**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and policy reviews, the facility failed to provide adequate supervision for residents identified as high risk for elopement for 2 out of 14 vulnerable residents (Residents #1 and #2) and for one resident identified as physically aggressive towards self, staff, and residents (Resident #4). The facility failed to provide supervision to prevent an unwitnessed exit from the facility for Resident #1 and Resident #2 on 8/30/2025 while Resident #2 was assigned to one-to-one (1:1) supervision and both Residents #1 and #2 were located on a secured, locked unit of the facility. The facility failed to prevent Resident #4 from self-injury while on one-to-one supervision on 9/8/2025 and failed to prevent physical aggression by Resident #4 on 9/9/2025 resulting in Resident #4 punching a nurse in the face and being removed from the facility by law enforcement under an order for involuntary psychiatric examination. The cumulative effect of these events resulted in deficient practice the level of Immediate Jeopardy starting on 8/8/2025.This situation resulted in a finding of Immediate Jeopardy at a scope and severity of Pattern, (K). The facility's Administrator was notified of the Immediate Jeopardy on 9/11/2025 at 2:30 PM. The Immediate Jeopardy was determined to have begun on 8/08/2025. At the time of the survey exit on 9/11/2025, the Immediate Jeopardy was ongoing.Cross reference to F600.The findings include:Resident #1 and #2 A record review for Resident #1 included diagnoses of chronic kidney disease stage 3, hyperlipidemia, generalized anxiety, hypertension, Atrial fibrillation, chronic systolic heart failure, and Traumatic Brain Injury. A minimum data set (MDS) assessment, dated 8/12/2025, included a brief interview for mental status score (BIMS) of 7. A score of 0-7 indicates severe problems with thinking or memory according to Cleveland Clinic, accessed at my.clevelandclinic.org on 09/17/2025. A comprehensive care plan initiated for Resident #1 on 8/5/2025 included a care plan for elopement risk/wanderer related to impaired safety awareness/wanders aimlessly with a goal for safety to be maintained. Interventions included assess for elopement risk, distract from wandering by offering pleasant diversions, electronic monitoring device, and place on secured unit under increased supervision. A psychiatric admission note dated 8/6/2025 documented “patient presents guarded and non-cooperative initially during interview, patient states, I don't ever sleep, and I just want to get out of here.” A record review for Resident #2 documented admission to the facility occurred on 6/17/2025 with diagnoses of unspecified dementia, type 2 diabetes, difficulty in walking, cognitive deficits, and mood disorder. On 6/17/25, an elopement risk screen was completed which indicated a score of 3.0, indicating at risk for elopement. Review of the care plan for Resident #2 revealed there was a care plan initiated on 6/18/2025 documenting “resident is an elopement risk/wanderer related to disoriented to place, impaired safety awareness, and resident wanders aimlessly. Interventions include assess for elopement risk, distract resident from wandering by offering pleasant diversions and structured activities, electronic monitoring device per MD (doctor) orders, and place on the unit for increased supervision. On 6/20/2025, Resident #2's care plan was updated to “resident being placed on 1:1 supervision due to cutting off his wander guard bracelet and exit seeking.” A progress note dated 6/20/2025 at 11:40 pm stated “at approximately 2225 pm (10:25PM) CNA (certified nursing assistant) assigned as 1:1 stated Resident #2 was missing, the nurse checked patient's room and confirmed Resident #2 was not present, observed patient window inside of room was opened, and no visual of resident outside of room, DON (Director of Nursing) was notified and elopement protocol was initiated. A psychiatric progress note dated 6/21/2025 documented Resident #2 was able to engage in a rational process of relevant information, able to recognize the importance of medication and treatment compliance, able to recognize his medical condition and consequences of lack of treatment and had the capacity to make decisions related to his need for healthcare or long-term placement. He was documented as able to understand the nature, extent, and probable outcome of not receiving medical care and was alert and oriented to self, place, time, and situation. On 6/21/2025, an elopement risk evaluation was repeated and again indicated a score of 3.0, indicating at risk for elopement. On 6/23/2025, the care plan for Resident #2 was updated for behaviors due to “refusing care and medications, becoming agitated and will curse at staff. He slams the door and tells staff to stop following him, removes his wander guard, and is able to unscrew his window to leave facility. Interventions include administer medications as ordered, anticipate resident's needs, explain