**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to properly assess and supervise a resident during an out of state physician's appointment for 1 of 4 residents (R2) reviewed for supervision in a sample of 16. This failure resulted in R2 who is known of returning from day passes intoxicated, not returning to the facility on [DATE] directly after the appointment with non-emergency ambulance transportation provider or staff escort and instead returning on public transportation after going sightseeing.The Immediate Jeopardy began on 08/19/25 when Due to the facility's failure to properly assess and supervise a resident (R2) during an out of state physician's appointment. This failure resulted in R2 not returning to the facility on [DATE] and instead going sightseeing on public transportation. This comes following a history of R2 not returning to the facility as planned, after being signed out with V5, R2's friend and the facility not being able to locate R2, despite contacting the friend. R2 subsequently arrived back to the facility intoxicated after being on a leave of absence (LOA) on both 06/15/25 and 08/15/25. Findings Include: V1, Administrator, V20, Regional Operations, and V22, Registered Nurse Certified (RNC) were notified of the Immediate Jeopardy on 09/04/2025 at 10:46 AM. Abatement number one and two on 09/04/25 were not accepted. Abatement number three accepted on 09/04/25 at 2:44 PM. The Immediate Jeopardy was removed on 09/05/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R2's admission Sheet, admission date of 11/20/24, documented R2 has diagnoses of but not limited to spinal stenosis, major depressive disorder, repeated falls, other psychoactive substance abuse, alcohol use, unspecified with intoxication. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 out of 15 and he requires supervision or touching assistance with some of his activities of daily living (ADLs). R2's Care Plan, admission date of 11/20/24, documented ABUSE: R2 is at risk for abuse and neglect related to (r/t) polyneuropathy, alcohol abuse, major depression, malnutrition, and spinal stenosis. Resident prefers to go on appointments alone (revision date 08/28/25). Goals: Staff will monitor well-being of others. Resident will have zero episodes of abuse and neglect throughout next review. Interventions include but not limited to Assure resident that he/she is in a safe and secure environment with caring professionals. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, CNA, peer) and by verbalizing thoughts, needs and feelings, identify areas that put resident at risk.Review assessment information. Emphasize treatment of casual factors and/or interventions designed to moderate/reduce symptoms (make treatment of compulsive behavior, substance abuse, anger and mental health issues available to the resident, as indicated). It also documented R2 has a history of trauma related to being beat up in the community, and homeless. Some intervention includes but not limited to provide a safe and supportive environment. R2's care plan further documented R2 is at risk for injury related to impaired coordination, impaired judgment, and altered level of consciousness dur to alcohol intoxication. Goal Resident will remain safe and free from injury during and after the episode of intoxication. Intervention: Implement fall precautions (bed alarm, non-slip footwear, frequent rounding). R2's Elopement Evaluation, dated 11/20/24 at 5:03 PM, documented R2 had a score of 16 which is high risk for elopement. R2's Elopement Evaluation, dated 03/27/25 at 3:46 PM, documented R2 had a score of 2 which is no risk for elopement. The facility's Release of Responsibility for Leave of Absence dated 04/02/25, documented R2 was signed out of the facility by V5 (R2's Friend) at 2:46 PM and wasn't signed back into the facility until 04/03/25 at 10:06 PM. The facility's Release of Responsibility for Leave of Absence dated 04/15/25, documented R2 was signed out of the facility by V5 at 10:25 AM and was then signed back into the facility on [DATE] at 6:23 PM. R2's Progress Notes, effective date: 04/16/25 at 5:25 PM (created date: 04/16/25 at 10:27 PM), documented Resident called facility and stated that he will be arriving back to facility within a couple of hours. R2's Progress Notes, effective date: 04/16/25 at 6:23 PM (created date: 04/17/25 at 7:49 AM), documented Resident returned to facility via friend vehicle. Remains stable at this time. No signs of distress noted at this time. R2's Progress Notes, dated 6/15/2025 at 5:43 PM, documented Note Text: Resident returned from leave of absence (LOA), he appeared intoxicated and smelled like liquor. Resident gait is unsteady, alert with slurred speech. VS (vital signs) 97.8-82-20-92/60 sats 94% on RA (room air). Respirations even and unlabored. No s/s (signs/symptoms) of distress. Staff will monitor q (every) 15 min (minutes). Evening medications held. Resident now resting quietly in bed. NP (Nurse Practitioner) aware. Will continue to monitor. R2's Progress Notes, dated 6/15/2025 at 8:12 PM, documented Note Text: Resting in bed. Continues q 15min checks. Appetite good. Po (by mouth) fluids encouraged. Alert with decrease in slurred speech. No s/s of distress. Will continue to monitor. R2's Progress Notes, dated 6/16/2025 at 09:17 AM, documented Social Service Note: Spoke with resident in regard to accusations made by staff. Resident denied accusations stating he left the building on LOA between 9-10am and was out with his friend all day until around 5:30pm. Resident stated he did not sign back in at 2:30pm he did not get back to the facility until 5:30pm. Resident agreed to a behavior contract in regard to following the facility policies. R2's Behavior Contract, dated 06/16/25, documented R2 was placed on a behavior contract as an intervention to his treatment plan and in an attempt to maintain his safety, and well-being during his stay at the facility. He agreed to the following: Refrain from going out on LOA and returning to the facility intoxicated. R2's Elopement Evaluation, dated 06/16/25 at 10:43 AM, documented R2 had a score of 41 and is considered a high risk for elopement. The facility's Release of Responsibility for Leave of Absence dated 08/12/25, documented R2 left the facility with V5, R2's friend at 5:05 PM and the log says he was back at 12:48 AM on 08/13/25 but the Nurses notes said he didn't return until 7:53 AM. R2's Progress Notes, dated 8/12/2025 at 5:18 PM, documented Note Text: Resident going out LOA at this time without meds with plans to return in a few hours. Resident informed to notify staff upon return. R2's Progress Notes, dated 8/13/2025 at 07:53 AM, documented Nurses Notes Resident returned no sign/symptoms (s/s) of discomfort and no new skin issues. The facility's Release of Responsibility for Leave of Absence dated 08/15/25, documented R2 left the facility with V5 at 10:00 AM and returned to the facility at 5:35 PM. Nurses note said he appeared intoxicated. R2's Progress Notes, dated 8/15/2025 at 6:08 PM, documented Note Text: Resident came back LOA appeared intoxicated. spoke with Physician who said to hold narcotics and Psychotics just for tonight. Make sure blood pressure is taken before administering meds no blood thinners. Resident resting in bed call light in reach. On 8/15/2025 7:28 PM, Acute Care Note, documented Patient returned to facility from LOA with family patient mediation held due to nursing staff reporting patient observed with slurred speech and unsteady gait. patient approached by staff with reports of strong odor of alcohol on breath Patient admitted to consuming alcohol off site prior to return to facility. No chest pain or dizziness reported. No nausea or vomiting noted. History of Present Illness: This is a [AGE] year-old male admitted to the facility on [DATE] with a primary dx (diagnosis) of multiple falls, patient had multiple witnessed falls by bystanders, with at least one fall involving head trauma. In the ED (Emergency Department) patient was made code stroke status on arrival. CT (Computed Tomography scan) head negative for stroke or hemorrhage. Stroke team recommended no TNK (Tenecteplase). Patient was hypertensive to 165/104 with HR (Heart Rate) 113. R2's Electronic Medical Record (EMR) was reviewed and had no documented time of when R2 left for his appointment or documented time of when he returned to the facility from his appointment. R2's EMR had three prescriptions from the out-of-town appointment, dated 08/19/25 at 10:33 AM, and documented he was to start on Gabapentin 300 milligrams (mg) take on capsule three times a day, Camphor-menthol 0.5-0.5% lotion, apply to affected area three times daily as needed for itching, and Kenalog 0.1% cream, apply to affected areas twice daily as needed for itch. On 08/27/25 at 11:15 AM, V3, Activities Aide said the incident happened sometime last week she isn't sure of the dated. She said R3 went out to a doctor's appointment by himself and when transportation went to go and pick him up, he wasn't there. She said V1 and two other staff went to look for him and they found him down on state street and he was drunk. V3 said transportation called up to the facility and asked if R3 was back yet and they told them no. She said that's why residents aren't allowed to go by themselves on appointments now someone must go with them. On 08/28/25 at 9:15 AM, R2 said when he goes on appointments the facility will take him in the van or they will have a med car or uber take him sometimes. R2 said after his doctor's appointment on the 19th (August) he was supposed to call the driver of the car service, and the driver would come back and get him, but he didn't do that. He said he found an adventure pass for the bus, so he used it to come back to the facility. He said he wanted to just go sight-seeing, and he returned to the facility about 2:00 PM or 3:00 PM at afternoon. R2 said the time he was found on State/25th street was a different time. He said V5, (R2's friend), had signed him out and he had slipped away from V5 because V5 was being a little irresponsible. R2 said the facility had then called V5 to track him down because V5 would know where to find him. He said V5 found him on 25th street after he spent the night there. R2 said when he is out, he will have a cigarette and a beer sometimes. On 08/28/25 at 11:37 AM, V5, (R2's friend) said on one incident the facility called him and asked if he knew where R2 was at. He said I know where he hangs out, so I went and found him and took him back to the facility. V5 said he did not stay with him that night and he doesn't know where he stayed. V5 said that was the first time R2 had left him like that. V5 said R2 use to work down on 25th street so he knows a lot of people from that area. On 09/02/25 at 11:10 AM, V7, Transportation stated when someone has an appointment, he is the one who makes up all of the resident packets that is sent with them and he is also the one who calls and makes the arrangements for the resident's rides to and from the appointments. He said with R2 he called the insurance company and gave them the information regarding the appointment. The insurance company then will put it out there for someone to pick it up. V7 said he knows on the day of R2's appointment it was A- One med care that picked R2 up from the facility. He said R2 had an envelope with all of information in it and on the back of the envelope was the phone number of the facility and of the car service. V7 said R2 was to either call the car service or he could call