**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that R10 was free from physical, mental, and emotional abuse from an agency staff, V15 (CNA/Certified Nurse Assistant). The facility also failed to implement its policy to keep R10 free from further abuse. This failure resulted in Immediate Jeopardy on 11/5/2023 at 9:00 A.M., when R10 had sustained physical, emotional harm and mental distress from abusive care provided by V15. The facility also failed to implement their abuse policy by not reporting and investigating V15's inappropriate behavior such as yanking resident's bed rail, abrupt with care, ignoring call lights, that had occurred on 11/1/2023, and this had led to physical abuse on 11/5/2023 when V15 jerked R10's arm. The facility also failed to protect other residents from potential abuse when V15 was not suspended from work after the incident with R10. V1 (Administrator), V2 (Director of Nursing) and V28 (Vice President of Operations) were notified of the immediate jeopardy on 11/27/2023 12:15 P.M. The surveyor confirmed by observation, interview, and record review that immediate jeopardy was removed on 11/29/2023 at 12:40 P.M., but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. This applies to one of three residents (R10) reviewed for injuries of unknown origin and abuse. The findings include: The EMR (Electronic Medical Record) showed that R10, an [AGE] year-old, was admitted to the facility on [DATE]. R10's diagnoses included but not limited to atrial fibrillation, thrombocytopenia, S/P (status post) CABG (coronary artery bypass graft), history of DVT (deep vein thrombosis), iron deficiency anemia, myocardial infarction, obsessive-compulsive disorder, CAD (coronary artery disease), anxiety and depression. The MDS (Minimum Data Set) dated 9/21/2023 showed that R10 was moderately impaired in cognition with BIMS (Brief Interview Mental Status) and score of 12/15. R10's functional status showed she required one-person physical assistance with ADLs (Activities of Daily Living). The MDS showed that R10 was not delusional, no psychosis, no negative behavior and was not rejecting care. The care plan dated 9/21/2023 showed that R10 had no negative behavior such as being hostile, aggressive and or combative. The progress notes dated 11/7/2023 at 6:00 P.M. documents Bruising noted to left inner forearm from base of wrist to elbow and on left bicep area. Head to toe assessment done .Family member made aware (R1's MD) made aware. Order given to obtain x-ray to left arm and PT/INR in morning 11/8/23. Review further of the progress notes showed that last documentation of the progress notes before 11/7/2023 was 11/2/2023. The documentation for 11/2/2023 was related to medication order. The EMR/progress notes showed that there was no documentation regarding the bruise not until 11/7/2023. The facility's incident report dated 11/7/2023 at 4:57 P.M. showed there was an allegation of resident abuse that occurred 11/5/2023. The resident referred to was R10 and V15 (CNA/Certified Nurse Assistant) as the perpetuator. The incident report showed that on a 11/7/2023 at around 4:00 P.M., V25 (Transportation Coordinator/Unit Clerk) reported that R10 had stated that (V15) was rough during patient care. On 11/8/2023 at 10:30 A.M., together with V2 (Director of Nursing), R10 was observed and interviewed. R10 was alert and oriented and had responded to questions coherently. R10 was aware of time, name and place and current events. R10 showed her left arm. R10's left forearm was observed with a bruise that extended from her wrist to the elbow, the bruise was irregular in shape, the color was dark purple/blue. There was no other visible bruise noted on R10's extremities. R10 said this bruise was caused by rough handling from (V15, CNA from staffing agency), I was pulled from my left arm by (V15) with force on 11/5/2023 around 9:00 A.M. I thought (V15) was not to take care of me because of an incident that occurred on 11/1/2023 when (V15) took care of me during the evening shift. (V15) had a nasty attitude, very abrupt when she talked, no respect, and she broke and yanked my bed rail. R10 pointed her bed's left upper rail that was tied with a rope. R10 said I told everyone (staff) I don't remember each of their names but told (V19/nurse) since he runs the ship regarding (V15) not to return to facility anymore because she had handled me roughly, with nasty attitude, and (V15) even said she doesn't care, she can be assigned anywhere because she is from staffing agency. R10 continued to state that on 11/5/2023, (V15) came in early morning, with nasty attitude like she does not want to be at work, verbally abrupt when questions were asked, or she does not answer at all, and will not listen to my request that I wear a blue color brief and not yellow and (V15) insisted on putting the yellow brief. I am scared of her (V15) and I do not want her to take care of me. R10 said she called V20 (Receptionist on Duty) in the morning of 11/5/2023 that V15 should not be assigned to her because V15 was rough handling her and R10 might get hurt. However, R10 said that she was told by V20 that she will inform V21 (RN/MOD/Manager of the Day) when she comes in that day. R10 continued to state that (V15) pulled my left arm with force when she was getting me out of bed, I felt the pain, then few hours later, I saw this big bruise on my left forearm. (V21) came in around 9:30 A.M. and she acted like she was a MEDIATOR and advised me to say PLEASE when asking for care. (V15) continued to give me care, and other residents (R4, R6, R14) and they saw me how upset I was because they also complained how (V15) treated them. I know (V15) did hurt me intentionally because she jerked my arm. On 11/8/2023 at 2:00 P.M., R10 was sitting in the activity department and was interviewed again about the incident involving V15. R10 repeated the same account of events as stated during the earlier interview. During this time of interview, V23 (Police Officer) came in and said he had to ask R10 for few more questions. R10 had agreed. V23 said he saw R10 the day before (11/7/2023) for initial investigation of physical abuse by V15. V23 and R10 gave permission for the surveyor to stay during V23's interview. R10 was consistent with her statement stating that V15 had rough handled her during care in the morning of 11/5/2023. After the interview, R10 was assisted back by a staff to the activity department and R10 was seen sobbing, tears