**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the residents right to be free from physical abuse by staff. This failure affected one resident (R1) who was handled roughly and was hit on the arm and the back by a facility CNA (Certified Nursing Assistant) as she attempted to redirect R1. This was identified as an Immediate Jeopardy which began on 06/30/24 when V20, Certified Nursing Assistant, physically abused R1. The immediacy was removed on 07/22/24. On 07/17/24, V1 (Administrator) was informed of the Immediate Jeopardy and the Immediate Jeopardy template was presented on 07/17/24 at 2:41pm. The facility provided an acceptable removal plan on 07/22/34 at 5:34pm. On 07/23/24, through onsite observation, interviews, and record reviews, the surveyor confirmed the implementation of facility's removal plan. Although the immediacy was removed and the removal plan accepted, the deficiency remains at the second level of harm until the facility can determine the effectiveness of the implementation of removal. Findings include: R1's medical record documented R1 was admitted [DATE], with diagnoses that includes but not limited to Dementia in other diseases classified elsewhere mild with agitation, insomnia due to medical condition, essential hypertension, and chronic obstructive pulmonary disease. R1's plan of care for potential to demonstrate verbally and physically aggressive behaviors related to dementia, with initial date 08/11/2022, listed interventions including but not limited to when R1 becomes agitated, staff should walk calmly away, and approach later. R1's plan of care for presence of abuse and neglect factors, initiated 05/18/2024, has goals that include R1 will be treated with respect, dignity and reside in the facility free of mistreatment (abuse/neglect). On 07/10/24 at 10:34am, R1 was noted in the dining area, which is also used for activity with peers. R1 does not speak English, but is able to understand greetings in English language. At 12:25pm, V14 (Activity Director) stated R1 speaks Chinese; R1 was unable to recollect or speak of any abuse incident. On 7/10/24 at 12:26pm, V4 (Registered Nurse) and V5 (Registered Nurse) assessed R1's body, which showed bruising to the right antecubital area, which V4 attributed to R1's visitation to ER (Emergency Room) on 07/08/24. V4 stated the bruising might be from possible IV insertion site at the hospital ER (Emergency Room). On 07/10/24 at 3:00pm, V20, CNA (Certified Nursing Assistant), stated, I (V20) will tell you the truth. It happened about two weeks ago, and the whole thing was in the hallway where the video camera can pick it up (see it). Another staff, (V21, CNA) was also present when the incident occurred. V20 checked the calendar for the day she worked, and stated the incident happened on 06/30/24. V20 stated, (R1) was trying to sit on the floor. (R1) usually does this, and I was trying to grab (R1) quickly to get (R1) seated in the chair to avoid sitting on the floor. (R1) hit me with the elbow on the same spot I have being having pain. To be honest with you, I hit (R1) on the right hand. V20 was asked whether hitting a resident is a form of abuse, and whether V20 reported it to V1 (Administrator). V20 stated, Yes it is a form of abuse, but I never saw it as an abuse. When V20 was asked about the facility abuse policy and prevention of abuse and what V20 will do if she witnesses a resident being abused by staff, peers, or family member, V20 stated, I will report it immediately within 2 hours. On 07/10/24 3:13pm, V1, Administrator, stated the camera is reviewed daily and only 7 days of recording is stored. The only video camera recording history was from 07/01/24 to 07/10/24. V1 stated, The history from 06/30/24 has been wiped off. V1 was asked about the facility policy, and whether it is appropriate for staff to hit any of the residents. V1 stated, Abuse is a willful act that causes harm. V1 was asked under what situation/condition it is appropriate for your staff to hit a resident? V1 stated, Under no condition. V1 was asked whether hitting is a form of abuse, and V1 stated, Yes. On 07/11/24 at 4:05pm, V21 (CNA), whom V20 stated was present and witnessed the incident at the time of alleged abuse, stated, (R1) has dementia and can be combative at times, but that does not mean that the staff should abuse him ). I was in the dining area, and I saw (V20) hitting (R1) multiple times on the back, hands, and grabbing (R1) roughly on the arm. I told (V20) not to hit (R1), and (V20) said that (R1) hit her first, and 'I am not going to let (R1) hit me.' I told (V20) that she should have handled it in a better way that does not involve hitting (R1), which will not be abusive. No staff should hit any of the residents or handle them roughly, even with their bad behavior. V21 stated R1 has dementia and does not speak English. V21 stated, (R1) was crying and shouting, and that was why I looked in their direction. I reported it to the nurse (on duty) (V10), and nothing was done until you (referring to the surveyor) came here (facility). V21 was asked when would you report any alleged abuse. V21 stated, Immediately