the facility to let them know he was done with his appointment and the facility would then call the car service and let them know he was ready to be picked up. V7 said when you call to inform the car service you are ready to be picked up it can take them up to an hour to come and get you. V7 said on this day R2 didn't call the facility or the car service to let them know he was ready to be picked up. He said the car service then called the facility and asked them if they had heard from R2 because it was getting close to time for him to quit for the day and he hadn't heard from R2. The facility told him they haven't seen R2 and that he wasn't at the facility at that time. V7 said he believes Illinois Department of Public Health (IDPH) was in the facility at the time this all happened. He said some of the staff went over to the doctor's office where R2 had his appointment and were looking for him and he wasn't there. V7, he doesn't believe R2 returned with the staff when they came back either. He said this has happened on several occasions and they haven't been documenting on it. V7 said he know for a fact that on this day V8, Receptionist was on and off the phone with the car service regarding R2. On 09/02/25 at 12:48 PM, V11, (med car transport) said he was the person who took R2 to his doctor's appointment in St. Louis. He said he dropped R2 off at the appointment and just kind of waited around for R2 to get a hold of him after he was done with the appointment, but he never contacted him. He said it was getting late and close to the end of his shift for the day, so he called the facility and checked to see if R2 was there. He said he talked with V8 at the facility and she called the doctor's office and was on hold for 30 minutes and while she was on hold R2 came walking in the doors. V11 said they don't know how he made it home he just showed up. On 09/02/25 at 1:23 PM, V9, Primary Care Physician said R2's baseline is he is cognitively intact with a BIMS of 15 so he can make sound decisions. As for when he is drinking is anybody capable of making sound decisions. V9 said they should always monitor and make sure the resident is okay while they are intoxicated. He said they have policies in place for that to determine their cognition. V9 said if he would expect the facility to assess the resident at that point and time and monitor their alcohol use. It's kind of bordering on resident rights. He would also expect them to make an on-the-spot assessment to determine if they are cognitively impaired in anyway. On 09/02/25 at 1:45 PM, V8, Receptionist said she let R2 know when he was done with his appointment to contact the facility, and they would call the ride company and send them to get him. She said R2 never did contact the facility, and the car company called the facility asking if they knew where R2 was. She said the car company was closing early that day, and they still hadn't heard from R2, and he was calling to check about him. V8 said she did try and contact the doctor's office regarding R2, but she could never get through to anyone and she was on the phone waiting for over a half an hour. She said she was on hold until after 1 PM. She said that was when she informed them (facility staff) here about R2. V8 said he did come in the front door during this time, but she isn't sure how he got here to the facility. She said she was busy working the desk and didn't see how he got here. On 09/02/25 at 2:40 PM, V12, Licensed Practical Nurse (LPN) said when someone goes on an appointment, they usually send someone with that person, and she doesn't know why he (R2) didn't have someone with him. V12 said no she doesn't feel like R2 is able to make safe decisions at all. She said he wouldn't be here if he was. He's here for a reason. V12 said she has seen R2 here at the facility intoxicated. On 09/02/25 at 2:45 PM, V13, LPN said she usually isn't R2's nurse that she always works on a different hall when she works. She said she heard about R2 and what happened but that's it. She said they usually have someone with them when they go out on an appointment. She doesn't feel R2 is safe to make sound decisions at all. On 09/03/25 at 1:40 PM, V17, Certified Nursing Assistant (CNA) said 25th and State Street is a busy street, and a lot of people hang out there. She said it depends on what you get yourself into, but that street can be rough. V17 said about six to eight months ago a restaurant located on that street had an employee who was shot and fatally wounded while at work and it was shut down for about three weeks. She said there is a lot of drinking and some people there are doing drugs. She said you will see people begging for $2 or $3 to get themselves something to eat and when they get the money, they will go to the convenience store and buy alcohol. On 09/09/25 at 2:25 PM, V1, Administrator stated she doesn't know why R2 was sent on a doctor's appointment without staff. She said her and two other staff members went to the doctor's office to check and see if he (R2) was there at the office. V2 said while they were at the doctor's office R2 returned to the facility.The facility's Leave of Absence policy, review date of 09/2024, documented General: To document a resident has taken a leave of absence and verify their safe return. It further documented 3. The resident must let the nursing staff know when they are leaving and returning to the building. 4. When a resident is ready to leave, the resident or responsible party must let the nurse know where they are going and their expected return time. The resident or responsible party should call the facility if they are going to be late. It also documented 6. If the resident does not return by the anticipated time, the staff will try to contact the resident or their responsible party. 7. If the nurse cannot get a hold of the resident or responsible party, then the DON (Director of Nursing) and/or Administrator are notified and make a determination regarding alerting the police. 8. If the resident or responsible party does not return the resident to the facility as planned, the resident is considered AMA (Against Medical Advice) and the physician is notified. 9. If the resident does not return, the responsible party is notified within 24 hours. 10. The above will be documented in the progress notes. The facility's Appointments and Transportation policy, review date of 9/2024, documented Policy: When a resident has an appointment outside of the facility, the staff will make the transportation arrangements, unless the responsible party choses to make the arrangements themselves. Purpose The purpose of this policy is to provide guidance for appointments and transportation in the facility. It further documented Procedure: If the family will not be accompanying the resident, the staff nurse or designee will inform the DON (director of nursing) to determine if an escort is needed for the resident. The Immediate Jeopardy that began on 08/19/25 was removed on 09/05/25 when the facility took the following actions to remove the immediacy. 1. Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. Completion Date: 9/4/25 R2 resides at the facility Admin/DON/Designee initiated in-servicing on elopement policy & LOA policy 9/04/25 and will be ongoing. staff to be in-serviced prior to the start of their next shift. R2 was offered substance abuse rehabilitation offsite on 9/4/25 Completed by Admin. Resident care plans have been reviewed and updated to meet residents' needs. Completed by RNC 9/4/25. RNC/VP reviewed Elopement & LOA policy 9/04/25 Residents will be supervised when going offsite to medical appointments as of 8/21/25. In Serviced all nursing staff prior to next shift 9/4/25. Completed by DON. Transportation and Medical records were in serviced by Administrator on ensuring all residents are accompanied by staff for appointments. 8/21/25 All residents were reassessed by the clinical leadership team, using the Elopement Risk Assessment Tool completed 8/31/25. Completed by Administrator/SSD. All residents identified as at risk for elopements have had their care plans reviewed by the MDS nurses for resident specific interventions. Completed 8/31/25. The elopement binder was reviewed by the SSD, to ensure those residents at risk for elopement, have a face sheet and picture in the binder. Completed 8/31/25.2. Actions to Prevent Occurrence/Recurrence:The facility took the following actions to prevent an adverse outcome from reoccurring. Initiated 9/4/25. The DON/designee will in-service staff on facility elopement policy once a month for the next 3 months. The DON/designee will audit all new admissions and readmissions daily to ensure the Elopement Assessment Tool has been completed and that risk factors, safety measures, and resident specific interventions are reflected on the care plan as well as updated on the individualized service plan. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months.Completion Date: 9/04/25

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide supervision to prevent elopement for 1 of 5 residents (R5) reviewed for supervision to prevent accidents in a sample of 8. This failure resulted in R5 eloping through the front entrance at 2:38 AM, on 8/13/25, unsupervised and returning to the facility at 3:36 AM after staff found him approximately 1.2 miles from the facility.The Immediate Jeopardy began on 8/13/25 at 2:38 AM when R5, a confused resident, exited the facility unsupervised and was found 1.2 miles away. R5 returned back to the facility with staff at 3:36 AM. On 8/19/25 at 9:03 AM, V1 (Administrator) was notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 8/20/25. Findings include:R5's Face Sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, epilepsy, moderate protein-calorie malnutrition, cannabis abuse and schizophrenia.R5's Minimum Data Set (MDS) dated [DATE], documented R5 was severely cognitively impaired and required supervision or touching assistance with transfers. R5's MDS continued to document his ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel was not attempted due to medical condition or safety concerns. R5's Care Plan dated 7/7/25, documented he was at risk for elopement with the following interventions put in place for R5 to be 1:1 with staff date initiated: 07/02/2025; encourage R5 to keep busy with activities date initiated: 07/02/2025; give R5 an opportunity to talk about why he wants to leave, remind him that the doctor would need to approve him leaving date Initiated: 07/07/2025; praise R5 when cooperative date initiated: 07/02/2025; when R5 begins to make statements that he want to go home distract with an activity, offer him a drink, based on weather offer to accompany him to patio date initiated: 07/07/2025. R5's Elopement Risk Assessments dated 7/7/25 and 8/14/25 documented he was at high risk. R5's Progress Note dated 7/6/25 at 5:03 PM documented, Code yellow called this nurse along with other staff exited the facility to retrieve the R5. R5 noted at the end of the with staff following at a safe distance. Staff asked resident multiple times to return to the facility. R5 cont. (continued) to refuse, R5 yelled he would not return and took off walking faster. Local police arrived and was able to talk R5 into returning. R5 was transported back by cop car, and c/o (complaints of) not wanting to stay and being locked in a prison when he has to work. R5 noted to be mentally unstable and very confused. R5 agreed to wait in the dining room but states he will not stay here at the facility. N.P. (Nurse