flowing down her cheeks, was shaking, and said, I am scared of (V15) she might come back again, and I do not want other residents to go through what I have been through with her (V15). During this time R10 was noted to be shaken and other residents came to comfort her. R12 was holding R10's hands continuously consoling her, R8, R13 and R14 also tried to console R10. V2 then removed R10 from activity room and once again, R10 stated, I want to make sure (V15) she will not take care of me again. R10 was noted to keep asking V2 who would take care of her and that she did not want V15 to provide care since she was afraid of V15. The following residents were assigned to V15 on 11/5/2023 during the day shift. They were interviewed on 11/8/2023 from 11:00 A.M. to 2:30 P.M. at an intermittent time: R14 said I filed a grievance on 11/5/2023 regarding (V15's) that she has bad attitude causing us mental and emotional distress, but up to now, I have not heard from the management. (V15) told me on 11/5/2023 I am not your CNA, I cannot take care of you, you are so fat. R14 also said that she needs help with transfers and uses a mechanical transfer lift device. R14 also said that she was incontinent of bladder function and that V15 refused to change her incontinence brief and that R14 wore the soaked brief at least 5-6 hours. R4 said she requested V15 to pick up condiments that was dropped off from her lunch tray on 11/5/2023. R4 said that V15 responded I am not your C.N.A. R4 said (V15) then left the room and does not care at all. On 11/8/2023 at 4:52 P.M., V20 (Receptionist) said that on 11/5/2023 at around 9:00 A.M., R10 called her via phone and informed that V15 was rough handling her. V20 also said that she that she could tell from R10's voice that R10 was upset. V20 added that R10 was crying and stating that V15 was rough with her and had a nasty attitude. V20 said she told R10 that she will inform V21 as soon as she arrives at the facility since V21 was the assigned MOD (manager on duty) for the day. On 11/8/2023 at 4:30 P.M., V21 (RN/Registered Nurse) said that when she arrived at the facility on 11/5/2023 at around 9:30 A.M., she was informed by V20 that R10 was upset due to V15 being rough with care and with a bad attitude. V21 said she went to R10's room around 9:45 A.M. V20 said she saw R10 lying in bed, and V15 pulling up R10's pants. V21 said I can tell that there was an argument between the two, I saw R10 crying and visibly upset. I helped (V15) get (R10) up and stayed with (R10) for a while since she was crying. Surveyor asked V21 what the argument was, and the reason of R10 being upset and crying. Surveyor also asked if it makes sense for V15 to pull up R10's pants if V15 can do it while R10 was standing up. V21 had no explanation or answer what the argument was and why R10 was upset. V21 said she did not remove V15 from work and V15 continued to work until the end of the shift (10:00PM). V21 also said she did not report this incident to the administrator, nor had she initiated an investigation for potential abuse. On 11/8/2023 at 3:45 P.M., V19 (Nurse) said R10 had informed him regarding V15 that she has a nasty attitude and that V15 broke R10's bed rail on 11/1/2023. V19 added that he saw the bed rail on the floor and was detached from R10's bed on 11/1/2023 evening shift. V19 also said that he also worked on 11/5/2023 and that V15 had ignored residents' call lights and will not answer for 35 minutes. V19 showed to surveyor a monitor screen that showed V15 had not responded to residents' call light for 35 minutes. V19 said that V15 had bad attitude, abrupt, not motivated to work. V19 added that she had texted V16 (staffing scheduler) on 11/5/2023 for V15 not to return to facility since V15 was from staffing agency. On 11/11/2023 at 8:30 A.M., V16 (staffing scheduler) had validated that V15 had worked double shift (6:00 A.M. through 10:00 P.M.) on 11/5/2023. V16 also confirmed that V15 took care of R10 on 11/1/2023 for the evening shift and morning shift on 11/5/2023. On 11/8/2023, at 3:00 P.M., V1 (Administrator) said she was only informed regarding alleged physical abuse by V15 towards R10 by V25 (Transportation Coordinator) on 11/7/2023 at 4:00 P.M. On 11/27/2023 at 10:30 A.M., V20 was asked again regarding the phone call that she had received from R10 on 11/5/2023 in the morning. V20 had verbalized the same statement when first interviewed on 11/8/2023. V20 said R10 called around 9:00 A.M. on 11/5/2023, and that R10 said she does not want V15 to take care of her because V15 was rude, and rough when handling R10. V15 also said that R10 was crying and upset. V20 said she told R10 that she will inform V21 as soon as she arrives at the facility. V20 said that she had reported this to V21 as soon as V21 arrived at the facility around 9:30 A.M. V20 added that she had not received abuse training provided by the facility when asked on 11/28/2023. On 11/27/2023 at 2:35 P.M., V21 was again interviewed. V21 had said that V15 has bad attitude/loud talking to residents and that she had reported this to V2 on 11/8/2023. When asked to verify the date, since facility had in initiated the abuse allegation investigation on 11/7/2023 due to a report made by V25 to V1, V21 responded oh, I must have reported on 11/5/2023 to (V2). On 11/27/2023 at 3:00 P.M., V1 and V2 were asked about V21's statement that she had reported to V2 regarding V15's bad attitude/loud talking to residents. V1 answered that (V2) would have reported to me immediately if (V21) had reported this to him (V2). V2 said that V21 had never mentioned anything regarding V15's inappropriate behavior, bad attitude /loud talking to residents. V2 added that he would have reported this to V1 immediately if V21 had informed him. V1 said she only found out the abuse allegation by R10 towards V15 when V25 had reported to her on 11/7/2023. On 11/27/2023 at 11:30 A.M., V25 (Unit Secretary/Transportation Clerk) said that on 11/7/2023 around 4:00 P.M., R10 had informed her that on 11/5/2023 during the morning care, V15 had roughly handled her, grabbed her left arm with force that had caused a huge bruise from the wrist all around the elbow. V25 said she immediately informed nurse supervisor and they both informed V1 on 11/7/2023 at around 4:00 P.M. regarding the allegation of physical abuse by V15 towards R10. On 11/27/2023 from 4:30 P.M. to 5:30 P.M., at an intermittent time, the following residents were interviewed again. V2 