**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to protect residents' right to be free from sexual abuse by a resident. Three residents (#2, #4, #8) of five with physician-signed lack of capacity to consent documents experienced sexual abuse in the facility. Resident #1 had a documented history of inappropriately touching and attempting to kiss staff beginning August 25, 2023. The facility did not respond with interventions that prevented sexual abuse from occurring to vulnerable residents. On 9/5/23 Resident #4 was discovered naked in their room with another resident (Resident #1). On 3/29/24 staff observed a resident (Resident #7) removing his hand from Resident #8's pants. On 4/15/24 during the 3:00 p.m. to 11:00 p.m., shift staff observed Resident #1 masturbating while Resident #2 watched standing in his room's doorway. Facility staff did not respond to this observation. On 4/16/2024 Resident #2 was observed in bed with another resident (Resident #1) standing next to the bed, his penis in her mouth. Applying the reasonable person concept to Residents #2, #4, and #8 due to their severe cognitive impairments, they would be expected to be distressed and/or afraid after non-consensual or coerced sexual contact. These failures created situations that resulted in a worsened condition for Residents #2, #4, and #8 and the likelihood for continued sexual abuse to these and other residents and resulted in the determination of Immediate Jeopardy that began on 1/26/2024. The findings of Immediate Jeopardy were determined to be removed on 5/17/2024 and the severity and scope was reduced to E after verification of removal of immediacy of harm. Findings Included: An interview was conducted with Staff E, CNA, on 5/15/24 at 1:38 p.m. Staff E, CNA, stated she knew Resident #1 prior to the incident on 4/16/24 with Resident #2. Staff E said while completing shift change rounds with Staff T, CNA, Resident #1 was observed going across the hallway into Resident #2's room. Staff E, CNA, said when she entered Resident #2's room, Resident #2 was sucking his [Resident #1's] thing, and he was so into it he didn't know I was there, I yelled at him to stop. Resident #2 was observed in the B-bed laying on her side, the bed was raised to [Resident #1's] waist . He [Resident #1] had his hand behind his head. I [had] never seen it before that and haven't seen that since. Staff E, CNA, said It was like she [Resident #2] never had a reaction; she went back to sleep, she did not react. Resident #1 didn't say anything to Staff E, CNA, and Staff T, CNA. The Unit Manager, Staff U, Licensed Practical Nurse (LPN), said to Resident #1 I thought you stopped doing that, and he [Resident #1] stated No, I've never stopped that. Staff T, CNA, told Staff E, CNA, she observed the night before [April 15, 2024] Resident #1 was ejaculating and Resident #2 was watching. Attempts were made to telephone Staff T, CNA, messages left, and no response received. An interview was conducted with Staff R, CNA, on 5/15/24 at 1:57 p.m. Staff R, CNA, said she typically works on the first floor [Memory Unit] and is familiar with Resident #1 and Resident #2. He [Resident #1] has a habit of being sexual. Yesterday [Resident #1] was playing with self in room in his bed. [I] have seen him standing naked. On 4/16/24 Staff R, CNA, was assigned to care for Resident #1 and Resident #2 on the 7:00 a.m. to 3:00 p.m. shift. Staff R, CNA, said at approximately 2:00 p.m. after providing care to Resident #2, she observed Resident #1 sitting on the side of his bed and left both room doors open. Staff R, CNA, heard Staff T, CNA, ask Resident #1 What are you doing? Staff R, CNA said she went to Resident #2's room and was told Resident #1's penis was in the mouth of Resident #2. She observed Resident #2 covered with a cloth bed pad. Staff R, CNA, said Staff T, CNA, told her on 4/14/24 during the 3:00 p.m. to 11:00 p.m. shift Resident #2 was peeking in the door and Resident #1 who was sitting on his bed with pants down and he was playing with himself. Staff R, CNA said Staff T, CNA, said she told the nurse of her observation of Resident #1 and Resident #2. Staff R, CNA, heard Resident #1 tell Staff U, LPN, I can't stop, I don't want to. Staff R, CNA, said when assigned to 1:1 observation (staff supervision requiring constant visualization of the resident) for Resident #1 would be sexual and would come and stand over me. Staff R, CNA, said when assigned to hall monitoring, she received safety check logs from the hall monitor on the previous shift. Each resident on every 15 minutes, every 30 minute or every 1 hour checks will have separate logs. An interview was conducted on 5/15/24 at 2:34 p.m. with Staff C, Social Services Director (SSD), who said she was familiar with the 4/16/24 incident involving Resident #1 and Resident #2. Staff C, SSD, said she spoke with Resident #2 and asked, If she was ok, remembered anything happen. Resident #2 said She was in pain but did not report area. We sent her to the hospital on the same day and they sent her back. Staff C, SSD, said she spoke with Resident #1 to find out what he was thinking before going deep into investigation. When Resident #1 was asked why he did it, he said because he wanted to. After the incident, she completed a psychosocial evaluation on Resident #1 and Resident #2 and contacted family members for each resident. Resident #2's family member did not want to press charges. Staff C, SSD, said she assumed a full-time employee position at the facility in late February 2024. She did not know Resident #1's history and he was not discussed during the transition by the previous Social Services staff. Staff C, SSD, said Resident #1 had been discussed in Quality Assurance Performance Improvement meetings (QAPI) and the following interventions had been implemented: 1:1 monitoring, room changes and hallway changes. I know right now he's 1:1, prior to this [4/16/24] incident he was referred for transfer to other facilities. During the interview with Staff C, SSD, Staff D, LPN, Staff Development Coordinator (SDC) said, no one wants him [Resident #1], family wants to keep him on 1:1 forever. Staff D, LPN, SDC, said according to Resident #1's family, elopement risk was the reason for his admission to the facility. Resident #1's family member doesn't want anything to do with him and hasn't been forthright with any information. Staff C, SSD, said I did the psychosocial evaluation with Resident #8. I notified Resident #8's family member of the incident on 3/29/24. Resident #8's family did not want the [resident] in the solarium without facility staff. Staff C, SSD, said when Resident #8 was asked about the incident, there was no response. During the interview on 5/15/24 at 2:34 p.m. a situation between Residents #7 and #4 was discussed, Staff C, Social Services Director (SSD) said when Resident #7 was asked about the incident, the resident did not admit the incident occurred. Staff C, SSD, said 1:1 monitoring of Resident #7 was started immediately. Staff C, SSD, said Resident #4 does not remember anything from September. Resident #4 hangs out with others from the same culture and communicates in her [native language]. Resident #2 Review of Resident #2's admission record revealed initial admission to the facility was on 6/4/2023 with diagnoses of Parkinson's disease, major depressive disorder, heart failure, chronic kidney disease, dementia, hyperlipidemia, high blood pressure, encephalopathy, and dysphagia. Review of Resident #2's Minimum Data Set (MDS), quarterly dated 12/4/23, revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, meaning severe cognitive impairment. Section GG for Functional abilities and goals revealed Resident #2 uses a wheelchair for mobility. Review of section E, Wandering - Presence and Frequency revealed Resident #2 wanders daily. Review of section J, Prognosis revealed Resident #2 has a medical condition or chronic disease that may result in a life expectancy of less than 6 months. Review of a care plan, created on 6/6/23, revealed Resident #2 has impaired cognitive function/dementia or impaired thought processes related to dementia, impaired decision-making, long-term memory loss, short term memory loss. The care plan's goal is Resident #2 will maintain current level of cognitive functioning. Review a of care plan, created on 2/26/24, revealed Resident #2 is receiving hospice services due to terminal diagnosis of Parkinson's disease. The care plan's goal is to keep Resident #2 comfortable throughout the end-of-life journey. Review of a care plan created on 3/4/24, revealed Resident #2 has a terminal condition related to Parkinson's disease. The care plan's goal is Resident #2's comfort to be maintained. Review of care plan, Resident #2 is at risk for cardiovascular complications related to congestive heart failure and high blood pressure. The care plan's goal is Resident #2 will have minimized complications related to cardiac (heart) condition. Review of the care plan created on 6/23/23, revealed Resident #2 at times wanders but is usually easily redirected to the nurses' station or day activities. The care plan's goal is Resident #2's safety will be maintained through next review date. Review of a care plan created on 9/17/23 revealed Resident #2 is impulsive and pulls wheelchair behind her difficult to redirect. The care plan's goal is Resident #2 will cooperate with care through the next review date. Review of order summary report revealed physician orders active as on 5/13/24 included 1) actively exit seeking, record number of occurrences every shift; 2) Hospice services for Parkinson's disease; 3) Trazodone for depression; 4) Metoprolol for Hypertension; 5) Morphine Sulfate 20 mg/ml (milligrams per milliliter) by mouth every 6 hours when needed for pain ; 6) Ativan 1 mg for anxiety every 4 hours as needed. Review of Resident #2's Determination of Incapacity, dated 4/5/24, and signed by two providers, revealed .resident lacks capacity to give informed consent to make medical decisions and does not have reasonable probability of recovering mental and physical capacity to directly exercise rights. Review of a psychiatric note, authored by the psychiatric-mental health nurse practitioner (PMHNP), dated 4/2/24. The history of present illness section revealed no reports of anxiety symptoms .no behaviors reported at this time. Resident #2's mental status examination section revealed the following: Appearance/ behaviors: confused. Mood: Patient mood is fine Affect: constricted Insight judgement: Impaired The plan of action section revealed continue medications, lorazepam for agitation intramuscularly (IM) three times daily as needed (PRN) for the next two weeks. Review of a subsequent psychiatric note, authored by the PMHNP, dated 4/17/24, section history of present illness revealed Prior to last visit, patient was doing well. Patient was not depressed or anxious. Patient had no behaviors reported. During the last visit, patient had no distress noted unit manager and director of nursing (DON) requested resident to be [evaluated] via tele psych due to patient having increase agitation and combativeness. Patient appeared irritable. Resident #2's mental status examination section revealed the following: Appearance/ behaviors: Well groomed, poor eye contact Mood: Patient mood is irritable Affect: Tensed Insight judgement: Impaired The sectioned titled assessment and plan revealed patient is unstable requiring medication changes .symptoms are occurring due to exacerbation of underlying .mood disorder. the symptoms occurring almost daily causing severe distress. The start medication section revealed Trazadone 25mg three times daily. On 5/13/24 at 9:48 a.m. during observation and interview, Resident #2 was found lying on her left side, linen up to her shoulders. Resident #2 opened her eyes when greeted, and nodded when asked if she was feeling okay. She did not respond