Practitioner) and Admin (administrator) and management made aware.R5's Psychotropic Provider Note dated 7/8/25 at 10:50 AM documented, 70 yo (year old) M (male) with Schizophrenia, restlessness and agitations. Update obtained from R5 and staff. R5 pleasant and cooperative with assessment. Recently admitted after being hospitalized for a witness seizure. Sitting in the common area at time of assessment. R5 is an elopement risk and is disruptive with his behaviors.R5's Progress Note dated 7/24/25 at 10:02 AM documented, R5 attempted to leave facility at 9:50 am. Staff able to redirect patient away from door. R5 placed on 15-minute face checks at this time.R5's Progress Note dated 8/1/25 at 2:45 AM documented, R5 has been awake/up most of NOC (night), wanders halls and sits in dining room. Elopement attempt x 2, this nurse able to redirect without difficulty. Frequent monitoring continues. R5's Psychotropic Provider Note dated 8/1/25 at 1:01 PM documented, 70 yo M with restlessness and agitation and unspecified sleep disorder. Update obtained from patient and staff. Patient pleasant and cooperative with assessment with confusion. Noted to be ambulating the halls at time of assessment. Speech continues to be intermittently nonsensical. Staff report that patient stays up most nights wandering the facility and attempting to elope.R5's Progress Note dated 8/13/25 at 2:45 AM documented, R5 in bed at this time. At approx. (approximately) 0300 (3:00 AM) staff hears front door alarm with no staff exiting building and no one seen outside the front doors. Staff begins room checks for resident accountability. CNA (Certified Nursing Assistant) reports that said resident is not accounted for. Administrator notified. Staff splits up and building search repeated and other staff members outside of building to search with no results. 3 different staff members leave facility in cars to search surrounding areas. Police notified by staff member/receptionist. R5 located on local street (street facility is located on) by staff member at approx. (approximately) 0325 (3:25 AM). Resident returns to facility via private vehicle. No injury noted. No distress. R5 states I just needed my ID, I'm going to local town Call placed to ambulance for transfer of resident to have eval (evaluation) done. Ambulance arrives at approx 0425 (4:25 AM) with 2 attendants and will be taken to local hospital for eval and tx (treatment).R5's Ambulance Report dated 8/13/25 at 4:30 AM, documented he was being transferred to a local hospital for a psychiatric evaluation after elopement from the facility approximately one hour prior. R5's Progress Note dated 8/13/25 at 10:16 AM documented, R5 returned from local hospital with no new orders.On 8/14/25 at 11:53 AM, V3, CNA, stated she is sitting one on one with R5 to make sure he doesn't go outside. R5 was laying with his blanket over his body and head in bed while V3 sat in a chair at the end of his bed. V3 stated she was not sure what happened, and this is the first time she's really had direct care of R5 so she's not familiar with his behaviors or past if he's ever eloped.On 8/14/25 at 11:58 AM, R5 stated he doesn't remember being outside the facility or at the hospital. R5 stated he was hungry and felt messed up after being asked if he was hurt in any way. R5 did not respond to questions at times and continued to lay in bed with his blanket over his head.On 8/14/25 at 12:35 PM, V1, Administrator, stated on the night of the 12th to the 13th (August 2025), she saw via video footage, R5 exit the building unsupervised at approximately 2:37 AM through the front door. V1 stated the receptionist working at the time was on a lunch break but somebody really needs to sit up there while she is on break, and she was educated on that after it happened. V1 stated staff called her at about 3:00 AM to let her know R5 had eloped then shortly after that they found him between 3:00 AM and 3:30 AM. V1 stated her staff did a quick head count twice after hearing the front door alarm and found that R5 was not in his room. V1 stated staff reported they had seen R5 in his room about 10 minutes prior to him leaving the facility. V1 stated she is currently investigating the incident of elopement on R5.On 8/14/25 at 1:42 PM, V5, Receptionist, stated she was working the night R5 eloped. V5 stated she was on a lunch break when R5 got out the front entrance and was told by another CNA when she was returning to the facility that a resident had gotten outside so she turned around a left to look for them. V5 stated she saw R5 close to the board of education building, but he didn't recognize her and told her he was going to the gas station. V5 stated she was nervous about trying to get R5 into her car alone, so she called the police and waited with him. V5 stated after 10-12 minutes she called the facility because the police didn't show. V5 stated R5's CNA V6 was a male and agreed to come help get him back to the facility. V5 stated R5 was not injured from what she could tell but he was out of breath when they got back. V5 stated R5's nurse, V7, gave him a soda to drink. V5 stated she had seen R5 try to exit the building multiple times but was able to redirect him. V5 stated R5 had not eloped for her before this. V5 stated the facility is keeping R5 safely supervised now with a CNA 1:1 assigned to him. V5 stated staff do hourly checks to supervise the residents, door alarms alert us and using visual site to keep residents safe from elopement. V5 stated she had concerns about R5 because he was a flight risk. V5 stated she had never been told not to leave the front reception desk empty but after it happened, she was retrained and told someone needs to be up there at all times. V5 stated she had told a CNA she was going to a local fast-food restaurant before she left. V5 stated she was not sure if the front door alarm could be heard back behind the front doors. V5 stated she was gone for about 15-20 minutes after leaving at 2:15 AM but by the time she came back, R5 was gone.On 8/14/25 at 2:17 PM, V8, Licensed Practical Nurse, LPN, stated she was working when R5 got out. V8 stated a CNA came to her and said R5 was not in his bed so she got in her car and started looking for him. V8 stated she's never been R5's nurse but she noticed the aides had been checking on him often. V8 stated his nurse said R5 was in his bed just 30 minutes prior to him leaving. V8 stated she could not hear the front door alarm going off, but she thinks one of the CNAs heard it and that's what prompted everyone to start looking for R5. V8 stated R5 was not injured. V8 stated 1:1 supervision is put in place and frequent rounding is done to prevent elopements. V8 stated the staff were doing everything they were supposed to do, and it still happened. V8 stated R5's room was not close to a nurse's station or any exits and cannot be seen from a nurse's station either. On 8/14/25 at 2:34 PM, V9, CNA, stated her and V6, CNA, had been doing rounds the night R5 eloped. V9 stated V6 noticed R5 wasn't in his bed and continued to look for him then when he wasn't found quickly, the code yellow for elopement was called. V9 stated for a code yellow everyone stops what they are doing to search for the resident. V9 stated R5 had been in his room around 2:00 AM sleeping. V9 stated they do rounds every two hours and she would take turns with other staff to walk by R5's room more frequently. V9 stated V6 was in close proximity to R5 most of the night she thought. V9 stated interventions to prevent elopement are frequent checks and psychosocial staff located on each hall. V9 stated everyone was doing what they were supposed to. V9 stated she doesn't leave her section assigned and will sit on the hall. V9 stated V6 noticed first that R5 was not in his room and then noticed the front door alarm had been going off. V9 stated she was not sure how long it took for R5 to be found and doesn't think he was injured.On 8/18/25 at 11:25 AM, V11, Registered Nurse, RN stated R5 usually stays quiet in his room, he will have cigarettes outside but then goes back to bed. V11 stated every once in a while, R5 wants to leave the building but she is able to redirect him by letting him know they can get things for him like cigarettes. V11 stated R5 is usually confused that he still needs to go get things for himself like at the gas station or the bank but is reminded we can do that for him here. V11 stated 15-minute face checks are implemented for 24 hours after attempting to leave the facility and 1:1 but not sure how long for 1:1. V11 stated it is for R5's benefit to be in a facility because he requires assistance to take care of himself safely. V11 stated it is not safe for R5 to be outside unsupervised on his own because it could have the potential for him to get into an unsafe situation such as someone else being afraid of him, he's a very tall guy. V11 stated R5's room is not close to the nurse's station but is able to alternate checking on him frequently with the CNAs. V11 stated it's random when R5 is exit seeking, not sure what prompts it and not often.On 8/18/25 at 11:34 AM, V12, CNA, stated R5 is pretty chill, he comes out to eat and then goes back to lay down, at nighttime he will ask for snacks around 12:00 and go back to his room. V12 stated R5 just stays to himself, and he's never tried to leave the building while he was working. V12 stated at nighttime, if R5 is out of his room, he will try to keep him occupied and redirect him. V12 stated he keeps a close eye on all of his residents typically doing rounds every 30 minutes to an hour. V12 stated R5 doesn't have many needs. V12 stated when assigned to R5's hall it is just his hallway, and it's split with another CNA. V12 stated when he goes on breaks, he will let someone else know. V12 stated it's not safe for R5 to be outside the building on his own; he needs the assistance and direction of staff to cue him and help with his care or it won't get done and wouldn't know how to get back.On 8/18/25 at 12:33 PM, V10, Medical Director, stated he was aware R5 eloped on 8/13/25 and expects staff does everything they can to prevent. V10 stated being in a facility is necessary for R5.On 8/18/25 at 12:35 PM, V13, Nurse Practitioner, stated she was aware R5 eloped on 8/13/25. V13 stated not only is it unsafe for R5 to be outside the facility unsupervised but it is unsafe for any resident to be unsupervised outside this facility. V13 stated 1:1 supervision and frequent rounds help prevent elopement. V13 stated she expects staff to be doing frequent rounds and for staff to be at the front reception door to know that no one has gotten out. V13 stated the area this facility is in isn't the best and not many people are walking outside to begin with. V13 stated it would be suspicious to see R5 walking alone at night outside.On 8/18/25 at 3:20 PM, in a joint interview with V1, Administrator, and V14, Corporate/Regional Nurse, V1 stated on 7/6/25 R5 left the facility but staff had eyes on him the entire time until police arrived to take him back to the facility because he didn't want to come back. V1 stated R5 was then placed on 1:1 supervision for 72 hours with no signs of elopement behaviors and put on 15-minute checks after that. V1 stated R5 was trying to leave that time because he didn't have any more cigarettes. V1 and V14 stated R5's initial admission Elopement Risk Assessment was high because they do that for new admissions to be safe being in a new environment. V1 and V14 stated after that initial assessment was done, the social worker will