was present during the interview except with R8: R14, lying in bed in her room. R14 said I remember you; you are the investigator from the state. I tell you, other staff here are nice, but no way in H*LL that (V15) should come back here nor work in a facility where residents are subjected to abuse. (V15's) licensed to work in a nursing home should be removed, she has a nasty behavior, does not provide care, ignore our needs, have to wait 5-6 hours before our brief be changed, told me to find another nurse or CNA to care for me because I am F*T. (V15) gave me so much aggravation that she is a bully to us, she does whatever she wants and does not listen to our needs. I don't want her here and I hope she goes to jail. R4, sitting in her chair in her room. R4 said that V15 ignored their needs, she waited prolong hours for her meal and when it was given to her, the food was cold. R4 also said that (V15) does her own thing, and she does not care to attend to our needs because she said she works from agency, and she can go anywhere. R8, requested that V2 not present during the interview. R8 said that (V15) was no good, bad attitude, and intimidating. I am a big man, but she was also a big woman, and with her bad attitude she was a bully. The way she (V15) talks to us, and her approach was bad. The staff knows how she was (V15), but she came back and had worked again here. R10, sitting in her wheelchair in her room. R10 said she remember the surveyor. R10 said so many people were asking me about this abuse, I am already overwhelmed with questions. The main issue here was that (V15) had jerked my arm, grabbed me roughly (pointed her left arm), and she should have not come back here when she did this to me Sunday (11/5/2023). (V15) was here before that (Wednesday) and broke by bed rail. I told the staff, showed to (V19/Nurse) that my bed rail on the floor because (V15) broke it. I was seen by a shrink because of this but was not seen by the social worker. On 11/29/2023 at 10:30 A.M., R10 was in her room. R10 was sitting in her wheelchair. R10 said her left arm was still sore from being jerked and grabbed by (V15). She should be in jail; I would like to pursue criminal charges against her (V15). Review of the police report dated 11/7/2023 showed that V15 was charged for aggravated battery and warrant of detention was processed. The facility's abuse policy dated 7/14/2023 showed It is the facility's policy to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and through investigations of allegations Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm maybe considered abuse. Types of abuse: 1. Physical 2. Verbal 3. Mental 9. Injury of unknown origin Prevention of abuse: Identify, correct, and intervene in situations in which abuse, neglect .is more likely to occur .Establish a safe environment Supervision of staff to identify inappropriate behaviors, such as derogatory language, rough handling, ignoring residents while giving care .Employee accused must be suspended pending investigation . Reporting . must be reported to the administrator immediately . The Immediate Jeopardy that began on 11/5/2023 at 9:00 A.M. was removed on 11/29/2023 at 12:40 P.M. when the facility took the following actions to remove the immediacy: 1) R10 remains in the facility in stable condition. 2) R10 was seen by a psychotherapist on 11/9/23, and wellness checks by the social services department have been ongoing from 11/9/23 and will continue 3x/week for 30 days. 3) V15 agency CNA was removed and placed on the do not return list on 11/7/23 and has not returned to the facility since. 4) On 11/27/23, Administrator notified [NAME] Agency that V15 was asked not to return due to an abuse allegation that IDPH has substantiated. 5) V15's background check was obtained from [NAME] agency and is clear. 6) On 11/27/23, the facility re-opened the abuse allegation related to R10 due to new information available. This investigation is ongoing and will be concluded in five business days. 7) All new agency staff will be provided onboarding training (facilities policies and procedures including Abuse) prior to the start of their shift by the DON or designee. Any new agency staff scheduled to start on off hours (weekend or night shift), the nurse in charge at the time will provide the onboarding training. Compliance will be audited 3x/week for the first month and reviewed weekly for compliance and a plan will be reviewed and discussed until compliance. 8) The facility has contracts with agencies, and it is the agency's responsibility to conduct background checks in accordance with the Illinois regulations. The facility will make every effort to obtain a copy of the background checks for agency employees prior to the start of their shift, if the facility is unable to obtain the background check prior to the start of the shift, then the facility will obtain the background check at its earliest possible time. 9) Staff were re-educated on the facility Abuse and Neglect policy by the Administrator and/or designee on 11/15/23. This re-education will continue and be completed by 11/28/23. Return demonstration of understanding provided by way conducting an audit questionnaire. Re-education emphasis on identifying staff behaviors such as being rude & rough during care AND reporting abuse immediately to the Administrator. if any resident would present signs of crying, anxiety and any form of mental distress, to provide comfort and re-assurance and to immediately report it to Abuse coordinator. Staff will be re-educated prior to their next shift. Agency staff will be re-educated prior to start of their shifts also by the DON (Director of Nursing) or designee. Compliance will be audited 3x/week for the first month and reviewed weekly for compliance and a plan will be reviewed and discussed until compliance. 10) Facility will request abuse training proof showing that agency staff have been educated on the facility's abuse policy and procedure. The facility abuse education materials will be sent to the contracted agencies. This will start on 11/28/23 and anticipated completion is 11/28/23. 11) Residents who are alert and oriented were also re-educated on the facility's abuse policy and procedures and provided reassurance of their safety, and comfort to be able to verbalize any abuse related concerns to staff immediately on 11/27/23, this is ongoing and will be completed by 11/27/23. 