as soon as you see it. I reported it to the nurse on duty (V10) and they did nothing. She did it in front of the camera, it's not like she was hiding it. Even when I told her that it is not right, (V20) was confrontational about it. (V20) retaliated by hitting (R1) and that is wrong. On 07/11/24 at 4:30pm, V2, Director of Nursing (DON), stated, It is not appropriate for any of the staff to hit or handle any of the resident roughly. It should be reported when that happens. According to facility investigation, the facility concluded the allegation of abuse cannot be substantiated. On 07/23/24 at 2:09pm, V27 (Facility Medical Director) was asked whether hitting a resident is a form of abuse in V27's professional opinion. V27 stated, In this case, we (facility) think it is a form of self-defense. Residents should not be touched (physically abused). We protect them at all costs. They (staff) have the right to defend themselves. V27 stated the staff should defend themselves without aggressively attacking the resident and de-escalate the situation. V27 was asked whether staff should be correcting residents' aggressive behavior by hitting or slapping a resident. V27 stated, Of course not, no one should hit anyone. De-escalate. Protect your face, move away, and ask for help. On 7/23/24 at 2:26pm, V28 (Social Services Director) stated, (R1) has dementia and that was why (R1) was discharged to a memory care unit at a long-term care yesterday (07/22/24). (R1) has wandering behavior. Cognitively is severely impaired. Some behavior problems with history of verbal and physical aggression. V28 was asked whether V28 was informed of R1 being physically hit by staff. V28 stated, Yes, by (V1) when (V1) was informed (07/10/24). V28 stated staff hitting a resident is a form of physical abuse. V28 stated, It is never appropriate to hit a resident. Staff should de-escalate a resident's aggressive behavior, separate, get help, and make sure the resident is safe. V28 stated the Abuse Coordinator (V1), the Administrator, must be informed of any alleged abuse incident. On 7/23/24 at 3:09pm, V1 (Administrator) was asked whether it is appropriate for staff to hit a resident to de-escalate aggressive behavior. V1 stated, No, it is not appropriate. At no time is it appropriate for staff to hit a resident. V1 was asked how about in self-defense. V1 stated, It is not appropriate to hit a resident. It is a form of abuse. The facility policy titled Abuse and Neglect, with revised date of 06/06/24, documented it is the policy of the facility to provide professional care and services in an environment that is free from abuse, corporal punishment, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Abuse is defined as willful infliction mistreatment that includes punishment. The policy documented examples of physical abuse that includes but not limited to hitting, slapping, grabbing, and roughly handing. Potential aggressors listed include but not limited to facility staff. The policy listed 7 steps in abuse prevention including reporting/response. Listed procedure includes all allegations and/or suspicion of abuse must be reported to the administrator immediately. The facility Behavior Monitoring of Residents presented, with revised date of 06/06/24, documented policy statement it is the facility's policy to ensure that the residents with aggressive behavior are monitored. Listed procedure includes but not limited to if the resident's aggressive behavior is monitored anytime. On 07/23/24, the surveyor through observations, interviews, and record review, confirmed the following removal plan by the facility: 1. V20 suspended 07/10/14. 2. R1 is no longer residing at the facility. R1 has been discharged to another Long-Term Care on 07/11/24 3. R1 full skin assessment conducted 07/10/24. 4. R1 seen by psychotherapist on 07/10/24. 5. R1 evaluated by Physiatrist. 6. R1 screened for abuse/neglect 07/10/24. 7. V21 was suspended on 07/11/24 for not reporting to V1, pending investigation. 8. Staff are being educated on Abuse, initiated 07/10/24, with quiz to monitor effectiveness. 9. Abuse in-service completed 07/16/24. 10. Abuse in-service on Handling Aggressive Behaviors with quiz for 5 staff members three times per week for 12 weeks on-going. 11. Social Work outside consultation group initiated monthly in-service on de-escalation techniques and handling aggressive residents, initiated 07/19/24. 12. Staff training on facility code gray for aggressive behavior/violence, initiated and completed 07/22/24. 13. QA (Quality Assurance) audit on 3 times weekly times 12 weeks to ensure direct staff care staff (Nurses and CNA's), initiated 07/15/24. 14. Thirteen residents R1, R7, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22, were reviewed for abuse and aggressive behaviors. List of residents with behaviors provided and posted at the nurse's station inside a closed cupboard. 15. V27 (Medical Director) interviewed and was aware of the removal plan with V27's approval. 