complete another one and update it in the records with their first visit. V1 stated the 6/23/25 assessment was high because he was new and then on 6/30/25 he was re-evaluated and deemed not at risk and that is what we were going off of prior to his elopement on 7/6/25.On 8/14/25 at 1:06 PM, the facility's video footage of R5 on 8/13/25 at 2:38 AM was reviewed and showed R5 exiting the front door of the facility unsupervised. At 2:40 AM, a person outside the front door appears but does not enter and walks away. At 2:51 AM, staff appear inside the building checking the front door.On 8/14/25 at 2:47 PM, the facility's video footage was reviewed and showed R5 returning to the facility on 8/13/25 at 3:36 AM accompanied by staff.On 8/14/25 at 1:05 PM, V1 activated the facility's front door alarm and went back to where the floor staff would be (past two double doors after walking in the front entry doorway. V1 stated she could not hear the alarm. This surveyor went past the double doors where staff would be working behind and could not hear the front door alarm. V4 (receptionist) stated the front door alarm could not be heard past the double doors.The facility's Elopement Policy last reviewed on 9/2022 documented residents who are at risk to elope are closely supervised to keep them safe in their environment, while allowing them to move freely about the safe environment. The policy further documented elopement occurs when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so. It continued to document alert residents are not in the same category of potential danger as the resident with impair cognition trying to leave the facility. During the validation of the facility's abatement plan, on 8/20/25, some staff had not had in-services regarding the elopement policy. The facility re-inserviced all staff on 8/20/25. The facility took the following to remove the Immediacy which began on 8/13/25:Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. Completion Date: 8/20/25.1. R5 returned to the facility and has been on 1:1 supervision since returning. Facility is looking for alternate placement for R5. 8/13/25 Completed by V1, Administrator/V35 SSD (social services director) RNC (regional nurse consultant) in-serviced V2, Director of Nurses, (DON) and V1, Administrator on elopement policy 8/14/25 completed by V14, RN (registered nurse) RNC V2, DON/Designees to provide in-serving on elopement policy to all staff by 8/20/25 or prior to the start of their next shift. All residents were reassessed by the clinical leadership team, using the Elopement Risk Assessment Tool completed 8/14/25. Completed by DON/SSD All residents identified as at risk for elopements have had their care plans reviewed by the V36, MDS (minimum data set) nurses for resident specific interventions. Completed 8/14/25 The elopement binder was reviewed by the Regional Nurse Consultant, to ensure those residents at risk for elopement, have a face sheet and picture in the binder. Completed 8/14/25. Facility has 24 Hour a day Receptionist from 8/13/25 revised by V1, Administrator/Lead Receptionist V1, Administrator/Designee In-Serviced All Receptionist on not leaving the Front Desk unattended 8/13/25. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. Completion Date: 8/20/25 The DON/designee will in-service staff on facility elopement policy once a month for the next 3 months. The DON/designee will audit all new admissions and readmissions daily to ensure the Elopement Assessment Tool has been completed and that risk factors, safety measures, and resident specific interventions are reflected on the care plan as well as updated on the individualized service plan. A QAPI (Quality Assurance and Performance Improvement) PIP (performance improvement plan) has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA (quality assurance and assessment) meeting. Monitoring/auditing and reporting will continue for a minimum of three months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide supervision to prevent elopement for 1 of 5 residents (R1) reviewed for supervision and accident prevention in the sample of 29. This failure resulted in an Immediate Jeopardy when R1 exited the facility and was found on the ground, in a field, near a busy interstate and road. This failure has the potential to affect not only R1, but R4, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R25, who have been identified as a high risk for elopement by the facility. The Immediate Jeopardy began on 8/10/23 at 9:00 PM when R1 was last seen in the facility. R1 was found at approximately 5:00 AM on 8/11/23, lying down in a field near a busy interstate and road. R1 was brought back inside the facility, assessed, and sent out to the Emergency Department for acute medical evaluation. V1 (Administrator), V2 (Director of Nursing/DON), and V14 (Vice President of Operations and Regulatory Compliance) were notified of Immediate Jeopardy on 8/25/23 at 1:00 PM. The surveyor confirmed by observation, record review, and interview that the Immediate Jeopardy was removed on 8/25/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and the revisions of the elopement policy and procedures. Findings include: R1's Face Sheet documents, R1 was admitted to the facility on [DATE] with diagnoses, including Unspecified Dementia, Emphysema, Encephalopathy, Dysphagia, (Difficulty Swallowing), and Weakness. R1's Minimum Data Set, (MDS), dated [DATE] documented, R1 was severely cognitively impaired, required extensive assistance with walking, and had no exhibited wandering behavior. R1's Care Plan, initiated 12/29/2022 documents, (R1) is at a high risk for elopement. The Care Plan was last updated on 8/20/23, to include the following interventions, 8/20/23 q15, (every 15 minute), checks; Allow concerns to be expressed; Encourage resident to keep busy with activities; Monitor where abouts PRN, (as needed); Redirect resident to activities of choice or SS (Social Services) group. R1's Care Plan also documented R1 was at risk for falls related to dementia. R1's Elopement Evaluation, dated 5/17/2023, documented, R1 was at high risk of elopement. R1's next Elopement Evaluation was prior to his elopement on 8/6/2023 and documented, R1 was at low risk of elopement. R1's Elopement Evaluation following his elopement on 8/11/2023 documented, R1 was again at high risk of elopement. R1's Progress Note by V28 (Licensed Practical Nurse/LPN), on 6/19/23 at 7:25 AM documents, Resident awoke (woke), up and walked the hall and urinated in the hallway. Resident easily redirected and care provided. R1's Progress Note by V28 (LPN) on 6/25/23 at 6:01 AM documents, Resident up at nursing station most of night shift. Easily redirect able. Wonders (Wanders) unit. R1's Progress Note by V28 (LPN) on 7/8/23 at 12:18 AM documents, Resident awake, closely monitored, due to wondering (wandering) behavior. R1's Progress Note by V28 (LPN) on 8/11/2023 at 7:15 AM documents, CNA (Certified Nursing Aide) approached writer at 0345 (3:45 AM), stating that (R1) was not in his room and asked where he was. (R1) unable to express event (sic). Immediately, writer went to room and (R1) not in bed. Asked CNA assigned to (R1) and stated that when she came in at before 10:00 pm shift she asked nurse where (R1) was and stated, that the previous nurse stated, that (R1) went to hospital. Writer immediately went into nurses notes and noted that there were no notes indicated (indicating) (R1) went to hospital. Writer initiated a search of the complete facility including shower rooms and bathrooms. (R1) unfounded (not found) at that time. Writer and fellow nurse did complete perimeter search. Ensuring all doors were alarmed and (R1) not in closed patio areas. Call placed to (V2) DON (Director of Nursing). (V2) instructed to call 911 and that she would notify (V1) Administrator and would call writer back. In the meantime, fellow staff drove around 1 mile radius of facility including church parking lots, surrounding field and ditches on sides of the roads at 0500 (5:00 AM), (R1) noted on the grounds (sic) when completing another search. RN (Registered Nurse), DON, along with Administrative Staff assessed resident prior to (R1) getting off the ground. (R1) noted to be laying (lying) on right side in grass. ROM (Range of Motion) attempted, resident had difficulty with movement to right arm and right leg. (R1) base line is alert and orientated (oriented) to self, able to make needs known at times. (R1) hard to direct with ROM. Due to that fact, (R1) then assisted to a wheelchair and back in the building before further evaluation. R1's Emergency Department Note from (Local Hospital) dated 8/11/23 at 7:19 AM documents, this [AGE] year-old male who arrives via EMS (Emergency Medical Services) from (Facility). Apparently, this patient was found outside of the (Facility), and the confusion arises now how long he was outside. One story states 2 days and the other source states 1 hour. General appearance: cooperative, comfortable, frail appearing and appears older than stated age. Other: there are minor nontender abrasions over both shoulders anteriorly (on front side). This patient's mental and physical status has remained unchanged while in department. CT (Computed Tomography) of the neck and head are unremarkable. Patient to be discharged back to (Facility). R1's Progress Notes by V36 (LPN) on 8/11/2023 at 12:10 PM documents, (R1) returned from (Local Hospital). NNO (No New Orders) were received from hospital visit. All labs were WNL (Within Normal Limits). (R1) CT and xrays (X-rays), were negative and did not have any fractures present. (R1) is now resting in his bed at this time. The Facility's Incident Timeline dated 8/11/23 documents: 4:00 am (V2) DON received call from (V28) Charge Nurse to inform they could not locate resident (R1). 4:06 am received call from (V2) DON informing me of resident (R1) not located in facility. (V2) informed to contact Police for assistance. (V1) informed by (V2) this time, that charge nurse contacting hospitals. (V28) stated, she had directed staff to do complete head count in facility and search for resident. (V28) directed staff outside facility to search for resident. Guardian notified. 4:08 am (V1) Administrator began notifying managers of situation and requesting to assistance. 4:10 am (V35) NP (Nurse Practitioner) notified of not being able to locate. 4:15 am Police arrived at facility, police received information including picture of resident, distinguishing markings, demographics. Police assist with search. (V2) DON initiated staff interviews. 4:30 am search continues involving the immediate area outside facility and surrounding areas. 5:00 am Resident located lying on ground in adjacent grassy area, nursing assessment completed. Resident assisted to WC (wheelchair) to transport back in facility and further nursing assessment. Resident transferred to Hospital as precautionary. Police, Physician and Guardian notified. Staff remained 1:1(one on one supervision), with res(resident), until EMS (Emergency Medical Services), arrived. 