**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from physical and verbal abuse and identify and investigate a potential allegation of abuse and protect resident from further abuse from R500, with a known history of verbal and physical aggression. These failures resulted in R500 verbally yelling and physically hitting R134 and shoving both R84 and R103 to the ground. R84 sustained a bleeding laceration to posterior head, facial bruising, and hospitalization requiring three staples to R84's posterior head. R103 experienced hip and knee pain, bruising, and hospital evaluation. R134 was hit in the face. These failures have the potential to affect all 35 residents residing in the facility's Dementia unit. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 8/29/24, the facility remains out of compliance at a Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of the facility's removal plan and quality assurance monitoring. Findings include: The facility's Abuse Prevention Program policy, revised 3/1/21, documents It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. This policy also documents Identification of Allegations/ Internal Reporting Requirements: Employees are required to immediately report and incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or crime against a resident they observe, hear about, or suspect to the Administrator if available or an immediate supervisor who must immediately report it to the Administrator. In the absence of the Administrator, reporting can be made to the DON (Director of Nursing). Any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or crime against a resident is reported to a covered individual; covered individuals are notified annually of these reporting requirements. Employees without fear of retaliation may also independently report to the state survey agency any allegation of abuse, neglect, exploitation, or mistreatment of resident property, and to local law enforcement if they have a reasonable suspicion that a crime was committed. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Reports should be documented, and a record kept of the documentation. Upon learning of the report, the Administrator or in the absence of the Administrator, the DON shall initiate an incident investigation. Investigation: All incidents, allegation or suspicion of abuse, neglect, exploitation, misappropriation of property, or crime against a resident will be documented. Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or crime against a resident will result in an abuse investigation. Once the Administrator or in the absence of the Administrator the DON determines that there is an allegation or a reasonable cause for suspecting abuse, neglect, exploitation, misappropriation of property, or a crime against a resident, the Administrator or appointed investigator will investigate the allegation and obtain a copy of any documentation relative to the incident. This policy also documents Protection of Residents: The facility will take steps to prevent mistreatment while the investigation is underway. Residents who allegedly mistreated another resident will be immediately removed from contact with that resident during course of investigation. The accused resident's condition 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 the other residents and employees of the facility. All personnel, residents, visitors, etc. (etcetera) are encouraged to report incidents of resident abuse, mistreatment or neglect or suspected abuse, mistreatment, or neglect, without fear of retaliation or retribution from facility or its staff. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This same policy also documents Procedure: Upon receiving reports of physical or sexual abuse, the Charge Nurse will immediately examine the resident. Findings of the examination must be recorded in a separate incident report and in the resident's medical record. This report shall be made immediately, but no later than two hours after the allegation is made. If the events that cause the allegation involve abuse or resulted in serious bodily injury, or not less than 24 hours if the events that cause the allegation do not involve abuse and did not result in serious bodily injury. Crimes include but may not be limited to murder, manslaughter, rape, assault and battery, sexual abuse, theft robbery, drug diversion for personal use or gain, identify theft, and fraud and forgery. When an alleged or suspected case of abuse, neglect, exploitation, or crime against a resident is reported to the facility Administrator, the Administrator, or DON in the Administrator's absence, will notify the following persons or agencies of such incident immediately. Any incident that involves crimes or significant injury to a resident will be reported within two hours of the incident. Any incident that involves a resident death will be called to the (State Agency) immediately. Abuse allegations involving one resident upon resident upon another resident will be reported to (the States Agency). The Diagnosis Report for R500, documents R500 admitted to the facility on [DATE] with a diagnosis of Schizoaffective Disorder. R500 was diagnosed with Obsessive Compulsive Personality Disorder on 7/15/24 and diagnosed with Bipolar and Metabolic Encephalopathy on 7/25/23. R500 was also diagnosed with Anxiety on 8/21/24 after readmitting to the facility on 8/19/24 from psychological hospitalization. The facility Psychiatric service report for R500, dated 6/5/24, documents R500 with a diagnosis of Dementia. This report documents R500 with auditory hallucinations and delusions and making false accusations of staff. Psychiatric History includes multiple psychiatric hospitalizations and multiple medication changes prior to facility admission. The current Care Plan for R500 documents the following: Focus areas with goals and interventions listed: R500 has chronic health conditions, behaviors, challenges, and co-morbidities that include Schizoaffective and bipolar disorder. R500 requires the support, services and structure of the care setting and is under the care of psychiatry and receives medications and illness management through psychological services and psychosocial group programming; R500 demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming the unit; R500 uses antipsychotic medications r/t (related to) behavior management; R500 displays behavioral symptoms related to Bipolar Disorder; R500 has behavior problem r/t anxiety, depression, change in mood, self-isolation, false accusations, repetitive questioning, agitation, tearful episodes, cursing, decreased socialization, delusions, hallucinations, pacing, panic, paranoia, and verbal aggression; R500 has impaired cognitive function, becomes easily confused, overwhelmed and disoriented; and R500 had chronic psychiatric illness and determined to have ineffective coping modalities that include disorganized thought processes and mood patterns, delusions, hallucinations, difficulty meeting basic physiological/self-care needs, and having reduced insight and judgement r/t Schizoaffective disorder; and R500 displays conflictual, difficult behavior with other persons with symptoms of open conflict with or repeated criticism of staff and unprovoked expressions of anger towards staff and peer. Being verbally and physically aggressive with her peers. Interventions include: Teach and remind the resident to communicate his/her feelings, including anger and frustration through means other than hitting, touching or verbally abusing another person; R500 has rapid cycling and significant shifts in mood that include mania and depression that may last for several days r/t bipolar disorder with following symptoms of hallucinations, becoming easily agitated, irritated, disturbed, having illogical thinking, and paranoid delusional thoughts about others. Goal is for R500 to seek assistance when experiencing aggressive impulses and refrain from engaging in verbal threats and loud, profane language toward others. Interventions include: Monitor/record/report to MD (medical doctor) prn (as needed) risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons; and R500 has Behavioral Symptoms/Altercation with Roommate initiated on 4/4/24 as: R500 demonstrates behavioral distress related to: Ineffective coping mechanisms, bipolar disorder and Schizoaffective disorder. Problems are manifested by: Physically abusive behavior when agitated such as slapping or attempting to cause harm to a peer. The Behavior Monitoring Report for R500, dated 7/01/24 through 8/28/24 documents the following behaviors have been noted over the past 30 days: grabbing others, hitting others, kicking others, pushing others, physically aggressive towards others, scratching others, accusing of others, cursing at others, expressing frustration/anger