**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to secure the physical environment (window) in R1's room and implement appropriate precautions for a resident with a history of elopement risk, high suicidal risk, high risk per criminal background/ behavioral history, and assessed as being unsafe in the community unsupervised for one resident (R1) of three residents reviewed for elopement. This failure resulted in R1 removing the stationary window brackets that prevent the window from opening in his room, jumping out of the window, and eloping through the open back gate of the facility undetected by staff.The immediate jeopardy began on 7/3/25 at 10:28 PM, when R1 removed the stationary window brackets that prevent the window from opening in his room, jumped out of the window, and eloped through the open back gate of the facility undetected by staff. V3 DON Director of Nursing and V27 Regional Director of Operations were notified of the immediate jeopardy on 7/17/25 at 2:42 PM. The surveyor confirmed by interview and record review that the immediate jeopardy was removed on 7/24/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:R1 is a [AGE] year old resident with diagnoses that include Bipolar Disorder Severe with Psychotic Features, Delusional Disorder, Suicidal Ideation, Suicide Attempt, Major Depressive Disorder, Psychosis, Schizoaffective Disorder, Violent Behavior, and Attention Deficit Hyperactivity Disorder.On 7/9/25 at 9:49 AM, V5 Family Member was inquired of R1. V5 said, I was told R1 unscrewed the window screws with a fork and jumped out the window of his room on 7/3/25 during the night. I was notified later that night. R1 hasn't been found. R1 sent a text message to his father and I from different phones saying he wants to die. He won't go to the hospital or tell us his location. He wants to care for himself. He has Bipolar with Schizoaffective Disorder. He tried to commit suicide before in jail, he jumped headfirst from the balcony.On 7/9/25 at 10:45 AM, upon observation R1's room is locked when attempting to enter. V6 Maintenance Director arrived to open the room for this surveyor. V6 said, It's a one person room so since R1's things are here I just locked it. R1 has a private room three doors from the nurse's station. Upon entrance to the room, it appears to be organized, there are food items, R1's identification card, and phone charger are on the bed. There are 2-3 bags of clothing stacked up in the left corner in a laundry basket. There is one large window with 3 windowpanes facing the back of the facility. V6 moved the center windowpane into the open position it was in when he arrived in the room after R1's elopement. V6 said, I came in on the of July 4th day shift. His room was a wreck. His clothes and food were all over the floor. The middle window was open and slide to the right. This part of the window isn't supposed to open, it's stationary. R1 broke the stoppers off the window.Upon observation, the window screws at the top are bent and V6 opened the middle windowpane and slide it over to the right as it was when he found it. The middle windowpane appears to have been dislodged from the window frame from the top allowing it to become unsecured and opened. On 7/9/25 at 11:08 AM, V6 escorted this surveyor to the backyard area of the facility. Upon entrance to the backyard there is a wooden fence that is secured by a lock that was opened by V6. There are 2 cameras on the back of the building facing the yard area. Under R1's window are pieces of a broken fence on the ground. There is a basement level window beneath R1's first floor window. V6 measured the space from R1's window to the ground which measured a 9-10 foot drop from the 1st story window. The wooden fence was observed to be intact. There is another gate entrance on the east side that is not secured. V6 said, R1 must have jumped the fence.On 7/9/25 at 11:24 AM, V7 RN Registered Nurse was inquired of R1. V7 said, R1 always isolates himself. If I ask how he is, he can't answer correctly. He'll say something off the topic. R1 did get out the building before. I had an instance when a CNA (Certified Nurse Assistant) opened the ramp door for a family member, and he ran in front of them into the parking lot. We got him back in. He only had a day pass if the family requested, and they had to pick him up here. I came in on July 4th 7AM to 3PM shift. I was told in report R1 eloped on 3PM to 11PM shift, they looked for him and called the police.On 7/9/25 at 11:50 AM, V9 Restorative CNA said, I was here on July 3rd, on 3PM to 11PM shift. I came by to get the linen bin by his room and his door and window was open. I checked the bathroom, and he was gone. I ran to the nurse's station and called a code pink. Staff went outside and police were called. I didn't see anything on the windowsill. I saw him last around 10:15 PM just in his room.On 7/9/25 at 12:22 PM, V11 CNA was inquired of R1. V11 said, I