12:10 pm Ret'd (Returned) from ER (Emergency Room). No sig (significant injuries), 1:1 continued, Elopement Assessments for all res reviewed along with CP (Care Plan), updates as needed. Elopement Binders reviewed et (and) updated as needed. Res returned to facility 1:1 continued. On 8/24/23 at 11:56 AM, V13 (CNA) stated, she arrived at work around 9:45 PM on 8/10/22 and was doing a walk through to check on her residents, when V31 (Agency Nurse) told her R1 was in the hospital. Later in the shift, V30 (Unknown Employee) came to V13 and asked where R1 was located. V30 stated, R1 had a doctor's appointment earlier in the day, but came back to the facility afterwards. V13 stated, she went back to check with V31 (Agency Nurse), and they discovered R1 was missing. He was found at a church by the facility. V13 was helping search for him. Staff looked all through the facility and someone else finally found him outside behind the laundry area and by the church. When V13 went outside, R1 was lying on the ground and had right eye swelling. She stated, R1's tongue was sticking out of his mouth and swollen. He was on the ground and complained about his leg, but they moved him to a wheelchair. V13 stated it was light outside when they found R1 and estimates finding him at 4-5:00 AM but was unsure exactly how long they were looking for him. V13 stated, when she got to the door to go outside to check on R1 there were no alarms going off, and she assumed they had already been turned off. She stated, (R1) wasn't able to tell me what happened. I think he has dementia and is always pretty confused. On 8/24/2023 at 12:00 PM V1 (Administrator) stated, the CNA on night shift thought R1 was out of the facility for a visit. She stated the last time R1 was seen on 8/10/23 was at 10:30 PM and was later found in a grassy area near the facility by staff. On 8/24/2023 at 12:45 PM V15 (Dietary Aide) stated he has seen R1 trying to get out of the facility. On 8/24/23 at 1:14 PM, V16 (Laundry Aide) stated R1 wanders throughout the building and often stands by the doors and watches the cats outside. On 8/24/23 at 1:20 PM, V11 (CNA) stated, R1 has tried to get out of the facility before and can be combative at times. She stated someone must have shut off the alarm without checking to see if anyone was outside. On 8/24/23 at 1:58 PM, V22 (Ombudsman) stated she was not made aware of R1's elopement, but sometimes during the day they let residents on the independent side of the building go outside, and the door at the end of the Women's Hall is left unlocked. She stated, she has seen residents trying to get out of the building. On 8/24/23 at 2:18 PM, V21 (CNA) stated she remembers R1 being anxious that day and trying to get out of the facility. On 8/24/23 at 3:17 PM, V23 (CNA) stated R1 wanders around the facility and pushes on the doors. On 8/24/23 at 3:25 PM, V25 (CNA) stated R1 wanders the halls all the time and shakes the door handles. On 8/24/23 at 3:29 PM, V29 (LPN) stated R1 is very confused. On 8/25/23 at 8:30 AM, V26 (CNA) stated, R1 kept going back and forth to the door and setting off the alarm on 8/10/23. She stated, everybody watches (R1) because he is always wandering and needs to be redirected. She reported cleaning R1 up around 8:30-9:00 PM and took a break between 10:15 and 10:30 PM. R1's roommate usually likes to keep his door closed, and when she walked by around 2:30 AM she noticed R1 wasn't in there. V13 (CNA) stated, she was told he was in the hospital. I checked with the nurse (V28), and she said R1 was not on the list of hospitalized residents. I said, We've gotta find (R1). He has dementia and likes to walk. We went outside, couldn't find him anywhere. I can't remember who found him, but he was responding and talking. He said, his shoulder hurt. He was lying on his right side and that was the shoulder he complained about. (R1) had a bruise over his right eye that looked like he had fallen. He was wearing a pair of jeans; that is all I remember. He was also, wearing a diaper; we brought him in and cleaned him up. He had urinated in his diaper. I don't know how he got out. I think someone turned off the alarm and didn't look to see if he was out there. On 8/25/23 at 9:11 AM, V27 (Business Office Manager) stated, he got a call around 4:45 AM on 8/11/23 from V1. He was here by 5:00 AM and joined the search for R1. He looked at the field in back and it was starting to get light out. He came around a large mound of gravel and saw R1 lying on the ground by the back of the church building. He stated, R1 was just lying there and responded when spoken to. V27 called the nurses, and they assessed R1 and put him in a wheelchair. V27 could not recall whether R1 was wearing shoes but remembers him wearing a white shirt and jeans which were covered in grass. V27 showed surveyors where R1 was found. This was estimated to be about 250 yards from the street on which the facility resides with a speed limit of 35 mph (miles per hour), and 400 yards from Interstate 255 with a speed limit of 65 mph. On 8/25/2023 at 9:45 AM, V28 (LPN) stated, I came in 8/10/2023 at 10:45 PM. The nurse, (unknown), who gave me report was very flustered. I did not get a detailed report. There were all kinds of room changes and residents wanting my attention at the beginning of my shift. I was working with a seasoned CNA, I don't remember her name, but she was doing rounds and she said everyone was ok. Later in our shift, I'm not sure what time, a CNA asked where (R1) was. V13 said R1 was at the hospital. We saw he wasn't sent to the hospital. We immediately did a full facility check. I drove my car around and shined my lights in the grassy area. I then called the Police and the DON (V2). (R1) was found lying on his right side. We rolled him over on his back and did range of motion. We stood him up and put him in a wheelchair. The Corporate Team was here, and they assessed him. I did not do a full body assessment. R1 had on a shirt and pants. I don't know if he had shoes on or not. He complained of pain all over, but mostly on the right side. The (Local Police Department) Report dated 8/11/23 at 4:14 AM by V54 (Police Officer) documents, I, (V54), responded to (Facility) located at (Address) in reference to a missing person report. Upon arrival, I spoke with (V28), who stated, a resident by the name of (R1) had not been seen since approximately 1500hrs, (3:00 PM), on 8/10/2023. (V28) stated, when she arrived at work at 2300hrs (11:00 PM) on 8/10/2023, she was advised by the on-shift CNA (V13), that (R1) had been sent out, however, there was no chart of which hospital he was transported to or what time he left. (V28) stated, (R1) normally walks the halls, however, he has never left the facility. V28 stated, they have a receptionist normally sitting at the desk and advised her (R1) never left facility that they saw. (V28) stated, the company removed the camera system, so there was no way of seeing if he left the building. (V28) provided me with a picture of (R1) which was forwarded to my shift, in case they noticed anyone walking in the area matching the description of (R1). I requested to check (R1)'s room, at which time I was escorted to his room, where I noticed his bed was still made, and both of roommates were sleeping. As I exited the room, I spoke with (V13), who stated she came into work at 2200hrs (10:00 PM) and when she checked (R1)'s room, she noticed the bed was made, and asked the nurse she was relieving where (R1) was, and she advised he had been sent out, but nothing further. I asked the facility administrator (V1) if they wanted (R1) entered as missing, and she stated yes. I then requested dispatch enter (R1) as missing and was provided the FOLLOWING LEADS. A short time later, I was advised by dispatch (Facility) called back, and advised they located (R1) hiding in the grass behind the facility. V64 (R1's Medical Doctor) was unavailable by phone on 8/24/23 at 3:28 PM, 8/24/23 at 3:40 PM, 8/25/23 at 8:50 AM, and 8/31/23 at 9:06 AM. On 8/24/23, the facility provided the following information which identified the residents who were at risk for elopement: -R1's Elopement Evaluation dated 8/11/23 documented R1 was at high risk for elopement. -R4's Elopement Evaluation dated 8/11/23 documented R4 was at high risk for elopement. -R8's Elopement Evaluation dated 8/11/23 documented R8 was at high risk for elopement. -R9's Elopement Evaluation dated 8/11/23 documented R9 was at high risk for elopement. -R10's Elopement Evaluation dated 8/11/23 documented R10 was at high risk for elopement. -R11's Elopement Evaluation dated 8/11/23 documented R11 was at high risk for elopement. -R12's Elopement Evaluation dated 8/11/23 documented R12 was at high risk for elopement. -R13's Elopement Evaluation dated 8/11/23 documented R13 was at high risk for elopement. -R14's Elopement Evaluation dated 8/11/23 documented R14 was at high risk for elopement. -R15's Elopement Evaluation dated 8/11/23 documented R15 was at high risk for elopement. -R16's Elopement Evaluation dated 8/11/23 documented R16 was at high risk for elopement. -R17's Elopement Evaluation dated 8/11/23 documented R17 was at high risk for elopement. -R18's Elopement Evaluation dated 8/11/23 documented R18 was at high risk for elopement. -R19's Elopement Evaluation dated 8/11/23 documented R19 was at high risk for elopement. -R20's Elopement Evaluation dated 8/11/23 documented R20 was at high risk for elopement. -R21's Elopement Evaluation dated 8/11/23 documented R21 was at high risk for elopement. -R22's Elopement Evaluation dated 8/11/23 documented R22 was at high risk for elopement. -R23's Elopement Evaluation dated 8/11/23 documented R23 was at high risk for elopement. -R25's Elopement Evaluation dated 8/18/23 documented R25 was at high risk for elopement. The Facility's Elopement Policy revised 9/2021 documents, A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Residents who are at risk to elope are closely supervised to keep them safe in their environment, while allowing them to move freely about the safe environment. Residents at risk to elope will be closely monitored. All facility staff are responsible for responding to a door/elevator alarm immediately. This response will include visual check of the immediate vicinity surrounding the door/elevator that tripped the alarm, including the stairwells and outside area. The Facility's Elopement Policy revised 8/2023 documents, Elopement is defined as a situation where a resident who cannot recognize normal dangers and hazards outside the facility leaves the facility without staff knowledge. All residents will be evaluated upon admission, quarterly, and as needed with newly identified wandering or elopement behavior. The Administrator, DON, Nursing Supervisor, Department Heads, Therapy Department, each Nursing Station, Reception and Beauty Shop, will keep the list. Facility exit doors are alarmed so that staff can secure the environment and intercede when a resident attempts to leave the facility. If no identifiable cause for the triggering alarm can be found, the following measures will be taken a. Administration will be notified. b. Account for all residents performing whole house head count. c. other steps may be taken as warranted. The state agency validated the removal of abatement by observations of exit doors to ensure they were in operating order, alarmed, and monitored, when indicated. Surveyors conducted a review of all Facility in-services. R1's medical records were reviewed for care plans and elopement assessments with no concerns. V57 (Social Service) was observed conducting enhanced supervision for R1. The Enhanced Supervision Form Monitoring Tool was reviewed for R1 and included times of observations. Surveyors reviewed Elopement Evaluations and Care Plans of residents who have been identified at risk for elopement and verified they had been updated. Employees (V23 CNA, V38 CNA, V39 LPN, V40 Housekeeper, V41 Housekeeper, V43 MDS Coordinator, V46 LPN, V44 Activity Aide, V51 CNA, V52 CNA, V55 Physical Therapy Assistant, V56 LPN, and V58 LPN) were interviewed to ensure they were aware of current policies and procedures and had been in-service. The Immediate Jeopardy that began on August 10, 2023 was removed on August 25, 2023 when the facility took the following actions to remove the immediacy. A. Identification of Residents Affected or Likely to be Affected: 1-R1 was assessed on 8/11/2023 by V2 (Director of Nursing). Resident was transferred to (local hospital) for evaluation, returning with no new orders. Resident remains in facility with implementation of enhanced supervision. Resident was placed on enhanced supervision 1:1 from 8/11/2023-8/15/2023. He was hospitalized due to unrelated medical needs 8/15-8/20/2023. Upon return 8/20/2023 resident was placed on enhanced supervision every 15 minutes. 