12) All residents that V15 took care from 11-1-23 to 11-7-23, an audit will be conducted to ensure abuse did not occur with anyone else. This was completed on 11/27/23 and there were no reports of abuse. 13) Quality assurance audit will be conducted daily by the Administrator and/or designee to ensure staff are identifying any abuse and reporting it timely. This will start on 11/27/23 and continue for the first month. All identified trends will be reviewed by the monthly QAPI committee, and a plan will be discussed and implemented until resolution. 14) The incident and abatement plan will be discussed and reviewed with the facility medical director on 11/28/23 at 3pm. 15) Emergency QAPI meeting was conducted on 11/27/23 at 4:45pm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to supervise residents with wandering and elopement risks. The facility also failed to provide adequate supervision to prevent elopement from the facility. The facility failed to ensure all facility's exit door alarm systems (9 exit doors) were maintained in functioning order to alert staff and able to respond to residents exiting the facility. The facility also failed to follow its elopement policy by not determining the cause of the triggered alarms, failing to monitor safety alarm systems to ensure they function, and assessing residents for risk of elopement behavior. This failure resulted in Immediate Jeopardy when R1 and R2 had eloped from the facility without being witnessed by facility staff on 4/11/2023 at 4:30 P.M. This applies to 6 of 6 residents (R1, R2, R3, R4, R5, R6) reviewed for supervision/elopement risk in the sample of 19. The Immediate Jeopardy began on 4/11/2023 at 4:30 P.M., when R1 and R2 eloped from the facility. R1 and R2, a husband and wife, both confused, with diagnoses of dementia, were wandering and unsupervised along well-traveled community roads when found by police officers due to a call from a concern citizen. R1 and R2 were a mile away from the facility when they were found. R1 and R2 were outside on a 4 lane well-traveled road with major intersections. This road included a hospital on one side of the road and a school on the opposite side and R1 and R2 also passed through roads that were elevated and hilly areas, with no walkways between pedestrians and vehicles. The police report shows that R1 and R2 were unsupervised and away from the facility caretakers for a period of approximately 90 minutes. The facility failed to report R1 and R2 were missing to the police department. The police determined which facility R1 and R2 resided. The clinical record dated 4/11/2023 shows that R1 and R2 was last seen by facility staff at 4:30 P.M., overhead paged for CODE YELLOW ALERT (missing residents) at 5:45 P.M. and police officer called facility at 6:25 P.M. to informed them they found R1 and R2. This was a two-hour duration that R1 and R2 was without supervision from staff. R1 refused to go back to the facility, hence, was taken to the hospital, but later was returned to the facility. R2 was picked from the location where she was found by a facility staff and returned to the facility at 7:30 P.M. The Immediate Jeopardy was identified on 4/17/2023. V1 (Administrator) was notified of the immediate jeopardy on 4/17/2023 at 11:24 A.M. The surveyor confirmed by observation, interview, and record review that the immediate jeopardy was removed on 4/18/2023 at 11:49 A.M., but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan, including in-service training of staff on elopement drills and door alarm response, panel system of alarm exit doors replaced, and monitoring safety alarm device be in functioning order, to ensure that a resident wearing this device can be detected when enters the perimeter of the exit alarm exit door. The findings include: R1, an [AGE] year-old with diagnoses of dementia with behavioral symptoms, encephalopathy, cognitive communication deficit, PTSD (post-traumatic stress syndrome), paranoid personality disorder, altered mental status, anxiety disorder, depression, CKD (chronic kidney disease), gout, unsteadiness of feet, and lack of coordination. R1 was admitted to the facility on [DATE] from hospital admission on [DATE] due to aggressive, belligerent behavior, confusion and change in mental status. The MDS (Minimum Data Set) dated 3/9/2023 shows R1's BIMS (Brief Interview Mental Status) score of 3/15 (severely impaired); with moods of feeling down, trouble falling asleep, feeling tired, poor appetite that were exhibited in 12 out of 14 days duration. R1 was also assessed with poor balance when moving around from surface to surface, transfers, and walking. R1's primary locomotion was a wheelchair. The EMR (Electronic Medical Record) of R1 have multiple physician progress notes that show the following: -3/13/2023; R1's dementia is getting worse -3/15/2023; R1 with aggressive behavior; will need Long Term Care Memory Care Unit. -3/15/2023; R1 was looking for papers to take to the bank -3/17/2023. R1's initial psychiatric visit in the facility: HISTORY OF PRESENT ILLNESS: (R1) is an [AGE] year-old male, with past medical history of: HTN (hypertension), HLD (hyperlipidemia), Gout, Colon Cancer s/p Colon Resection, CKD3, mild Dementia, Depression, left hip fracture with repair 9/2022, who present to (hospital) on 2/23/23 from PCP (primary care physician) office with confusion. (R1) was initially sent to ED (Emergency Department), due to altered mental status. (R1) was transferred to another hospital for further evaluation. (R1) was very belligerent and uncooperative, requiring Haldol (antipsychotic medication to treat schizophrenia and help rebalances and improve thinking, mood and behavior). (R1) was seen by Psychiatry and was diagnosed with dementia with behavioral disturbance. (R1) was started on Depakote, Risperdal, Trazodone, Donepezil (antipsychotic/mood stabilizers medications) -3/27/2023: R1 with aggressive behavior -4/3/2023: There were 2 notes on same day that R1 continues to ask to go home -4/6/2023; R1 was fixated going home -4/7/2023; R1 needed a secured unit due to dementia -4/10/2023; Further notes showing that R1 was fixated going home Review of R1's elopement risk assessment log shows that comprehensive elopement assessment was not done until R1 had eloped on 4/11/2023. Despite of the multiple notes from physician provider that R1 was fixated of going home with worsening dementia, the facility failed to assess R1 and provide preventative measure to prevent elopement. The care plan also