worked 3PM to 11PM. R1 is quiet and stays to himself. I checked on him during rounds and mealtimes. He ate his own food in his room. Closer to the end of the shift V9 CNA and I peeked in his room, and he was gone. We checked his bathroom. The middle part of the window was open. I didn't notice anything else. We called a code pink. The nurse called 911, staff searched and drove around to see if he was in the area. It was close to 11PM when police came.On 7/9/25 at 12:45 PM, V3 DON Director of Nursing was inquired of R1's elopement being notified to Illinois Department of Public Health. V3 said, We didn't report it because he's been in contact with his family via phone and we don't have knowledge of him being injured or hurt.On 7/9/25 at 12:55 PM, V12 RN Registered Nurse said, I was the nurse on first floor on July 3rd 3PM to 11PM shift. R1 hangs out in his room. He's a smoker. That night I did my rounds. He took his medication. I saw him last around 10 PM. He was in his room sitting on the bed. V9 CNA came to me at the nurse's station around 10:30 PM. She said she was doing her rounds and didn't see R1 in his room. I got up, went to his room, looked, and called his name. I checked the bathroom and the room and saw the middle of the window was open. I called a code pink. Staff came down and went outside the building. I called 911, the administrator, director of nursing, and the family. I went back into the room; I didn't see anything on the windowsill. I looked out the window and saw a part of a fence on the ground. I didn't hear anything.On 7/9/2025 at 1:30 PM, V13 PRSC Psychiatric Rehab Services Coordinator was inquired of R1. V13 said, I was R1's social worker. I worked July 3rd till 4:30 PM. R1 is very anxious, and he paces. It's his baseline behavior. He was quieter that day, he didn't come into my office. He usually comes in every day. His diagnoses are Bipolar Schizoaffective Disorder, Schizophrenia, Delusional Disorder, Hallucinations, Anxiety, and Depression. He only has community access with family if he's compliant with medication. He's never had an independent pass. His last community survival assessment was on 5/1/25, it says he has behavioral concerns and elopement. I spoke with him on July 2nd, he came to my office with some books and talked about things that didn't make sense. His delusions were mixing with reality. But it was getting harder for me to understand what he was talking about. This week I was trying really hard to understand. He was someone we'd keep an eye on more and look through his things. We'd take things so he's safe. He's an identified offender because of his charge of aggravated battery and bodily harm. He was sent out on petition on June 10th to the hospital because of his behavior, but I wasn't aware he got out the building. I feel his behaviors built up.On 7/9/25 at 2:15 PM, R5 was inquired of R1. R5 said, R1 was very anxious. He was just talking to himself before he left and was pacing. It startled me. A couple of days before we were in the basement, and he took a fork and showed me how to pry open the door and escape. He asked me if I wanted to escape, and I said I wasn't going to do it. I saw him last at smoke break around 6PM. He must have got out before 11PM because he usually meets me by the vending machine at night to get snacks. He texted me the night after he escaped. I tried to call him back, but his phone was off.On 7/14/25 at 12:29 PM, V3 DON Director of Nursing was inquired of R1's elopement. V3 said, I got a call from the assistant director of nursing maybe 10:45 PM on July 3rd. Assistant Director of Nursing called me, and V12 RN notified me and said R1 was missing. V9 CNA checked his room and noticed the window was out. They initiated a code pink; they did a facility search and checked all exit door which were secured. Staff went out on the grounds to look for him. The police were called, they arrived at the facility before midnight. They took a report and gave the report number to the ADON. The doctor, family and administrator were notified. Change of shift was reported that R1 was missing, and I asked them to call local hospitals and be on standby if he comes back. He has gotten out before. He pushed out the front door and staff was behind him. He walked down the road, and we called the police to redirect him back to the facility. He was petitioned back to the hospital for a psychiatric evaluation. The psychiatrist did a medication adjustment for him. Elopement risk assessment done, he got out, but staff was behind him. He was placed on a one to one supervision until he was transferred to the hospital. We sent him out for another hospital psychiatric evaluation. He has a history of suicidal ideation. Prior to coming to this facility, he had a suicidal attempt in the hospital. When he initially came, he was identified as an extreme offender on his background check. It was recommended from his criminal background to be placed