at others, screaming at others, threatening others, entering other resident's rooms/personal space, disruptive sounds, repetitive motions, rummaging, agitated, anxious and restless, elopement and exit seeking, experiencing something not there, hoarding, neglecting self care, pacing, panic, refusing care, wandering and withdrawn/isolation. The Psychiatry Note for R500, dated 4/5/24, documents On 4/4/24 (R500) became agitated at her roommate (R134) for wandering on her (R500) side of the room and going through her (R500) belongings. When R500 attempted to take her belongings back, R134 raised their arms at R500 so (R500) struck (R134). R500 was sent to the local hospital for an evaluation and returned to the facility. On 8/27/24 at 2:47 pm, V2 DON (Director of Nursing) stated she does the Fall Investigations and V1 Administrator does the Abuse Investigations and there has only been one abuse allegation involving R500 and that was with R103. R500 is very territorial about her room and space and had just been at Geriatric psychological hospital for manic behavior, not for being aggressive. V2 DON stated That is the only incident she's had. There are no others. V2 DON stated R500 went out to the psychological hospital on 8/2/24 and just readmitted back to the facility on 8/19/24. On 8/20/24 R500 pushed R103 and R103 fell to the floor. V2 stated both residents went out to the local the hospital for evaluations, returned with no injuries and R500 was placed on one-to-one staff monitoring when she returned from the hospital. On 8/27/24 at 3:15 pm, V1 Administrator stated he is the Abuse Coordinator but was not involved in the incident with R84 because he was not at the facility but was involved with the altercation between R500 and R103. V1 Administrator stated V2 DON (Director of Nursing) does all the fall investigations and did R84's investigation as a fall, it was not considered abuse and he is unaware of the incident being potential abuse. On 8/23/24 at 11:40 am, R500's door was closed, and V20 Transportation CNA was sitting outside of R500's room. Upon entering R500's room noted two mattresses on the floor with bed frames standing empty. R500 was lying on one of the mattresses and R500's personal items were randomly scattered on the other mattress on the floor. R500 stated she was not feeling very good, had recently been in the hospital, has lost weight, doesn't know why, and requested a soda to drink. 1. A facility Abuse Investigation for R500 and R134, dated 4/4/24, documents V38 CNA (Certified Nursing Assistant) heard noise and went into R500 and R134's room, (R134) had two bears and a flower in her hand. (R500) went and took the bears out of (R134's) hand. (R134) got upset and raised her hands in the air. (V38) got in between the two (R134 and R500) and tried to intervene and (R500) reached around and slapped (R134). V22 RN (Registered Nurse) witness statement documents (V22 RN) was standing at the nurses' station and was trying to get there asap (as soon as possible) because (V22 RN) was hearing a commotion. When (V22) got in the room (R500) was complaining about (R134) getting into (R500's) stuff. (R134) put her hands up in the air and (R500) slapped (R134). The local hospital ED (emergency department) Physician Notes for R500, dated 4/4/24, documents R500 is from (The Facility) and staff sent her (R500) in due to having an altercation with her roommate. The Final Abuse Investigation documents the facility is unable to substantiate this allegation as well as (R500) made contact with (R134); regardless that V38 CNA and V22 RN witnessed R500 hit R134. On 8/23/24 at 12:00 pm, V22 RN stated R500 has had some bizarre behaviors, is aggressive at times and there was an incident awhile back with another resident, her old roommate before she moved and R500 has been aggressive with the staff. 2. A facility Fall Investigation for R84, dated 8/20/24 at 12:23 pm, documented by V29 LPN (Licensed Practical Nurse) documents staff was in the dining room at lunch when someone (R500) was heard yelling on the hallway. V29 LPN asked V41 CNA to go observe the area. V41 CNA went to the hall and started to go down the hall and observed (R84) at the end of the hall. (R84) was observed falling backwards. V41 CNA was unable to assist (R84) d/t not being close enough. V41 CNA's statement is documented as: I was serving food. I heard someone yell. I went to observe the area and resident was at the end of the hall by (R500's) room. I observed the resident falling backwards and was unable to assist d/t not being close enough. The resident in the room had yelled, stepped back into her room and slammed the door. The local hospital ED (emergency department) Physician Notes for R84, dated 8/20/24, documents R84 presented to ED with a head injury. Chief complaint was an unwitnessed fall with wound to the posterior scalp and bleeding controlled at this time. CT (computed tomography) of the cervical spine and the head were completed with small left posterior scalp contusion without hemorrhage or fractures. On 8/28/24 at 10:45 am. the facility's Video Surveillance surrounding R84's on 8/20/24 at 12:23 pm incident viewed with V1 Administrator and V2 DON and shows R84 standing in R500's doorway area. R500 cannot be seen due to recession of R500's door. V41 CNA is seen walking down the hallway towards R500's door, and at approximately 15 feet from R500's door R84 is seen quickly and forcefully falling, hitting the back of her head on the floor. V41 CNA is then seen anxiously and rapidly moving in circles and about the hallway with arms flailing about. Other Staff members are then seen going down the hallway to assist. The Video Surveillance does not show R500 at the doorway due to the surrounding walls; however, there is some shadowing movement to the left upper exterior door frame area that quickly disappears while R84 is falling backwards. R84 does not appear to have stumbled backwards as the fall was so quick and forceful. R84's walker is also noted to move in the lower middle door area but does not fall over. On 8/27/24 at 1:30 pm, V8 Anonymous Staff Member stated R500 has had a lot of behaviors lately and over the past month or so and has been in and out of the hospital because of aggressive behaviors. V8 stated on 8/20/24 around 12:30 pm she heard R500 yelling and screaming and (V8) was approximately 15 feet from R500's room when R500 took both of her hands, grabbed R84 and like a bowling ball slammed R84 to the floor. She (R500) hulk smacked her (R84's) head and R84's head was gushing blood all over the floor. V8 stated she has never seen anything like that happen before, witnessed the entire incident and wrote a witness statement stating exactly what she saw and gave it to V29 LPN. V8 stated her statement was changed to reflect something other than what she saw. V8 stated V2 DON told (V8) she watched the camera, R84 had stumbled, and V2 DON needed V8 to stop telling people that R500 slammed R84 down. V8 stated she kept telling V2 DON what (V8) saw and that there was no stumbling or (V8) would have seen that. V8 stated she also told V14 ADON (Assistant Director of Nursing) what she witnessed. On 8/28/24 at 10:45 pm, V2 DON stated R84 was startled by R500 when R500 yelled and slammed her door and R84 stumbled back and fell. R84 never said she was pushed. V2 DON stated she heard rumors that were going around about R84 being pushed down the next day (8/21/24). V2 DON stated V41 CNA was telling everyone that she saw R500 push R84 down and was told to stop telling people that because the facility cameras do not show R500 pushing R84 down. When asked if the cameras show R500 not pushing R84 down or why V2 DON didn't investigate V41 CNA's allegation of abuse; regardless of when the allegation was made, V2 DON became irritated, raised her voice and stated R500 did not push R84 down, R84 stumbled and fell back. On 8/28/24 at 10:50 am, V1 Administrator stated the incident with R84 was reported to the State Agency as a fall and even if it was found to be abuse after investigating, he would not have resubmitted the incident as abuse, he would document it on the five day only. V1 also stated a abuse allegations with residents with dementia, confusion or one with a UTI (urinary tract infection) would not be considered willful abuse due to the resident not having the cognition to be willful and he would not report it as abuse. V1 Administrator confirmed the video surveillance did not show that there was or was not contact between R500 and R84 due to quality of video and positioning of camera. On 8/23/24 at 11:30 am, 12:01 pm, and 12:17 pm R84 was wandering the Dementia unit hallways with a wheeled walker and with a slow and steady gait. Bruising was noted to R84's right cheek and three staples to back of her head. On this same date at 12:18 pm, R84 