16. Staff interviewed: V4, V33, V40, RN (Registered Nurse), V14 (Activity Director), V29, V38 (Activity Aides), V22, HR (Human Resources), V28, SSD (Social Services Director), V31 (restorative aide), V37 (Certified Nurse's Aide Supervisor), V30, V32, V36 CNAs (Certified Nurse's Aides), V24, V26, V34 and V39 LPNs (Licensed Practical Nurses) were interviewed. No concerns identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor R2, a cognitively impaired resident who was a known wanderer with an electronic monitoring safety device on R2's right wrist and left ankle; failed to respond to a stairwell door alarm; failed to identify R2, who was assessed at risk for elopement, on the facility's elopement risk list; failed to check the placement of R2's electronic monitoring safety device every shift per facility policy; and failed to weekly test the functioning of R2's electronic monitoring safety device per facility policy. These failures affected R2 who eloped from the facility on 6/4/23, was in an apartment 4 miles away and was returned to the facility over 15 hours later by the local police department which placed R2 at a potential risk for harm when reviewed for improper nursing care in the sample of six elopement risk residents (R2, R5, R6, R7, R8, R9). These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on 6/4/23 at 11:08 am when facility video footage showed R2 walking out the back door of the facility by R2's self into the parking lot then into the street. On 6/12/23 at 12:57 pm, V1 (Administrator) and V2 (Director of Nursing, DON) were notified of the Immediate Jeopardy. The survey team confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/21/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R2's admission Record documents, in part, that R2's diagnoses include traumatic subdural hemorrhage, cognition communication deficit, restlessness and agitation, lack of coordination, unsteadiness on feet, abnormalities of gait and mobility and repeated falls. R2's admission date to the facility was documented as 5/13/23. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 2 which indicates that R2 has severe cognitive impairment. R2's Functional Status indicates that for R2's ADL (Activities of Daily Living) task like walking in room, walking in corridor and locomotion on unit, R2 is coded for a staff support of supervision - oversight, encouragement or cueing. On 6/6/23 at 11:38 am, R2 was asked about leaving the facility (eloping) on 6/4/23. R2 stated, R2 doesn't go outside. R2, asked again about walking out of the facility on 6/4/23. R2 stated, R2 doesn't remember. On 6/6/23 at 1:19 pm, V1 (Administrator) viewed the facility's video footage from separate video camera views as follows: 3rd floor video camera: 6/4/23 11:05 am: R2 observed walking in the hallway near the nurse's station wearing a hoodie jacket, shirt, pants, and shoes. R2 turns out of the view of video camera back towards R2's room. 6/4/23 11:06 am: V4 (Agency Registered Nurse, RN) and V5 (Agency Certified Nursing Assistant, CNA) observed at the 3rd floor nurse's station. V4 is standing outside of the nurse's station with the medication cart up against the nurse's station wall. V5 is sitting in a chair at nurse's station. R2 enters the video camera view and walks behind V4 (who's back was to R2) and walks down the 3rd floor hallway. R2 was wearing a hoodie jacket (color appears gray or pale brown), shirt, pants, and shoes. 6/4/23 11:06:50 am: R2 observed pushing the 3rd floor west stairwell door open and exiting through the door. V4 observed with V4's head down looking at the medication cart. V5 observed sitting in the nurse's station in a chair with V5's head down looking at V5's cellular phone. Neither V4 or V5 turn their heads towards the west stairwell alarm or make any attempt to respond to the alarm. 6/4/23 11:08 am: V15 (Housekeeper) observed in view next to V4 still standing at the 3rd floor nurse's station medication cart. V15 observed conversing with V4 at the medication cart. 6/4/23 11:09 am: V5 observed walking down the 3rd floor hallway. V3 (CNA) observed walking out of the bathroom directly next to the nurse's station. After observing the 3rd floor video footage (from 6/4/23), V1 showed the video footage in a split screen with the 1ST floor back door, 3RD floor, and 2ND floor cameras at the same time. 1st floor video camera: 6/4/23 11:07:46: R2 observed walking out of the west stairwell into1st floor hallway. 6/4/23 11:07:56: R2 observed walking out of the first back door of the facility. V18 (Dietary Aide) observed walking in the 1st floor hallway towards the back door direction. Blue laundry bins observed in the 1st floor hallway. 2nd floor video camera: 6/4/23 11:07 am: 2nd floor nurse's station observed with several staff members sitting in chairs at the nurse's station. V1 stated, the electronic monitoring safety device alarm wasn't going off on the second floor. Parking lot camera: 6/4/23 11:08:12 am: R2 observed walking from the second back door of the facility into the parking lot. R2 walked through the small parking lot to the adjoining street (alley-like). R2 walked south (turning left) and then turned and walked north in the street. 