busy four lane road to get to the gas station located on a busy eight lane highway. The facility failure to ensure adequate supervision to prevent unsafe wandering and elopement of cognitively impaired, and confused residents created a likelihood of avoidable accidents for Resident #53 and other cognitively impaired and confused residents at risk for elopement which could result in serious harm, serious injury, serious impairment or death of the residents. This failure resulted in the determination of Immediate Jeopardy. The findings included: Cross Reference to F600 and F835. Review of the clinical record revealed Resident #53 was admitted to the facility from an acute care hospital on 4/26/25. Review of the hospital physician Discharge summary dated [DATE] revealed Resident #53's main problem during the hospital admission has been delirium (serious changes in mental abilities resulting in confused thinking and lack of awareness of surroundings), active delirium and agitation. The practitioner documented, We do suspect this patient has Alzheimer [sic] dementia. She was treated with Seroquel (antipsychotic) while here . I do not think this patient can go back to her independent living facility. She will need constant supervision from now on . The patient transfer form (Agency for Health Care Administration Form 3008) dated 4/26/25 noted Resident #53 was alert, disoriented but could follow simple instructions. Resident #53 ambulated with assistance. The admission Nursing Evaluation note dated 4/26/25 at 9:35 p.m., noted Resident #53 has no weight bearing restrictions. The resident utilizes the following mobility devices: Walker, Wheelchair. Review of the elopement risk evaluation dated 4/26/25 at 9:35 p.m. revealed the nurse completing the form entered No for the following questions: Resident has cognitive status impairment (i.e. short-term memory loss, BIMS (Brief Interview for Mental Status) score, diagnosis, etc.), Does the resident have the ability to ambulate independently (with or without use of assistive device/wheelchair)?, Does the resident exhibit exit-seeking behavior (e.g. walk towards exits, manipulate doors, handles etc.). The facility determined Resident #53 was not an elopement risk but checked Increased staff observation in the Interventions/Approaches section of the elopement evaluation. Review of the behavior monitoring on the Medication Administration Record (MAR) for April 2025 revealed Resident #53's documented behaviors did not include wandering. Review of the progress notes revealed on 4/27/25 at 6:37 a.m., Resident #53 was sitting on the floor next to her bed. Her oxygen was off. Resident #53 was yelling at the nurse, You're trying to murder me, you're in love with my husband, you're having an affair with him. The nurse documented the resident was very confused and became more lucid with the oxygen on at 3 liters. On 4/29/25 at 1:27 a.m., a nursing progress note documented Resident #53 was standing naked in the hallway yelling, calling this nurse a witch and refusing to put O2 (oxygen) on. On 4/29/25 at 2:30 a.m., a nursing progress note documented the resident continued to yell at staff; sat on the floor from the wheelchair trying to hit and kick staff. The resident kicked and scratched the nurse. When the oxygen was put on, the resident became calmer. On 4/30/25 at 6:22 a.m., a Social Service progress note documented speaking to the resident's son. The son said he did not feel his mother could return to independent living and was looking into memory care facilities. The son shared that Resident #53 has had paranoid behaviors for some time now. She would call the police and say her son was beating her and taking her money. On 5/1/25, an initial psychiatric evaluation progress note documented Resident #53 had a psychiatric history of dementia with other behavioral disturbances, delirium and insomnia. Resident #53 was observed sitting in her wheelchair. She was alert with severe cognitive impairment. Resident #53 scored a 5 on the BIMS which indicated severely impaired cognition. The resident was difficult to redirect. The practitioner documented Resident #53 was unstable. The symptoms were occurring daily and causing severe distress. The practitioner discontinued the Seroquel and ordered Depakote sprinkles 250 mg three times daily (Used to manage irritable mood and impulsivity). On 5/1/25, the attending physician signed a statement noting in his opinion Resident #53 no longer had the capacity to make knowing health care decisions for herself or provide informed consent after a sufficient explanation without coercion or undue influence. On 5/12/25 at 12:08 p.m., in an interview, Licensed Practical Nurse (LPN) Staff A said on 5/2/25 she was assigned to Resident #53. She said historically Resident #53 was confused and often had extreme behaviors including not staying in one spot. LPN Staff A said she usually kept a close eye on Resident #53, as she liked to wander. LPN Staff A said on 5/2/25 