all procedures to resident before starting care, if reasonable discuss residents behaviors and why behavior is inappropriate.” On 6/29/2025, Resident #2 was transferred from the facility for an involuntary psychiatric evaluation due to mood disorder unspecified with documentation stating “patient has become violent towards staff, he is attempting to assault them and commit battery, he has a knife and is trying to break out the windows and exit facility. Due to his current state, he cannot be managed safely at this location and requires a higher level of care. Patient has failed all interventions by staff to help alleviate current symptoms. Due to these impulsive unpredictable and violent behaviors, the patient requires a higher level of care to ensure the safety of others at this time.” Resident #2 was discharged and re-admitted on [DATE] to facility. An MDS assessment for Resident #2 dated 6/23/2025 documented a BIMS score of 5 (severe problems with thinking or memory). During the 7-day assessment period associated with the MDS, wandering was documented to have occurred on 1-3 days and to place the resident at significant risk of getting to a potentially dangerous place. Diagnoses included: dementia, neurological disorders, diabetes, malnutrition, anxiety, bipolar disorder, encephalopathy, muscle weakness, difficulty walking, cognitive communication deficit, history of alcohol abuse. A progress note dated 7/13/2025 revealed: “alarm to the back door going off, when checking it out, they said that [Resident #2] was messing with the alarm on the door, they saw him doing it and told him several times to leave the door alone, after the alarm would not shut off, this nurse trouble shooting the problem and noticed that [Resident #2] had pulled the wires and tripping the connections to the alarm. A temporary fix on the door alarm, risk manager and maintenance is aware. [Resident #2] continues on 1:1 supervision.” Documentation demonstrated Resident #2 continued to refuse medications from the facility except for metformin. On 7/22/2025, Resident #2 refused medications, education was provided. Resident #2 stated he is going home and doesn't need anything from here. A progress note dated 7/23/2025 documented Resident #2 was not sleeping at night, stayed up all night, and was verbally aggressive to staff. Nurse able to re-direct resident. A 7/26/25 behavior progress note stated that while the nurse was in the lock down unit Resident #2 was witnessed using a butter knife to attempt to take the brackets off the window or pry the window open, the aide that witnessed this got him to give her the knife. Progress note dated 8/6/25 stated that Resident #2 declined to have a wander guard on his ankle. Resident #2 takes the wander guard off and continues on 1:1 care. A police report related to an elopement of Residents #1 and #2, which occurred on 8/30/2025, included documentation that a call was received from the facility at 7:13 PM to report a missing person – adult endangered. The description stated a window was broken during the escape attempt. The officer responded to a missing person and stolen vehicle at the facility. During the course of the investigation it was discovered that room [ROOM NUMBER] had a broken window, which was used by Resident #1 and Resident #2 to escape the nursing home. At approximately 8:04 pm, dispatch received a call reporting the potential whereabouts of Resident #2 at a local store approximately 1.8 miles from the facility. At approximately 11:59 pm, dispatch received a call with the whereabouts of Resident #1, who was observed walking on Interstate 10 near the 255 east bound mile marker. The stolen vehicle was located at mile marker 254 on the side of the road. The location where Resident #1 was located was approximately 40 miles from the facility. Resident #1 had an active warrant and was arrested and transported to jail. The facility is surrounded by wooded areas on the back and left and right sides, with access to highways in front and on the sides of the building. There is easy access to a creek area with a portion of the creek unfenced near the facility. Both Resident #1 and #2 faced hazards along the paths of the elopement which included the potential of being hit by a vehicle, being involved in a motor vehicle accident, being abducted, falling, and/or drowning which could have resulted in serious physical injury or death. Resident #1, who stole a facility employee's vehicle which was left unsecured with the window open and keys in the vehicle from the parking lot, drove it approximately 40 miles on a busy Interstate and then abandoned the vehicle and was found walking along the interstate near midnight in the dark experienced an increased level of risk based on the distance, method, and location traveled. A timeline of events of the elopement of Residents #1 and #2 on 8/30/2025 based on witness statements collected by the facility describe the following: Staff Member F, a certified nursing assistant, was assigned