6/4/23 11:08:53 am: R2 last observed on the facility video footage. On 6/6/23 at 11:17 am, V3 (CNA) stated, V3 was working on 6/4/23 on the 7:00 am to 3:00 pm shift on the 3rd floor and was R2's assigned CNA. V3 stated, (R2) speaks Spanish and a little English. (R2) likes to walk around all on the floor. (R2) goes into other resident's rooms. When (R2) does, I (V3) do redirection. When asked if R2 responds to the redirection, V3 stated, Sometimes redirection don't work. V3 stated, the 3rd floor is not a locked floor, and staff have a code for the stairwell doors when they exit via the stairwell doors. When asked to see the code keypad for the stairwell door, V3 walked to the west stairwell door. V3 then demonstrated, that the stairwell door will open by pushing the bar on the door, but then the alarm goes off, and staff must put in the code on the keypad, which V3 performed, to stop the alarm. When asked about R2's elopement from the facility on 6/4/23, V3 stated, It was around 11:00 am. When asked V3 about seeing R2 prior to 11:00 am on 6/4/23, V3 stated, V3 saw R2 in R2's bed at 7:00 am when V3 started the shift. V3 stated, (R2) ate (R2's) breakfast. (R2) was already dressed. Wandering, which is constant for (R2). I (V3) would redirect (R2). (R2) was going into other resident's rooms. They (other residents) were frightened. They (other residents) would put on the call light, and they would say, 'There's a (person) in my room.' I (V3) know who they (other residents) were talking about. Then I (V3) would see (R2) and redirect (R2) out of their (other persons') room. When asked about R2's cognitive status on 6/4/23, V3 stated (R2) was up and alert that morning. (R2) was roaming in other rooms. I (V3) was redirecting (R2), but I (V3) have to clean other patients and am doing my rounds. When asked the last time that V3 saw R2 on 6/4/23, V3 stated, It was in the hallway, but I (V3) don't know the exact time. When (R2) went missing, I (V3) was in the washroom. I (V3) heard the alarm going off when I (V3) came out of the bathroom walking down the hallway. (V4, Agency RN) or CNA (V5) heard it. They (V4, V5) were saying, 'Where did (R2) go?' I (V3) hear the alarm going off, possibly (R2) could have closed it (the west stairwell door). I (V3) then went down the stairs (west stairwell) and didn't see (R2). I (V3) asked (V21, Receptionist), and (V21) didn't see (R2). I (V3) thought that maybe (R2's) still here, so I went out the back door to the parking lot. I (V3) didn't see (R2). I (V3) came back to the floor, and we (staff) searched all the rooms and in empty room, room [ROOM NUMBER]. When asked how is V3 ensuring that a resident who wanders, like R2, is safely supervised, V3 stated, For me (V3) personally, I know (R2) likes to walk. I (V3) let (R2) walk. (R2) doesn't like being in (R2's) room. I (V3) let (R2) walk sometimes and give (R2) a cookie if (R2) goes into someone's room. I (V3) have rounds to do. I (V3) have other patients to care for. V3 stated, Sometimes (R2's) confused and V3 gives R2 verbal cues if R2 needs it. R2's Progress Notes, on 6/4/23 at 2:48 pm, V4 (Agency RN) documents, in part, 11:05 am: (R2) walked up to (V4) to get (R2's) scheduled medication. 11:10 am: It was reported that (R2) was no longer in (R2's) room. Room search was done on the facility and a code was called. (R2) was still not found. (V1) was called and the security camera reviewed that (R2) left through the back door. On 6/7/23 at 4:00 pm, V4 (Agency RN) stated, V4 works frequently at the facility as an agency nurse, and V4 stated, on 6/4/23, V4 worked the 7:00 am to 3:00 pm shift on R2's floor (3rd floor). When asked about R2 on 6/4/23 at beginning of V4's shift, V4 stated, I (V4) saw (R2) standing by (R2) room. (R2) stood there. I (V4) said, 'Hi, I am your nurse. I am going to be giving you your meds.' (R2) said (R2) wanted to go pee in the staff bathroom. I (V4) told (R2) there is a bathroom in (R2's) room; pointing to (R2's) room. V4 stated, the staff bathroom is not open for R2 to use. V4 stated, I (V4) told the CNAs (V4 and V5, Agency CNA) to pay attention to (R2). V4 stated, (R2) looked confused. V4 stated, Sometimes, I (V4) did not understand (R2). (R2) would go to elevator. (R2) always asking for (R2's) insurance money. (R2) needs (R2's) money. (R2) needs to go get it. At the moment, I (V4) didn't understand. I (V4) then put 2 and 2 together. V4 stated, R2 was making these statement about getting R2's money on 6/4/23 prior to eloping from the facility. When asked if R2 had spoken about getting R2's money prior to 6/4/23, V4 stated, On other occasions, (R2) had talked about getting money from somewhere. When asked if R2 would give specifics about where R2 was wanting to go to get R2's money, V4 stated, No location. (R2) would point to elevator to go down. V4 stated, V4 never see him get in the elevator, but R2 would stand next (to the) elevator and did not get in the elevator because (R2) didn't recognize that there was a button. V4 stated, (R2) has (an) alarm. (R2) never seen that (R2) activated an (electronic monitoring safety device) alarm. V4 stated, (R2) always had on (electronic monitoring safety device). Surveyor asked V4 if V4 observed R2's electronic