she had been with a different resident when she noticed Resident #53 was gone. Staff A said they looked for the resident all around the building. She said Resident #53 got out of the building and was eventually located at the gas station across the street. She said Resident #53 explained how she went out the back door and pushed the egress bar for 15 seconds to be let out. LPN Staff A said the door alarm did go off. She notified the Director of Nursing (DON), the Administrator, and called the family. LPN Staff A verified Resident #53's wandering behavior and not staying in one spot were not documented in the clinical record. She verified the lack of documented individualized interventions, including necessary and adequate supervision to ensure Resident #53's safety and prevent elopement. LPN Staff A said she had no explanation for the lack of documentation. She said, It was all just verbal. On 5/12/25 at 12:40 p.m., in an interview, LPN Staff B said she was on duty on 5/2/25 but was not directly working with Resident #53 when she left the building. LPN Staff B said EMS (Emergency Medical Services) came to the facility and said they had found someone at the gas station and were trying to find out where that person belonged. They did not recognize the name provided by EMS. LPN Staff A searched in the computer and could not locate any resident with the last name EMS provided. LPN Staff B said a little bit after that LPN Staff A was going down the hall looking for Resident #53 but could not locate her. LPN Staff B said earlier that day, before they knew Resident #53 was gone, she had heard the door alarm by room [ROOM NUMBER] and 332 go off. LPN Staff A said it was one of her visually impaired residents who had pushed on the door causing it to alarm. She shut the alarm off. EMS showed up at the facility 20 to 30 minutes after she heard the door alarm to see if they had a missing resident. The Administrator and Director of Nursing (DON) were notified and came to the facility. Staff B and Staff A went to the gas station recognized Resident #53 and brought her back to the facility. On 5/12/25 at 12:32 p.m., in an interview, the interim DON verified on 5/2/25 Resident #53 exited the facility through the back door and was found at the gas station across the street. She said upon the resident's return, she evaluated the resident's cognition. Resident #53 was alert and oriented and scored 13 on the Brief Interview for Mental Status which indicated intact cognition. She said she was not aware on 5/1/25 the psychiatrist noted Resident #53's cognition was severely impaired and scored a 5 on the BIMS. The DON said they conducted a soft investigation. They did not consider the incident an elopement but a near miss. The DON said Resident #53 knew what she was doing and was able to describe it that Friday and again the next day on Saturday. On 5/12/25 at 3:10 p.m., in an interview, the Administrator verified on 5/2/25 the staff called him, said they could not find Resident #53 and had called a code orange (Code used by the facility to alert staff of a missing resident). The Administrator said they did a reenactment with Resident #53. She took him to the exit door and was able to demonstrate how she opened the door. She was able to do it again the next day. The Administrator said they did not consider it an elopement. The Administrator said they did elopement drills the next day and retrained staff on elopement. They did a root cause analysis of the incident and determined it was not an elopement. The Administrator said the incident was discussed in the Quality Assurance and Performance Improvement meeting on 5/9/25 but no performance improvement plan was put in place since they did not consider it an elopement. On 5/13/25 at 1:02 p.m., the hospital discharge summary noting Resident #53 required constant supervision and a potential diagnosis of Alzheimer's disease was reviewed with the DON. She said constant supervision did not mean the resident was exit seeking. It meant she needed to be in a skilled nursing facility. On 5/15/25 at 10:14 a.m., in an interview, the Interim DON said if staff hear an alarm go off, they are supposed to go to the door, check the surrounding area outside to see if a resident exited, do a head count and call a code orange. On 5/16/25 at 3:34 p.m., in a telephone interview, Resident #53's son said the facility notified him of the elopement. He said it should never have happened, absolutely not. He said the facility called and told him they no longer could provide services for her. It's been an ongoing battle for two to three years. She did not have a place to go due to her behaviors. The son said his mother has always had wandering behaviors. She had the behavior when she was living with him. Review of the facility's Standards and Guidelines: Elopement and Wandering revised on 1/1/24 provided by the DON revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for incapacitated residents . Definition: A situation