shows that it was only on 4/13/2023 that interventions which included a monitoring alarm safety device to be applied, which obviously will not work since the facility was not equipped with detecting this monitoring alarm device. The EMR shows that R2, an [AGE] year-old female, wife of R1, was originally admitted to the facility on [DATE]. R2's diagnoses included but not limited to Alzheimer's disease, worsening dementia, anxiety disorder, major depressive disorder, lack of coordination, abnormality of gait and mobility, unsteadiness of feet, bilateral hearing loss, malignant neoplasm of breast, and gastrointestinal bleed. R2 was sent out to the hospital and was admitted from 3/22-27/2023. R2 returned to the facility on 3/27/2023. The MDS dated [DATE]; 3/17/2023; and 3/29/2023 shows that R2's BIMS (Brief Interview Mental Status) score of 5/15 (severely impaired); with moods of feeling down, trouble falling asleep, feeling tired, poor appetite that were exhibited in 12 out of 14 days duration. R2 was also assessed with poor balance when moving around from surface to surface, transfers, and walking. R2 was ambulatory and does not use assistive devices for ambulation. R2 was assessed requiring assistance from staff for her ADLs (Activities of Daily Living). The EMR of R2 have multiple physician progress notes that show the following: -3/5/2023; R2's insight was poor -3/14/2023; wander guard (monitoring alarm safety device ) -3/15/2023: needs memory care unit -3/30/2023: (R2) wants to go home with [NAME] (R1, the husband) -4/3/2023: (R2's) dementia is getting worse; has extreme short memory loss, need memory care unit placement, is Elopement Risk -3/27/2023: has order for monitoring alarm safety device received by V10 (RN). The assessment log from 3/9/2023 through 4/13/2023 shows that Elopement Risk was not done until 4/11/2023 after R2 had eloped. The care plan dated 3/10/2023 shows that R2 was to be applied a monitoring safety alarm device on 3/27/2023. The order was obtained by V10 (RN/Nurse). There was no documentation that the device was applied, monitored, or checked whether the exit door can detect the alarm device if R2 passes by. When interviewed on 4/14/2023 at 1:48 P.M., V10 said he does not remember if R2 wears the device nor had check if it was applied. The incidental progress note report dated 4/11/2023 shows at about 1630 (R1 and R2) not being seen in the facility, resulted in massive searching, in the building and around. patient was later found by the police and taken to the hospital for assessment. The social service notes dated 4/11/2023 shows that (R1 and R2) was last seen by facility staff at 4:30 P.M., overhead paged for CODE YELLOW ALERT (missing residents) at 5:45 P.M. and police officer called facility at 6:25 P.M. to informed them they found (R1 and R2). On 4/13/2023 at 10:45 A.M. R1 and R2 were observed in their room. R1 was sitting in his wheelchair. When asked his name, R1 did not response. R1 was asked what his current location was, R1 responded with a loud voice HELL! R1 continued to yell saying he was on his way TO HELL when he left the placed with his wife (R2). For the meantime, R2 was telling R1 to shut up, this lady is trying to help us. R2, knows her name, but does not know her location, time and no idea of the staff around her. When R2 was asked why they left the faciity on 4/11/2023, R2 had no response and have a confuse look on her face what the surveyor was talking about. On 4/13/2023 at 11:00 A.M. V2 (Director of Nursing) showed to surveyor the exit door where R1 and R2 had exited. The exit door was called Southwest (SW) Exit door. This exit door was about 15 feet away from the SW nurses' station. There was also a wall that faces the exit door and was blocking the visibility whoever is entering or exiting the SW exit door. It is only through an alarm system to alert staff and detect anyone opening this exit door. The 300 residents' hallway connects vertically to the SW nurses' station and 200 hallway connects perpendicular to same nurse's station. The panel for the alarm system was located attached to the wall in the SW nurse' station. The panel for the alarm system was to help identify which exit door the alarm was triggered. During this observation, V2 had open the SW exit door, and alarm was triggered. There was no staff who came to check for the panel system nor check the SW exit door. Furthermore, the alarm sound was not audible to 200 and 300 hallways. These are the hallways that are of proximity to the SW exit door. After V2 had turned off the alarm, V6 (LPN/License Practical Nurse) came to the SW nurse' station. V6 said that the SW exit door alarm was not audible and if you are next to the SW exit door, you are lucky to hear that faint alarm. The alarm sound is also confusing because it sounded like an oxygen being administered or a gastric tube pump that was beeping. V6 said that she had worked around 300 hallway when R1 and R2 had eloped, but she did not hear the alarm sound. Together with V2, staff that had worked on 4/11/2023 when R1 and R2 had eloped were identified. Interviews were held with these staff on 4/14/2023 and 4/15/2023. -at 1:48 P.M, V10 (Registered Nurse/RN) said he was assigned to R1 and R2 the evening shift of 4/11/2023. V10 said he saw R1 and R2 wandering around the hallways of all units of the facility with R2, pushing R1 in a wheelchair. V10 said that he was not aware of their elopement risk. V10 said he was not aware that R2 wears a monitoring safety device and nor had checked if she has one. V10 said that he last saw them around 4:00 P.M. when he was passing medications. -at 2:08 P.M., V11(CNA/Certified Nurse Assistant) said that she was the assigned CNA for both R1 and R2 on 4/11/2023 for the evening shift. V11 said that she saw them wandering around all units of the facility. V11 said that she found out they were missing when R1 and R2's dinner trays were left in the dinner cart after she passed trays for her assigned residents. V11 said she then started to look and asked other staff if they saw R1 and R2 since she cannot find them. V11 said that this was 5:00 P.M. when she was done passing dinner trays and realized that R1 and R2 were nowhere to be found. V11 said she did not hear an alarm from any exit door. V11 also said that she did not know that R2 wears the monitoring safety device nor had checked R2 is she wears one. V11 said she did not know that R1 and R2 were elopement risk. V11 said that