monitoring safety device prior to 6/4/23. V4 stated, Yes, before June 4th, (R2) had on (electronic monitoring safety device). Asked what R2 continued to do throughout the morning on 6/4/23. V4 stated, The next time I (V4) see (R2). I (V4) push my (medication) cart down the hall. I (V4) saw (R2). (R2) says, 'Where's my room?' (R2) came again into another resident's room. I (V4) redirected (R2) to (R2's) room. I (V4) talked to the CNAs (V3, V5) and told them to watch (R2), and it's not appropriate for (R2) to go into another resident's room. When asked which room did R2 go into, V4 stated that it was the room opposite, the room right across the stair door at the (west) end. V4 stated, R2 took one medication from V4. V4 stated, I (V4) told (R2) (about the medication). (R2) refused. So, I (V4) pushed back and at 11:00 am, (R2) said, (R2) wants (R2's) meds. V4 stated, on 6/4/23 at 11:00 am, V4 stated, I (V4) asked (R2) why (R2) was wearing a sweater. (R2) said, 'It was cold.' Then in a 5-to-7-minute time (frame), it was 'Where was (R2) '?' V4 stated, (R2) was not in (R2's) room. Oh, okay. I (V4) felt like (R2) was confused. I (V4) told CNAs (V3, V5) to focus on (R2) all the time. 'You need to pay attention.' Redirect as much as possible. (R2) listens. It's a different story if (R2) doesn't listen. No pacing. (R2) was just walking. When asked where was V4 at 11:07 am on 6/4/23, V4 stated, Then I (V4) was at nurse's station at the med cart. I (V4) had to do (blood sugar checks) and had the paper and was checking from the (medication) cart; from the people (residents) and marking through the names. I (V4) checked my list. Then (R2) walked behind me. V4 stated, 5 minutes later. I (V4) turned to (V15, Housekeeper) 'Where's (R2)?' (V15) said, 'Where is (R2)?' I (V4) said let's check the bathroom. Nobody. We opened all the bathrooms. V4 stated, First thing, (R2) was walking close to the stairs. Maybe (R2) went through. That was by the original bathroom (R2) was trying to get into. V4 stated, We checked all resident rooms. When asked did V4 hear any alarms on 6/4/23 at 11:07 am, I (V4) was focusing on it (blood sugar checks). There was like a bed alarm. When a resident moves (with a bed alarm) and it (stairwell alarm) was the same thing. I (V4) look at all the residents. My thinking, it was the alarm. I (V4) was thinking it (stairwell alarm) was a bed alarm. When asked where other staff (V3, V5) were at when V4 heard the alarm, V4 stated, People were looking, moving around, and came back to my station. (V15) was there in front of (R2's) room. CNA (V3) was in the (staff) bathroom. My mind was that (R2) was in the bathroom. V4 stated, V3 (CNA) then went to the 2nd floor. V4 stated, V4 called the 4th floor staff and R2 was not on the 4th floor. V4 stated, I (V4) called down to reception (V21) for a code (yellow). V4 stated, I (V4) did hear (the stairwell) alarm. It wasn't loud, so you can know that someone can pass through. It was like a bed alarm. I (V4) am not familiar with stairs alarm. People don't use the stairs. 'Where is this alarm coming from?' V4 stated, CNA (V5) was running with me (V4). We have resident bathroom down there. We were looking. I (V4) called him then, called a code (yellow). (V21, Receptionist) said, 'I didn't see (R2) down there.' I (V4) said, 'Be on the lookout. (R2) didn't go on elevator.' V4 stated, I (V4) hear it, (stairwell) alarm, but it's like a bed alarm. You use a code to stop it (stairwell alarm). V4 stated, (V3, CNA) was down the stairs then. I guess we (V3, V4) met at reception. We can't find (R2). On 6/6/23 at 2:15 pm, V5 (Agency CNA) stated, on 6/4/23 from 7:00 am to 3:00 pm, V5 worked on R2's floor (3rd floor). V5 stated, on 6/4/23 prior to R2's elopement, I (V5) see (R2). Both in (R2's) room and hallway. At the beginning, (R2) was in other resident rooms. I (V5) was assisting (R2) back to (R2's) room. I would redirect (R2) saying, 'Hey, let's go back to your room. You are in someone else's room.' (R2) didn't speak much English. (R2) speaking back in Spanish. I (V5) escorted (R2) in (R2's) room for a while then (R2) came back out. I (V5) was at nurse's station. (V4) asked me (V5) by the stairs (about R2's location). I (V5) didn't see (R2) walk out it (stairwell door). When asked where was V5 on 6/4/23 at 11:07 am, I (V5) was at nurse's station. (V3) was in the bathroom. (V4) was at the med cart who saw (R2) walking towards (the west stairwell) door. I (V5) didn't hear the stair alarm. Surveyor asked if R2 had an electronic monitoring safety device on. V5 stated, Yes. On (R2's) wrist and ankle. Normally, the alarm will go off. That's what the CNA (V3) told me. I (V5) didn't hear it. That's why I (V5) didn't see (R2) leave. On 6/8/23 at 11:17 am, V15 (Housekeeper) stated, V15 worked on the 3rd floor on 6/4/23 from 7:00 am to 3:00 pm. When asked if V15 was familiar with R2, V15 stated, I (V15) could say something specific about (R2). (R2) was walking whenever (R2) wanted and sometimes coming from other people rooms. So, CNAs and nurse keep eye on (R2) all the time. Sometimes (R2) would go back to (R2's) room. (R2) was nervous about it. (R2) would do