wandered into another resident room. On 8/27/24 at 12:57 pm and on 8/28/24 at 10:09 am, R84 was pacing the hallways with a wheeled walker with a slow steady gait. On 8/27/24 at 1:10 pm, V33 CNA stated she and other nursing staff were in the dining room on 8/20/24 at noon assisting residents with lunch and heard R500 screaming, heard a big loud bump; like something hit on the floor, and then heard a door slam. V33 CNA stated R84 was down by R500's room, in front of R500's door and then just fell back. R500's room is at the end of the hall and the camera at beginning of hall. R500's room has an entryway so her door cannot be seen unless your closer to her room. V33 CNA stated V41 CNA told (V33) that she saw R500's hands push R84 down. V33 CNA stated R84's fall was an aggressive fall. A slower fall would not have caused that to her head. On 8/23/24 at 11:58 am, V21 Restorative Nurse stated on 8/20/24, R84 lost her balance and fell backwards, hit her head and had bruising from the fall, went to the hospital and That's all I know. On 8/27/24 at 1:00 pm, V34 CNA stated on 8/20/24, during shift change report, she was informed that on day shift R84 was walking with her walker, fell, and hit her head by R500's door, but doesn't know the details. V34 stated R500 was not on one-to-one monitoring at that time. 3. A facility Physical Abuse Investigation for R500 and R103, dated 8/20/24 at 4:40 pm, documents the Nurse heard loud screaming from around the corner in the hallway and Housekeeper in the hallway witnessed physical aggression from R500 towards R103. The victim (R103) had a fall to the floor as a result of R500's Physical Aggression. The investigation includes a statement for V39 and V40 CNA's documenting witnessing R500 yelling at R103 you stay away from me and then R500 pushing R103 to the floor. There is no witness statement from a Housekeeper included in investigation. R103 fell to the floor onto left side and complained of left hip and left knee pain. R103 and R500 were both sent to the local hospital for evaluation and treatment. The Change in Condition Evaluation for R500, dated 8/20/24 at 4:44 pm documents: R500's behavioral changes as physical and verbal aggression and a danger to self and others; Dangerous behavior as pushed peer and as a result of the physical aggression receiver of the aggression fell to the floor; Behavioral changes as resident moving furniture around and had made comment of being filthy and disgusting; and Resident has new orders to be on 1:1 supervision until further notice when she returns from ED (emergency department). The ED Physician Notes for R500, dated 8/20/24, documents R500 was recently discharged from local behavioral hospital yesterday (8/19/24), re- admitted to (the Facility) and altercation occurred (8/20/24) between R500 and another resident. The local hospital Emergency Department Provider Notes for R103, dated 8/20/24 documents the patient (R103) was in an altercation at (the Facility) on memory unit, was pushed hard and fell down and complained of left hip and left knee pain. On 8/28/24 at 10:45 am, the facility's Video Surveillance surrounding R103's 8/20/24 at 4:40 pm incident was reviewed with V1 Administrator and V2 DON and shows R103 and R500 at a table near the entrance of the hallway. R500 is seen standing facing R103 and appears to be talking to R103 and then R500 is seen quickly and forcefully grabbing R103 and shoving R103 towards the floor. R500 is then seen standing nearby while R103 is being assisted. On 8/23/24 at 11:48 am, R103 was in the dining room, standing next to a table talking to other residents. Between 11:50 am through 12:38 pm, R103 was walking independently around the dining room, sat in a stationary chair in the dining room, fed self lunch and at 12:38 pm remained sitting in the dining room. On 8/27/24 at 12:54 pm, R103 was pacing the hallways independently. On 8/30/24 at 2:30 pm, V3 Infection Preventionist assisted R103 with lowering her left pant leg. A large bruise measuring approximately 13 inches was noted to R103's left hip. V3 confirmed this was from R103's fall. On 8/27/24 at 1:30 pm, V8 Anonymous Staff Member stated on 8/20/24 around 4:35 pm she heard and witnessed R500 scream out at R103, grab R103 and throw R103 into the hallway wall, very forcefully. V8 stated after this incident R500 was put on one-to-one monitoring. V8 stated They should have done that after the first time and the second time wouldn't have happened. On 8/23/24 at 11:58 am, V21 Restorative Nurse stated on 8/20/24, R500 and R103 had a resident to resident altercation and both residents went to the hospital and came back and That's all I know. On 8/27/24 at 1:00 pm, V34 CNA stated on 8/20/24, during second shift R103 was walking and R500 pushed R103 down in the hallway. V34 stated she didn't see it happen but heard the staff talking about seeing R500 push R103 and stated, That's how I know. V34 CNA stated R500 and R103 went out to the local hospital and R500 was put on one-to-one monitoring when she returned from the hospital and had not been on one-to-one prior to that. On 8/23/24 at 11:35 am, V20 Transportation CNA was sitting just outside of R500's room. V20 stated V41 CNA had to leave for family emergency so (V20) was filling in to help with R500's one-to-one monitoring. V20 stated she transported R500 to a behavioral health hospital on 8/2/24 after R500 attacked the staff and was having bizarre behaviors. R500 screamed at the top of her lungs during the last hour of the ride but other than that she didn't have any behaviors. V20 stated R500 just came back here on 8/19/24 and had to be put on one-to-one a couple of days ago. The medical record for R500 documents another emergency room evaluation occurred for R500 on 8/26/24 due to aggressive physical behavior. The local hospital ED report for R500, dated 8/26/24, documents (R500) is a resident of (the Facility) and was apparently becoming quite aggressive with staff. Patient came flying down the hallway and pushed staff x (times) 2. She has no idea why she is in the emergency department, and has some unusual behavior at times and flaps her hands around stating that she is shaking all over. This report documents R500 is positive for agitation and behavioral problems. The Final diagnoses for R500 is documented as Behavior concern in adult and Aggressive behavior. The facility's Abuse log, dated 2024, documents one abuse allegation involving R500, dated 8/20/24 at 4:40 pm and does not include the allegation involving R134 or R84. The Immediate Jeopardy began on 8/20/24 at 12:23 pm when the facility failed to prevent, identify and investigate a potential allegation of abuse and protect residents from further abuse. V1 Administrator was notified of the Immediate Jeopardy on 8/29/24 at 11:28 am. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Investigation of both incidents were completed and reported to state survey agency and physician for R84, R103, and R500. 2. R84 was transferred to the hospital for evaluation. 3. R103 was transferred to the hospital for evaluation. No injuries were noted and R103 returned to the facility with no new orders. 4. R500 was placed on one-to-one supervision on 8/20/24. 5. R500 care plan was updated to include one-to-one supervision and again updated to include one-to-one supervision until the resident is deemed safe by psychiatry and/or nursing assessment. 6. R500 care plan was updated to include behavior monitoring Q (every) shift. 7. R84, R103, and R500 care plans have been updated to include one-to-one time with Social Services as needed to vent feelings. 8. Administrator in-serviced by Risk Management Consultant on 8/29/24 regarding Abuse Prevention Policy. 9. In-servicing training by Administrator/designee on Abuse Prevention Policy with all staff was initiated on 8/29/24. 10. In-servicing training by Administrator/designee on Abuse Prevention Policy with all staff will continue, and any remaining employees must be trained prior to reporting for work for their next scheduled shift. Employees will not be allowed to work after 11:59 pm on 8/29/24 until they have completed the in-service. 11. QAA (Quality Assessment and Assurance) team members were in-serviced on the facility's Abuse Prevention Program policy and procedure by the Administrator on 8/29/24. 12. Social Services Director and/or designee will audit Trauma Screening assessments and Screening Assessments for Indicators of Aggressive and/or Harmful Behavior for all 35 residents with the potential to be affected by this alleged deficiency to ensure those assessments are current. Social Services Director/designee will ensure interventions are care planned for any residents assessed to be at risk. The audits will be completed by 11:59 pm on 8/29/24. 