in a private room due to his history of suicidal attempt with jumping out of a third story window prior to his admission. Our administration decided it would be safer for him to be on the 1st floor opposed to the higher floor being more potentially dangerous. He is just supervised and encouraged about medication compliance. During the investigation, we didn't find any utensils, a room search was done, and nothing was found. R1 was found in a hospital in Wisconsin on yesterday and was checked medically and deemed safe with no medical issues. Due to their state regulations, they were unable to admit him to inpatient psychiatric care. R1 was transferred back to this facility via ambulance yesterday evening and staff notified his physician. He was transferred to the hospital for psychiatric evaluation.On 7/14/2025 at 1:05 PM, V1 Administrator was inquired of R1's elopement. V1 said, V28 ADON called me during the night around 10:30 PM. They said the window was out in his room. The staff called a code pink that went and searched the building and outside in the back and around the area. They went to 7-11 store but didn't see him. Police were called. Police did a missing person report for all the surrounding cities. We started calling local hospitals, but he didn't show up. We called the doctor and family. His mom or dad said he uploaded an Instagram picture, but we couldn't locate him. He got out before but didn't make it far. In June got out the front door behind a visitor, but staff went out behind him. He hasn't gotten aggressive since being here. His criminal history showed he has aggression and needed a private room. We did have to call the police and they brought him back and we petitioned him out the hospital for psych evaluation. He's not exit seeking usually, it just happened. His room is by the nurse's station. We didn't put him on 3rd floor, but due to his history we put him on 1st floor due to him jumping from windows. We didn't find anything. We have cameras and saw him tumble out the window, he got up and walked away fast. He walked toward the 7-11 store. The staff went over there but didn't find him. We checked the camera and it showed R1's legs and he rolled out the window, got up and walked fast to the other side of the yard and went out the gate.On 7/14/25 at 1:42 PM, V3 DON was inquired of security and cameras. V3 said, The last smoke break time is between 6-7PM. Residents with an independent pass have to be back in the building by 7:30 PM. They can go in and out of the back gate, it's not locked. We have staff monitor it. The security cameras are in V1's (Administrator) office and she's the only person with access. We don't have security.On 7/15/25 at 2:26 PM, V14 PRSC Psychiatric Rehab Services Coordinator was inquired of R1's 6/18/25 elopement risk review decision score. V14 said, The elopement risk is triggered within the first 24hrs when a resident comes in. Sometimes nurses will complete it. It's a part of the admission documents. Social Service staff should review the elopement risk and correct it if it's not right. It's especially important for R1 because he is high risk for elopement. We know he's not a low risk elopement taking account his history.On 7/16/25 at 10:40 AM, V6 Maintenance Director was inquired of R1's window in the room. This surveyor and two other survey staff reviewed R1's room window with V6 Maintenance Director. V6 said, I don't know how he would have gotten the window open with his hands. He must have used something to get it open because the brackets to keep the window from opening were broken. I added bolts to reinforce the window and L bracket to prevent it from being pulled back.On 7/14/25 at 9:50 AM, V3 DON was inquired of R1's status. V3 said, R1 was found in a hospital in Wisconsin diagnosed with altered mental status then transferred back to the facility. R1 was evaluated and ordered to be sent out for psychiatric evaluation at the local hospital.On 7/14/25 at 1:30 PM, V1 Administrator and this surveyor viewed the security camera footage from July 3, 2025, at 10:28 PM. The camera showed R1 jump from his window to the ground, rolled once and stood up. R1 walked quickly toward the east side of the back yard on the sidewalk through the open gate. V1 Administrator was inquired of the east gate being left open. V1 said, The gate is usually left open for the residents that have an independent pass. The residents come and go from that gate and sit in the yard area.On 7/24/25 at 9:53 AM, V3 DON Director of Nursing was inquired of R1's involuntary discharge. V3 said, Due to his high elopement risk he was deemed not fit for the facility. He may need a different environment. He was bored here. He's younger. The population wasn't conducive for him along with his diagnosis and extreme exiting desire. We provided all the services he needed, but he spoke with his mom and said he was bored here. He wants to be free and work. He just wanted to