whatever (R2) wanted to do. It was Sunday (6/4/23). That morning, (R2) was the same. Nothing different in (R2's) behavior. I (V15) said, 'How are you?' V15 stated, (R2) was talking to (V4, Agency RN). (R2) going back and forth to (V4) and (R2's) room. When asked on 6/4/23 at 11:07 am, where was V15 on the 3rd floor, and V15 stated, When I (V15) came to clean (R2's) room. (R2) was there, standing in the door. (R2) going back and forth to (V4) and talking about something. (R2) coming back and forth. I (V15) cleaned (R2's) room and mopped the floor. I (V15) was at the door and (R2) was there just a couple of minutes ago and I (V15) didn't see (R2). I (V15) told (V4) that I didn't see (R2). Then (V4) and CNA went to look (for R2). They checked other rooms, bathrooms and shower room on the floor and didn't find (R2). When asked the description of what (R2) was wearing, V15 stated, Jacket with zipper in front. Put zipper on. (V4) turned. (V4) asked (R2) 'Why (R2's) wearing jacket? It's hot here.' R2 said, '(R2's) cold.' That's when (R2) was coming out of (R2's) room to the nurse's station. (V4) was standing by nurses' station at (medication) cart. In front of cart. One CNA (V5). I (V15) don't remember where other CNA (V3) came from. When asked if V15 heard any alarms, V15 stated, No, I (V15) didn't hear any alarm from the stairs. On 6/12/23 at 11:00 am, V21 (Receptionist) stated, V21 worked from 8:30 am to 9:00 pm on 6/4/23 at the receptionist station at the desk in the front lobby of the facility. V21 stated, as part of V21's responsibilities, the video footage images are monitored by us (receptionists) of each screening area in the facility including the back door on the 1st floor. When asked about the 1st floor back door alarm, V21 stated, We are also monitoring. They (visitors) must ring doorbell. Back door visitors must be buzzed in 24 (hours)/7 (days a week). Workers or employees will use code for entry. Visitors must be buzzed in. When asked if V21 is sitting at the receptionist desk in the front lobby, can V21 visually see the back door, and V21 stated, Sitting there physically. I (V21) can see normally down the hallway. I (V21) can see that door. When asked would V21 be able to see someone leaving the facility via the back door, V21 stated, It depends. I (V21) can see. I (V21) can't make there person out. I could make out body stance. There are 3 racks with towels. When those (racks) are there, they are blocking. (They're) not all the way blocking the (back) door. It's iffy, I (V21) can't see. I (V21) can't make them (person exiting back door) out. When asked if the blue laundry bins (racks) are in the 1st floor hallway on the wall, can V21 physically see a person exiting at the back door without the video camera screen, and V21 stated, No, not really. When asked how would V21 be able to see the person leaving out the back door then, V21 stated, Camera. V21 stated, it's not a clear picture of individuals with seeing the back of their head since the video camera is positioned from the hallway view outward. When asked if there is an alarm system on facility 1st floor doors, V21 stated, Yes. They (front and back doors) both do. V21 stated, the 1st floor front and back doors are equipped with an electronic monitoring safety device alarm, and when a resident with an electronic monitoring safety device gets near the front and back doors, the alarm would be activated. V21 stated, I (V21) would hear 'beep and beep' as I am sitting there at desk. V21 stated, when the 1st floor back door alarm is triggered, V21 would hear the alarm noise at the back door location. When asked if V21 can hear the 1st floor back door electronic monitoring safety device alarm, V21 stated, I (V21) would have to be listening. If they (the resident with an electronic monitoring safety device) got out. I (V21) would hear beep, beep. I (V21) would see on the camera and see if there is an individual. A resident or something that would have caused the issue. I (V21) physically go down (to the back door) and disarm the alarm. When asked how the alarm is disarmed, V21 stated, V21 puts in a number code, and it (alarm) will fade out and go away. V21 stated, It will continue to beep until you disarm it. When asked if V21 knew R2 prior to R2's elopement on 6/4/23, V21 stated, Yes that it was when R2 was first admitted to the facility (R2's admission date is 5/13/23). When asked if V21 would be able to visually recognize R2 in physical appearance, V21 stated, Yes. V21 stated, On 6/4/23, it was a typical morning. Around 11:00 am something. I (V21) can't recall exact time. I (V21) got a call from (V4), asking if I knew where abouts of R2. I (V21) told (V4) that I (V21) haven't seen (R2). I (V21) asked 'What happened?' (V4) said, (V4) don't see (R2) in (R2's) room. I (V21) told (V4) that I (V21) never saw (R2) come down the front or side elevators. I (V21) am thinking if (R2) came down the stairs, I (V21) could see the back of (R2). But how did (R2) get downstairs? I (V21) told (V4) if you are not seeing (R2), I (V21) will call code yellow. After (V4) confirmed, I (V21) got on overhead page. When asked where was V21 