2-Initiating reassessments for elopement risk on all residents by V46 (Infection Preventionist/Licensed Practical Nurse), V43 (Minimum Data Set/MDS Coordinator), V27 (Business Office Manager), V1 (Administrator), V47 (Admissions Director), and V48 (Activity Director) on 8/11/2023. All assessments were completed by 8/12/2023. All to be ongoing for new residents will be assessed for elopement risk and residents with newly identified exit seeking behaviors will be reassessed for elopement risk. 3-Care plans were updated with interventions to address identified risks by V1 (Administrator), V2 (Director of Nursing), V18 (Psychosocial Director) on 8/11/2023 and to be ongoing to include all new residents and as needed for newly identified exit seeking behaviors. B. Actions to Prevent Occurrence/Recurrence: 1-The [NAME] President of Regulatory Compliance and Clinical Operations, V14, reviewed and revised elopement policy and procedures on 8/11/2023. Revisions made to tailor building specific needs such code color updated to yellow, removal of electronic monitoring devices (the facility does not have electronic monitoring system), response required when cause of alarm is not immediately identified including an immediate whole house head count completed on 8/11/2023. 2-The interdisciplinary team including V1 (Administrator), V2 (Director of Nursing), V48 (Activity Director), V27 (Business Office Manager), V47 (Admissions Coordinator), V43 (Rehab/Restorative Nurse), and V46 (Infection Preventionist/LPN) educated on revised policy and procedures to be ongoing for new hires and agency staff. 3-The training will also include providing supervision/monitoring to prevent elopements, immediate head count upon recognition of missing resident and recognizing when a resident exits the facility or has newly identified exit seeking behaviors to be ongoing to include new hires and agency staff. 4-Residents exhibiting newly identified exit seeking behaviors will be placed on enhanced supervision 1:1 until interdisciplinary team and provider decide enhanced supervision can be reduced or discontinued. 5-All nursing staff will be educated on performing a whole house head count at the beginning of their shift with outgoing shift to ensure all residents are accounted for by V2 (Director of Nursing), V49 (Assistant Director of Nursing), V43 (Rehab/Restorative Nurse), V46 (IP Nurse/LPN), and V12 (Director of Staffing) on 8/25/2023. 6-Psychosocial and activities staff will be educated on the process of residents with west hall patio privileges. The west hall door will be unarmed for open patio hours from 10am-12pm and 2p-4pm daily to be completed on 8/25/2023 and ongoing for any newly hired staff by V18 (Psychosocial Director) and V48 (Activity Director). 7-Psychosocial and activities staff will be parked at the west hall patio exit door during open patio hours to provide adequate supervision of the residents initiated on 8/25/2023 and to be ongoing. 8-Emergency resident council meeting to be held on 8/25/2023 by V48 (Activity Director) to inform residents of new open patio hours the West-Hall door will be unlocked. 9-All agency staff and new hires will be educated on the above policies and processes prior to beginning their shift by V1 (Administrator), V2 (Director of Nursing), V12 (Director of Staffing) to be ongoing. 10-Safety checks of all potential exits daily to ensure they are secure. This will be done by the V37 (Maintenance Director) to be ongoing. 11-V37 (Maintenance Director) will remove access to the bypass keys for exit doors from all staff with exception of psychosocial staff. 12-V37 (Maintenance Director) will conduct elopement drills at least three (3) times a month, at different shifts to ensure compliance to be ongoing. 13-The elopement drill will be evaluated by the Administrator (V1) and any identified concern will be addressed. Additional staff training will be completed on an ongoing basis. 14-An Ad-Hoc QAPI meeting will be held weekly for four (4) weeks by the QAPI team to discuss this removal plan and identify if additional interventions are necessary to be ongoing. 15-Monitoring/auditing of ongoing education of staff for elopement policy and procedures, daily safety checks of all potential exits, and elopement drills and ongoing assessments of new residents and residents with newly identified issues regarding elopement by V1 (Administrator) will continue for a minimum of three months to be ongoing and will part of the QAPI process. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 8/25/2023

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent resident-to-resident physical and sexual abuse for 8 of 12 residents (R2, R8, R9, R12, R13, R14, R15 and R16) reviewed for abuse in the sample of 30. This failure resulted in an Immediate Jeopardy when the following resident-to-resident physical abuses occurred: R15 struck R12 in the head with an unknown object causing a lump to R12's head. On a later date, R15 stabbed R16 in the left chest with a paring knife causing R16 to require emergency medical services and R15 was arrested and remains police custody; and R13 hit R14 on the head with an object and on a later date, R13 stabbed R14 in the head with a pen causing R14 to require emergency medical services and R13 was sent out for psychiatric evaluation. The Immediate Jeopardy began on 5/5/23 when R15 physically abused R12 by striking him in the head with an object causing a lump. On 6/25/23, R15 and R16 got into a verbal and physical altercation and R15 stabbed R16 with a paring knife in R16's chest. V1 (Administrator), V2 (Director of Nursing), V5 (Regional Director of Operations), and V22 (Vice President of Regulatory Compliance and Clinical Operations) were notified of the Immediate Jeopardy on 7/7/23 at 1:50 PM. The surveyor confirmed by observation, interview, and record that the Immediate Jeopardy was removed on 7/12/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the facility's policies and procedures and in-service training. Findings include: 1.R15's Face Sheet documents his diagnoses to include Asthma, Difficulty in Walking, Low Back Pain, Chronic Obstructive Pulmonary Disease (COPD), Non-Displaced Longitudinal Fracture of Left Patella, Alcohol Abuse, Anemia and Gastroesophageal Reflux Disease (GERD). R15's Minimum Data Set (MDS) dated [DATE] documents he is alert and oriented and independent with his Activities of Daily Living (ADLs). R15's Facility Incident Report documented R15 had a resident-to-resident altercation with R12 on 5/5/23 at 1:15 PM. The Facility's Incident Report, dated 5/5/23, documented Two male residents involved in an altercation. Immediately separated and assessed. Full investigation to follow. During the course of the investigation, the following facts were determined: (R12) was noted ambulating in the day area with a lump noted to his forehead. When (R12) was asked about what happened, he stated another male resident, (R15), had hit him in the head with something hard. (R12) was assessed and was noted with no other injuries or impairments. (R15) stated that (R12) had been coming into his room and threatening to take his phone and other items out of his room. (R15) admitted he struck another resident but would not admit to the item that was used during the altercation. Room searches were performed on both men's' rooms and all items of concern were removed. (R15) was placed in a group for anger management and for 15-minute checks. The two men have had no further incidents or altercations since the date of this altercation, and both have maintained their prior level of functioning. There was no documentation of what items of concern were removed from R12's and R15's rooms. R15's Care Plan, date initiated 5/30/22, document Abuse: Resident is at risk for abuse and neglect related to Chronic Obstructive Pulmonary Disease, Unspecified, and Alcohol Abuse. Resident is an Identified Offender. He has a history of peer-to-peer altercations. 6/25/23: resident to resident altercation. R15's peer to peer altercation that occurred on 5/5/23 with R12 was not documented on R15's Care Plan. There were no updated interventions after R15's resident to resident altercation with R12 on 5/5/23 until 5/30/23. These interventions include Assess resident for abuse and neglect upon admission and quarterly. Assure resident that he/she is in a safe and secure environment with caring professionals. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (for example, social worker, nurse, CNA, peer) and by verbalizing thoughts, needs and feelings. Assure the resident that staff members are available to help, and department heads maintain an open door policy. Continue to monitor medication, ADLs, status, and behaviors. Establish a counseling schedule with resident. Encourage the resident to verbalize/share thoughts, anxieties, fears, concerns, and general feelings. Identify areas that put resident at risk. Immediately report any episodes of unknown injury, abuse, or changes in resident's behaviors to Administrator for immediate intervention and review. R15's Care Plan Focus, dated 3/30/22, documents The resident has a history of criminal behavior. The resident has demonstrated stability during the admission screening process and does not appear to present an unusual risk at this time. The Illinois Department of Public Health performed a Criminal History Analysis and made a determination regarding his level of risk. He was deemed a moderate risk. According to the resident's history he has been charged with unlawful possession of a weapon by a felon, Theft/Control/Firearm, Car Theft, and Aggravated Assault. The resident has a diagnosis of Alcohol Abuse, Uncomplicated. Interventions for this care plan include Evaluate the resident's ability to control impulses, document accordingly. Teach impulse control strategies. Follow facility protocol addressing substance abuse. If substance abuse is suspected utilize appropriate blood/urine testing, limit setting, counseling, and consequences. Review the IDPH Criminal History Analysis ([NAME]). Implement suggestions, if reasonable and appropriate. Moderate risk interventions include appropriate supervision and observation, regular monitoring, attention to behavior changes, visual monitoring if warranted and periodic reassessment. The facility's document, Facility-Reported Incident Form Initial Report dated 6/25/23 documents, On 6/25/23 at 8:25 PM Staff reported that they responded to loud voices, upon responding they observed (R15) and (R16) in verbal exchange. (R15) then was observed with small paring knife in his hand making contact with (R16's) left side rib area. The incident occurred in the doorway of Room (room number listed). (R16) sustained a small puncture wound