be outside. It was an interdisciplinary decision with his physician and R1. His family lives out of state and the facilities there are not up to their standards so R1 was accepted into a facility in Waukegan. He agreed to go. R1 could potentially lure or coax other residents to elope or help them elope. He wasn't appropriate for this facility; he was a safety risk. R1 was hand delivered a petition at the hospital with a stamped envelope. He was explained the appeal process, and his family was notified. We'll coordinate with the other facility to transfer his belongings. The facility will have to do a medical request for pertinent information, and it will be sent from medical records.R1's records were reviewed as follows.R1's progress notes from 6/10/25 at 11:30 AM document being discharged to the hospital. R1 is delusional, hallucinating and paranoid. Unable to take vital signs, patient is refusing. 911 called. R1's physician ordered him to be sent to the hospital for a psychiatric evaluation. On 6/10/25 V14 PSRAD Psychiatric Rehab Services Assistant Director completed a petition for R1 to be hospitalized . R1 eloped out of the front door of the facility pushing past visitors leaving the grounds. The facility required police intervention to transfer R1 to the hospital for psychiatric evaluation. R1 was hospitalized for six days. R1 returned to the facility 6/16/25.On 6/16/25 V20 NP Nurse Practitioner documented R1 was hospitalized for Psychosis. Hospital reports states patient presented to the hospital via EMS (Emergency Medical Services) after eloping from a nursing home and being found trespassing behind a dumpster smoking marijuana.On 6/18/25 at 20:53 (8:53 PM) R1 was evaluated by V21 Nurse Practitioner Psychiatrist following his hospitalization. Assessment- this patient has multiple psychiatric complexities and would benefit from continued management with monitoring of mood and behavior. Will titrate medications based on current symptom progression.The 6/18/25 elopement risk review documents: 2. elopement history/community risk- reported/documented episodes of elopement and/or attempts to elope: 2. no. Total score: 23 low risk.On 7/15/25 at 2:26 PM, V14 PRSAD Psychiatric Rehab Services Assistant Director was inquired of R1's 6/18/25 elopement risk review decision score. V14 said, The elopement risk is triggered within the first 24hrs when a resident comes in. Sometimes nurses will complete it. It's a part of the admission documents. Social Service staff should review the elopement risk and correct it if it's not right. It's especially important for R1 because he is high risk for elopement. We know he's not a low risk elopement taking account his history.R1's June 2025 and July 2025 behavior monitoring from his 6/16/25 readmission to 7/3/25 does not document any identified behaviors.R1's July 2025 MAR (Medication Administration Record) documents he received Depakote ER (extended release) oral tablet 250mg (milligrams) give 3 tablets by mouth at bedtime for Schizoaffective Disorder on 7/3/25 at 2100.R1's progress note states: 7/3/25 at 23:20 (11:20 PM), V12 RN Registered Nurse documented at 10:30PM, CNA Certified Nurse Assistant observed resident sitting in his room. At approximately 10:35 PM, CNA walked past resident's room and noted his window was open and he was no longer present. Upon further inspection, it was discovered that part of the window had been removed. A code pink was immediately called. All exit doors were secured, and staff completed a search of the facility and grounds The Administrator, DON, Social Services, MD, and resident's mother was notified. Monitoring and communication with local hospitals, police, and emergency services are ongoing.On 7/4/25 at 12:26 AM, the police department official report documents the police response to the facility for a missing person R1.R1's 5/1/25 community survival skills assessment recommendations indicate resident has supervised community access due to behavioral concerns as well as history of elopement. The care plan documents an updated 6/18/25 assessment but is not found in R1 records upon his readmission to the facility. R1's 2/20/24 criminal history record indicates aggravated battery and bodily harm.R1's care plan documents the following: Elopement Risk I, R1, am challenged by mental illness and poor insight. I have a history of leaving my former facility without notifying staff and having a responsible escort (elopement). I also have a history of wandering into restricted and/or dangerous places. I will respond to staff direction to redirect his attention away from a potentially problematic situation (i.e. trying to exit the facility without supervision) when this behavior occurs.Interventions: Elopement Risk assessment completed per policy. Implement preventive intervention strategies that include: Assess me for potential elopement/unauthorized departure risk. Make rounds/room checks per facility protocol to