13. QAA team will review the Trauma Screening assessments and Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors during quarterly QA (Quality Assurance) meetings with medical director and address any concerns. 14. QAA team will review the Trauma Screening assessments and Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors during Morning QA meetings daily x 30 days on all new admits to assure compliance. 15. The facility will follow state and federal guidelines regarding Abuse Reporting by requiring reporting of all reports of abuse to be reported to the facility QA Committee for follow up and review. 16. In-service training by Administrator/designee on Abuse Prevention Policy with all staff will continue monthly for the next 3 months, then quarterly x 3 by the DON or Administrator. 17. Administrator will enforce the interventions of plan of removal of immediacy and assurance of continued compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately provide CPR (Cardiopulmonary Resuscitation) to one resident (R1) identified as having no Advance Directives and failed to follow their policy which documents that Direct and non-direct care staff upon finding a resident non-responsive shall remain with that resident as is possible while signaling for assistance. The facility also failed to ensure all staff received training on the facility CPR Policy. On [DATE] at approximately 9:25am R1 was found unresponsive and without a pulse or respirations in his room by V7 (RN - Registered Nurse). V7 then left R1's room to make telephone calls to another nurse regarding R1's condition and to V2, (DON - Director of Nursing). This failure resulted in R1 not receiving Cardiopulmonary Resuscitation when found without a pulse and not breathing by V7, (RN) who left R1 and did not return to R1's room until V5, (RN) and V6, (LPN - Licensed Practical Nurse) had started CPR. This failure placed 59 current residents (R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, R44, R45, R46, R47, R48, R49, R50, R51, R52, R53, R54, R55, R56, R57, R58, R59, R60, R61) identified as having Advanced Directives indicating Full Code status at risk of not receiving immediate life sustaining treatment. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified to have started on [DATE] at 9:25am when R1 was found by V7 (RN) without a pulse or respirations and did not stay with R1 to initiate CPR. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 2:20pm. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level Two as the facility continues to monitor the effectiveness and training related to Advance Directives, code status, and initiation of CPR. Findings include: Facility Policy/Cardiopulmonary Resuscitation (undated) documents: It is the policy of (the facility) that Cardiopulmonary Resuscitation (CPR) shall be initiated and maintained by qualified staff in cases of recognized cardiac and/or pulmonary arrest to sustain or support a resident's cardiac and/or pulmonary function until advanced life support systems are available. Cardiopulmonary Resuscitation shall be initiated on all residents except those who have designated through advanced directives and/or have a specific physician order for DNR (Do Not Resuscitate), No Code or No CPR. Implementation of a code is as follows: Direct and non-direct care staff upon finding a resident non-responsive shall remain with that resident as is possible while signaling for assistance. The facility shall provide education to all employees regarding advance directives and the implementation of such. In servicing of advance directives policy and procedure shall be conducted annually. AHA (American Heart Association) Cardiac Arrest Treatment dated/reviewed [DATE] documents: If you think the person may be suffering cardiac arrest and you're a trained lay rescuer: Ensure scene safety. Check for response. Shout for help. Tell someone nearby to call 911 or your emergency response number. Ask that person or another bystander to bring you an AED (automated external defibrillator), if there's one on hand. Tell them to hurry - time is critical. If you're alone with an adult who has signs of cardiac arrest, call 911 and get an AED (if one is available). Check for no breathing or only gasping. If the person isn't breathing or is only gasping, begin CPR with compressions. Administer high-quality CPR. Push down at least two inches in the center of the chest at a rate of 100 to 120 pushes a minute. Allow the chest to come back up to its normal position after each push. Use an AED. As soon as it arrives, turn it on and follow the prompts. Continue CPR. Administer it until the person starts to breathe or move, or until someone with more advanced training, such as an EMS team member, takes over. Progress Note dated [DATE] at 5:34pm indicates R1 was admitted to the facility at 4:50pm with a gastric feeding tube and on dialysis. Note indicates R1 was receiving oxygen at 3L (liters). Physician Order Summary Report (POS) indicates R1 was admitted with diagnoses that included Congestive Heart Failure, Critical Illness Myopathy, Dilated Cardiomyopathy, Diabetes Mellitus, History of Prostate Cancer, Seizure Disorder, Encephalopathy, Dysphagia, Respiratory Failure. R1's electronic medical record did not contain Advanced Directives/Code Status. Progress Note dated [DATE] at 9:00am (documented by V5, RN - Registered Nurse) indicates V5 was called to come to building/Unit 2 by V7 (Charge Nurse). Note indicates V5 arrived and initially saw a resident on the floor in the dining room. Note indicates V5 was then sent to R1's room by V7 who stated that (R1) died. Note indicates V5 entered R1's room where family was present and noted R1 with no pulse and unresponsive. Note indicates V5 received a call at that time from V2 (DON - Director of Nursing) asking what was being done for R1. Note indicates V5 told V2 that she had just entered R1's room and did not know R1's code status but was instructed by V7 to start CPR. Note indicates another nurse (V6, LPN) arrived with the crash cart and began respirations for R1. Note indicates EMT's (Emergency Medical Technicians) arrived and took over CPR for R1. Progress Note - Clarification note dated [DATE] at 2:55pm indicates V5 was called to Unit 2 by V7, RN on duty related to an emergency. Note indicates V5 immediately responded to Unit 2 and upon arrival noted a female resident on the floor with a hematoma on her head. Note indicates as V5 went to assess the resident on the floor, the RN on duty (V7) informed V5 that V5 was needed down the hallway for a code. Note indicates V5 responded to R1's room where family was present and yelling and confirmed that R1 had no pulse or respirations. Note indicates the assigned nurse (V7) confirmed R1 was a full code and shortly thereafter V6 (LPN) arrived with the crash cart. Note indicates EMT's arrived and took over the code. On [DATE] at 1:45pm V7 (RN) stated that the night nurse told her in report that R1 had no code status identified, so R1 would be a Full Code. V7 stated I was in same hallway passing meds, (R1's) daughter came out of room to tell me R1 was dead. I immediately went into his room, and he had no pulse, no breathing. I left (R1's) room to call the house supervisor, she then called Code Pink. V7 stated she then called V2 (DON) and told her R1 did not have a POLST (Physician Orders for Life-Sustaining Treatment) and V2 said to start CPR. V7 stated she then went back to R1's room and V5 and V6 were placing the backboard under R1 and started CPR. V7 stated Sometimes we have to call the DON to find out what to do. On [DATE] at 9:10am V2, (DON) stated the first call she received was at 9:29am on [DATE] from V7, (RN) who reported The new guy is dead. V2 reported that V7 told her that R1 had no POLST and they are going to do CPR. After confirming phone calls were made I told (V5) to go back into the room to help the other nurses. On [DATE] V5 stated that she immediately responded to the Code called and arrived on Unit 2. V5 stated that V7 (RN) was standing by the nurse's station, did not appear to be on the phone and was not assisting a resident who was on the floor. V5 stated she asked V7 where was the Emergency? and V7 pointed toward R1's room. V5 stated R1 had no pulse, no respirations and she immediately started compressions. V5 stated she did not know why V7 left R1 to come out and make phone calls if she already knew R1 was a Full Code. V5 stated she would have stayed with the resident, started CPR and started yelling for other staff to come and help - make phone calls, etc. On [DATE] at 3:37pm V18 (Medical Director) stated that it's very hard to determine if the brief delay in initiating CPR lessened chances of survivability but of course the sooner starting the better. V18 stated staff should follow facility protocol as far as responding to CPR. On [DATE] V1 (Administrator) stated, We do not have signatures for (V5, RN) or (V7, RN -Agency staff) indicating that they received training on our CPR policy. All staff, including Agency staff should be familiar with our critical policies and I would say the CPR policy is critical. All licensed nurses should know how to respond and be familiar with CPR procedures. V1 confirmed that both V5 and V7 work regularly at the facility. On [DATE] the surveyor confirmed through interview and record review the facility took the following actions to remove the immediacy: 1. In-servicing by members of the Nurse Management team for licensed and certified staff on the facilities Advanced Directives, Cardiopulmonary Resuscitation, POLST Form, and Code Pink-Nurse Emergency Page was initiated on [DATE]. 