to lower left rib area. Physician notified; new orders received to send to ER (Emergency Room). Type of injury: puncture wound. The facility's Follow-up Investigation Report, dated 6/30/23, documents, under Conclusion, Staff reported that (R15) had just returned from LOA (Leave of Absence) with family, he was requesting snacks from staff at which time (R16) made a statement towards him resulting in (R16) placing hands on (R15) and giving a light push, staff saw something in (R15's) hand while swinging arm towards (R16) making contact. Residents were immediately separated, staff remained with (R15) until police, EMS (Emergency Medical Services) arrived with (R15) escorted from facility by police. Licensed nurse provided pressure to left lower rib area with pressure applied until EMS arrived. (R16) transferred to ER (Emergency Room) for evaluation with no significant injury and/or treatment required, all diagnostic testing negative. (R15) medical record review reveals he has a history of Alcohol Abuse, history of homelessness, strained family relationships and BUE (Bilateral Upper Extremity) ROM (Range of Motion) loss related to weakness. (R16's) medical record review: he has poor social skills, limited coping skills which at times leads to conflict with others. History of Alcohol Abuse, inappropriate attention seeking behaviors along with maladaptive behaviors. He has a history of using loud tone when expressing frustration. (R16) has maintained his usual routine with no signs of mental anguish noted and no psychosocial distress noted. He continues to be visualized throughout facility interacting with peers, attending activities of his choice. When asked, he states, I'm fine. Police investigation ongoing, once investigation completed, addendum will be sent. R16's Hospital Records dated 6/25/23 at 9:00 PM document, Description of Mechanism: Stabbing to left chest. Review of systems: Respiratory: cough, hemoptysis, sputum, dyspnea on exertion, dyspnea at rest, wheezing. Cardiovascular: chest pain from stab; Gastrointestinal: abdominal pain left upper quadrant. Chest x-ray: Impression: Sequelae of penetrating injury in the lateral chest wall without extension into the thoracic and peritoneal cavity. Injuries: puncture wound to left chest. Plan: wound washed out and dressed. Follow up with trauma clinic as needed. R16's Face Sheet documents his diagnoses to include Major Depressive Disorder, Cutaneous Abscess of Right Hand, Osteoarthritis, Hypertension and Alcohol Abuse. R16's MDS dated [DATE] documents R16 is alert and oriented and independent with his ADLs. R16's Care Plan documents Abuse: (R16) is at risk of abuse and neglect related to history of assault leading to rib fractures and other injury prior to admission. (R16) is noted to have a history of peer-to-peer altercations. 4/4/23: peer to peer incident; 6/25/23: resident to resident altercation. On 6/29/23 at 3:15 PM R16 was lying on his bed in his room with a clean, dry, intact white gauze bandage on his left side of torso. He stated he and (R15) usually got along good and would play dominos out in the dining room with a couple of other residents. R16 stated sometimes they would have words during a game but all in fun, nothing serious. R16 stated the agency nurse was passing medications and had called his name so he went to the door to get his meds and R15 kept walking past his door, saying things about R16 arguing with the new guy and R15 was being disrespectful. R16 stated R15 came between the nurse and her cart, and the nurse yelled, He's got a knife! and then R15 stabbed him. R16 stated he went in his room and slammed the door closed. R16 stated R15 walked up the hall to the front after he stabbed him. R16 stated, He (R15) was drunk. He just came back from being out with his family. On 7/5/23 at 3:09 PM, V16 (Licensed Practical Nurse/LPN) stated, I was standing right by the double doors at the nurse's station, and I heard arguing between (R15) and (R16). Their voices were getting louder so I started walking towards them to see what was going on and try to diffuse the situation, and when I was within about two feet from them, (R15) pulled out the knife and jabbed him (R16) with it. (R16) put his hand over it and went into his room and closed the door. (R15) had the knife at his side, not trying to hide it, and started walking fast up the hall. I yelled out, He's got a knife. Call 911. He just stabbed him (R16). The other staff said, No, he's armed. We don't get involved with that. I went in to check on (R16) and he was lying on his bed with his hand over his left side, with his shirt over it, lying in the fetal position. He (R16) said, I'm fine. but he let me look at the wound. It was about 1-2 centimeters with a little bit of flesh coming out of it. It wasn't bleeding a lot by then, but there was blood on his shirt and on the floor. I put some gauze over it and held pressure on the wound until EMS arrived. I work for agency, and this was the first and last time I worked at this facility. From what some of the other staff told me, and I cannot recall their names, (R15) went out with his family and had just got back and he was drunk. Another staff told me (R15) made the statement to her, It wasn't my knife. There's no blood on it and my prints aren't on it. V16 stated the other staff told her this was unusual behavior for (R15) and that he was usually a very nice gentleman. The staff had called the police and the Administrator, and the Director of Nursing (DON) came in and did the report. 2. R13's Face Sheet documents his diagnoses to include: COPD, Diabetes Mellitus with Hyperglycemia, CVA (stroke) with Hemiparesis and Hemiplegia Affecting the Right Non-Dominant Side; Auditory Hallucinations and Schizoaffective Disorder. R13's MDS dated [DATE] documents he is alert and oriented. R13's Care Plan dated 3/13/17 documents: Abuse: At risk for abuse and neglect related to Schizoaffective Disorder, Depression, Auditory Hallucinations, history of behaviors and requires some assistance with care. He is noted to have a history of peer-to-peer altercations. 3/12/23 peer to peer altercation. 6/13/23 Peer to peer altercation. The Facility's Initial Report, dated 7/10/23 at 1:45 AM documents, under Allegation Details, Staff reported responding to loud voices, upon approaching, (R14) stated (R13) made physical contact with him. The report further documents R14 was transferred to ER for evaluation and there is no serious bodily injury or sign of mental anguish identified. Injuries described in report are as follows: Scratches, small open area. The report documents there is no known witness at this time. R13's Progress Note, dated 7/10/23, at 4:54 AM documents, Resident initiated resident to resident altercation. Residents immediately separated; local police notified. Physician notified with new orders received to send to ER for psychiatric evaluation related to physically aggressive behaviors towards peer. Behavior was not easily redirected. Staff provided 1:1 to ensure safety of patient and peers until EMS/police arrived. MD/Guardian notified. Resident going to local regional hospital. Emergency transfer discharge provided at local ER, copy provided and explained to supervisor in ER department, copy provided and explained to resident. Copy provided to resident. IDPH and ombudsman notified via email. Call placed to resident daughter/guardian with no answer, left message to return call as soon as she received message, will attempt until contact made. On 7/10/23 at 7:01 PM, V20 (Emergency Room/ER Nurse) stated R14 was brought to the emergency room by ambulance on 7/10/23 around 3:00 AM. V20 stated R14 told her another resident named (R13) had come into his room and punched him in the face several times and then stabbed him in the head with a pen. V20 stated R14 never really answered her as to whether R13 was his roommate or if he lived on the same hall as R14. V20 stated R14 had what appeared to be fresh injuries to his face and head including a black eye, a laceration to his left cheek over his cheekbone area and three puncture wounds to his scalp, two in front and one in the back of his head, and the puncture wounds had hematomas around them. V20 stated R14 had told this same resident (R13) has assaulted him multiple times in the past. V20 stated R14 received facial x-rays and a head Computed Tomography Scan (CT scan) to rule out facial fractures and she stated they were negative for fractures and showed the puncture wounds were superficial and did not penetrate his skull. V20 stated R14 had other injuries that appeared older, including bruises to the right side of his face, including eyebrow and cheek, upper left arm bruising, and scratches on his mid-lower back that looked like fingernails. V20 stated she attempted to call the facility to verify R14's report that he was assaulted by R13 before this. V20 stated she called the facility at least a dozen times and someone would pick up the phone and hang it back up without answering. V20 stated at about 6:00 AM a nurse (V14) answered the phone, but refused to answer any questions, and informed V20 she would have to talk to the Administrator. V20 stated (V1 Administrator) returned her call within a few minutes and she (V1) did confirm that this was not the first time R13 had assaulted R14. V20 stated V1 informed her that she had been at another hospital with R13 on that night and stated V1 informed her R13 would not be returning to the facility. V20 stated V1 informed her R13 had been on special monitoring, and she did not know why he assaulted R14 or how this protection plan failed. V20 stated R14 did not want to return to the facility, but his brother was his Power of Attorney, and they were unable to reach him by phone. V20 stated R14 was having visual hallucinations while in the emergency room, responding to his wife in the room when there was no one else in the room. V20 stated R14 was discharged back to the facility that same morning. On 7/12/23 at 9:16 PM, during phone interview, V14 (Licensed Practical Nurse/LPN) stated she was not R14's nurse on 7/10/23 but she was the first staff to respond when she heard R14 yelling out. She stated she could not understand what R14 was saying, but she ran to his room and when she entered, R14 was sitting in his wheelchair with R13 standing over him, and R13 was stabbing R14 in his head with a pen. V14 stated she yelled at R13 to stop, and he did not immediately stop but finally did without her having to lay hands on him. V14 stated she did not know how many times R13 stabbed R14 with the pen, but stated he was going at it. R14 stated other staff responded and entered R14's room and redirected R13 out of the room and he was taken to his room and kept on 1 on 1 until the ambulance arrived. V14 stated R13 did not say why he was assaulting R14, but when the EMTs (Emergency Medical Technicians), one of them reported to her that R13 stated he had assaulted R14 because R14 had thrown urine on him a month ago. V14 stated she assessed R14, and he had two puncture wounds on his head, one in front and one in back, and he also had several scratches on his face. V14 stated both R13 and R14 were sent to the hospital. She stated the incident happened around 1:40 AM. She stated there were no more behaviors between R13 and R14 before they left the facility. V14 stated she had not seen R13 have any aggression towards R14 prior to R13 attacking R14. She stated this type of behavior was over the top for R13. According to facility documents, there were two incidents when R13 