to 1:1 supervision of Resident #2 on 8/30/2025. According to the Administrator, who is also the Risk Manager, based on the facility investigation, Residents #1 and #2 were last seen on 8/30/2025 between 6:30 – 6:50 pm during change of shift. An announcement was made on the overhead page system for elopement at 7:05PM (which was 7 minutes prior to the time Staff Member F reported to ask for help in finding the residents). At approximately 7:00 PM, per witness statement, Resident #1 went to the bathroom and Staff Member F exited the doors of the locked unit where Residents #1 and #2 resided to get someone to sit with Resident #2 while she used the restroom. At 7:10pm, Staff Member F knocked on the door to check on him and there was no answer. Staff Member F entered the room next door and noticed the window was busted out and at approximately 7:12 PM ran to the nurses' station to get help finding the two residents. Staff Member P made a witness statement that the elopement announcement occurred at 7:15pm. The Administrator reported that Resident #2 was spotted in town at 7:44PM. On 9/11/2025, an interview was conducted with Staff Member H, who found Resident #2 after he eloped from the facility on 8/30/2025. Staff Member H said she was in a vehicle and observed Resident #2 walking across the highway to the store and stopped next to Resident #2 speaking with him. She stated Resident #2 had a mouth full of snuff and asked if she would take him to Lake City. Staff Member H described that three other staff members pulled into the parking lot along with law enforcement and she observed Resident #2 state to law enforcement that he and Resident #1 left the facility through the window, Resident #1 got into a truck in the parking lot, but he did not because he does not steal. She reported Resident #2 said, “I am no thief.” Staff Member H described the facility's procedure for elopement as “Once a page is announced of an elopement, we report to the nurses station of where the elopement occurred and receive a blue card telling us where we are assigned to search for missing resident, once that area is searched, we return it to the nurses' station. If the resident is not located after 10 minutes, law enforcement is to be notified.” In an interview with the Administrator on 9/8/2025 at 1:18 pm, the administrator confirmed the facility does not have a policy for resident supervision or one-to-one (1:1) supervision. A follow up interview with the Regional [NAME] President of Operations (RVPO) and the Regional Director of Clinical Services (RDCS) on 9/8/2025 at 4:08 pm confirmed there is not a policy for supervision, and this includes no policy for staff expectations for staff observing residents on 1:1 supervision but there was training after the elopements happened. The RDCS was not able to answer what type of training or expectations occurred prior to the elopements. The RVPO brought a set of toenail clippers to the interview and described them as the implement thought to have been used by Resident #2 to cut the wire located in his room which powered the gate alarm to the gate believed to have been used to exit the facility during the elopement on 8/30/2025. The RVPO and RDCS confirmed the wires powering the alarm were located in a resident room on a secured, locked unit and accessible to the resident. The facility policy Elopement (N-1031 effective date 9/21/2016 revised 8/1/2020) revealed, Patients to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change, and elopement event using the risk tool. Further review of best practice training only reveals that an organized search will be conducted immediately when a resident is determined missing (usually the resident does not go far from the facility unless it is an alert-oriented resident who has planned his leave). During the first 10 minutes of discovering that a resident is missing states time is important, announce all staff to a central location, search facility, search outside grounds, notify the executive director and director of clinical services, notify the police within 10 minutes of discovering the resident is missing. Staff training information that was given after the 8/30/25 incident reveals, One to one supervision is assigned to a resident based on behaviors that require monitoring. This could be risk of elopement, suicidal ideation, attempts to harm self or others. The staff should always place themselves in a location where they have a clear view to maintain observation of the resident and to be close enough to the resident to intervene should a behavior occur. Resident #4 A record review for Resident #4 included the following diagnoses: schizoaffective disorder, anxiety, trauma, “brittle” diabetic, anemia, other impulse disorders, restlessness and agitation, major depressive disorder, single episode, personal history of traumatic brain injury, mixed hyperlipidemia, epilepsy, intractable with status epilepticus, abnormal involuntary movements. A care plan was initiated on 1/11/2022 