in which an incapacitated resident leaves the facility grounds or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement . Each incapacitated resident will be assessed for wandering upon admission, readmission, and whenever an elopement attempt or new wandering behavior is observed or identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility administration failed to utilize its resources effectively to ensure processes were in place and implemented to prevent neglect and maintain the safety of cognitively impaired and confused residents to prevent unsafe wandering and elopement. Resident #53 was a vulnerable adult with severe cognitive impairment, confusion and multiple behaviors such as yelling out, disrobing in the hallway and constant wandering. On 5/2/25 at an unknown time after 6:00 p.m., staff failed to adequately supervise Resident #53. Resident #53 exited the facility without staff knowledge and necessary supervision. Staff were not aware of the resident's exit until 5/2/25 at approximately 7:00 p.m. On 5/2/25 at an unknown time after 7:00 p.m., Resident #53 was found at a gas station located approximately 0.1 mile from the facility. Resident #53 crossed a busy four lane road to get to the gas station located on a busy eight lane highway. The facility administration failed to recognize the neglect of Resident #53 and called the resident's elopement a near miss. The facility administration failed to complete a thorough investigation and failed to implement immediate and appropriate action to prevent the neglect of other cognitively impaired, confused and mobile residents to prevent further incidents of unsafe wandering and elopement. The facility administration failure to use its resources effectively to maintain residents' safety created a likelihood of serious harm, serious injury or death of Resident #53 and other cognitively impaired residents who exit the facility without staff knowledge. The residents could cross the nearby busy four lane road or nearby eight lane highway, get hit by a car, or sustain a fall resulting in serious injury from walking the uneven ground around the facility. This failure resulted in the determination of Immediate Jeopardy. The findings included: Cross reference F600 and F689. Review of the Administrator's job description revealed, The Administrator administers, directs, and coordinated all functions of the facility to assure that the highest degree of quality of care is consistently provided to the patients . Responsibilities: . Understand the facility's care regulations and support the patient care program by regularly meeting with the Patient Services Director to discuss and address concerns of the department . Ensure adherence to the Patient's [NAME] of Rights . Operate the facility in accordance with (name) Care Center policies and federal, state and local regulations . Assist in the Quality Assurance and Performance Improvement (QAPI) process. The form noted, Employee signature below constitutes employees understanding of the requirements, essential functions and duties of the position. The Administrator signed the job description on 12/9/24. Review of the Director of Nursing job description revealed, Overview: Executes the goals and objectives of the nursing department in regard to patient/resident rights, patient/resident care and reflects the mission statement of the facility . Provides leadership and direction for the nursing staff while being responsible for the overall management of the Nursing Department. Ensures nursing staff's compliance with all facility and nursing policies and procedures as well as compliance with regulatory requirements. Responsibilities: . Ensure compliance with government and accrediting agency standards and regulations pertaining to Nursing. Directs systems and programs within the department designed to meet regulatory standards. Assess, coordinate, plan and implement the systems required to deliver a high standard of care to patients/residents . Participate in QA/PI Programs by providing for the collection and analysis of data for the continuous quality improvement program . Ensure residents' safety in accordance with resident safety program . The form noted, Employee signature below constitutes employees understanding of the requirements, essential functions and duties of the position. The interim DON signed the form on 5/5/25. Review of the clinical record revealed Resident #53 was admitted to the facility from an acute care hospital on 4/26/25. Review of the hospital physician Discharge summary dated [DATE] revealed Resident #53's main problem during the hospital admission had been delirium [serious changes in mental abilities resulting in confused thinking and lack of awareness of surroundings], active delirium and agitation. The practitioner documented, We do suspect this patient has Alzheimer [sic] dementia. She was treated with Seroquel [antipsychotic] while here . I do not think this patient can go back to her