minimize chance of unauthorized leave. Implement Elopement Risk Protocol Redirect resident to room/unit Use distraction to try to distract resident away from the current situation.Suicidal Risk: I, R1, have a history of suicidal ideations and attempts related to mental illness. I deny current S/I or intent. My self-identified triggers include medication noncompliance and using illicit substances. Interventions: As warranted conduct/carry out: Daily monitoring & supervision of the resident.SMI Severe Mental Illness: The resident has a diagnosis & history of severe mental illness (SMI) of Bipolar, Schizoaffective & Depression. The resident will: take medication as prescribed. Interventions: Explain facility rules, resident behavioral expectations & resident rights. R1 requires psychotropic medication to help manage and alleviate: Bipolar, SA Schizoaffective Disorder, SI Suicidal Ideation, AH Auditory Hallucination, Psychosis, Delusions, Agitation and Aggressive Behavior, ADHD Attention Deficit Hyperactivity Disorder, Depression, Behavior with Depressive Features, Anxiety, Neurosis.Aggression Risk: I, R1, am challenged by mental illness, mania, and psychosis. I am noted to respond/react to internal stimuli. Symptoms are manifested by aggression when agitated. Behavior: The resident expresses maladaptive behavioral symptoms related to: A diagnosis of chronic mental illness, a substance abuse disorder.R1 has presented with using the utensils that are provided at mealtime, to barricade himself in his room. Due to R1's h/o suicidal ideation this behavior poses a risk to his safety. R1 is to be provided with plastic silverware only. R1 is given plastic silverware to prevent him from barricading himself in the room.Isolating: The resident expresses maladaptive behavioral symptoms related to isolating himself in his room. Intervention: Involve the resident to supportive incidental, group or 1:1 counseling, as appropriate. Indicate treatment modality.Community Access: I, R1, do not appear to be capable of unsupervised outside pass privileges at this time. I require support and supervision in order to safely access the community independently rt: mental health needs. Intervention: Conduct a community survival skills assessment or similar community safety evaluation to reasonably the person's ability to safely determine and respectfully negotiate within the outside community. Initiated 6/18/25. No assessment dated [DATE] found in R1's documents.R1's comprehensive assessment section C cognitive patterns dated 5/7/2025 documents a brief interview for mental status score of 14. R1 is cognitively intact.R1's comprehensive assessment section E behavior dated 5/7/25 does not document any behaviors despite V13 PRSC's concern of R1's delusions prior to his elopement during interview on 7/9/25. R1's comprehensive assessment section GG functional abilities dated 5/7/25 documents he required supervision or touching assistance (helper provides verbal cues and/or touching/steading and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. The following activities are documented: toileting hygiene, shower/bathing, personal hygiene, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, walking 10 feet, 50 feet with two turns, and 150 feet.R1's 7/13/25 hospital records document a referring diagnosis of Schizoaffective disorder (a mental illness characterized by psychotic symptoms of hallucinations and delusions plus significant mood disturbances (mania or depression)). R1 presented to the emergency department for increased mania and eloping from a nursing facility to Wisconsin. R1 stated, I just wanted to leave for a while. He is internally preoccupied. Patient is in need of inpatient psychiatric hospitalization for mood stabilization and safety.Visit diagnoses include Compulsive behavior, Bipolar affective disorder, current episode manic (a period of abnormally elevated or irritable mood, increased energy, and activity levels, often associated with bipolar disorder. Schizoaffective disorder.R1's mental status exam documents: patient's grooming and hygiene is poor. Thought content: Auditory hallucinations are present. Delusions and paranoia are present. Insight/Judgment: poor.This patient is admitted to the hospital for stabilization of acute psychiatric issues. Will titrate medications and provide psychotherapeutic services on the unit and within the milieu in order to improve decompensated symptoms.R1 received prescribed medications for stabilization and remained hospitalized .On 7/15/25 at 3:59 PM, V21 NP Nurse Practitioner documented on R1 during his hospitalization: Late Entry: Facility cannot meet the resident's requirements due to extreme psychiatric needs. He is an elopement risk. Presently patient is a threat to himself and others and is not appropriate to remain at Briar Place. Involuntary discharge requested.On 7/17/25 at 11:35 AM, V14 Psychiatric Rehab Services Assistant Director documented on R1 