verbally during the interaction. On 5/14/24 at 2:45 p.m. Resident #2 was observed in bed with her eyes closed. She appeared calm without any indication of pain or discomfort. On 5/17/2024 at approximately 3:40 p.m. Resident #2 was observed waking and was accompanied back to her wheelchair by staff. Review of a progress note, dated 4/17/24 at 10:42 p.m. authored by Staff CC, RN, revealed . Lorazepam was administered due to agitation. Review of Resident #2's facility progress note, dated 4/18/24 at 12:26 p.m. authored by Staff U, LPN, revealed resident noted very agitated refusing care combative Ativan 0.5 mg IM resident placed in crisis care by hospice with 24 hours at bedside. Review of Resident #2's facility progress note, dated 4/19/24 at 9:21 p.m. authored by Staff CC, RN, revealed . resident had increased agitation during the shift. Lorazepam 1 mg administered .to decrease agitation. Review of Resident #2's facility progress note, dated 4/23/23 authored by Staff EE, LPN revealed new order was given by the hospice nurse Lorazepam (Ativan) 1mg every four hours and d/c (discontinue Lorazepam 0.5 mg). Review of Resident #2's eINTERACT SBAR Summary for Providers note dated, 4/16/24 at 6:25 p.m., authored by Staff U, LPN, Unit Manager, revealed the change in condition (CIC) being reported is: other change in condition, and lists vital signs from 4/16/24 at 6:31 p.m. The section titled Outcomes of Physical Assessment revealed: Mental Status evaluation: No changes observed. Functional status evaluation: No changes observed. Behavioral status evaluation: No documentation Nursing observations, evaluation, and recommendation resident to resident altercation MD order resident out evaluation. Review of Resident # 2's progress notes, dated 4/16/24 at 5:00 p.m., authored by Staff C, SSD, revealed, resident was interviewed by writer and does not have memory of a male being in her room or a memory of anything happening to her .verbalized she was not feeling well and was in pain. Review of Resident # 2's progress notes, dated 4/16/24 at 4:02 p.m., authored by Staff DD, RN, revealed tele health done, no new orders. A review of Resident #2's Emergency Department discharge instructions, dated [DATE], section titled, Tests Performed, revealed blood tests for hepatitis and HIV screen were performed. Section titled: Education Material revealed Treating sexual assault. Resident #4 Review of Resident #4's admission record revealed the initial admission date was on 8/11/23 with diagnoses including gastroesophageal reflux disease, hyperlipidemia (high fat content in the blood), dementia, mood disturbance, Alzheimer's disease, cerebral atherosclerosis (buildup of plaque in the artery) major depressive disorder, generalized anxiety disorder, other persistent mood disorders and brief psychotic disorder. Review of Resident #4's Minimum Data Set (MDS), quarterly dated 4/21/24, revealed a Brief Interview for Mental Status (BIMS) score 1 out of 15 meaning severe cognitive impairment. Section GG for Functional abilities and goals revealed Resident #4 walks independently and is dependent with personal hygiene. Review of Resident #4's Determination of Incapacity, dated 2/2/24, and signed by two providers revealed .resident lacks capacity to give informed consent to make medical decisions and does not have reasonable probability of recovering mental and physical capacity to directly exercise rights. On 5/13/24 at 11:30 a.m. Resident #4 was observed sitting on the side of her bed. English is a second language for Resident #4 and an interpreter was used for communication. Resident #4 said she was doing well and did not have any concerns. On 5/114 at 2:15 p.m., Resident #4's family member was contacted by telephone and said they would return the phone call with another family member due to language barrier. A return call was not received. Review of Order Summary Report active orders as of 5/15/24 reveal Resident #4: 1) actively exit seek, record interventions. admitted to hospice on 10/23/23 related to diagnosis of cerebral atherosclerosis. 2) Attest that rounding with visualization of resident has been completed every two hours during the shift, ordered on 8/22/23. Resident #4's Depakote for mood disorder, Trazadone for depression, Paxil for depression, Zonisamide for seizures, and Olanzapine for psychosis. A review of the care plan focus created on 8/14/23 revealed Resident #4 had potential for pain related to muscle weakness and terminal prognosis, and the care plan's goal was Resident #4 will not experience a decline in overall function. A care plan created on 8/20/23 revealed Resident #4 was at risk for complications due to being incontinent of urine and bowel. At risk for developing areas of impaired skin integrity and UTIs (Urinary Tract Infections). The goal was to minimize Resident #4's risk for skin breakdown and infection. A care plan created on 8/14/23 revealed Resident #4 was an elopement risk/wanderer related to impaired safety awareness, resident wanders aimlessly. The care plan's goal was Resident #4's safety will be maintained through the next review date. A review of the care plan created on 8/13/23 revealed Resident #4 had potential to be physically aggressive related to dementia, history of harm to others, poor impulse control, and inappropriate behaviors. The care plan goal was Resident #4 will not harm self or others through the next review date. A review of the care plan created on 8/14/23 revealed Resident #4 had impaired cognitive function/dementia or impaired thought processes related to dementia, impaired decision making, and short-term memory loss. The care plan goal was Resident #4 will maintain level of cognitive function through the review date. A review of Resident #4's care plan focusing on impaired thought process related to dementia, impaired decision making and short-term memory loss, initiated on 8/14/23, stated the care plan goal was resident will maintain the current level of cognitive function through review date. The care plan interventions include cue, reorient and supervise as needed. A review of Resident #4's progress note dated 9/5/23 at 11:25 p.m. revealed .Resident was observed by staff in room with [Resident #1], at this time resident was without clothing, resident was redirected .family member and physician notified. Resident #8 Review of Resident #8's admission record revealed initial admission to the facility was on 6/29/20 with diagnoses of cerebral atherosclerosis, depression, dementia, psychotic disturbance, anxiety, pseudobulbar affect (condition that affects how the brain controls emotion), high blood pressure, type 2 diabetes, pressure ulcer (sore) right hip. Review of Resident #8's active orders as of 5/14/24 revealed: 1) hospice services effective 7/6/23 for cerebral atherosclerosis. 2) attest that rounding with visualization of resident every 2 hours. 3) Hydrocodone with acetaminophen every 12 hours as needed for pain. 4) Levothyroxine for hypothyroidism. 5) Trazodone for depression. Review of Resident #8's Minimum Data Set (MDS) quarterly, dated 4/5/24, revealed a Brief Interview for Mental Status (BIMS) score of 99, meaning severe cognitive Impairment. Section F, Preferences for Customary routine Activities, revealed Resident #8 is rarely/never understood and family/significant is not available. Section GG, Functional Abilities and Goals, reveals Resident #8 uses a wheelchair and is dependent on staff for mobility and self-care. On 5/14 at 3:17 p.m. Resident #8 was observed sitting in a Geri chair by the nurses' station. Her eyes were open; she did not react to greetings or respond to questions. Review of Resident #8's Determination of Incapacity, dated 6/8/20, and signed by two providers, revealed .resident lacks capacity to give informed consent to make medical decisions and does not have reasonable probability of recovering mental and physical capacity to directly exercise rights. Review of care plan focus revealed Resident #8 was at risk for skin breakdown. The care plan's goal was Resident #8's Risk for skin breakdown will be minimized through next review. Review of care plan focus revealed Resident #8 had a pressure wound to right hip. The care plan goal was Resident #8 wound will heal without complications. Review of care plan revealed Resident #8 had diabetes and was at risk for high and low blood sugars. The care plan's goal was Resident #8 will remain free from complications related to high and low blood sugars. Review of care plan focus revealed Resident #8 was at risk for decreased ability to perform activities of daily living in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. The care plan goal revealed Resident #8 will continue to participate in activities of daily living as tolerated. Review of care plan revealed Resident #8 had the potential for pain related to wound, diabetes and depression. The care plan's goal was Resident #8 will not experience a decline in overall function. Review of care plan focus revealed Resident #8 was at risk for complications due to being incontinent of urine and bowel related to impaired cognition and impaired mobility. The care plan goal was Resident #8 will minimize the resident's risk of skin breakdown through the next review date. Review of care plan focus revealed Resident #8 was receiving Hospice services as of 7/6/23 for diagnosis of cerebral atherosclerosis. The care plan goal was Resident #8 will be kept comfortable throughout the end-of-life journey. Review of care plan focus revealed Resident #8 had a terminal condition related to cerebral atherosclerosis. The care plan's goal was Resident #8's comfort will be maintained through next review date. Review of care plan focus revealed Resident #8 had impaired cognitive function/dementia or impaired thought processes related to dementia. The care plan goal was Resident #8 will maintain current cognitive function through review date. Review of Resident #8's Psychiatry Subsequent Note, authored by the psychiatric-mental health nurse practitioner (PMHNP), date of service (DOS) 3/29/24, the History of Present illness section, revealed . as per collected information, DON requested patient to be seen as patient was touched by a male patient. Patient did not respond to providers questions but appears to be lying comfortably with eyes open. No noted signs or symptoms of distress. No other psychiatric symptoms observed. Dementia is persistent, but no behaviors noted. The Mental status examination section revealed; Appearance/ Behaviors: calm, Mood: stable, Affect: appropriate, Insight and Judgement: Impaired. The Plan of action section revealed no medication changes. Resident #1 Review of Resident #1's admission record revealed initial admission to the facility was on 6/22/2023 with diagnoses of Syncope and collapse, Hyperlipidemia, Dementia, Anxiety Disorder, Depressive Disorder, Persistent Mood Disorders, Insomnia, Essential hypertension, Muscle weakness and bradycardia. Review of Resident #1's Determination of Incapacity, dated 3/7/24, and signed by a provider revealed .resident lacks capacity to give informed consent to make medical decisions and does not have reasonable probability of recovering mental and physical capacity to directly exercise rights. Review of Resident #1's Minimum Data Set (MDS) quarterly, dated 3/22/24, revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, meaning moderate cognitive Impairment. Functional Abilities revealed he was independent in walking and transferring from bed to chair. Behaviors showed he had verbal behaviors directed towards others and other behavioral symptoms. He exhibited wandering in the past one to three days. Review of the Facility's progress notes, order summary report and interviews for Resident #1 revealed the following: 7/19/23 transferred to the facility's memory unit due to behaviors. Resident #1 was reported to inappropriately touch and attempt to kiss staff. On 