2. In-service by members of the Quality Assurance team for All staff on the facilities Advanced Directives, Cardiopulmonary Resuscitation, POLST Form, and Code Pink-Nurse Emergency Page was initiated on [DATE]. 3. DON/MDSC (Minimum Data Set Coordinator)/SS (Social Services) team members completed an audit of all residents' code status orders, POLST Forms and advanced directive care plans on [DATE]. This audit was repeated [DATE] with no inconstancies noted. A review of all new admits on [DATE] and [DATE] completed. 4. V7 has been removed from the facility's schedule and has not worked since the alleged deficiency. 5. All staff who have not received the above-mentioned in-service will by 11:00 PM on [DATE] or will be removed from the facility schedules until the in-servicing has been completed with a QAT (Quality Assurance Team) member. Quality Assurance Activities to assure the alleged deficient practice will not recur include: 1. In-servicing training by members of the Nurse Manager Quality Assurance Team on Advanced Directives, Cardiopulmonary Resuscitation, POLST Form, and Code Pink-Nurse Emergency Page with all staff will continue monthly for the next 3 months, then quarterly x 3 quarters. 2. DON/MDSC/SSD will complete an audit of all residents' code status orders, POLST Forms and advanced directive care plans monthly x 3 months then quarterly and PRN (as needed). 3. LNHA (Licensed Nursing Home Administrator) will enforce the interventions of plan of removal of immediacy.

Based on interview and record review the facility failed to develop a system to assess and evaluate residents for capacity to consent to sexual activity, failed to ensure two cognitively impaired residents (R1, R2) who engaged in a sexual act had the capacity to consent, and failed to prevent two cognitively impaired residents (R1, R2) who didn't have the capacity to consent, from engaging in a sexual act resulting in (R1) experiencing psychosocial harm as any reasonable person would be affected in a total sample of four resident reviewed for abuse. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4/4/24, the facility remains out of compliance at a Severity Level Two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their Inservice Training and Quality Assessment oversite. Findings include: Facility Policy Abuse Prevention Program dated 3/1/21 documents: As part of the social history evaluation and MDS (Minimum Data Set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or who have needs and behaviors that might lead to conflict. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual Abuse: Including, but not limited to, sexual harassment, sexual coercion, or sexual assault. Facility Assessment of Resident Capacity to Consent Sexual activity Policy (undated) documents: Purpose: To protect and ensure safety, health, and well-being of residents of (the Facility) who engages in sexual activity. Policy: It is the facility's policy to recognize and support each resident's right to engage in sexual activity, so long as the Facility is certain that there is consent among all parties to the sexual activity. This policy applies to all residents who are able to demonstrate consent by words and/or affirmative actions, even if the resident is non-verbal or is suffering from Dementia or some other cognitive deficit. Capacity to engage in sexual activity is defined as: I. The ability to understand information relevant to a decision to engage in sexual activity, and II. the ability to appreciate the reasonably foreseeable consequences of such a decision or lack of a decision. Capacity to consent to sexual activity has four key components: I. The ability to communicate a decision to engage in sexual activity. II. The ability to understand a decision to engage in sexual activity, consistent with an individual's values. III. The ability to appreciate the potential consequences of a decision to engage in sexual activity, including risks and benefits. IV. The ability to rationalize and reason the process utilized to reach the decision to engage in sexual activity, free from undue influence or coercion. Facility Incident Report dated 3/13/24 indicates on 3/13/24 at 1:00am V3, CNA (Certified Nurse Assistant) found R1 standing on the side of R2's bed with R1's penis in R2's mouth. Room Census Report indicates on 3/13/24 R1 and R2 were roommates at that time. Current MDS (Minimum Data Set)/BIMS (Brief Interview for Mental Status) indicate both R1 and R2 are severely cognitively impaired and unable to give consent. On 4/2/24 at 11:40am R1's spouse (V5) who visits R1 every day, stated prior to R1 becoming cognitively impaired, R1 was very cognizant of boundaries, never experimented sexually like that and he would have been devastated to have been found in that situation. V5 stated she absolutely believes R1 had no idea what he was doing or who he was doing it with. V5 stated (R1) is no longer a reasonable person, but when he was a reasonable person, this would have never happened. On 4/2/24 at 9:14am V11, R2's Family stated R2 was bisexual and would not have had any trauma related to this incident. On 4/2/24 at 3:15pm V1, Administrator stated that they concluded the investigation and found the sexual act between R1 and R2 was consensual. V1 stated that the facility does have an assessment to determine ability to consent for non-cognitive impaired residents, however it was not utilized due to R1 and R2's cognitive impairments. No assessment was completed to confirm R1 or R2's ability to consent to sexual activity was performed prior to the incident or after the incident. Consensual Sexual Relationship Agreement (undated) indicates the resident will be assessed by the professional staff to be alert, aware, coherent and capable of making decisions supporting their own choices and welfare. Agreement states residents are to be counseled regarding safe sex practices/behavior and to engage only with other residents who have decisional capacity AND consent to the relationship. On 4/2/24 at 3;21pm V12, Medical Director stated that with (BIMS) scores like that, neither R1 nor R2 would be able to consent. V12 stated R1 and R2 would not be able to understand the consequences of their actions due to their level of cognitive impairments. V12 stated the facility needs to focus on how to prevent this from happening in the future. The Immediate Jeopardy was identified to have started on (3/13/24) when R1 was found at R2's bedside with (R1's) penis in R2's mouth. . V1, Administrator was notified of the Immediate Jeopardy on 4/3/24 at 1:15pm. On 4/4/24 the surveyor confirmed through observation, interview and record review the facility took the following action to remove the immediacy. 1.Investigation of alleged abuse completed and reported to IDPH, alleged perpetrator and alleged victim's physician and resident representatives notified of alleged abuse. Investigation was initiated 3/13/24 and concluded 3/18/24. Initial Report was sent to IDPH 3/13/24 and Final Investigation Report was sent to IDPH on 3/18/24. 2. Both R1 & R2 were immediately separated by nursing staff and assessed for any signs of injury or trauma by Licensed Practical Nurse on 3/13/24. 3. Both R1 & R2 were sent to the local emergency room for evaluation on 3/13/24 and returned with no evidence of any injury or harm the same day. No new orders. 4. Both R1 & R2 were moved to two separate rooms in two separate hallways within the facility on 3/13/24. 5. The local police department was notified of the alleged incident on 3/13/2024. 6. R1 care plan has been updated to include one on one with staff times 7 days on 3/13/24 by SSD (Social Services Director). 7. R2 care plan has been updated to include Behavior Monitoring every hour x 7 days to assess for changes in mood/behavior post incident on 3/13/24 by Social Services Director. 8. R1 & R2 care plan has been updated to include 1 on 1 time with Social Services as needed to vent feelings. Facility SSD will continue to meet with R1 to assure R1 remains at baseline for mood and behavior on 3/13/24 by Social Services Director. 