and most recently revised on 8/6/2025 for behaviors related to agitation, physically aggressive and combative with staff/residents and refusal of care, described that Resident #4 gets on the floor on his hands/knees disrobing and wandering in and out of others room, suffers from impulse disorder (sexual) and banging head/face episodes against wall. Resident #4 refuses to wear his helmet daily. The care plan included documentation under the heading “Interventions” that, on 8/31/2024, Resident #4 was 1:1 supervision and became hostile and overpowered the aide and entered into a fellow resident's room and struck the resident after he exited out the opposite door when using the restroom. Both parties were separated and addressed. Another care plan was initiated on 1/11/2022 for elopement risk wanderer related to disorientation to place, impaired safety awareness, resident wanders aimlessly, significantly intrudes on the privacy or activities. Interventions included: 1:1 supervision 24/7 for safety due to aggressive behaviors with others. DO NOT sit inside resident's room – sit in the doorway facing him so that he remains in your visual field – If he goes into the restroom, you are to stand by the door with it cracked, to ensure that he does not go through the door on the other side. This care plan was initiated on 3/12/2023 with a most recent revision on 9/8/2025. The most recent MDS assessment for Resident #4 was completed on 7/1/2025 and documented a BIMS score of 9, which indicated “moderate problems with thinking or memory” according to Cleveland Clinic accessed at https://my.clevelandclinic.org/health/diagnostics/bims-score on 9/17/2025. A progress note dated 9/4/2025 at 5:40am documented “Resident was observed waking from sleep and immediately began pacing rapidly up and down the halls. Assigned CNA followed for supervision. Resident began attempting to exit through the doors and became agitated. Resident [#4] went out the facility along with 3 other staff members. The other nurse on shift attempted to support the resident to prevent him from falling. During the intervention, the resident forcefully moved his head forward and made contact with nurse. Resident then attempted to leave the premises and fell into the bushes hitting his head. Resident was noted with abrasions to his left forehead and left knee. Due to continued attempts to leave the facility and inability of staff to maintain control, law enforcement was contacted. Resident [#4] was redirected back into the facility prior to their arrival. Police arrived shortly thereafter. Resident [#4] continues to be combative and agitated.” A psychiatric progress note date 8/18/2025 documented “The patient is seen today at the request of the staff after a report of the patient hitting a staff member. Staff reports that the patient was informed not to exit the building, and he responded aggressively and hit staff. The patient was temporarily restrained by holding his hands/arms in order to prevent him from further hitting the staff and once he was calm, his 1:1 CNA was changed out.” A psychiatric service note dated 8/17/2025 documented Resident #4 “has consistently demonstrated psychotic symptoms, including fixed delusions, auditory hallucinations, disorganized speech with derailment and incoherence, and grossly disorganized behavior.” A progress note dated 8/15/2025 noted “Resident attacked PCA (patient care assistant) assigned to 1:1 with him. Resident was informed not to exit building and punched staff in chest. Staff member restrained resident to ensure safety and resident then head-butted him. PCA removed from 1:1 new 1:1 placed with resident.” A transfer/discharge notice signed by the Administrator on 07/04/2025 documented that a discharge notice was provided to the resident/legal guardian for the reason “Your needs cannot be met in this facility” and “the safety of other individuals in this facility is endangered.” The document also included a brief explanation to support this action as “physical aggression toward staff, safety of staff and others compromised by his impulsive aggressive behaviors. Intervention unsuccessful in managing his behavior and impulsive aggressive behavior resulting in [involuntary psychological examination]. A PASRR (pre-admission screening and resident review) level 2 dated 7/11/2025 documented that any receiving nursing facility should assess the patient to confirm they are able to meet his needs and ensure the patient's safety, as well as the safety of others. On 9/8/2025 at 3:15 pm at the end of a hallway with patient rooms, a staff member and a younger resident were observed standing. The resident, later identified as Resident #4, had a raised red mark in the center of his forehead. A record review for Resident #4 included a progress note dated 9/8/2025 and described that Resident #4 “hit and head butted his head on the floor, he later hit his head on his bed siderail and then got up to go to the bathroom and hit his head on the door. A later