9/5/23 Resident #1 and Resident #4 were observed naked in Resident #1's bedroom. On 9/6/23 he was moved to a room on the opposite hallway away from Resident #4. On 9/8/24 Depakote 250 mgs was prescribed for mood disorder. On 11/6/23 and 12/16/23 Resident #1 had physical and verbal altercations with other residents. On 12/17/23 Resident #1's room was changed due to the 12/16/23 altercation with his roommate. On 2/6/24 resident was redirected because of inappropriate conversation with a female resident. On 2/7/24 Resident #1 was observed exhibiting inappropriate sexual behaviors. On 3/5/24 Resident #1 was observed following a female resident, when redirected he became agitated and said, he can if he wants to. On 4/15/24 Resident #1 was masturbating while Resident #2 was watching. On 4/16/24 Resident #1 was observed in Resident #2's room engaged in oral sex. Review of Resident #1's care plans revealed the following focus Resident #1 is at risk for hypersexual behaviors. Resident is inappropriate at times with others, initiated on 10/13/2023. The care plan goal was Resident #1 will be free from inappropriate sexual behaviors through next review, initiated on 10/13/2023. The interventions included medication adjustments, initiated on 12/21/23. Monitor each shift for inappropriate sexual behaviors, initiated on 10/13/23. Resident 1:1 supervision, initiated on 4/17/24. Review of Resident #1's care plans revealed the following focus Resident can be sexually inappropriate with others, initiated on 7/5/23 and revised on 4/30/24. The goal was Resident #1 will cooperate with care through next review date, initiated on 7/5/23. The interventions included psych consult with medication adjustments, initiated on 9/8/23. Review of Resident #1's care plans revealed the following focus: Resident #1 has poor impulse control, initiated on 11/6/23. The goal is Resident will not harm self or others through review date, initiated on 11/6/23. The interventions included psychiatric/psychogeriatric consult as indicated, initiated on 11/6/23. Redirect others as needed from his room, initiated 11/14/23. Review of Resident #1's care plans revealed the following focus: Resident #1 has impaired cognition impaired decision making, initiated on 6/26/23. The goal was Resident will maintain current level of cognitive function through the review date, initiated on 6/26/23. The interventions included cue, reorient and supervise as needed, initiated on 6/26/23. Review of the facility's care plan meeting minutes quarterly, dated 4/9/24, revealed 4 signatures for the team members in attendance. The Discussion section listed the following: Discharge Plans: Long Term Care (LTC) Advanced Directive: Full Code incapacity Acute Medical Conditions: No documentation Chronic Medical Conditions: hypertension (HTN) and hyperlipidemia Skin/ Wound Conditions: Within Normal Limits (WNL) Nutrition/ Hydration: Regular thin liquid Bowel/ Bladder: Continent Rehabilitation Service: No documentation Physical Function: requires assist to complete ADL's. Behavioral Health/ Activities: No documentation Resident/ Family Concerns: No Documentation Review of Resident #1's Order Summary Report, Active orders as of 5/13/24 revealed the following: 1:1 supervision every shift, start date 4/30/24 Observe sexual behaviors. Document 'Y' if resident has behaviors and 'N' if the resident does not have behaviors. If 'Y' document in the progress notes (PNs) and notify provider, start date 4/30/24. Depakote 250 mg three times daily for mood disorder. Estradiol 2 mg twice daily for hypersexual behaviors Lithium 150 mg twice daily for mood disorder, the start date is 5/11/24. Paroxetine 20 mg daily for Major Depressive Disorder (MDD) Trazodone 50 mg for depression. Review of Resident #1's facility progress note, dated 8/24/23 at 2:29 p.m. authored by Social Services, revealed notified by staff resident has been inappropriate at times, attempts to hit them on butt and has attempted to kiss them. Review of Resident #1's facility progress note, dated 9/5/23 at 9:32 p.m. authored by Staff FF, LPN, revealed Resident is alert, resident was observed with a female resident in his bed. Resident was not dressed he was redirected to get dressed . [family member] was informed of incident and that there will also be a room change . MD was notified. Review of Resident #1's facility progress note, dated 9/5/23 at 10:17 p.m. authored by Staff GG, LPN, revealed Resident is alert oriented able to make needs known, Resident was observed by staff in a female resident room with missing clothing, resident was redirected, call was placed to [family member] to inform her of current situation, .MD notified .room was changed and staff to constantly monitor resident and redirect as needed. Review of Resident #1's facility progress note, dated 11/6/2023, Nursing, revealed, Resident pushed another resident from his room to the floor on the hallway floor. Resident's family member and MD aware, psych consult, increase Trazadone 25 mg po bid and 50 mg po [milligrams by mouth twice a day] at night, resident stated he is not sleeping at night. Review of Resident 1's facility progress note, dated 12/16/2023, Nursing, revealed, Resident became aggressive towards roommate, started yelling and cursing because roommate stated he was wearing his clothes. Review of Resident1's facility progress note, dated 12/17/2023, Nursing, revealed, Resident had a room change. Review of Resident #1's progress note, dated 2/7/2024 at 9:02 a.m., Social Service Note, Resident was noted to exhibit inappropriate sexual behaviors. Resident was redirected and was currently on every hour checks. Psych was notified for consult. MD was notified regarding behaviors. Resident will be placed on 1:1 observation with staff. Review of Resident #1's progress note dated 3/5/2024 at 8:58 a.m., Nursing, revealed Resident observed following a female resident, when redirected he became agitated and said, he can if he wants to. Review of Resident #1's facility progress note, dated 4/16/24 at 4:08 p.m. authored by Staff FF, LPN, revealed Resident is alert, resident was observed in another resident room inappropriate sexually with another resident. Resident told staff he had no regrets, Resident was removed from the situation and placed on 1:1 supervision. [family member] and MD notified. Review of Resident #1's Medication Administration Record/Treatment Administration Record, dated April 2024, revealed sexual behaviors were observed 4/15/24, on the night shift and 4/22/24 on the day and night shifts. Review of resident #1's progress notes dated 4/15/24 and 4/22/24 did not describe the behaviors or if the medical team was notified as ordered. Review of a Psychiatry Subsequent Note, authored by the psychiatric-mental health nurse practitioner (PMHNP), date of stay (DOS) 4/5/24 revealed the following: The Reason for Today's encounter: .medication management, Mental Status Exam: Appearance Behaviors: Disheveled Mood: Patient mood is okay Affect: [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure the residents' environment remained free of accident hazards for 2 of 2 sampled residents reviewed for accident hazards (Residents #25 and #53). The findings included: Review of the facility's policy, titled, Safe and Homelike Environment with a reviewed/revised date of 04/11/23, included: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Review of the facility's policy, titled, Administration of Injections with a reviewed/revised date of September 2023, included Practices to prevent injuries: Dispose of sharps in puncture-resistant containers near the point of use. 1. Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses that included: Age-Related Nuclear Cataract, Bilateral, Anxiety Disorder, and Mild Intellectual Disabilities. The Minimum Data Set (MDS) assessment for Resident #25 dated 12/16/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) assessment was not attempted due to resident is rarely / never understood. Section GG revealed for personal hygiene the resident is dependent on staff. Review of the Care Plan for Resident #25 dated 06/01/23 with a focus on the resident having an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) confusion and impaired mobility. The goal was to maintain the current level of function through the review date. The interventions included: Set up for eating. Dependent for hygiene, dressing and shower. Review of the Care Plan for Resident #25 dated 06/01/23 with a focus on the resident is an elopement risk/wanderer r/t disoriented to place, impaired safety awareness. Resident wanders aimlessly, significantly intrudes on the privacy or activities (of others). The goal was for the resident's safety to be maintained through the review date. The interventions included: Redirect resident from other resident's room. Review of the Care Plan for Resident #25 dated 06/12/23 with a focus on the resident has the following behavior problem(s) combative and aggressiveness. The goal was to have fewer episodes of disruptive behavior through the next review date. The interventions included: Intervene as necessary to protect the rights and safety of others. Redirect resident as necessary. Review of the Care Plan for Resident #25 dated 12/06/23 with a focus on the resident is/has potential to be physically aggressive r/t dementia, poor impulse control. Resident has physical behavioral symptoms toward others and staff such as striking out, propels w/c (wheelchair) without avoiding personal spaces of others, and undresses self in inappropriate areas. Resident does propel self in corners and in different room he is able to lock and unlock his own brakes, will sometimes refuse meals, [NAME] aggressively when agitated, resident showing increased behaviors restlessness, grabbing others, grabbing others food, medications adjusted, 9 swats at nurse while attempting to give him medication, throws food, drinks, grabs food from others or tray carts. The goal was for the resident to not harm self or others through the review date. The interventions included: When resident becomes agitated: intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. On 01/22/24 at 8:18 AM, an observation was made in the bathroom for Resident #25 of 3 safety razors in the bathroom cabinet. Photographic Evidence Obtained. On 1/22/24 at 3:00 PM, an observation was made in the bathroom for Resident #25 of 3 safety razors in the bathroom cabinet. On 01/23/24 at 9:00 AM, an observation was made in the bathroom for Resident #25 of 3 safety razors in the bathroom cabinet. During an environmental tour conducted on 01/24/24 at 1:30 PM with the Director of Plant Operations, the Director of Maintenance (DOM), and the Maintenance Assistant (MA), they acknowledged the 3 safety razors in the unlocked bathroom cabinet for Resident #25. An interview was conducted on 01/25/24 at 10:30 PM with Staff D, Certified Nursing Assistant (CNA), who stated she has been working at the facility for 2 months. When asked about razors, the CNA stated if a resident needs a razor the nurse will have to get the razor to give to the CNA, so the CNA can shave the resident. The razors are never left with the resident or in the resident's room. Once the razor is used it is disposed of in one of the sharp containers, which are in the shower rooms. There are 2 shower rooms on the first floor that are utilized for residents. Shower rooms are locked at all times and residents are never left in the shower rooms unattended. An interview was conducted on 01/25/24 at 11:00 AM with Staff C, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 2 months. When asked about razors, the LPN stated the nurses get the razors and only give them to a CNA to shave the resident. The LPN said the CNA is responsible for disposing of the razor after use. An interview was conducted on 01/25/24 at 11:30 AM with Staff B, LPN, who stated she has worked at the facility for 1 year. When asked about razors, the LPN stated she will get the razor for a CNA to shave the resident and the CNA disposes of the razor after use. An interview was conducted on 01/25/24 at 11:50 AM with Staff A, LPN/Unit Manager (LPN/UM), who stated he has worked at the facility since August/September of 2023. When asked about razors, the LPN/UM stated residents cannot have razors in their rooms. We [staff] shave the residents. Razors are disposed of after 1 use. This is a memory unit, and the residents are cognitively impaired. The LPN/UM stated he does rounds each day of each of the residents' rooms to make sure each resident is okay, and the residents' rooms are safe. Staff A had no response about the razors being found in Resident #25's bathroom cabinet. 2. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Muscle Weakness, Unspecified Abnormalities of Gait and Mobility, and Unspecified Hearing Loss Bilateral. Review of the MDS for Resident #53 dated 11/19/23 revealed in Section C, a BIMS score of 1, indicating severe cognitive impairment. In Section GG, it revealed for toilet hygiene the resident had a performance of partial / moderate assistance, for walking 10 feet, walking 50 feet with two turns and walking 150 feet, and the resident had a performance of partial/moderate assistance. Review of the Care Plan for Resident #53 dated 06/06/23 with a focus on the resident is at risk for elopement as evidenced by resident currently on memory unit has verbalizations of wanting to go home. Resident can usually be redirected. Can resist care at times showers and wander. The goals were for the resident's safety will be maintained through the next review date and the resident will not leave facility unattended through the next review date. The interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers music, talking about fishing and hunting. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is the resident looking for something: Does it indicate the need for more exercise? Intervene as appropriate. Review of the Care Plan for Resident #53 dated 06/06/23 with a focus on the resident has behavioral symptoms not directed to others per spouse has history of sitting himself on floor and even laying on floor at times. Per spouse resident has had episodes of aggressive behavior. Resident has been noted laying himself on the floor in his room beside his bed. The goal was to not harm self and/or others secondary to socially inappropriate and/or disruptive behavior. The interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Explain all procedures to the resident before starting and allow the resident to adjust to changes. Review of the Care Plan for Resident #53 dated 06/06/23 with a focus on the resident has impaired decision-making r/t diagnosis of Dementia, speaks in low voice memory impaired long and short resident is able to answer simple questions and can make simple needs known. The goal was to maintain current level of cognitive function through the review date. The interventions included: Ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed. Review of the Care Plan for Resident #53 dated 08/18/23 with a focus on the resident is at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. The goal was to continue to participate in their ADLs as tolerated daily through the next review date. The interventions included: Independent for eating, supervision/touch assist for dressing, partial/moderate assist for hygiene, showers. Transfers independently. On 01/22/24 at 7:45 AM, an observation was made of Resident # 53 in his room and upon opening Resident #53's bathroom there was an overwhelming urine smell, the toilet was closed with plastic over it. On 01/22/24 at 7:55 AM, an observation was made in Resident #53's room of a white uncovered bin with magazines, unused briefs, loose disposable gloves, items of clothing and a spray bottle of fabric spray. Photographic Evidence Obtained. During an interview conducted on 01/22/24 at 7:48 AM with Staff E, Certified Nursing Assistant (CNA), she stated she has worked at the facility for 1 month. When asked about the bottle fabric spray in the uncovered bin, she said she was not sure about that, but acknowledged that the bottle of fabric spray was in Resident #53's room.

**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 Staff Development Coordinator, 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 ensure one resident (#1), at risk for elopement, was provided with services related to the resident's known cognitive deficits and history of wandering out of 47 residents sampled. The facility nursing staff neglected to ensure the safety of Resident #1; between approximately 9:00 PM on 7/18/2023 and 4:00 AM on 7/19/2023, Resident #1 ambulated from his room on the second floor of the facility, passed the unit nurse's station, and walked approximately 40 feet to the facility elevator. Resident #1 pushed the elevator button to access the rear service hallway of the facility where no staff were present. Resident #1 walked approximately 45 feet unsupervised through the rear service hallway and pushed open a staff entrance door, equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked), which was not locked. Resident #1 exited the facility without staff knowledge and walked appropriately 3.1 miles without shoes, through areas with no sidewalks, and along 4 lane roads, to a private residence. The facility neglected to take action to prevent the resident from accessing the rear service hallway by not providing supervision for the resident, not accounting for the resident for approximately 10 hours, and not ensuring facility doors were secured before the resident eloped. Resident #1 was discovered by police on 7/19/2023 at approximately 7:00 AM in the backyard of a community member, sitting on a trampoline. Resident #1 was returned to the facility by police at approximately 7:30 AM, disheveled with holes in his socks, and was discovered to have multiple insect bites and a blister to his left heel. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 8/17/2023. The findings of Immediate Jeopardy were determined to be removed on 8/18/2023 and the severity and scope was reduced to a D. Findings included: A review of a law enforcement report dated 7/19/2023 at 5:41 AM revealed law enforcement responded to the facility at approximately 6:11 AM for a report of a missing endangered person, who went missing around 6:00 PM on 7/18/2023. A search of the facility was conducted by law enforcement but Resident #1 was not found on the facility grounds. The report revealed Staff H, CNA, who was the last caretaker to have contact with Resident #1, provided law enforcement with a description of the resident. Law enforcement received a service call at a residence approximately 3.1 miles from the facility involving a suspicious person matching Resident #1's description. Upon arrival at the residence, law enforcement observed Resident #1 in the backyard of the residence sitting on a trampoline. Resident #1 was returned to the facility and interviewed by law enforcement. Resident #1 told law enforcement he exited the facility around 4:30 PM on 7/18/2023 to go for a walk. A review of Resident #1's progress notes dated 7/19/2023 at 11:49 AM and authored by Staff A, Licensed Practical Nurse (LPN), revealed the following: Upon arrival to facility, [Resident #1] alert with some confusion. Head to toe assessment performed .[Resident #1] c/o [complained of ] pain to [the] left heel. Tylenol was given for mild pain .Skin assessment was complete and possible mosquito bites on back, [Resident #1] noted scratching areas [to] bilateral arm, abdomen, back of both legs as well as front of legs, left foot heel has a blister MD is aware and ordered scheduled Tylenol for pain r/t [related to] left heel as well as skin prep [a protective wipe which forms a barrier between the patient's skin and adhesives to help preserve skin integrity] to left heel blister and Hydrocortisone cream for itching . A telephone interview was conducted on 8/16/2023 at 2:24 PM with Resident #1's Responsible Party (RP). The RP stated prior to being admitted to the facility, Resident #1 went missing in December of 2022 after getting lost and was found by law enforcement. The RP stated Resident #1 had gone missing several times and had to be located by law enforcement prior to admission to the facility and was not able to make medical decisions due to his dementia. A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of encephalopathy, unspecified; dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; cognitive communication deficit; unspecified abnormalities of gait and mobility; muscle weakness (generalized); depression, unspecified; and anxiety disorder. A review of Resident #1's physician's orders revealed the following: - An order dated 8/1/2023 to record active exit seeking behaviors and record the following intervention code(s) every shift: 1: N/A, 2. Engage in conversation, 3. Redirect to alternative location in facility, 4. Call family/friend, 5. Activity, 6. Give snacks/food, 7. Give fluids, 8. Toileting. - An order dated 8/1/2023 for behavioral monitoring related to exit-seeking behaviors and record the number of occurrences every shift. A review of Resident #1's baseline care plan, dated 6/23/2023, did not reveal problems or potential concerns related to elopement risk. A review of Resident #1's 5-Day Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/27/2023 revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of C - BIMS: 7 which indicated severely impaired cognition. Resident #1's MDS assessment revealed under Section E - Behavior, Resident #1 did not display behaviors of wandering but rejected care 1 to 3 days of the assessment period. Section G - Functional Status revealed Resident #1 required supervision and set up help only with locomotion on the unit and required one-person physical assistance with locomotion off the unit. Resident #1 was unsteady, but able to stabilize without staff assistance while walking and turning around. Resident #1 did not require an assistive device for mobility. Resident #1's MDS assessment revealed under Section I - Active Diagnoses Resident #1 had diagnoses of Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Encephalopathy, unspecified. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%20severe%20injury%20and%20death.