9. DON (Director of Nursing) and LNHA/(Licensed Nursing Home Administrator) were in-serviced on Assessment of Residents Capacity to Consent Sexual Activity Policy and Procedures by V13, Consulting Company CEO (Chief Executive Officer) on 4/3/24. 10. In-servicing by DON (Director of Nursing)/LNHA (Licensed Nursing Home Administrator) on Abuse Prevention Policy with facility staff was initiated 3/13/2024 and repeated 3/20/2024. Additional in-servicing regarding facility's abuse prevention policy will be completed by the Administrator or designee on or before 5:00 PM on 4/4/24. Any staff who has not been in-serviced on the facility's Abuse Prevention Policy by 5:00 PM on 4/4/24 will not be able to clock-in for work. 11. In-servicing training by Human Resources Director on Abuse Prevention Policy with facility staff will continue, and any remaining employees must be trained prior to reporting for work for their next scheduled shift. 12. QAT (Quality Assurance Team) members were in-serviced on Assessment of Residents Capacity to Consent Sexual Activity Policy and Procedures by the LNHA on 4/3/2024. 13. Social Service Director and Social Services Coordinator or designee will complete the Capacity to Consent Worksheet on all residents on or before 5PM 4/4/2024. 14.Social Service Director and Social Services Coordinator will complete the Capacity to Consent Worksheet on all residents going forward upon admission and quarterly. 15. In-service training by DON/LNHA on Abuse Prevention Policy with all staff will continue monthly for the next 3 months, then quarterly x 3 by the DON or Administrator. 16. LNHA will enforce the interventions of plan of removal of immediacy and assurance of continued compliance. 17. Quality Assurance (QA) Activities to ensure the alleged deficient practice will not recur include: -- QAT will review the Capacity to Consent Worksheet during quarterly QA meetings with medical director and address any concerns. -- QAT will review the Capacity to Consent Worksheet during Morning QA meetings daily x 30 days on all new admits to ensure compliance. -- QAT will review the Brief Assessment of Informed/Intimate Relationships during quarterly QA meetings with Medical Director and address any concerns. -- QAT will review the Brief Assessment of Informed/Intimate Relationships during morning QA meetings daily x 30 days on all new admits to ensure compliance. -- The facility will follow state and federal guidelines regarding Abuse Reporting by requiring reporting of all reports of abuse to be reported to the Regional Consultants and facility QA Committee for follow up and review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision during a period of increased facility visitation where visitors were exiting the facility locked unit doors, when a daily pacing, agitated, cognitively impaired resident exited the facility through the Locked Unit doors. These failures resulted in R4 not being adequately supervised and exiting from the facility, through the locked unit doors, on 2/05/23 around 1:40 P.M. R4 was last observed by staff between 12:15 P.M and 12:30 P.M. Staff did not observe R4 exiting the building and were unaware that R4 had left the facility, crossed a busy two-lane road to a gas station to purchase cigarettes. R4 was found by a passerby lying in the road, approximately two blocks from the facility, after being observed falling multiple times, next to a major four lane highway with a posted speed limit of 45 MPH. The passerby (V15) drove R4 to the local (ER) emergency room where ER staff phoned facility staff, who were unaware that R4 was missing, approximately 30 minutes later to alert them of R4's location. R4 is one of twenty five residents (R4 - R28) residing on the facility first floor locked memory care unit. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 2/09/2023, the facility remains out of compliance at a Severity Level 11 as the facility continues to educate staff on elopement policies and procedures including Wanderguards (electronic monitoring device), perform elopement drills with utilization of Code Orange, and continue monitoring of compliance with follow up as part of the facility's QAPI (Quality Assurance and Performance Improvement) program. FINDINGS INCLUDE: The (undated) facility policy, Policy and Procedure Regarding Missing Residents and Elopement documents, It is the policy of this facility that all residents are provided adequate supervision to meet each resident's nursing and personal care needs. All staff will be trained upon orientation, missing resident in-service training will be conducted at minimum annually. Random elopement drills will be conducted at a minimum every 6 months. An 'At Risk List' shall be posted at each nurses' station and at the reception area. All residents shall be assessed for behaviors that place them at risk of elopement utilizing an elopement risk assessment upon admission, quarterly, annually and upon significant change of condition. R4's facility admission Record documents that R4 was admitted to the facility on [DATE] with the following diagnoses: Disorganized Schizophrenia, Dementia and Tobacco Use. R4's Nursing Progress Notes, dated 10/19/2020 document, 2:30 P.M. (R4) arrived to facility at 2:30 P.M. by way of family vehicle. Resident alert with confusion. Noticeable involuntary hand movements. VA (Veteran's Administration) meds received in a box from family. Dark circles around his eyes unsure if there was a previous fall. Area appears to be healing. Skin dry and intact. Catheter noted on arrival. Resident was also noted with 200 cash that was immediately given to his brother that was still in the building. Brother also noted that the catheter was a new insert from the VA hospital. Resident noted with missing teeth and no dentures. Resident stated that he wears glasses but not sure where they are. Resident stated that he would like to be a DNR however not sure if he fully understands the concept. Bed placed in a low position and mats on both sides. Call light in place. Takes meds whole, general diet. R4's Wandering Risk Assessment, dated 10/19/2020 documents, (R4) is confused and may at some point exit seek, however (R4) is new to the facility and it's hard to determine that at this time. Based on the responses provided above, do you feel this resident is at risk for wandering, elopement, or getting lost. Yes: very likely to wander, elope, or get lost. No further Wandering Risk Assessments/Elopement Risk Assessments are present in R4's electronic medical record, until 5/31/22. R4's Nursing Progress Notes, dated 10/20/2020 document, Wanderguard placed on (R4's) right ankle. R4's Nursing Progress Notes, dated 4/06/2021 document, (R4) approached CNA stating that he removed his wanderguard off of his leg and flushed it down the toilet. CNA (Certified Nursing Assistant) asked resident why he removed the wanderguard and resident stated because he didn't want it. CNA told DON (Director of Nursing) and this charge nurse. This nurse called V26/ADON (Acting Director of Nursing) who states that facility is out of the wanderguards and to have staff be sure to monitor resident. R4's Nursing Progress Notes, dated 11/01/2022 document, (R4) alert with confusion, pacing hallways - bringing staff various items from room, gait unsteady at times, speech difficult to understand d/t (due to) mumbling, able to understand when spoken to and able to follow commands. Gray discoloration to face. Appears comfortable. Continent of Bowel and Bladder. Feeds self meals with no difficulties. R4's Nursing Progress Notes, dated 1/09/2023 document, (R4's) brother came to this nurse and asked if something happened with resident today. He stated that resident has called him several times wanting to leave here now. Resident has not made any complaints or accusations about anyone or anything today. I was in his room [ROOM NUMBER] minutes earlier to give him his medicine and he was lying, relaxed in bed watching TV. Brother took resident with him and stated he would call back in the morning. R4's Nursing Progress Notes, dated 1/29/2023 document, (R4) alert to self only with confusion per normal, up ad lib (as desired), pacing from room to nurses station all day shift, showing staff his possessions from his room, in good spirits, mumbles words, unable to understand what he says, took all meds well, ate all meals well, no agitation noted. R4's current Minimum Data Set Assessment, dated 12/02/2022 documents R4's Cognitive Status as 9:15 (moderate impairment) and R4's Activities of Daily Living, Ambulation as 1/1 (requires staff supervision). R4's current Physician Order Sheet, dated February 2022 includes the following physician orders, dated 1/13/2021: Wandering every shift, (R4) wanders at times; Hallucinations every shift and Clozapine (anti-psychotic) 50 