at 11:08 am on 6/4/23, V21 stated, I (V21) was at the receptionist desk, speaking to (R13) in a wheelchair. When asked where was R13 positioned when V21 was conversing with R13, V21 stated, R13 was kitty corner (diagonal) on my right side, and I (V21) am facing the middle elevator. V21 stated, from the back area (on 1st floor), R2 did not come towards the receptionist desk, Not at all. V21 stated, never heard anything. Nothing alarmed that someone got out there (back door). When asked if the back stairwell (west stairwell) is locked on the first floor, V21 stated, No. Residents can take a stairwell down. When asked if V21 heard an electronic monitoring safety device alarm from the 1st floor back door on 6/4/23 at 11:08 am, V21 stated, No. Nope. When asked if there were blue laundry bins (racks) in the 1st floor hallway on 6/4/23, V21 stated, Yes. When asked if V21 saw R2 on the 1st floor back door video camera view on 6/4/23 at 11:08 am, V21 stated, No. If there was an image, I (V21) wouldn't have known it was (R2). (R2) would have had an (electronic monitoring safety device) on. We have regular employees who walk back there. I (V21) would not be able to make (R2) out. On 6/14/23 at 2:01 pm, V21 (Receptionist) stated, the elopement risk list (residents who are assessed as an elopement risk) is posted at the receptionist's desk in a red binder. V21 stated, V21 checked the elopement risk list on 6/4/23. V21 was asked on 6/4/23, was R2 on the elopement risk. V21 stated, No, I (V21) don't think so. On 6/8/23 at 1:42 pm, V18 (Dietary Aide) stated, V18 works in the kitchen and works on the weekends. V18 stated, on 6/4/23, V18 worked from 6:00 am to 2:00 pm. When asked on 6/4/23 at 11:08 am, did V18 see R2 eloping from back door on the 1st floor, and V18 stated, No, I (V18) don't recall. V18 stated, V18 had met R2 prior to 6/4/23 and V18 would see R2 in R2's bed each time V18 would be picking up meal trays. V18 stated, I (V18) know (R2's) general appearance. I (V18) would recognize (R2) if I saw (R2). This surveyor informed V18 that this surveyor and V1 viewed the facility video footage from 6/4/23 when R2 eloped out the 1st floor back door. When asked where V18 was going when V18 was walking down the 1st floor hallway towards the back door direction on 6/4/23 (as observed on the video), V18 stated, Around that time, I (V18) turned to the laundry or lady's locker room. When asked on 6/4/23 at 11:08 am, did V18 hear alarms at the back door, V18 stated, No, I (V18) didn't hear anything. On 6/8/23 at 11:30 am, V16 (Clinical Care Coordinator) stated, V16 was the manager on duty or MOD on 6/4/23 and arrived around 9:10 am. V16 stated, one of V16's responsibilities as the MOD is to use the remote for the electronic monitoring safety device alarm systems for the 1st floor front and back doors in the facility. V16 stated, V16 checked the doors on 6/4/23 around 10:00 am after V16 did V16's rounds and the remote showed Good when the door is working. V16 stated, So, I was in my office, around 11:00 am. (V21, Receptionist) said (V4, Agency RN) was saying that they can't find (R2). I (V16) asked (V4) when (V4) saw (V4) last, and (V4) said, 'Recently. I (V4) just gave (R2) (R2's) medications.' I (V16) said, 'Did you see (R2) in what direction?' (V4) could not identify which door and maybe (R2) left in back door because (V21) didn't see (R2). When asked as the MOD, does V16 review the elopement risk list? V16 stated, It's at the front desk at receptionist (desk). Yes, I (V16) check on it. When asked on 6/4/23, did V16 check the elopement risk list, and V16 stated, I (V16) check the list, but we were already searching (for R2). I (V16) check on the pictures. We are looking for (R2). When asked was R2 on the elopement risk list on 6/4/23, V16 stated, I (V16) don't think so. V16 verified with this surveyor that it was the elopement risk list, updated on 6/2/23, that V16 saw on 6/4/23. V16 stated, (R2) was not on this (elopement risk) list at this time. When asked did V16 have knowledge that R2 was at risk for elopement (prior to 6/4/23), V16 stated, No, not really. On 6/7/23 at 12:53 pm, V13 (Social Worker) stated, I (V13) report to (V11, Social Services Director, SSD) and was assigned to the 3rd floor and half of the 2nd floor. V13 stated, When (R2) was first admitted , (R2) was confused and wandering a little bit. Since (R2) was Spanish speaking, we had a couple staff members who speak Spanish. A CNA who speaks Spanish translated for (the social services) intake. (R2) had wandering tendencies. Nursing was asking if we could put an (electronic monitoring safety device) on (R2). I (V13) put it (electronic monitoring safety device) on (R2) on 5/16/23. I (V13) placed it on (R2's) right wrist. I (V13) checked it (electronic monitoring safety device) prior to putting it on (R2). We had the old one (from the previous electronic monitoring safety device alarm system). And then I (V13) grabbed a new one. And I (V13) checked it prior. I (V13) used a remote to check it. We can get the remote. It's (remote for electronic monitoring safety device checks) in (V12's, Maintenance Director) office. V13 