physically assaulted R14 prior to the incident on 7/10/23 and are as follows: The Facility's Follow-up Investigation Report, dated 6/14/23, documents, under Conclusion: On June 13, 2023, staff responded to loud voices, upon entering room (R13) stated, He thought the back scratcher was his and when I told him it wasn't, he picked up his urinal and threw his urine at me so when he did, I reached over and made contact with his head. I didn't mean it, I just reacted to the urine being thrown this way. (R14) stated, Yeah, I threw it at him, then he got me on top of the head. Skin assessment completed on both residents with (R14) observed to have small scratch on top of head. (R14) denied pain. (R13) was immediately relocated to another room with enhanced monitoring provided. Based on complete, comprehensive investigation, facility cannot substantiate intention abuse and facility believes situation occurred, however based on interviews with both residents the situation was without any intent as (R13) reacted to situation, both residents agree that situation was a disagreement over who the back scratcher belonged to. The Facility's Facility Reported Incident Form, Initial Report dated 6/29/23 at 8:30 AM documents, Staff reported (R13) approached (R14) making physical contact. Staff witnesses stated that (R13) was sitting in the dining room waiting for meal tray, he moved away from table and approached (R14) making contact with face. Residents immediately separated; physician notified with new orders to send (R13) to ER (Emergency Room) for psych evaluation. The facility's Final Report for this incident, dated 7/7/23 documents, On 6/29/23 R13 was sitting in the dining room at table during breakfast meal; R13 removed self from table and approached R14 making contact. R13 was placed on enhanced monitoring. On 7/11/23 at 9:10 AM R14 was sitting in his wheelchair in his room. R14 had small purplish-black bruises under both eyes. R14 was wearing a hat with headphones over it and declined to let his head/scalp be observed, stating, No, you don't need to look at that. I'm fine. I'm not having any pain. I don't know what happened. He's (R13) just some crazy guy who came in and beat me up in the middle of the night. R14 stated, I feel fine. I feel safe. You can go now. R14's Face Sheet documents his diagnoses to include Type 2 Diabetes Mellitus with Diabetic Retinopathy and Macular Edema; Acute Kidney Failure; Bipolar Disorder; HTN; History of Falls; and Schizophrenia. R14's MDS dated [DATE] documents he is alert and oriented. R14's Care Plan dated 4/20/22 documents: Abuse: (R14) is at risk for abuse and neglect related to impaired cognition secondary to psychiatric diagnosis. He is noted to have a court appointed guardian at this time, his brother. 6/13/23 peer to peer altercation. 3. R12's Face Sheet documents his diagnoses to include Paranoid Schizophrenia, Drug Induced Subacute Dyskinesia, Other Sexual Dysfunction Not Due to Substance or Known Physiological Condition, Anxiety Disorder, Cognitive Communication Deficit and Borderline Intellectual Functioning. R12's MDS dated [DATE] documents he is alert and oriented and requires supervision with his ADLs. R12's Care Plan dated 3/31/22 documents Abuse: At risk for abuse and neglect related to his diagnosis of Depression, Schizophrenia, and Borderline Intellectual Functioning. He has been noted to ask for items of others in a way that is not appropriate such as give me some of that. Has a history of peer-to-peer altercations. 6/22/23 Resident reported to stop resident who was independently propelling self down hall and ask her to suck his d***, while masturbating. R12's peer to peer altercation with R15 was not documented on his care plan. The Facility's Follow-up Investigation Report, dated 6/29/23, documents, under Conclusion documents On June 22, 2023, (R2) reported as she was independently propelling her electric wheelchair down the hall upon approaching (R12's) room he asked her to stop and once she did, he asked her to suck his d*** while masturbating. (R2) immediately removed herself from the situation and reported to staff. Local police were immediately notified. Physician notified with new orders to send (R12) to ER for evaluation. Complete comprehensive investigation has been completed with facility unable to substantiate abuse. Medical record review and interviews reveal (R12) has no previous behaviors of this nature. (R2) has shown no signs of mental anguish, psychosocial distress and has maintained her usual routine with her being observed in common areas interacting with peers, attending activities of her choice. (R12) remains hospitalized . R2's MDS dated [DATE] documents she is alert and oriented. R2's Care Plan dated 5/28/23 documents Abuse: (R2) is at risk for abuse and neglect related to her diagnoses of CHF (Congestive Heart Failure), history of multiple Myocardial Infarctions (MI) and multiple CVAs, Hypertension, COPD, decreased ability to complete all her care tasks on her own and requires assistance. Resident shared during assessment that she has been a victim of domestic violence, addiction in the past and diagnosis of depression. History of altercations with peers. 3/27/23 peer to peer altercation. 5/28/23 peer to peer occurrence. On 6/27/23 at 10:45 AM R2 stated R12 called her over to his room and asked her to suck his p**** while he was masturbating. R2 stated one other time he had called her over to his doorway while he was masturbating, and she was disgusted, and she turned around and left immediately. R2 stated she got angry the second time and immediately reported the incident to the Director of Nursing, who called the Administrator and R12 was sent out of the facility right away. R2 stated if they hadn't sent (R12) out of the facility, she would not have felt safe taking a shower, and would have been afraid he might come into her room at night. R2 stated she never went into R12's room and he never came into her room. R12's Progress Notes dated 6/22/23 at 11:01 PM documents, Resident 1 (R12) verbally sexually assaulted another resident. Resident 2 that was assaulted stated, I was coming down the hallway and when I got to his door, he started patting his bare private area and ask me to suck his d***. Resident 2 (R2) was extremely uncomfortable and stated that she was afraid to lay down because she was afraid that he would assault her. Resident 1 (R12) was escorted to room; staff did 1 on 1 with resident until EMS present. DON notified, EMS called and said they would be a few hours until pick up report called into (hospital) for psych evaluation, will continue to monitor. R12's Progress Notes for April, May and June 2023 were reviewed and documented four other times R12 was noted to be sexually inappropriate towards staff prior to resident-to-resident sexual abuse with R2 on 6/22/23. 4. The Facility's Follow-up Investigation Report, dated 6/23/23 documents, under, Conclusion documented On June 17, 2023 (R9) was standing next to (R8's) chair and was noted to have his hand resting under her shirt. Residents were immediately separated with (R9) being place on enhanced monitoring. R8's Face Sheet documents her diagnoses to include Adult Failure to Thrive, Weakness, Need for Assistance with Personal Care, Schizophrenia, Unspecified Psychosis Not Due to A Substance or Known Physiological Condition, and Alzheimer's Disease with Late Onset. R8's MDS dated [DATE] documents she is severely cognitively impaired. R8's Care Plan dated 10/16/19 documents, (R8) is at risk for abuse and neglect related to her impaired cognition related to diagnosis of psychosis and past TBI (traumatic brain injury) with cognitive and safety awareness deficits. 6/12/20 Involved in an altercation with a peer. R9' Face Sheet documents his diagnoses to include Alzheimer's Disease with Early Onset; Weakness; Schizoaffective Disorder, Bipolar Type; Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety; Major Depressive Disorder; and Alcohol Dependence with Alcohol Induced Persisting Dementia. R9's MDS dated [DATE] documents he is severely impaired cognitively. R9's Care Plan dated 12/12/14 documents, (R9) is at risk for abuse and neglect related to Psychosis, Cerebral vascular Accident (CVA), Severe neuro-cognitive disorder, Affective Mood Disorder, Depression, Dementia, and GERD (Gastroesophageal Reflux Disease. He expresses resistance with care needs such as changing clothing and personal hygiene. Has a history of getting physical with others over cigarettes. Has a history of peer-to-peer altercations. 6/17/23 resident observed with his hand resting under another resident's shirt. On 7/14/23, at 10:02 AM, V1, Administrator, stated With (R9) I did not feel the intent was there as he just had his hand resting under her shirt and they had a relationship before and were both confused so I did not substantiate it. The facility's policy, Abuse Policy and Prevention Program 2022 dated 10/2022, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; and implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making necessary changes to prevent future occurrences. Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update, as necessary. The facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of residents. The Immediate Jeopardy that began on 5/5/23 was removed on 7/12/23 when the facility took the following actions to remove the immediacy: A. Identification of Residents Affected or Likely to be Affected: 1.R15 no longer resides in the facility, discharged into police custody on 6/25/2023. 2.R12 no longer resides in the facility, discharged facility on 6/23/2023. 3.R16 was assessed for trauma related events on 6/26/2023 by V5 (Region Director of Operations). Care planned interventions relating to being a victim of abuse were entered on 6/25/2023 by V5. 4.R13 no longer resides in the facility, discharged on 7/10/2023. 5.R14 refused assessment for trauma related events, ad hoc care plan with R14 and POA held on 7/10/2023, R14 feels safe in the facility, care plan reviewed and updated by V22 (Vice President of Regulatory Compliance and Clinical Operations), V5, and V1 on 7/10/2023. 6.All residents will be assessed for aggressive behaviors by V1, V17 (Social Service Director), to be completed on 7/7/2023, 7/10/2023 and ongoing as needed to include new residents and newly identified behaviors. 7.Through the RAP rounds (customer service interviews) with all residents, no new allegations of abuse have been identified. Rap rounds to be completed Monday through Friday by V37 (Restorative Nurse), V38 (Infection Control Nurse), V36 (Medical Records), V35 (admission Coordinator), V55 (Business Office Manager), and V17 to be initiated on 7/12/23 and ongoing. 8.Potential admissions/referrals will be reviewed for appropriateness of admission by V35 (Admissions Coordinator) or V2 (Director of Nursing). Patients with a documented history of aggressive behaviors and any background check that identifies any potential risk factors for aggressive behaviors will not be accepted for admission completed 7/12/2023 and ongoing. 9.Care plans to be reviewed and revised as needed with implemented interventions to address resident specific behavioral needs and newly identified behaviors by V17, V36 and V37 to be ongoing. Any investigation of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property occurred shall be reviewed by the facility Quality Management committee for possible changes in facility practices to ensure that similar events do not occur again. At this time, the resident [TRUNCATED]