during his hospitalization: Social Service Note: On this date, [NAME] was reserved with IVD due to error on previous form. Attached with IVD was bed hold policy and stamped and addressed envelope. Social worker [NAME] present at the time of drop off. [NAME] was told how to appeal and the process. [NAME] expressed his understanding had no concerns.The revised 1/25 Policy and Procedure Missing Resident states in part: It is the policy of this facility to report and investigate all reports of missing residents.Procedure: 1. All personnel are responsible for reporting a resident attempting to leave the premises, or suspected of missing, to the charge nurse as soon as practical. This includes any resident that did not sign out on pass and/or did not notify a staff member of his or her leaving.3. Should an employee discover that a resident is missing from the facility, he or she should: f. The Administrator and Director of Nursing will evaluate the situation and develop a plan of action based on the individual resident. The following steps should occur: 11. The decision to notify the Illinois Department of Public Health is made by the Administrator.a. The Illinois Department of Public Health is notified after the confused/disoriented resident is missing for 24 hours and all attempts to locate the resident have been exhausted.- This notification does not include the resident who is alert/oriented and has made a decision to leave the facility and not return. The Immediate Jeopardy that began on 7/3/2025 was removed on 7/24/2025 when the facility took the following actions to remove the immediacy. R1's window and facility exit doors were immediately secured to prevent further risk of elopement. A full facility search was initiated, including resident rooms, common areas, stairwells, and secured outdoor spaces. A search of the surrounding community, including the parking lot, adjacent properties, and nearby streets was conducted. The local police department was notified, and a formal missing person's report was filed. R1's family/ responsible party was notified of the incident and ongoing search efforts. Staff contacted area hospitals and local shelters to inquire whether R1 had been admitted or presented for care.The Administrator and Assistant Director of Social Services remained in contact with law enforcement, family members, local hospitals, and shelters every four hours until R1 was located and transported to a hospital on 7/13/25. R1 is not returning to the facility.The facility Maintenance Director replaced the stationary window bracket in R1's room. The repair was verified by the Administrator to ensure the window was no longer able to be manipulated.The facility has implemented a system to ensure that residents who require supervision due to elopement risk and/or recent elopement attempts receive adequate supervision and do not leave unsupervised. The Administrator educated all staff including the Activity Director, Activity Aides, admission Director, Assistant Director of Nursing, Business Office Manager, Certified Drug and Alcohol Counselor, Certified Nursing Assistants, Cooks, Dietary Manager, Dietary Aides, Director of Nursing, Housekeeping Director, Housekeepers, Human Resources Director, Infection Preventionist, Licensed Practical Nurses, Maintenance Director, Maintenance Tech, MDS Nurse, Medical Records Director, Receptionists, Registered Nurses, Restorative Aides, Social Workers, Social Service Aides, Staffing Coordinator, and Wound Care Nurse on the facility's elopement policy and how to identify and respond to elopement risk in residents with psychiatric disorders. The education reviewed the facility's policy for identifying residents at risk for elopement through completion of the Elopement Risk Review assessment in the resident's chart on admission/re-admission (completed by admitting nurse) and quarterly and with changes in condition (completed by the social worker). Staff were educated that the results of these assessments are used to develop an individualized care plan to reduce the risk of resident elopement and that residents identified as high-risk for elopement have their pictures at the nurse's stations and the front desk. The education reviewed that staff are required to provide supervision for elopement risk residents as outlined in the resident care plan. No new policies, procedures, or protocols have been implemented. The facility reinforced the existing elopement prevention policy and procedure through comprehensive staff education. This education ensures that all team members understand the facility's current elopement prevention system, including how residents are assessed for risk, how care plans are developed and updated, and how supervision expectations are communicated and maintained.Additionally, staff were educated how to identify and manage behaviors associated with increased elopement risk in residents with psychiatric disorders. The staff