stated, I (V13) did see (R2) walking and pacing the hallway. When asked who the nurse was who asked for the electronic monitoring safety device to be placed on R2, V13 stated, It was the nurse on the floor, the restorative nurse (V14). When asked if V13 ever tested R2's electronic monitoring safety device after applying it on R2 on 5/16/23, V13 stated, I (V13) had tested it on another day because I (V13) tested it prior (to putting it on R2). When asked when this date was, V13 stated, It was on a really busy for (V11, SSD). (V11) does the updates on Fridays. I (V13) did it that next Friday (5/19/23). It (R2's electronic monitoring safety device) was functioning at that time. V13 was asked to demonstrate the testing method of a resident's electronic monitoring safety device with the remote (present in the conference room on the table), You turn it on. And the message says good. I (V13) tested it that way with (R2). V13 stated, V13 performed the elopement risk assessment for R2 on 5/16/23 as part of R2's social services admission assessments and V13 did (R2's) care plan. When asked about the score of R2's elopement risk assessment, V13 said, Score, right down here, would be (R2's) score. At risk. V13 stated, V13 fills out all the elopement risk evaluation questions, and the questions that are marked with yes totals for the final score. V13 stated, any score above a 4 is a high risk on the elopement risk evaluation. V13 stated for at risk for elopement residents does include behaviors that would be concerning, like wandering tendency. V13 stated, (R2) was at risk for elopement. Wandering tendency. Keep eye on (R2). Eye on (R2) and a personal safety alarm device. When asked what the personal safety alarm device (electronic monitoring safety device) is, V13 stated, It sounds an alarm that someone has gotten in the elevator or gone out one of the doors. Bracelets made to one of those 4 exits. Doors on the main floor and elevators, there's an alarm. V13 stated, (R2) is oriented to self. Oriented to person and not to situation or what was going on. When asked about testing R2's wander guard other than when V13 stated on 5/16/23 and on 5/19/23, V13 stated, I (V13) don't recall testing (R2) another time. When asked if V13 informed V11 (SSD) when V13 placed R2's electronic monitoring safety device on R2 on 5/16/23, V11 stated, I (V13) did not that day. It's one of those things that slipped through the crack. When asked V13 in reference to the elopement risk list, can V13 update the elopement risk list, and V13 stated, That's (V11, SSD.) I (V13) have not updated it. V13 stated, For the elopement risk list, they (residents) all have (electronic monitoring safety devices) on them attached. V13 stated, residents who are at risk for elopement are making statements, consecutively needing to go to the store, saying 'I need to pay my bills.' They have more of an idea or plan. Obsessive thinking with poor cognition. They have it in their mind that 'I have to do it.' V13 stated, (R2) was pacing, walking into rooms. Now (R2) has 1:1 sitter. V13 stated with R2's electronic monitoring safety device, (R2's) on the list now. That's how staff are able to know who an elopement risk is. V13 stated, on 5/16/23 when V13 applied R2's electronic monitoring safety device, I (V13) did not document the device number or mode. I (V13) was unaware that we needed to document it. On 6/8/23 at 3:39 pm, V13 (Social Worker) asked if she checked the functioning of the electronic monitoring safety device on 5/16/23 after placing it on R2. V13 stated, Since I (V13) checked it right before, I didn't check after putting on (R2). V13 asked if V13 completed electronic monitoring safety device inventory log. V13 stated, (V11) does the (electronic monitoring safety device) log. Not me. So, no. R2's Elopement Risk Evaluation, dated 5/16/23, documents, in part, 8 questions to be completed for the risk score total. V13 performed and documented R2's 5/16/23 Elopement Risk Evaluation and answered Yes to the following 3 questions: The resident has the physical ability to leave the facility, The resident has a firm desire/intent to leave the facility, and The resident has attempted or has an actual elopement in the last year. Question #8 (The resident is confused to time and place and has the physical ability to leave the building?) was not answered Yes or No by V13 (left blank). V13 documented that all interventions that apply to R2 is Personal Safety Alarm Device. On 6/20/23 at 1:58 pm, reviewed the 5/16/23 elopement risk evaluation V13 performed for R2, V13 stated, the answers to the questions determine the risk score. V13 stated, That's why (R2) had score of 3 because (R2) had 3 yeses. V13 stated, with question #5 The resident has attempted or has an actual elopement in the last year, V13 documented yes because of R2's wandering. V13 stated, R2 was at 'low risk' with a score of 3. This surveyor then pointed out to V13 that V13 did not answer question #8 The resident is confused to time and place and has the physical ability to leave the building? When asked why did V13 not answer question #8, V13 stated, It was a m[TRUNCATED]