&text=The%20persistent%20wandering%20behavior%20and,fractures%2C%20and%20accidents%20in%20PwD. An interview was conducted on 8/15/2023 at 12:30 PM with the facility's Social Services Director (SSD), the Staff Development Coordinator (SDC) and the Nursing Home Administrator (NHA). The SDC stated on 7/19/2023, Resident #1 was returned to the facility after Staff C, Certified Nursing Assistant (CNA) discovered Resident #1 was not in his room at approximately 4:00 AM. Staff C, CNA reported Resident #1 missing to Staff D, LPN, who reported the finding to Staff B, LPN Supervisor. A code pink was called through the facility, which alerted staff a resident was missing from the facility and a facility search was conducted. After verifying Resident #1 was not in the facility, Staff B, LPN Supervisor notified law enforcement and the NHA. The SDC stated the facility cameras did not capture Resident #1 leaving the facility due to a power surge. Law enforcement located Resident #1 in a community member's backyard on a trampoline. They said Resident #1 was returned to the facility on 7/19/2023 at 7:15 AM but they did not provide an address where Resident #1 was located. The SSD stated law enforcement did not provide an incident report and stated, they said if they had one, they would send it to us. The SDC and NHA stated they conducted an interview with Resident #1 following the elopement. Resident #1 stated he left the facility by accessing the facility elevator, walking through the rear service hallway of the facility, and pushing open a door to exit the facility. Resident #1 explained he wanted to go for a walk. Upon Resident #1's return to the facility, a head-to-toe assessment was completed by Staff A, LPN and the facility's Medical Director was notified. Staff A, LPN discovered several bites on the resident's body during the assessment. The NHA stated following the incident, the facility's former maintenance director conducted an exterior door security audit to ensure all exterior doors were secure. Modifications were made to the facility elevator so the rear service hallway could not be accessed through the elevator. The NHA stated the door Resident #1 exited the facility through was equipped with a magnetic lock, but the lock did not engage. The SDC stated the last time staff confirmed seeing Resident #1 was around 11 PM on 7/18/2023 when Staff E, Agency LPN handed the resident a snack. An interview was conducted on 8/16/2023 at 9:48 AM with Staff A, LPN. Staff A, LPN stated she was called into the facility on 7/19/2023 around 4:30 AM by Staff B, LPN Supervisor due to a resident elopement. Staff A, LPN stated she last saw Resident #1 on 7/18/2023 on the 7 AM to 3 PM shift and he did not express desires of leaving the facility. Staff A, LPN stated Resident #1 usually stayed in his room during the shift and was very pleasant. Staff A, LPN stated she arrived at the facility around 5:00 AM and joined the staff at the facility in searching for Resident #1. Staff A, LPN stated the last staff member to see Resident #1 was Staff F, LPN around 9:00 PM on 7/18/2023 when the LPN provided Resident #1 with a snack. Staff A, LPN stated Resident #1 was returned to the facility by law enforcement around 8:00 AM on 7/19/2023. Staff A, LPN spoke with Resident #1 upon his return and asked the resident what happened? Resident #1 responded to Staff A, LPN I don't know. Staff A, LPN stated Resident #1 was wearing a burgundy short sleeved shirt, blue basketball shorts, and non-skid socks with a tear in the left sock. Resident #1 was not observed wearing shoes. Once Resident #1 was back in the facility, Staff A, LPN performed an assessment. Staff A, LPN stated she documented several possible mosquito bites described as red dots throughout Resident #1's body and a blister on Resident #1's left foot. Staff A, LPN stated after the assessment, Resident #1 laid in the fetal position in his bed and appeared very tired. Staff A, LPN stated Resident #1 was provided fluids because he was very thirsty. Staff A, LPN stated the door Resident #1 exited out of was usually kept locked with a magnetic lock but Resident #1 was able to push the door open. Staff A, LPN stated she completed Resident #1's elopement assessment upon admission to the facility and did not assess the resident as an elopement risk. Staff A, LPN stated she would expect CNA staff to round every 30 minutes to an hour at the latest to check on the resident's needs and to take account of that resident. A review of Resident #1's admission assessment dated [DATE] revealed under the section titled EL. Elopement Risk a question Is resident ambulatory and/or able to self-propel wheelchair? and a documented response No. The section revealed If no, next question will be disabled. The disabled section of the EL. Elopement Risk portion of the admission assessment related to risk factors to indicate the resident was at risk for elopement and contained no information. An interview was conducted on 8/16/2023 at 10:16 AM with Staff F, LPN. Staff F, LPN stated she worked a double shift on 7/18/2023 during the 7 AM to 3 PM and the 3 PM to 11 PM shifts. Staff F, LPN stated Resident #1 would usually stay in his room and sometimes go to the nurse's station to ask for coffee. Staff F, LPN last saw Resident #1 on 7/18/2023 at 9:00 PM when the resident walked to the nurse's station and asked for a snack. Staff F, LPN left the facility around 11:15 PM and did not see Resident #1 between 9:00 PM and 11:15 PM. Staff F, LPN received a phone call around 6:00 AM on 7/19/2023 from facility staff telling her she needed to come to the facility. When Staff F, LPN arrived at the facility around 6:45 AM, facility staff were already searching for Resident #1 throughout the facility and the facility grounds. Staff F, LPN was not able to state what time Resident #1 was returned to the facility but stated the resident looked tired. Staff F, LPN stated she was not sure how Resident #1 exited the facility but thinks he might have gone out through the back door leading out to the facility staff parking lot. Staff F, LPN stated before Resident #1's elopement, staff would enter the facility through the rear entrance and the door was usually locked using the magnetic lock and could only be opened by entering a code. Staff F, LPN stated she would expect the CNA staff to check on residents at least every 2 hours to check on the resident's needs and to take account of that resident. An interview was conducted on 8/16/2023 at 10:40 AM with Staff G, CNA. Staff G, CNA stated she was familiar with Resident #1 and had transported him to several outside appointments. Staff G, CNA stated Resident #1 was normally quiet and laid back in demeanor but would observe a lot and was very sneaky. Staff G, CNA received a phone call on 7/19/2023 at approximately 4:30 AM from Staff B, LPN because Resident #1 was missing from the facility, and he was not sure what to do. Staff G, CNA told Staff B, LPN to contact the NHA and DON and to notify the police. Staff G, CNA called Staff A, LPN and Staff I, CNA and told them to come to the facility to assist in searching for Resident #1. Staff G, CNA arrived at the facility at approximately 4:45 AM and stated local law enforcement arrived after. After searching the facility grounds for Resident #1, Staff G, CNA stated she spoke with law enforcement around 6 or 7 AM, who told her they found Resident #1 in a lady's yard on a trampoline. Staff G, CNA stated she drove to Resident #1's location in the facility van around 7 AM and witnessed Resident #1 being escorted into a police car by law enforcement. Staff G, CNA drove back to the facility and saw Resident #1. Staff G, CNA observed Resident #1 with a lot of bites on his body and wearing socks with no shoes. Staff G, CNA stated Resident #1 told herself, Staff I, CNA, Staff A, LPN, and the SDC how he was able to exit the facility. Resident #1 told Staff G, CNA he walked through the elevator, accessed the rear service hallway, and exited out of the facility through the back door leading into the facility staff parking lot. A telephone interview was conducted on 8/16/2023 at 1:20 PM with the facility's Medical Director (MD), who was Resident #1's primary care provider. The MD stated Resident #1 was mildly confused but was able to follow commands and was easy to redirect during previous interactions with the resident. The MD was notified by the facility Resident #1 eloped from the facility by accessing the rear service hallway through the facility elevator and was found by law enforcement several hours later. The MD assessed Resident #1 around 10 or 11 AM after the resident was showered. The MD discovered a couple of abrasions here and there and a couple of bug bites presumed to be mosquito bites. The MD stated Resident #1's feet here mildly edematous but the resident did not sustain any injuries from the elopement. The MD stated Resident #1 was able to explain how he exited the facility and he was trying to go home. A review of a SOAP (Subjective, Objective, Assessment, Plan) note dated 7/19/2023 and authored by the MD revealed the following: .I was call[ed] to [Resident #1]'s bedside as it was brought to my attention that [Resident #1] had an elopement incident yesterday [7/18/2023]. [Resident #1] was found by the police and [br]ought back to the facility on examination. [Resident #1] appears to be stable and at baseline. [Resident #1] does have multiple mosquito bites. In various places .On questioning, [Resident #1] does not recall the incident. States that he was going for a walk . An interview was conducted on 8/16/2023 at 1:39 PM with Staff H, CNA, Resident #1's assigned CNA for the 7 AM to 3 PM shift on 7/18/2023. Staff H, CNA stated she frequently provided care for Resident #1 and Resident #1 was cooperative with care. Staff H, CNA stated on 7/13/2023, Resident #1 pressed his call light and asked Staff H, CNA how he could transfer out of here. Staff H, CNA stated Resident #1 did not express a desire to exit the facility other than that one incident. Staff H, CNA stated she arrived at the facility on 7/19/2023 around 6:45 AM and witnessed several law enforcement vehicles and personnel upon her arrival. Staff H, CNA provided a description of the clothing Resident #1 was wearing to law enforcement because other staff members gave the wrong description. Staff H, CNA stated about an hour after her arrival at the facility, Resident #1 was returned to the facility by law enforcement. Staff H, CNA stated Resident #1 appeared to be wearing wet clothing and had holes in his socks. Staff H, CNA provided Resident #1 with clean clothing and ice water because the resident stated he was thirsty. Staff H, CNA stated Resident #1 did not state how he exited the facility, but she found out by speaking with other facility staff. An interview was conducted on 8/16/2023 at 1:54 PM with Staff I, CNA. Staff I, CNA stated she received a phone call from Staff G, CNA on 7/19/2023 at approximately 4:30 AM who stated Resident #1 was missing from the facility. Staff I, CNA then drove to the facility and assisted staff in attempting to locate Resident #1 by searching inside and outside of the facility and near local businesses. Staff I, CNA stated law enforcement arrived during the search for Resident #1 and assisted in the search. Staff I, CNA stated Resident #1 was returned to the facility sometime before breakfast and appeared tired and walked out his socks, meaning Resident #1 had holes in the bottoms of his socks. Staff I, CNA spoke with Resident #1 following the incident, who stated he accessed the rear service hallway through the facility elevator, walked down the service hallway, pushed open the rear exit door and hit it, meaning he began walking down the street. Resident #1 stated to Staff I, CNA he was just going for a walk. Staff I, CNA stated Resident #1's memory comes and goes. An interview was conducted on 8/16/2023 at 2:40 PM with Resident #1 on the facility's dementia care unit. Resident #1 was observed lying in bed in his room. Resident #1 stated be remembered going for a walk and was gone from the facility for a few hours. Resident #1 was not able to recall details of the elopement and only stated he left through one of the exits and came back here. An interview was conducted on 8/16/2023 at 2:53 PM with the SSD and the facility's MDS Coordinator (MDS). The SSD stated when a resident is admitted to the facility, a welcome meeting or welcome conference is held with the resident and/or family to go over the resident's history. The MDS Coordinator stated the residents medications, baseline care plan, dietary preferences, allergies, and other care conditions are discussed during the meeting. The SSD stated if the resident is not alert and oriented, the resident's family is called to participate in the meeting. The SSD stated a welcome conference was conducted with Resident #1 upon admission and the RP was contact by phone to participate in the meeting. The SSD stated Resident #1 was his own responsible party upon admission. The RP told the SSD Resident #1 had an incident in December of 2022 where he went to the airport and got lost, but not much else. Telephone interviews were attempted on 8/16/2023 with Staff C, CNA, Resident #1's assigned CNA for the 11 PM to 7 AM shift on 7/18/2023, Staff B, LPN, the assigned facility supervisor for the 11 PM to 7 AM shift on 7/18/2023, Staff D, LPN, Resident #1's assigned nurse for the 11 PM to 7 AM shift on 7/18/2023, Staff J, CNA, Resident #1's assigned CNA for the 3 PM to 11 PM shift on 7/18/2023, and Staff E, Agency LPN, Resident #1's assigned nurse for the 3 PM to 11 PM shift on 7/18/2023. The staff members could not be reached. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 6/18/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form revealed under Section E: Medical Condition, primary discharge diagnoses of altered mental status (AMS) and incompetence. A review of Resident #1's psychology evaluation notes dated 7/5/2023 revealed under the section titled Patient Consent This provider confirms that the written consent to treat was obtained from the patient Power of Attorney (POA) as patient is not capable of giving the consent. The note revealed under the section titled History of Present Illness Patient has history of depression, anxiety, and dementia. Patient stated, 'my memory is bad'. He reported he feels depressed, sad, and irritable since he was admitted to the facility . An interview and tour were conducted on 8/17/2023 at 11:15 AM with the facility's Maintenance Director and NHA near the facility elevator. The NHA stated modifications were made to the facility elevator to ensure residents of the facility could not access the rear service hallway through the elevator. The NHA stated a keypad would be installed for the elevator and anyone who used the elevator would be required to enter a code, which would not be provided to facility residents. The NHA stated the rear service hallway could be accessed through the 200 unit and required a code to access. An observation of the facility elevator revealed the buttons to access the rear service hallway were not able to be pressed due to being covered with a cap and black tape. The NHA stated the modifications were temporary until the elevator vendor could install the keypad. A tour was conducted of the rear service of the facility. The facility elevator cannot be accessed through the rear service hallway and was observed to be blocked with yellow caution tape. An observation of the rear exit door of the facility revealed signage posted on the door entrance temporarily closed use front entrance!! The rear exit door was locked and secured. A review of the facility policy titled Abuse Prohibition/Investigative Policy, revised in August 2023, revealed under the section titled Policy the facility will prohibit abuse, neglect, misappropriation of resident property, and exploitation. The policy revealed under the section titled Purpose the purpose of the policy is to ensure the facility is doing all that is within its control to prevent occurrences of abuse/neglect. The policy defines neglect as .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. Facility's immediate actions to remove the Immediate Jeopardy included: o Facility egress doors checked for alarming/functioning with no other issues identified. The door that resident exited from noted to not automatically close has been taken out of services. An outside vendor was contacted on 7/19/2023 by the NHA to replace the door. The rear elevator door was taken out of service on 7/19/2023 by blocking the buttons to open them. An outside vendor was contacted on 7/19/2023 by the NHA to service the elevator and put a code box on to prevent it from opening without putting in the code. o Elopement drills initiated on 7/19/2023 starting on 7:00 AM to 3:00 PM shift then conducted every shift for 3 days then weekly for 4 weeks then monthly. o Staff education was initiated 7/19/2023 on Abuse, Neglect and Exploitation Policy w/ emphasis on neglect to include reporting requirements, elopement standard and guidelines, shift to shift rounds and mid night census by the staff development coordinator, this education included actual visualization of each resident during these rounds this education was completed on 7/20/2023. Newly hired staff and agency staff will be educated during the orientation process. Staff will be educated on every 2-hour rounding on residents to include physical visualization of residents. Licensed nurses will validate that this rounding is being done and document attestation of rounding in the medication administration record. Education will be completed by the SDC, or designee. Residents that are evaluated to be at risk for elopement and not placed on the secured unit will have rounding with physical visualization every 1 hour or as indicated in their plan of care. The licensed nurse will validate that this rounding is being done and document attestation of rounding the medication administration record. o Residents currently residing in the facility were re-evaluated for elopement risk by the DON or Designee on 7/19/2023 to 7/25/2023. No new residents identified at risk for elopement. o An ad-hoc QAPI meeting was held on 7/19/2023 at 3:00 PM. o Elopement risk alert binders reviewed for accuracy and confirmed to have demographics present for all residents at risk for elopement based on Elopement Risk Evaluations on 7/19/2023. The binders were again reviewed on 7/25/2023, no new updates were needed. New admissions or residents with a change in behavior that increases risk for elopement will be reviewed during morning clinical meeting and placed in the elopement risk binders located at each nurses station and at the receptionist desk. o Care plans for residents at risk for elopement confirmed to be present on 7/20/2023. Updates were completed as needed. o Rounds are conducted throughout each shift, at shift change, during AM, PM care, during meal services and during care provision. Mid-night census sheet will be signed by the unit nurse and turned into the Director of Nurses each day. Verification of the facility's removal plan was conducted by the survey team on 8/18/2023. An attestation provided by the facility revealed on 7/19/2023, the former maintenance director ensured the rear service elevator door, and the rear exit door of the facility were taken out of service and outside vendors were contacted to service the elevator door and to replace the rear door of the facility. A sample of five residents at risk for elopement, including Resident #1, were reviewed for verification of new orders related to rounding, care plan including elopement risk, elopement risk evaluation, and presence in the facility elopement book. Review of the five residents revealed all residents had new orders related to rounding, care plan including elopement risk, updated elopement risk evaluation, and presence in the facility elopement book. A review of education conducted by the DON and the SDC revealed education related to resident rounding was conducted on 8/17/2023 for facility nursing staff. Education related to abuse/neglect and elopement procedures was conducted on 7/19/2023 and completed on 7/20/2023 with all staff educated. Post-test and competencies included as part of the facility training. A review of facility elopement drills revealed elopement drills were conducted from 7/19/2023 to 7/22/2023. Elopement drills completed on all shifts with documentation of participating staff. Interviews were conducted with 48 staff members, including 2 Registered Nurses, 7 LPNs, 13 CNAs, 7 dietary staff, 3 therapy staff, 6 housekeeping staff, and 10 other staff members. The staff members were able to state that they had been trained and were knowledgeable about the policies and procedures. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 8/18/2023 and the non-compliance was reduced to a scope and severity of D.

**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 Staff Development Coordinator, 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 47 residents at risk for elopement, was provided with supervision and services related to the resident's known cognitive deficits and history of wandering before admission to the facility. The facility nursing staff failed to ensure the safety of Resident #1; between approximately 9:00 PM on 7/18/2023 and 4:00 AM on 7/19/2023, Resident #1 ambulated from his room on the second floor of the facility, passed the unit nurse's station, and walked approximately 40 feet to the facility elevator. Resident #1 pushed the elevator button to access the rear service hallway of the facility where no staff were present. Resident #1 walked approximately 45 feet unsupervised through the rear service hallway and pushed open a staff entrance door, equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked), which was not locked. Resident #1 exited the facility unsupervised and without staff knowledge and walked appropriately 3.1 miles without shoes, through areas with no sidewalks, and along 4 lane roads, to a private residence. The facility failed to take action to prevent the resident from accessing the rear service hallway by not providing supervision for the resident, not accounting for the resident for approximately 10 hours, and not ensuring facility doors were secured before the resident eloped. Resident #1 was discovered by police on 7/19/2023 at approximately 7:00 AM in the backyard of a community member, sitting on a trampoline. Resident #1 was returned to the facility by police at approximately 7:30 AM disheveled and with holes in his socks and was discovered to have multiple insect bites and a blister to his left heel. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 8/17/2023. The findings of Immediate Jeopardy were determined to be removed on 8/18/2023 and the severity and scope was reduced to a D. Findings included: A review of Resident #1's progress notes dated 7/19/2023 at 11:49 AM and authored by Staff A, Licensed Practical Nurse (LPN), revealed the following: Upon arrival to facility, [Resident #1] alert with some confusion. Head to toe assessment performed .[Resident #1] c/o [complained of ] pain to [the] left heel. Tylenol was given for mild pain .Skin assessment was complete and possible mosquito bites on back, [Resident #1] noted scratching areas [to] bilateral arm, abdomen, back of both legs as well as front of legs, left foot heel has a [has a] blister MD is aware and ordered scheduled Tylenol for pain r/t [related to] left heel as well as skin prep [a protective wipe which forms a barrier between the patient's skin and adhesives to help preserve skin integrity] to left heel blister and Hydrocortisone cream for itching . A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of encephalopathy, unspecified; dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; cognitive communication deficit; unspecified abnormalities of gait and mobility; muscle weakness (generalized); depression, unspecified; and anxiety disorder. A review of Resident #1's physician's orders revealed the following: - An order dated 8/1/2023 to record active exit seeking behaviors and record the following intervention code(s) every shift: 1: N/A, 2. Engage in conversation, 3. Redirect to alternative location in facility, 4. Call family/friend, 5. Activity, 6. Give snacks/food, 7. Give fluids, 8. Toileting. - An order dated 8/1/2023 for behavioral monitoring related to exit-seeking behaviors and record the number of occurrences every shift. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%20severe%20injury%20and%20death.