were educated that residents with psychiatric disorders may attempt to leave due to delusional beliefs, paranoia or hallucinations, manic impulsivity, agitation, suicidal ideations, history of trauma, substance cravings, and lack of insight into care needs. The warning signs of elopement risk were indicated including verbalizing distress, pacing, agitation, or trying to avoid staff, expressing paranoid thoughts, asking where exits are, loitering near doors/windows, packing bags or hiding items, refusing care, sudden isolation, or mood change. Situational triggers were also identified including new admission or recent hospitalization, medication changes, increased psychotic symptoms, conflict with peers or staff, and significant life events or trauma.Staff were educated to respond by not escalating the situation, remaining calm, validating the resident's feelings, not challenging hallucinations or delusions and instead validating feelings, ensuring safety by staying nearby and alerting the nurse immediately, not leaving the resident unsupervised, and reporting/documenting the behavior. Prevention strategies were discussed including knowing who is high-risk, reviewing care plans and supervision requirements, removing potentially harmful objects from the environment, securing rooms with compromised windows, and reporting any change in behavior immediately to the nurse. Evidence that education took place was documented by staff signing an in-service attendance sheet at the time education was provided in person. For staff who received education via phone, the Administrator documented educated via phone next to the staff member's name on the same in-service sheet, with a witness signature included. Staff who are on vacation or leave of absence will receive this education upon their return, prior to their next scheduled shift. This education will also be provided to all new hire staff during orientation. The facility does not employ agency staff. This education began on 7/9/25 and was completed on 7/17/25. The facility has implemented a comprehensive plan to ensure that all 3-piece windows in resident-accessible areas are secure and cannot be manipulated for elopement. A facility-wide inspection was completed by the Maintenance Director to verify that windows are secured and cannot be manipulated for elopement. Any windows identified as not secure or able to be manipulated for elopement

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to effectively supervise a resident with history of drug abuse. This deficient practice affects one resident of three residents reviewed for change in condition. R28 had multiple incidents of noncompliance for bringing in contraband and R28 tested positive for cocaine once during R28's stay in the facility. R28 expired on 12/2/23 in the facility with cause of death as combined drug toxicity: Drug fentanyl Acetyl despropionyl fentanyl raised to the level of an Immediate Jeopardy. The Immediate Jeopardy began on 12/2/23 when R28 was found to be unresponsive at the bedside without breath. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 4/12/24 at 10:18am. The surveyor confirmed by onsite observation, interview and record review that the immediacy was removed on 4/18/24, but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: R28 was admitted in the facility on 6/8/2023 and expired on 12/2/23. R28 is a [AGE] year old female resident. R28 has diagnoses but not limited to: post traumatic stress disorder, psychoactive substance abuse, anxiety disorder, major depressive disorder, attention-deficit hyperactivity disorder and suicidal ideation. R28's notes for Initial Meeting for [NAME]/Alcohol and Substance Abuse program/Introduction dated 6/9/23, reads in part: R28 noted using heroin and cocaine. R28 also reported that she was prescribed Vicodin (controlled substance pain medication) after car accident which caused R28 to start using again. R28 further reported using heroin for 5 or 6 years. Per medical records, R28 was noncompliant with her psychotropic medications. R28 was told that R28 will be referred to the [NAME] program for poly0substance abuse. R28 was made aware that this facility has zero tolerance for using alcohol, THC (Tetrahydrocannabinol-found in cannabis) or any mood-altering substances while in treatment inside and outside the facility and random UDS (Urine Drug Screening) and BAC (Blood Alcohol Concentration) will be administered and for suspicion of using. Social Service Note dated 6/15/23, reads in part: writer met with R28 due to R28 being on 72-hour smoking restriction as there was contraband found in her room. Writer re-educated R28 on the smoking policy and encouraged R28 to refrain from bringing contraband into the facility. Social Service Note dated 7/16/23, reads in part: Staff reported that R28 was seen with contraband in R28's room on 7/13/23. Writer approached R28 about the situation. R28 was calm when talking to the