independent living facility. She will need constant supervision from now on . On 5/1/25 the attending physician signed a statement noting in his opinion Resident #53 no longer had the capacity to make knowing health care decisions for herself or provide informed consent after a sufficient explanation without coercion or undue influence. On 5/12/25 at 12:08 p.m., in an interview, Licensed Practical Nurse (LPN) Staff A said on 5/2/25 she was assigned to Resident #53. She said historically Resident #53 was confused and often had extreme behaviors including not staying in one spot. LPN Staff A said she usually kept a close eye on Resident #53, as she liked to wander. LPN Staff A said on 5/2/25 she had been with a different resident when she noticed Resident #53 was gone. Staff A said they looked for the resident all around the building. She said Resident #53 got out of the building and was eventually located at the gas station across the street. The clinical record lacked documentation of Resident #53's wandering behavior and the elopement incident. LPN Staff A said, It was all just verbal. On 5/12/25 at 12:40 p.m., in an interview, LPN Staff B said she was on duty on 5/2/25 when Resident #53 exited the facility. She said earlier that day, before they knew Resident #53 was gone, she heard the door alarm by room [ROOM NUMBER] and 332 go off. LPN Staff A said it was one of her visually impaired residents who had pushed on the door causing it to alarm. She shut the alarm off. EMS (Emergency Medical Services) showed up at the facility 20 to 30 minutes after she heard the door alarm to see if they had a missing resident. A little bit after that LPN Staff A was going down the hall looking for Resident #53 but could not locate her. The Administrator and Director of Nursing (DON) were notified and came to the facility. Staff B and Staff A went to the gas station recognized Resident #53 and brought her back to the facility. On 5/12/25 at 12:32 p.m., in an interview, the interim DON verified on 5/2/25 Resident #53 exited the facility through the back door and was found at the gas station across the street. She said upon the resident's return, she evaluated the resident's cognition. Resident #53 was alert and oriented and scored 13 on the Brief Interview for Mental Status, indicative of intact cognition. The DON said they conducted a soft investigation. They did not consider the incident an elopement but a near miss. The interim DON said Resident #53 knew what she was doing and was able to describe that Friday and again the next day on Saturday how she left the facility. The facility's soft investigation determined the incident did not meet criteria for elopement as the resident was able to demonstrate how she left the facility and was taught as a child to look both ways to cross the street. The DON said as part of elopement prevention, the facility's front door, the 200 hall door and the 400 hall exit door are equipped with a wander alarm system. The wander alert bracelets would set off the alarm if a resident attempted to go through the doors. She said the other doors have an egress bar that alarms if opened and can only be shut off with a key. On 5/12/25 at 3:10 p.m., in an interview, the Administrator verified on 5/2/25 the staff called him, said they could not find Resident #53 and had called a code orange. They did a root cause analysis of the incident and determined it was not an elopement. The Administrator said it was a near miss since the resident was cognitively intact, knew where she was going, and had not been incapacitated. The near miss incident was discussed in the Quality Assurance and Performance Improvement meeting on 5/9/25 but no performance improvement plan was put in place since they did not consider the incident an elopement. The Administrator said Resident #53 simply failed to follow the facility's leave of absence policy. She wanted to go to the store per her normal routine. When asked about the incapacity statement signed by the attending physician on 5/1/25, the Administrator said, Had I known Resident #53 was incapacitated, I would have considered the incident an elopement without a doubt. The Administrator said they conducted elopement drills the next day and retrained staff on the elopement policy. He said at least 75% of the staff were reeducated on the elopement policy. Review of the facility's Standards and Guidelines: Elopement and Wandering revised on 1/1/24 provided by the DON on 5/12/25 revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for incapacitated residents . Definition: A situation in which an incapacitated resident leaves the facility grounds or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement . Each incapacitated resident will be assessed for wandering upon admission, readmission, and whenever an elopement attempt or new wandering behavior is observed or identified. If an incapacitated resident is missing who is considered at risk, initiate the elopement/missing resident