&text=The%20persistent%20wandering%20behavior%20and,fractures%2C%20and%20accidents%20in%20PwD. A review of Resident #1's baseline care plan, dated 6/23/2023, did not reveal problems or potential concerns related to elopement risk. A review of Resident #1's 5-Day Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/27/2023 revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of C - BIMS: 7 which indicated severely impaired cognition. Resident #1's MDS assessment revealed under Section E - Behavior, Resident #1 did not display behaviors of wandering but rejected care 1 to 3 days of the assessment period. Section G - Functional Status revealed Resident #1 required supervision and set up help only with locomotion on the unit and required one person physical assistance with locomotion off the unit. Resident #1 was unsteady, but able to stabilize without staff assistance while walking and turning around. Resident #1 did not require an assistive device for mobility. Resident #1's MDS assessment revealed under Section I - Active Diagnoses Resident #1 had diagnoses of Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Encephalopathy, unspecified. An interview was conducted on 8/15/2023 at 12:30 PM with the facility's Social Services Director (SSD), the Staff Development Coordinator (SDC) and the Nursing Home Administrator (NHA). The SDC stated on 7/19/2023, Resident #1 was returned to the facility after Staff C, Certified Nursing Assistant (CNA) discovered Resident #1 was not in his room at approximately 4:00 AM. Staff C, CNA reported Resident #1 missing to Staff D, LPN, who reported the finding to Staff B, LPN Supervisor. A code pink was called through the facility, which alerted staff a resident was missing from the facility and a facility search was conducted. After verifying Resident #1 was not in the facility, Staff B, LPN Supervisor notified law enforcement and the NHA. The SDC stated the facility cameras did not capture Resident #1 leaving the facility due to a power surge. Law enforcement located Resident #1 in a community member's backyard on a trampoline. They said Resident #1 was returned to the facility on 7/19/2023 at 7:15 AM but they did not provide an address where Resident #1 was located. The SSD stated law enforcement did not provide an incident report and stated, they said if they had one they would send it to us. The SDC and NHA stated they conducted an interview with Resident #1 following the elopement. Resident #1 stated he left the facility by accessing the facility elevator, walking through the rear service hallway of the facility, and pushing open a door to exit the facility. Resident #1 explained he wanted to go for a walk. Upon Resident #1's return to the facility, a head to toe assessment was completed by Staff A, LPN and the facility's Medical Director was notified. Staff A, LPN discovered several bites on the resident's body during the assessment. The NHA stated following the incident, the facility's former maintenance director conducted an exterior door security audit to ensure all exterior doors were secure. Modifications were made to the facility elevator so the rear service hallway could not be accessed through the elevator. The NHA stated the door Resident #1 exited the facility through was equipped with a magnetic lock, but the lock did not engage. The SDC stated the last time staff confirmed seeing Resident #1 was around 11 PM on 7/18/2023 when Staff E, Agency LPN handed the resident a snack. A review of the facility policy titled Safety and Supervision of Residents, revised in July of 2017, revealed under the section titled Policy Statement the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy revealed under the section titled Individualized, Resident-Centered Approach to Safety the individualized, resident centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. An interview was conducted on 8/16/2023 at 9:48 AM with Staff A, LPN. Staff A, LPN stated she was called into the facility on 7/19/2023 around 4:30 AM by Staff B, LPN Supervisor due to a resident elopement. Staff A, LPN stated she last saw Resident #1 on 7/18/2023 on the 7 AM to 3 PM shift and he did not express desires of leaving the facility. Staff A, LPN stated Resident #1 usually stayed in his room during the shift and was very pleasant. Staff A, LPN stated she arrived at the facility around 5:00 AM and joined the staff at the facility in searching for Resident #1. Staff A, LPN stated the last staff member to see Resident #1 was Staff F, LPN around 9:00 PM on 7/18/2023 when the LPN provided Resident #1 with a snack. Staff A, LPN stated Resident #1 was returned to the facility by law enforcement around 8:00 AM on 7/19/2023. Staff A, LPN spoke with Resident #1 upon his return and asked the resident what happened? Resident #1 responded to Staff A, LPN I don't know. Staff A, LPN stated Resident #1 was wearing a burgundy short sleeved shirt, blue basketball shorts, and non-skid socks with a tear in the left sock. Resident #1 was not observed wearing shoes. Once Resident #1 was back in the facility, Staff A, LPN performed an assessment. Staff A, LPN stated she documented several possible mosquito bites described as red dots throughout Resident #1's body and a blister on Resident #1's left foot. Staff A, LPN stated after the assessment, Resident #1 laid in the fetal position in his bed and appeared very tired. Staff A, LPN stated Resident #1 was provided fluids because he was very thirsty. Staff A, LPN stated the door Resident #1 exited out of was usually kept locked with a magnetic lock but Resident #1 was able to push the door open. Staff A, LPN stated she completed Resident #1's elopement assessment upon admission to the facility and did not assess the resident as an elopement risk. Staff A, LPN stated she would expect CNA staff to round every 30 minutes to an hour at the latest to check on the resident's needs and to take account of that resident. A review of Resident #1's admission assessment dated [DATE] revealed under the section titled EL. Elopement Risk a question Is resident ambulatory and/or able to self-propel wheelchair? and a documented response No. The section revealed If no, next question will be disabled. The disabled section of the EL. Elopement Risk portion of the admission assessment related to risk factors to indicate the resident was at risk for elopement and contained no information. An interview was conducted on 8/16/2023 at 10:16 AM with Staff F, LPN. Staff F, LPN stated she worked a double shift on 7/18/2023 during the 7 AM to 3 PM and the 3 PM to 11 PM shifts. Staff F, LPN stated Resident #1 would usually stay in his room and sometimes go to the nurse's station to ask for coffee. Staff F, LPN last saw Resident #1 on 7/18/2023 at 9:00 PM when the resident walked to the nurse's station and asked for a snack. Staff F, LPN left the facility around 11:15 PM and did not see Resident #1 between 9:00 PM and 11:15 PM. Staff F, LPN received a phone call around 6:00 AM on 7/19/2023 from facility staff telling her she needed to come to the facility. When Staff F, LPN arrived at the facility around 6:45 AM, facility staff were already searching for Resident #1 throughout the facility and the facility grounds. Staff F, LPN was not able to state what time Resident #1 was returned to the facility but stated the resident looked tired. Staff F, LPN stated she was not sure how Resident #1 exited the facility but thinks he might have gone out through the back door leading out to the facility staff parking lot. Staff F, LPN stated before Resident #1's elopement, staff would enter the facility through the rear entrance and the door was usually locked using the magnetic lock and could only be opened by entering a code. Staff F, LPN stated she would expect the CNA staff to check on residents at least every 2 hours to check on the resident's needs and to take account of that resident. An interview was conducted on 8/16/2023 at 10:40 AM with Staff G, CNA. Staff G, CNA stated she was familiar with Resident #1 and had transported him to several outside appointments. Staff G, CNA stated Resident #1 was normally quiet and laid back in demeanor but would observe a lot and was very sneaky. Staff G, CNA received a phone call on 7/19/2023 at approximately 4:30 AM from Staff B, LPN because Resident #1 was missing from the facility, and he was not sure what to do. Staff G, CNA told Staff B, LPN to contact the NHA and DON and to notify the police. Staff G, CNA called Staff A, LPN and Staff I, CNA and told them to come to the facility to assist in searching for Resident #1. Staff G, CNA arrived at the facility at approximately 4:45 AM and stated local law enforcement arrived after. After searching the facility grounds for Resident #1, Staff G, CNA stated she spoke with law enforcement around 6 or 7 AM, who told her they found Resident #1 in a lady's yard on a trampoline. Staff G, CNA stated she drove to Resident #1's location in the facility van around 7 AM and witnessed Resident #1 being escorted into a police car by law enforcement. Staff G, CNA drove back to the facility and saw Resident #1. Staff G, CNA observed Resident #1 with a lot of bites on his body and wearing socks with no shoes. Staff G, CNA stated Resident #1 told herself, Staff I, CNA, Staff A, LPN, and the SDC how he was able to exit the facility. Resident #1 told Staff G, CNA he walked through the elevator, accessed the rear service hallway, and exited out of the facility through the back door leading into the facility staff parking lot. A telephone interview was conducted on 8/16/2023 at 1:20 PM with the facility's Medical Director (MD), who was Resident #1's primary care provider. The MD stated Resident #1 was mildly confused but was able to follow commands and was easy to redirect during previous interactions with the resident. The MD was notified by the facility Resident #1 eloped from the facility by accessing the rear service hallway through the facility elevator and was found by law enforcement several hours later. The MD assessed Resident #1 around 10 or 11 AM after the resident was showered. The MD discovered a couple of abrasions here and there and a couple of bug bites presumed to be mosquito bites. The MD stated Resident #1's feet here mildly edematous but the resident did not sustain any injuries from the elopement. The MD stated Resident #1 was able to explain how he exited the facility and he was trying to go home. A review of a SOAP (Subjective, Objective, Assessment, Plan) note dated 7/19/2023 and authored by the MD revealed the following: .I was call[ed] to [Resident #1]'s bedside as it was brought to my attention that [Resident #1] had an elopement incident yesterday [7/18/2023]. [Resident #1] was found by the police and [r]ought back to the facility on examination. [Resident #1] appears to be stable and at baseline. [Resident #1] does have multiple mosquito bites. In various places .On questioning, [Resident #1] does not recall the incident. States that he was going for a walk . An interview was conducted on 8/16/2023 at 1:39 PM with Staff H, CNA, Resident #1's assigned CNA for the 7 AM to 3 PM shift on 7/18/2023. Staff H, CNA stated she frequently provided care for Resident #1 and Resident #1 was cooperative with care. Staff H, CNA stated on 7/13/2023, Resident #1 pressed his call light and asked Staff H, CNA how he could transfer out of here. Staff H, CNA stated Resident #1 did not express a desire to exit the facility other than that one incident. Staff H, CNA stated she arrived at the facility on 7/19/2023 around 6:45 AM and witnessed several law enforcement vehicles and personnel upon her arrival. Staff H, CNA provided a description of the clothing Resident #1 was wearing to law enforcement because other staff members gave the wrong description. Staff H, CNA stated about an hour after her arrival at the facility, Resident #1 was returned to the facility by law enforcement. Staff H, CNA stated Resident #1 appeared to be wearing wet clothing and had holes in his socks. Staff H, CNA provided Resident #1 with clean clothing and ice water because the resident stated he was thirsty. Staff H, CNA stated Resident #1 did not state how he exited the facility, but she found out by speaking with other facility staff. An interview was conducted on 8/16/2023 at 1:54 PM with Staff I, CNA. Staff I, CNA stated she received a phone call from Staff G, CNA on 7/19/2023 at approximately 4:30 AM who stated Resident #1 was missing from the facility. Staff I, CNA then drove to the facility and assisted staff in attempting to locate Resident #1 by searching inside and outside of the facility and