she last saw them at 4:00 P.M. on 4/11/2023. Interviews continued with other staff that worked at time of R1 and R2's elopement. They were V7 (LPN), V8 (RN), V9 (LPN), V12 (CNA), V13 (CNA), V14 (CNA), V15 (CNA), V16 (CNA), V17 (CNA), V18 (Receptionist), V19 (RN Supervisor), and V20 (Activity Director). All of them said that both R1 and R2 wanders around all the units, don't keep tract of their whereabouts, not knowing the time they left the facility and they do not know what time they last saw R1 and R2 the evening of 4/11/2023. Furthermore, they also said they did not hear the alarm sound off from any of the exit door nor had heard the alarm from R2's monitoring safety alarm device. There were 16 staff that were interviewed who worked the evening of 4/11/2023. They all said they did not hear any alarm that sounded off. Except one staff V7 (LPN) who said he heard a faint alarm when he was inside room [ROOM NUMBER] (300 hallway). V7 said that he came out of room [ROOM NUMBER] and a faint alarm sound was coming from the SW exit door. V7, said he started to walk towards the middle of hallway approaching the SW nurse's station and SW exit door. V7 continued to state that when he reached the middle of the hallway (room [ROOM NUMBER]), the alarm sound had stopped. V7 said from where he was at, he can view the SW nurse station where the panel was located. However, V7 said he did see who turned off the alarm from the panel system. V7 also said he did not attempt to find out who turned off the alarm, nor find out what caused the SW exit door alarm to be triggered. V7 said someone must have turned off the alarm from the panel system, otherwise the alarm will not shut off by itself, but when I'm on the middle of the hallway (room [ROOM NUMBER]), all of a sudden, the alarm had stopped, so someone had turned the alarm off. V7 also said that he did not check the SW exit door. V7 said he did not check the vicinity of the SW exit door to see possible elopement of resident(s). After the interview with V7, V2 accompanied the surveyor on 4/14/2023 at 2:45 P.M. and checked the distance and visibility between the location of where V7 was (room [ROOM NUMBER], 312), the panel system for alarm, SW nurse station and SW exit door. It shows that room [ROOM NUMBER] was the same hallway that extends all the way to the panel alarm system, which was approximately 15 feet away from the SW exit door. V2 asked V3 (Director of Maintenance) to measure the distance of these locations. The distance of room [ROOM NUMBER] to the SW nurse' station was 175 feet; from room [ROOM NUMBER] to the SW nurse' station was 115 feet. V2 stated that it was impossible for V7 not to see the individual that had turned off the alarm since it was of visible view where V7's location was. V2 said that nevertheless it was still expected that V7 should have checked the SW exit door and determine what cause the alarm to trigger. V2 also said that it was also expected that V7 should have check the vicinity around the exit door for possible elopement of resident(s). On 4/13/2023 at 1:20 P.M., V1 (Administrator), V2, V3 have all said that someone must had turned off the alarm without checking what had caused the alarm to trigger and failed to check if any residents had eloped. If someone had checked, (R1 and R2) would have been seen immediately after they exited the door. V1 said this is a serious matter and I do not get a straight answer from the staff. The alarm will not shut off by itself, it must be manually shut off from the panel system in the SW nurse's station to stop the alarm. V3 said if they did what they (staff) were supposed to do and check, this would have not happened that (R1 and R2) eloped. On 4/13/2023, at 1:40 P.M., V5 (Technician from an online communication company contracted by the facility) was interviewed with V2 and V3 present. V5 said the alarm system in the facility is old, not capable to alert/send signal to the staff when the alarm sound off. The staff might hear if near to the exit door that was triggered, but if the staff is far beyond 6 residents' room, the staff might not hear the alarm. We are waiting for the parts to replace the whole alarm/panel system and install new alarm system to all (9) exit doors of the facility. This is why the staff barely hear the alarm. It needed replacement. V3 commented he checks the 9 exit doors for lapse time required to close the door but did not ask staff if it was audible for all units. V3 also said that he does not check the monitoring alarm safety device if it was functioning. V3 said all I do is order the device but not check them if they were functioning. Anyway, there were only 2 doors that were supposed to trigger (the front and SW exit doors) when a resident wearing the monitoring alarm safety device passed by these doors. V3 added that the front and SW exit doors were nonfunctioning and do not detect the monitoring alarm safety device. Surveyor asked what the facility's current implementation since their exit doors alarm and monitoring alarm safety device was not detectable. V1, V2, V3 have all said that currently they do not have a plan to monitor their exit doors to ensure that their residents that are confused and have the potential for elopement be prevented from eloping. On 4/14/2023 at 9:30 A.M., V2 said that it is the responsibility of V3 to check the 2 doors (front and SW) if they were functional and can detect alarm for the monitoring alarm safety device. V3 was called and he said, I fixed the alarm on the SW exit door today, because the alarm system was bent down, and it was not producing an audible sound that alert staff. On 4/13/2023, together with V1, V2 and surveyor, the facility's video surveillance was reviewed for 4/11/2023 from 4:30 P.M. to 4:50 P.M. The video surveillance shows R1 and R2 had exited the SW exit door at 4:46 P.M. R2 was pushing R1 while seated in his wheelchair. The video shows that R1 and R2 headed to south parking lot of the facility. They headed to a direction that the only way out from the facility was to go to the main road. This main road has 2 opposite traffic lanes. There was also an adjacent building to this parking lot, however, the only way out from this adjacent building was to go to the same main road. The police report dated 4/11/2023 shows that R1 and R2 were unsupervised and away from the facility caretakers for a period of approximately 90 minutes. The facility failed to report R1 and R2 were missing, and