emergency procedure . Announce Code Orange [facility's code to alert staff of a missing resident]. Note the time that the resident was discovered missing, or the door alarmed. On 5/12/25 at 3:32 p.m., in an interview, the interim DON said she did not know on 5/1/25 the attending physician had signed an incapacity statement for Resident #53. She said definitely the incident would have been considered an elopement and would have been reported for sure. On 5/13/25 at 1:42 p.m., in an interview, the interim DON reviewed part of the soft file investigation. It included a near miss/missing resident checklist, elopement drills, elopement in-services, and door alarm testing. On 5/14/25 at 10:40 a.m., the DON provided a Standards and Guidelines: Elopement and Wandering policy revised 1/1/2025. She said she did not realize the policy had been updated. The policy read, A situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement and the situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning or being struck by a motor vehicle. The procedure only considered incapacitated residents and read in part, If identified at risk for wandering, elopement, or other safety issues, the incapacitated resident's care plan will include strategies and interventions to maintain the incapacitated resident's safety. Each incapacitated resident will be assessed for wandering and elopement upon admission, readmission, and whenever an elopement attempt or new wandering behavior is observed or identified. On 5/15/25 at 10:14 a.m., in an interview, the interim DON said if staff hear an alarm go off, they are supposed to go to the door, check the surrounding area outside to see if a resident exited, do a head count and call a code orange. The DON said the function of the wander alert bracelets is checked daily. On 5/16/25 at 12:22 p.m., during a review of the facility's Quality Assurance and Performance Improvement program, the Administrator reviewed the facility's Performance Improvement Plans (PIPs). He verified there was no current PIP related to elopement prevention. Review of the facility's neglect investigation initiated on 5/12/25 related to Resident #53's elopement revealed Resident #53's incapacity statement completed and signed by the attending physician on 5/1/25 was not uploaded to the resident's chart until 5/8/25 after the resident's discharge. The investigation also noted all the exit doors were checked for proper functioning. On 5/16/25 at 2:20 p.m., the DON demonstrated the function of the wander alert bracelets for the six current residents identified at risk of elopement. Resident #24 was identified at risk for elopement and wore a wander alert bracelet. When checked, the light verifying the wander alert bracelet was functioning properly did not come on, indicating the wander alert bracelet would not set off the alarm if the resident went through a door equipped with a wander alert system. The DON verified the wander alert bracelet was not functioning and said she would place the resident on 1 to 1 supervision until the wander alert bracelet could be replaced. Resident #59 was identified at risk for elopement and wore a wander alert bracelet. When the DON checked the resident's wander alert bracelet, a red light came on. The DON said the red light meant the wander alert battery was low. She said she would have it replaced immediately. On 5/16/25 at 2:45 p.m., a tour of the facility was completed with the Maintenance Director and the Maintenance Assistant to check the alarm system and function of the egress doors. The Maintenance Director explained when an egress door is pushed open, a very loud alarm will sound. The Maintenance Director pressed on the Heritage Hall East egress door bar. The door made a beeping sound. The Maintenance Director opened the door fully. The door alarm did not come on. The Maintenance Director then checked the Heritage Hall [NAME] egress door. The door made a beeping sound when pressed. The Maintenance Director pushed the door open. The alarm did not come on. On 5/16/2025 at 2:55 p.m., the Maintenance Director said the two egress doors should have sounded loudly when opened. He instructed the Maintenance Assistant to fix both doors. On 5/16/25 at 3:00 p.m., observation of the dining room with the Maintenance Director revealed an exit door that led to a screened porch. The Maintenance Director said the door was a mag locked door and could not be pushed open. The Maintenance Director demonstrated by pushing the door. The door easily opened and did not alarm. The Maintenance Director said, The door should not be able to be opened. My guy was out here power washing earlier. As of the exit date of 5/16/25 the facility's Administration failed to have documentation of a thorough investigation of Resident #53's elopement incident and effective use of resources to ensure processes were implemented to maintain the safety of cognitively impaired and confused residents to prevent unsafe wandering and elopement.