near local businesses. Staff I, CNA stated law enforcement arrived during the search for Resident #1 and assisted in the search. Staff I, CNA stated Resident #1 was returned to the facility sometime before breakfast and appeared tired and walked out his socks, meaning Resident #1 had holes in the bottoms of his socks. Staff I, CNA spoke with Resident #1 following the incident, who stated he accessed the rear service hallway through the facility elevator, walked down the service hallway, pushed open the rear exit door and hit it, meaning he began walking down the street. Resident #1 stated to Staff I, CNA he was just going for a walk. Staff I, CNA stated Resident #1's memory comes and goes. A review of the facility policy titled Emergency Procedure - Missing Resident, revised in August of 2016, revealed under the section titled Policy Statement a resident elopement resulting in a missing resident is considered a facility emergency. The policy revealed under the section titled Policy Interpretation and Implementation residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. Staff will implement the protocol for missing resident immediately upon discovering that a resident cannot be located. A review of a law enforcement report dated 7/19/2023 at 5:41 AM revealed law enforcement responded to the facility at approximately 6:11 AM for a report of a missing endangered person, who went missing around 6:00 PM on 7/18/2023. A search of the facility was conducted by law enforcement but Resident #1 was confirmed not on the facility grounds. The report revealed Staff H, CNA, who was the last caretaker to contact Resident #1, provided law enforcement with a description of the resident. Law enforcement received a service call at a residence approximately 3.1 miles from the facility involving a suspicious person matching Resident #1's description. Upon arrival at the residence, law enforcement observed Resident #1 in the backyard of the residence sitting on a trampoline. Resident #1 was returned to the facility and interviewed by law enforcement. Resident #1 told law enforcement he exited the facility around 4:30 PM on 7/18/2023 to go for a walk. A telephone interview was conducted on 8/16/2023 at 2:24 PM with Resident #1's responsible party (RP). The RP stated prior to being admitted to the facility, Resident #1 went missing in December of 2022 after getting lost and was found by law enforcement. The RP stated Resident #1 had gone missing several times and had to be located by law enforcement prior to admission to the facility and was not able to make medical decisions due to his dementia. A review of the facility policy titled Wandering and Elopements, revised in March of 2019, revealed under the section titled Policy Statement the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy revealed under the section titled Policy Interpretation and Implementation if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. An interview was conducted on 8/16/2023 at 2:40 PM with Resident #1 on the facility's dementia care unit. Resident #1 was observed lying in bed in his room. Resident #1 stated be remembered going for a walk and was gone from the facility for a few hours. Resident #1 was not able to recall details of the elopement and only stated he left through one of the exits and came back here. An interview was conducted on 8/16/2023 at 2:53 PM with the SSD and the facility's MDS Coordinator (MDS). The SSD stated when a resident is admitted to the facility, a welcome meeting or welcome conference is held with the resident and/or family to go over the resident's history. The MDS Coordinator stated the residents medications, baseline care plan, dietary preferences, allergies, and other care conditions are discussed during the meeting. The SSD stated if the resident is not alert and oriented, the resident's family is called to participate in the meeting. The SSD stated a welcome conference was conducted with Resident #1 upon admission and the RP was contact by phone to participate in the meeting. The SSD stated Resident #1 was his own responsible party upon admission. The RP told the SSD Resident #1 had an incident in December of 2022 where he went to the airport and got lost, but not much else. Telephone interviews were attempted on 8/16/2023 with Staff C, CNA, Resident #1's assigned CNA for the 11 PM to 7 AM shift on 7/18/2023, Staff B, LPN, the assigned facility supervisor for the 11 PM to 7 AM shift on 7/18/2023, Staff D, LPN, Resident #1's assigned nurse for the 11 PM to 7 AM shift on 7/18/2023, Staff J, CNA, Resident #1's assigned CNA for the 3 PM to 11 PM shift on 7/18/2023, and Staff E, Agency LPN, Resident #1's assigned nurse for the 3 PM to 11 PM shift on 7/18/2023. The staff members could not be reached. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 6/18/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form revealed under Section E: Medical Condition, primary discharge diagnoses of altered mental status (AMS) and incompetence. A review of Resident #1's psychology evaluation notes dated 7/5/2023 revealed under the section titled Patient Consent This provider confirms that the written consent to treat was obtained from the patient Power of Attorney (POA) as patient is not capable of giving the consent. The note revealed under the section titled History of Present Illness Patient has history of depression, anxiety, and dementia. Patient stated, 'my memory is bad'. He reported he feels depressed, sad, and irritable since he was admitted to the facility . A review of Resident #1's care plan meeting minutes, dated 6/23/2023 revealed a Welcome Meeting was conducted with Resident #1 and Resident #1's RP via telephone. The care plan meeting minutes did not reveal documentation under the sections titled Behavioral Health/Activities or Resident/Family Concerns. Resident #1's diagnosis of dementia was not documented on the care plan meeting minutes. An interview and tour was conducted on 8/17/2023 at 11:15 AM with the facility's Maintenance Director and NHA near the facility elevator. The NHA stated modifications were made to the facility elevator to ensure residents of the facility could not access the rear service hallway through the elevator. The NHA stated a keypad would be installed for the elevator and anyone who used the elevator would be required to enter a code, which would not be provided to facility residents. The NHA stated the rear service hallway could be accessed through the 200 unit and required a code to access. An observation of the facility elevator revealed the buttons to access the rear service hallway were not able to be pressed due to being covered with a cap and black tape. The NHA stated the modifications were temporary until the elevator vendor could install the keypad. A tour was conducted of the rear service of the facility. The facility elevator cannot be accessed through the rear service hallway and was observed to be blocked with yellow caution tape. An observation of the rear exit door of the facility revealed signage posted on the door entrance temporarily closed use front entrance!! The rear exit door was locked and secured. Facility's immediate actions to remove the Immediate Jeopardy included: o Facility egress doors checked for alarming/functioning with no other issues identified. The door that resident exited from noted to not automatically close has been taken out of services. An outside vendor was contacted on 7/19/2023 by the NHA to replace the door. The rear elevator door was taken out of service on 7/19/2023 by blocking the buttons to open them. An outside vendor was contacted on 7/19/2023 by the NHA to service the elevator and put a code box on to prevent it from opening without putting in the code. o Elopement drills initiated on 7/19/2023 starting on 7:00 AM to 3:00 PM shift then conducted every shift for 3 days then weekly for 4 weeks then monthly. o Staff education was initiated 7/19/2023 on Abuse, Neglect and Exploitation Policy w/ emphasis on neglect to include reporting requirements, elopement standard and guidelines, shift to shift rounds and mid night census by the staff development coordinator, this education included actual visualization of each resident during these rounds this education was completed on 7/20/2023. Newly hired staff and agency staff will be educated during the orientation process. Staff will be educated on every 2-hour rounding on residents to include physical visualization of residents. Licensed nurses will validate that this rounding is being done and document attestation of rounding in the medication administration record. Education will be completed by the SDC, or designee. Residents that are evaluated to be at risk for elopement and not placed on the secured unit will have rounding with physical visualization every 1 hour or as indicated in their plan of care. The licensed nurse will validate that this rounding is being done and document attestation of rounding the medication administration record. o Residents currently residing in the facility were re-evaluated for elopement risk by the DON or Designee on 7/19/2023 to 7/25/2023. No new residents identified at risk for elopement. o An ad-hoc QAPI meeting was held on 7/19/2023 at 3:00 PM. o Elopement risk alert binders reviewed for accuracy and confirmed to have demographics present for all residents at risk for elopement based on Elopement Risk Evaluations on 7/19/2023. The binders were again reviewed on 7/25/2023, no new updates were needed. New admissions or residents with a change in behavior that increases risk for elopement will be reviewed during morning clinical meeting and placed in the elopement risk binders located at each nurses station and at the receptionist desk. o Care plans for residents at risk for elopement confirmed to be present on 7/20/2023. Updates were completed as needed. o Rounds are conducted throughout each shift, at shift change, during AM, PM care, during meal services and during care provision. Mid-night census sheet will be signed by the unit nurse and turned into the Director of Nurses each day. Verification of the facility's removal plan was conducted by the survey team on 8/18/2023. An attestation provided by the facility revealed on 7/19/2023, the former maintenance director ensured the rear service elevator door, and the rear exit door of the facility were taken out of service and outside vendors were contacted to service the elevator door and to replace the rear door of the facility. A sample of five residents at risk for elopement, including Resident #1, were reviewed for verification of new orders related to rounding, care plan including elopement risk, elopement risk evaluation, and presence in the facility elopement book. Review of the five residents revealed all residents had new orders related to rounding, care plan including elopement risk, updated elopement risk evaluation, and presence in the facility elopement book. A review of education conducted by the DON and the SDC revealed education related to resident rounding was conducted on 8/17/2023 for facility nursing staff. Education related to abuse/neglect and elopement procedures was conducted on 7/19/2023 and completed on 7/20/2023 with all staff educated. Post-test and competencies included as part of the facility training. A review of facility elopement drills revealed elopement drills were conducted from 7/19/2023 to 7/22/2023. Elopement drills completed on all shifts with documentation of participating staff. Interviews were conducted with 48 staff members, including 2 Registered Nurses, 7 LPNs, 13 CNAs, 7 dietary staff, 3 therapy staff, 6 housekeeping staff, and 10 other staff members. The staff members were able to state that they had been trained and were knowledgeable about the policies and procedures. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 8/18/2023 and the non-compliance was reduced to a scope and severity of D.