with police investigation, they found out which facility R1 and R2 resides. The clinical record dated 4/11/2023 shows that R1 and R2 was last seen by facility staff at 4:30 P.M., overhead paged for CODE YELLOW ALERT (missing residents) at 5:45 P.M. and police officer called facility at 6:25 P.M. to informed them they found R1 and R2. This was a two-hour duration that R1 and R2 was without supervision from staff. R1 refused to go back to the facility, hence, was taken to the hospital, but later was returned to the facility. R2 was picked from the location where she was found by a facility staff and returned to the facility at 7:30 P.M. On 4/13/2023 at 3:00 P.M., V20 (Activity Director) said that she had picked R2 from the location where she and R1 were found. V20 said she had picked R2 on 4/11/2023 and returned to the facility at 7:30 P.M. On 4/13/2023 at 5:00 P.M., V20, V2, and surveyor drove and checked the roads and location where R1 and R2 were found. It was determined that it was one mile away from the facility. The route to the location shows that R1 and R2 must passed by main roads that encompasses 2 opposite traffic lanes, 2 traffic lights in major road intersections, 2 four way stop signs and a well-traveled areas as there was a hospital on one side of the road and a school on the opposite side. R1 and R2 also must passed through some roads that were elevated, hilly areas, with no walkways between pedestrians and vehicles. R1 and R2 was transferred on 4/13/2023 to another facility that has a secured/locked unit designated for residents with diagnosis of dementia. On 4/13/2023 at 11:34 A.M., V4 (Social Service Director) said that she did not do comprehensive elopement risk assessment for R1 and R2 until after they have eloped on 4/11/2023. V4 also said that R3 is an elopement risk, wanders around, exit seeking, and was applied a monitoring alarm safety device. When V4 and surveyor went to R3's room after the interview, R3 was sitting in a lounge chair in her room. V4 had checked R3's monitoring alarm safety device on R3's ankles and wrists and found none. V26 (R3's husband) was visiting. V26 was not aware that R3 was supposed to have the monitoring alarm safety device. V4 said to V26 that (R3) wanders around and was sundowning so we put the monitoring alarm safety device, but it does not work so we removed it already. V4 said that R3 is provided 1:1 supervision. However, on 4/14/2023 at 1:30 P.M., together with V2, the monitoring log for the morning shift of 4/14/2023 was blank and no documentation that sitter was provided. V27 (R3's 1:1 monitoring staff) said that when she came in at 11:00 A.M., there was no one providing 1:1 to R3. On 4/14/2023 at 3:00 P.M., V4 was asked for other residents who were at risk for elopement. V4 said the aside from R1 and R2, the other residents at risk for elopement were R3, R4, R5 and R6. On 4/14/2023 at 5:00 P.M., V21 (Social Service Director from sister company of the facility) said she is helping V4 to ensure accuracy and completeness of residents' assessment for the elopement risk. V21 said that for the total census of 102 residents/ 79 were so far reviewed for elopement risk. V21 also said that she had 10 residents that needed to have an extra look for elopement risk. V21 said that out of this 10, 4 residents (R12, R13, R14 and R5) do not have a completed BIMS. V21 also said that R5 is identified as an existing wanderer. V21 also said that 6 other residents were looked and reassessed because they are ambulatory and have lower BIMS score (R3, R15, R16, R17, R18, R19). The EMR of the following residents shows: -R3 is [AGE] year-old who was admitted to the facility on [DATE]. R3's diagnoses included but not limited to metabolic encephalopathy, dementia, altered mental status, cognitive communication deficit, unsteady gait and mobility, and lack of coordination. The MDS dated [DATE] shows that R3's BIMS score was 99 (meaning interview not completed). The assessment continued and showed R3's cognitive skill for decision making was moderately impaired, with short-term and long-term memory problem. R3 was assessed with moods of feeling down, depressed, hopeless, trouble falling asleep, feeling tired, poor appetite that were exhibited in 12 out of 14 days duration. R3 was also assessed with poor balance when moving around from surface to surface, transfers, and walking. R3 was ambulatory and does not use assistive device for ambulation. R3 requires assistance from staff for her ADLs. The assessment log from 3/9/2023 through 4/14/2023 shows that R3's Elopement Risk was not done until 4/14/2023. The assessment was inaccurately assessed since the it was not coded correctly. It was coded as 3 (low risk elopement) versus 4 (high risk elopement). The facility policy was not followed since the elopement assessment was not done timely. It was done on 4/14/2023 wherein R3 was admitted on [DATE]. The care plan dated 3/15/2023 shows that R3 was identified as elopement risk and with exit seeking behavior. The intervention shows that a monitor alarm safety device was the intervention. However, this intervention was not appropriate since the facility's exit door cannot detect the monitoring alarm safety device. On 4/13/2023 at 11:34 A.M., R3 was in her room. V4 checked R3's monitoring alarm safety device on ankles and wrist and none was found. R4 is a [AGE] year-old with diagnoses that includes but not limited to hydrocephalus, pre-diabetes, and benign neoplasm. R4 was admitted to the facility on [DATE]. The MDS dated [DATE] shows that R4's BIMS score was 3/15 (severely impaired). R4 was assessed with moods of feeling down, depressed, hopeless, trouble falling asleep, feeling tired, poor appetite that were exhibited in 12 out of 14 days duration. R4's primary locomotion was a wheelchair. R4 was able to propel his own wheelchair. The assessment log shows that R4's Elopement Risk were done on 11/16/2022 and 4/14/2023. The elopement risk was not done quarterly as per facility policy. R4 was a high risk for elopement. R5 is a [AGE] year-old admitted to the facility on [DATE]. R5 with multiple diagnoses included but not limited unsteadiness of feet, lack of coordination, diabetes mellitus, depression, repeated falls, and anxiety disorder. The elopement risk log shows that R5 was assessed for elopement on 1/11/2023 (high risk), 4/13/2023 (low risk) and 4/14/2023 (low risk). The facility policy was not followed by not assessing R5 timely. The MDS dated [DATE] and 2/3/2023 shows that R5 was assessed with moods of feeling down, depressed, hopeless, trouble falling asleep, feeling tired, poor appetite that were exhibited in 11-12 out of 14 days duration. R6, a [AGE] year-old with diagnoses that includes but not limited to rhabdomyolysis, history of falling, unsteadiness of feet, gait and mobility abnormality, lack of coordination, cognitive communication deficit, depression, seizures, and benign neoplasm of meninges. The MDS dated [DATE] and 3/27/2023 shows that R6 was assessed with moods of feeling down, depressed, hopeless, trouble falling asleep, feeling tired, poor appetite that were exhibited in 12 out of 14 days duration. The elopement risk log from shows that R6 was assessed for elopement on 4/14/2023 in which policy was not followed since it was untimely done. The progress notes from the physician dated 3/7/2023 shows that R6 planning to move to a long-term facility .will discuss with social services. HPI: 76 y/o admitted to hospital on [DATE] after fall, after he lost consciousness, he believes both are related to seizure, last seizure 9 years ago, it is believed that (R6) had been on the floor for 3 to 4 days. CT (Computerized Tomography) of the head showed Carotid Calcifications .MRI (Magnetic Imaging Reasoning) of the brain showed 1.5cm mass at level of cribriform plate without extension, meningioma. On 4/14/2023 at 1:45 P.M., V9 (LPN) stated that she noted R6 wandering around the facility with no direction where to go. The POS (Physician Order Sheet) for the month of March and April 2023 shows that there was no order for R6 to leave the facility unsupervised. On 4/13/2023 at 10:35 A.M., R6 was at the front lobby of the facility. R6 was waiting for the ambulance for a medical appointment. R6 was ambulatory. R6 was accompanied by a sitter. At 2:50 P.M., R6 was seen lying in his bed. R6 was asked about his appointment. R6 responded what appointment. V2 was present during this observation. The facility's policy regarding elopement dated 11/01/2016, revised 7/27/2022 shows: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors, or conditions that put them at risk for wandering/elopement. All residents identified will have these issues addressed in their individual plan of care Procedure. 1. Residents who have been assessed at risk for elopement /wandering shall be provided at least one of the following safety precautions by the facility; a) An adult electronic monitoring safety device will be used to notify /alert staff by sounding an alarm when the resident enters the perimeter around the alarmed door.b) Door alarms placed on facility exits.2) As part of preventative Maintenance Program, all doors will be checked for proper function daily by maintenance department 3. Residents with an adult electronic monitoring device will be checked every shift to ensure device is in place. 4. Adult electronic monitoring device will be checked weekly to ensure the device is functioning properly.5. At no time shall a door be TURNED OFF, without the continual supervision of the exit. If the alarm must be turned off, it is the responsibility of the person disarming it to make sure it is functioning properly once the alarm is turned back on .All residents shall be reviewed for safety awareness impairment and elopement /wandering concerns upon admission, readmission, quarterly, and significant change in condition and as needed. Residents identified at risk for elopement/wandering will have a plan of care implemented to address their elopement/wandering behaviors . When a door alarm sounds, staff members shall immediately respond to determine the cause of the alarm. The staff person responding to the alarm will check outside of the building/vicinity of the area to determine if a resident has exited the building. On 4/18/2023 at 11:00 A.M. V1, V2 and V3 (Regional Operation Manager) have all stated that comprehensive elopement risk assessment was supposed to be done within 48-72 hours upon admission and as needed to determine a specific plan of care to prevent elopement. V2 and V3 also said that the admission assessment done by the admitting nurse have few questions regarding elopement, but it was not considered a comprehensive elopement assessment that would determines an elopement risk. The Immediate Jeopardy that began on 4/11/2023 at 4:30 P.M. was removed on 4/18/2023 at 11:49 A.M. when the facility took the following actions to remove the immediacy: 1) R1 and R2 were located without any injuries within approximately two hours. Facility staff immediately arrived where the residents were found by the police approximately one mile away from the facility, she (V20) stayed onsite until R2 was brought back to the facility in stable condition at approximately 7:30p by the facility staff member, R1 was transported to the ED by [NAME] police and returned to the facility at approximately 1am in stable condition, neither had any injuries. 2) A head count was conducted on 4/11/23 immediately following the elopement incident with R1 and R2 on 4/11/23 and all residents were accounted for. Total census of 101 residents, all accounted for. 3) R1 & R2 were re-assessed for risk of elopement and care plan was initiated on 4/11/23. 4) R1 & R2 were placed on a 1:1 staff monitor until 4/13/23 and were discharged to a facility with a locked unit on 4/13/23. 5) All current residents were re-assessed for elopement risk by social service department and completed by 4/14/23. Care plans were revised as needed. 6) R3 and R4 are the only identified residents who are at risk for elopement at this time. Both R3 and R4 remain on a 1:1 staff monitor since 4/14/23 and this will continue until the new door alarms are upgraded. 7) R6 has a BIMS of 15/15 and therefore not an elopement risk per the MDS assessment on 3/27/23. Updated assessment competed on 4/14/23. R5 had a significant change on 2/3/23 and is no longer an elopement risk. Updated assessment and care plan completed on 4/14/23. 8) New admissions will be assessed for elopement risk upon admission by the nurse and/or designee and an interim care plan will be initiated. Social services department will update the elopement risk assessment for all new admissions within 72 hours of admission and update the care plan. Nurses who identify new admissions at risk for elopement will notify the Administrator and provide 1:1 staff monitoring until the new wander guard system/Door Alarm is installed. Nurse's including