note at 5:14pm documented the medical director was notified and advised “if resident is not complaining then just continue to monitor. Resident has not had any change in condition.” On 9/9/2025 at 11:30 am, Resident #4 was observed in the tv area sitting in a chair with CNA S near him. CNA S said she was trained to be within arm's reach for 1:1 observation and agreed Resident #4 exhibits aggressive behavior but said she had not received any training in how to deal with these behaviors. On 9/9/2025 at approximately 3:00 pm several law enforcement vehicles and personnel were observed in front of the facility entrance and, at 3:19 pm, an interview took place with Registered Nurse (RN) I, who explained Resident #4 punched her in the face and then assaulted a law enforcement officer when they were taking him out of the building. A certificate of Professional Initiating Involuntary Examination dated 9/9/2025 at 11:30am listed that “[Resident #4] has become psychotic, and violent, impulsive and has been physically aggressive towards staff. He has also assaulted the nurses. He is danger to others in his current state and needs a higher level of care to ensure his safety and the safety of others. Pt has failed all interventions by staff to help alleviate his current symptoms, due to these impulsive, unpredictable and violent behaviors, he needs a higher level of care to ensure the safety of others.” The form was signed by a doctor of nursing practice who is a psychiatric advanced practice registered nurse. On 9/9/2025 at 11:35am, Certified Nursing Assistant (CNA) B said in an interview that she doesn't feel safe working with Resident #4 and has observed aggressive behaviors and is aware Resident #4 tries to leave the building. She expressed that they were trained to back away and let him calm down, try to redirect him, and just stay close to him when he's running and alert the nurse. She said there isn't a specific way for staff to communicate or respond when the events happen. An interview with the Nurse Unit Manager (Staff Member R) on 9/9/2025 at 4:27 pm revealed that she said she has worked at the facility since May 13, 2025 and Resident #4 has been assigned 1:1 supervision for all the time she has worked at the facility. She described the 1:1 supervision duties for Resident #4 as “to make sure we kept ourselves and him safe, to be close enough to prevent bodily harm, to keep eyes on. We sit in the door[way] because it was very sporadic with his behaviors. He's been here the whole time I've been here and the behaviors are the same since he came. I was trained to keep him in the room as much as possible, to stay in the room, and to keep him at arms distance and to keep him from getting out. The only training we had was abuse and neglect training and told us to redirect him. I try to talk to him; I can't put my hands on him. I can't put my hands on him to restrain him. When he's on the floor I was told not to do anything to him because if I put my hands on him he thinks I'm part of his game.” She confirmed that if staff see him involved in acts of self-harm there is no action other than to watch him and report it. In an interview on 9/10/2025 at 5:12 pm, the psychiatric nurse practitioner assigned as the psychiatric services provider seeing Resident #4 said she has been seeing Resident #4 for about one month and agreed that the facility is not a safe setting for Resident #4, emphasizing “not at all.” She added, “I reached out today to ask why he isn't in a mental health facility and it's so clear that he can't manage his voices and they said that is a good idea. It takes specialized people to help to take care of them. I was talking to another resident and he said, ‘that guy was standing over me in my bed the other day – is he violent?' And the nurse came and they are all scared of him, I know that's true.” On 9/11/2025 at approximately 9:50am, an interview took place with the Administrator, the RVPO, and the RDCS regarding the facility's ability to meet the needs for safety for Resident #4 and why the facility continues to readmit Resident #4 after multiple discharges related to aggression and exiting the facility in which an involuntary psychological examination was ordered. The RVPO said that they have discussed it and reached out to the Long-Term Care Ombudsman and other facilities who refuse to accept Resident #4, and they take him back because “we'll be in trouble with the state if we don't.” The Administrator was asked about the discharge notice signed on July 4, 2025, which she signed and documented that Resident #4's needs could not be met at the facility and what had changed in Resident #4's condition or the services offered by the facility that indicated his needs could be met at the facility. The response was that “he's our resident and we have to take him back.” During the interview, copies of documentation of communication with the Ombudsman and requests to other facilities to accept Resident #4 were requested but not provided.