MG (milligrams) by mouth in the morning, 100 MG by mouth at bedtime. On 2/06/23 at 10:15 A.M., R4 was up ambulating in the hallway from his room to the nurses' station and back. R4 appeared agitated. R4 was confused and unable to answer questions. When staff attempted to intervene and calm R4, he became increasingly agitated. Staff finally able to redirect R4 back to his room. On 2/06/23 at 10:35 A.M., V6/Licensed Practical Nurse (LPN) stated, I have been an employee here for the past sixteen years. Oftentimes, I work on this Unit. (R4) hasn't eloped before (the incident on 2/05/23), but he does wander the unit pacing and agitated. I have seen him at the Exit doors, looking outside. (R4) didn't have a wanderguard bracelet on, prior to his actual elopement yesterday, that I can remember. When (R4) returned from the ER (Emergency Room) last night, they attempted to put one on him, but he wouldn't let them. Evidently, he has one in his shirt pocket. He keeps trying to hand it to me. I'm not sure why (R4) never had a bracelet on, he should have. On 2/6/23 at 11:02 A.M., V9/R4's Guardian stated, I have been (R4's) guardian for the past fifteen years. (R4) has had schizophrenia for many, many years. I take him to all his VA appointments. Previously he had been in a VA home in Iowa. I took him out of there because he was homesick, and I attempted to take care of him at my home. That didn't work out very well, so I placed him here. I live close by, and I visit him almost every day. He is a wanderer and a pacer. He is very anxious and paces constantly, usually from one door to another. I don't know if (R4) has ever tried to get out before, but I understand why he did on Sunday (2/05/23). When (R4) started the Clozapine many years ago, they told him he couldn't smoke. Well, smoking is the only pleasure (R4) has in life. I noticed he had been getting more and more agitated, so I bought him a pack of cigarettes, gave them to the nurse and asked if they take (R4) outside once a day for one cigarette. It seems to keep (R4) calm. Well, after his escape yesterday, I found out (R4) had been without cigarettes for the past three or four days. And that's exactly what (R4) did. (R4) walked right out of this building, through the front door and walked across that busy street and bought a pack of cigarettes. Then (R4) walked up to the busiest street around here, crossed the street and some lady found (R4) laying in the street and took him to the ER. I can't believe how (R4) walked out the front door. Other patients have bracelets on that won't let them out the door, but (R4) doesn't have one. I don't know why they never put one on him. At least (R4) wouldn't have been able to get outside and almost get hit by a car. On 2/6/23 at 11:20 A.M., V2/Director of Nurses (DON) stated, I have been the director of nurses here for the past six months or so. I don't recall (R4) ever attempting to elope before. I would think (R4) is at risk for eloping. (R4) is ambulatory, has a mental illness and paces frequently. I don't know why (R4) never had an elopement bracelet on before this. Maybe because (R4) never tried to escape before. I watched the video of (R4) leaving the building. It was around 1:40 in the afternoon. (R4) walked right out the front door. There was a couple in front of (R4), then (R4), then another person behind (R4). (V11/Receptionist) didn't recognize (R4) as a resident. When we talked to (V11) later that night, (V11) said she thought (R4) looked suspicious, so (V11) followed (R4) outside. (V11) saw (R4) go across the street and then (V11) went back inside and called one of the CNAs (Certified Nursing Assistants). They said no one was missing. It wasn't until the hospital called, 30 minutes or so (later) that we figured out it was (R4). At that time, V2/DON verified no Wandering Risk Assessments/Elopement Risk Assessments for R4 were completed between 10/19/20 and 5/31/22. On 2/06/23 at 11:29 A.M., V10/Licensed Practical Nurse (LPN) stated, I am the Restorative Nurse, but I just happened to volunteer for some over time, and I was the nurse on Sunday when (R4) eloped. We didn't even know (R4) was gone, until the hospital called and asked if we were missing a resident. I was in the middle of doing a 2 PM tube feeding. (R4) is usually very anxious and kind of agitated. (R4) likes to pace a lot. I heard (R4) walked right out of the locked door, behind some visitors. I don't know where the CNAs were when (R4) left. I know I was busy with other residents. I had someone fall around 1:00 (pm) and we had a lot of visitors in the Unit that day. On 2/06/23 at 1:41 P.M., V1/Administrator stated, (R4) doesn't have a care plan for elopement. (R4) didn't fit the criteria. At that time, V1/Administrator verified the facility had not followed its policy of having elopement drills every six months nor was list of residents at risk for eloping posted at the exits and each nurse's station. V1 also verified that V11/Receptionist had not attended the last facility in-service on resident elopement. On 2/06/23 at 2:04 P.M., V15/Concerned Citizen stated, (On Sunday-2/05/23) I was driving up the hill from (south of facility) and had driven by the (facility) when I saw (R4) walking. (R4) had shoes on, pants, a tee shirt, and a button-down shirt, that was unbuttoned. It was kind of cool out and it struck me as odd, as it was breezy outside. Also, I noticed (R4's) walk. (R4) walked with his head and chest out and his body was behind. I watched (R4) 'splat' on the road a couple of times. I mean (R4) fell, (R4) fell hard. I kept thinking (R4) had to be injured. Finally, the third time (R4) fell, (R4) was up to the frontage road, getting ready to cross that busy highway. When (R4) fell the last time, (R4) just laid on the road. I was terrified (R4) was going to get ran over by a car. It was a very busy on the road, cars go speeding by and run red lights all the time. I drove up to (R4) as (R4) was laying on the ground and asked (R4) if he was hurt. (R4) got up and came over to my truck and got in. My dog was in the front seat between us. I asked (R4) if he needed help and (R4) nodded yes. (R4) told me he wanted to go to [NAME] Rock (town he lived in before his stay at the facility), but I could tell that wouldn't be a good idea. The only place I could think to take (R4) was to the ER (Emergency Room). I live over by that way. (R4) never turned to look at me. (R4) stared straight ahead. I could tell something was wrong with (R4). (R4) shook and jerked the whole time and kept mumbling to himself. At one point (R4) lit up a cigarette and I told (R4) he couldn't smoke in my truck. (R4) didn't argue, (R4) threw it out immediately. I drove up to the ER and explained I found (R4) laying in the street. They could tell something was wrong with (R4) and got (R4) out of my truck and put (R4) in a wheelchair. They asked me for my name and telephone number, and I gave it to them, then I left. I was just trying to help. On 2/08/23 at 9:20 A.M., V20/Social Services Coordinator stated, I did (R4's) assessment for elopement in December 2022. (R4) only scored a 9, so (R4) wasn't considered high risk for eloping. I didn't do an elopement care plan for (R4). I rely on the nurses to guide some of my answers. I didn't know (R4) did not accept his nursing home placement. I thought (R4) was happy to be here. On 2/08/23 at 9:25 A.M., V2/Director of Nurses (DON) stated, The elopement risk assessment is completed by Social Services quarterly. The nurses do it on admission. I don't totally agree with the way (R4's) assessment was scored on 12/02/22. I think (R4) has always been at risk for eloping. (R4) fits the criteria due to his severe mental illness, dementia, agitation, and pacing. In my opinion, (R4) is at high risk for eloping. On 2/08/23 at 3:16 P.M., V11/Receptionist stated, I have been employed here for the past twelve years as a receptionist. On Sunday (2/05/23) I worked at the front reception desk from 8 AM until 7 PM. It was a busy day. We had a lot of visitors in the building. It was around 1:30 (P.M.) or so when another resident's spouse came up to me and said he saw a man with a blue shirt and pants on, that looked kind of odd, exiting the front door and wondered if it was a resident. I only saw the back of him. I went outside and I saw a man with a blouse shirt and pants on, walking down the hill, in front of the building, getting ready to cross the street to go to the gas station. The man was walking quickly. I came back inside and called the Unit on the first floor and (V23/Certified Nursing Assistant CNA) answered the phone. I didn't think it was a resident because any resident that lives back there has an alarm bracelet on that sounds when they come through the double doors, and I hadn't heard any alarm when (R4) came through. When (V23/CNA) answered, I asked (V23) if there had been a visitor back there with a blue shirt and pants on. She told me yes, one had been in the dining room, but he was no longer there. I went back outside and told the resident's spouse that (R4) wasn't a resident. So, he left. It wasn't until the hospital called around 2:05 (P.M.) asking if we were missing a resident, that we realized there was a problem. (R4) had left the building and was in the emergency room. At that time, V11/Receptionist verified she had not attended the yearly in-service on resident elopement in August 2022. On 2/09/23 at 10:57 A.M., V23/Certified Nursing Assistant (CNA) confirmed she worked in the unit on 2/05/23. At that time, V23/CNA stated, It was a nice day outside and we had a lot of visitors in the unit that day. At one time, I saw a man in the dining room with a blue shirt and blue pants on, so when (V11) called and asked me, I told her the man had left. (R4) was his normal self that day. He always paces back and forth and gets very agitated at times. There were three of us (CNAs) on Sunday and at 1:30 in the afternoon, we were taking turns, taking a break, and assisting other residents. No one saw (R4) go through the locked doors. On 2/09/23 at 11:22 A.M., V24/CNA verified she worked the locked unit on Sunday. V24/CNA stated, It was a busy day on Sunday (2/05/23), we had a lot of visitors. I saw (R4) that day. (R4) was his usual self, pacing up and down the hallway. I didn't see (R4) go through the locked doors that afternoon. I was helping another resident, at that time. On 2/09/23 at 11:54 A.M., V 25/CNA verified she was working the unit the past Sunday (2/05/23). V25/CNA stated, I don't recall anything different with (R4) on Sunday. (R4) paces all the time. I didn't see (R4) leave through the locked doors. I can't remember exactly what I was doing at that time. R4's Emergency Department (ED) Report, dated 2/05/23 at 2:07 P.M. documents, Time seen 2:07 P.M. [AGE] year old male presents to the ED. A bystander was driving when she found the patient on the ground on the side of the road. It is unknown where he was found but she picked him up and transported him here to the ED and left her number if we have further questions. Patient is oriented X (times) 1 and states he has fallen a couple of times and has scrapes and bruises. Patient is a resident at (facility) memory care unit. (Facility) was called and confirmed. It is unknown when they (facility) last saw him today. Health Status: Skin: Abrasion of left knee, ecchymosis of right thigh. Disposition: Medically cleared. (V2/Director of Nurses) called and states the last time they saw (R4) was around 1:50 P.M. R4's Nursing Progress Notes, dated 2/05/23 at 9:20 P.M. document, (R4) returned to this facility via medics, brother accompanied (R4) via private vehicle. (R4) agitated upon arrival. Medications given. Per brother's request a shower was given with skin checks completed. Three 1 CM (centimeter) circular red areas on top of right knee noted. 2 X 1 circular abrasion noted to right hip. The Immediate Jeopardy was identified to have begun on 2/05/23 when R4 exited the facility through the Locked Unit doors, walked across the street to buy cigarettes, and was found lying at the side of the road approximately two blocks from the facility, after being observed falling multiple times, next to a major four lane highway with a posted speed limit of 45 MPH. V1/Administrator and V2/Director of Nurses were notified of the Immediate Jeopardy on 2/09/23 at 3:45 P.M. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R4 was reassessed for elopement risk by the Charge Nurse on 2/05/2023. On 2/05/2023, Wanderguard placed on resident with resident being non-compliant. Wanderguard placement compliance occurred on 2/07/2023 per physician's order. Social Service Coordinator updated care plan on 2/06/2023 related to elopement on 2/05/2023. 2. On 2/05/2023 - 2/06/2023, Social Services and nursing management team re-assessed all current residents for elopement risk All residents who have cognitive impairment with behaviors of agitation and pacing were reviewed for elopement risk. Residents who meet criteria will be assessed by the IDT based on such assessments, the team will determine the appropriateness for the placement of a wanderguard with MD (Medical Doctor) orders. Additionally, all residents identified as high risk for elopement were immediately assessed by V26/ADON and social services for interventions to address their high risk for wandering to include placement of wanderguards and care plan updates related to elopement. List of residents at risk for elopement is posted at the reception area and all nurses station and will be updated by social services team. Residents will be assessed for elopement risk on admission, readmission, quarterly and with significant change. Missing person drills were conducted on all 3 shifts initiated on by Administrator/designee on 2/06/23 through 2/08/23 and will be conducted quarterly by Administrator/Designee. Administrator/designee will ensure that the facility utilizes Code Orange in the event of a missing person and follow its policy. 3. Administrator immediately educated receptionist to include validation of people leaving the facility on 2/05/2023. HR (Human Resource) Director/designee educated all remaining receptionists on 2/06/2023 and 2/07/2023. On 2/05/2023, Administrator immediately initiated education on missing person policy and to utilize Code Orange in event of a missing person and to follow missing policy procedure when there is concern for a missing person. Staff were educated to recognize residents at risk for elopement and interventions needed for high-risk residents. On 2/08/2023, Administrator initiated staff education to monitor the locked exit doors during periods of increased facility visitation. 4. On 2/09/2023 the Administrator educated Social Services team on identifying residents with cognitive impairment with behaviors of agitation and pacing. Monitoring for compliance related to this will be conducted by the Social Services Director or designee with oversight from the Administrator 7 days weekly. This monitoring will be done X 4 weeks. It will include various shifts as well as some weekend days. Afterwards, this monitoring will continue 3 days weekly for a period of not less than 6 months to ensure ongoing compliance. After that, random monitoring will occur ongoing. Any concerns will be addressed and if found the resident will be placed on the High Risk for Wandering List with the Interdisciplinary Team evaluating the resident(s) for a wanderguard bracelet. 5. On 2/05/2023, Administrator/designee began education of all staff on Missing person policy- to include prevention of missing residents and procedure for the response to missing person. Staff who were not present for the initial in-service and agency staff are required to be educated prior to beginning of their next scheduled shift at the facility. 6. On 2/09/2023, the Administrator/DON/Designee initiated all staff education to review residents with cognitive impairment with behaviors of agitation and pacing for elopement risk. Staff who were not present for the initial in-service and agency staff are required to be educated prior to the beginning of their next scheduled shift at the facility. 7. HR Director/designee will ensure that staff will be trained on missing person policy upon hire, quarterly and annually. This was initiated by HR/designee on 2/06/23 and is ongoing for all new staff upon orientation. 8. On 2/08/2023, Administrator/designee began education to all staff regarding monitoring the locked exit doors during increased numbers of visitors. Staff who were not present for the initial in-service and agency staff are required to be educated prior to the beginning of the next scheduled shift at the facility. 9. On 2/06/2023, social services ensured that an updated list of residents at risk for elopement was posted at the reception area and at every nurses' station. 10. On 2/09/2023, Regional Director of Operations in-serviced administrator on the risks, severity, and prevention of elopement for facility residents. 11. All monitoring done by facility staff as well as by Regional Team staff (RDO/RNC) will be presented to the QAPI Committee at their weekly meetings. Any concerns will have been addressed. However, any patterns will be identified. If indicated, an Action Plan will be written by the QAPI Committee. Any Action Plan will be monitored weekly by the Administrator until resolved. 12. A member of the Regional Team, (RDO/RNC), will attend the QAPI meetings either in person or remotely for a period of not less than 3 months to serve as additional oversight, reference, and support. Note: When the facility is placed back into substantial compliance, QAPI meetings will go to monthly.