writer. Writer reminded R28 about the house rules. After releasing R28's frustration, R28 began to understand what writer explained to R28. Care plan will be updated as needed. Staff will continue to monitor accordingly. Social Service Note dated 7/19/23, reads in part: Writer spoke to R28 after witnessing R28 smoking in the hallway. Writer confiscated R28's vape and re-directed R28 to social service office. R28 stated to have gotten them when R28 went out and forgot to turn it over. Writer educated R28 on the house rules regarding smoking materials outside of designated area and encouraged R28 to turn in material at the front desk upon re-entry. Due to multiple violations, R28 smoking privileges will be taken for 30 days. Social Service Note dated 7/23/23 reads in part: Writer notified that on 7/20/23 R28 had contraband. Upon entering the room bathroom was not smoky as R28 exiting the bathroom. An unlit cigarette was located in R28's bedroom. R28 was educated about the hazards/safety risks of smoking inside the facility. R28 is restricted from smoking for 30 days. Social Service Note dated 9/18/23 at 12:30PM, reads in part: Conducted a random UDS (Urine Drug Screening) and results were positive for THC and opioids. It is apparent that R28 currently uses THC and R28 takes pain pill under doctor's and facility's supervision. R28 stated I smoked a joint at the reunion but did not do other drug or alcohol. CADC (Certified Alcohol and Drug Counselor) commended R28 not using other mood-altering substances. Furthermore, CADC told R28 that R28 cannot use marijuana while in treatment. Offered another level of treatment but R28 refused, stating it's only marijuana. Will continue [NAME] (mental illness and substance abuse) programming. Social Service Note dated 9/18/23 at 12:36PM, reads in part: Writer met with R28 due to having contraband. Upon entering room, bathroom was not smoky as R28 was exiting the bathroom. A vape was located in R28's bedroom. R28 is restricted from smoking for 60 days. Social Service Note dated 9/25/23, reads in part: R28 mother called and spoke to writer, when she was out of town, R28 was caught using cocaine with first cousin and lying about her drug use. Will follow up. Social Service Note dated 10/1/23, reads in part: CADC and R28's mom met briefly yesterday impromptu as she was coming to visit R28. R28's current drug use activity and last positive UDS (THC and Cocaine) were discussed in the meeting. Both agreed that inpatient or residential treatment for R28 is recommended, will continue to follow up. Contract for Refusing Inpatient Residential Treatment dated 10/2/23, reads in part: R28 has been observed on several occasions with positive UDS with THC and opiates which she is currently taking while under supervision of doctors and other IDT members. The latest UDS was positive for cocaine. Her Drug and Alcohol Therapist has offered R28 an opportunity to attend an inpatient or residential Treatment for her substance abuse issues but R28 adamantly refused to do so. On 3/22/24 at 11:15AM, V17 (Substance Abuse Coordinator) stated in regards to 10/2/23 contract positive result of cocaine: It was false positive, I should have documented false positive and not positive for cocaine. We asked R28 and R28 denied it, and there could be over the counter medication that can give false positive result. Based on my clinical observation and assessment that day, the result was false positive, but I did not document because I did not see it would be important to document my clinical observation and assessment at the time. Social Service Note dated 11/28/23, reads in part: Writer was informed that resident was caught in possession of contraband. Social service staff confiscated the items (Vape and THC pens) and performed consensual room search. R28 placed on 90-day smoking restriction. On 3/20/24 at 1PM, V4 (Social Service Director) regarding delivered items, reception will check and if the social services are available they will also check. Unfortunately we are not able to do search for visitors. We check the package once the package is left by the visitor to any residents. Regarding 11/28/23 we confiscated contraband, vape /THC pen was found. We checked and searched the whole room and nothing else was found. R28 was placed on smoking restriction. V4 cannot recall how R28 got the vape. R28 was already on red pass. R28 can go out to community with family members and friends but not unsupervised. Someone has to sign R28 out before R28 can go out on pass. On 3/21/24 at 1:15PM, V4 stated that for dropped off essential items and groceries, social service brings it to the residents. Reception will call the nurse to come and get the food delivered and the receptionist should have checked it prior to calling and giving it to the nurse. Unless the resident is waiting down in the unit by the reception area, the receptionist will check the bag before giving it to the resident. Also, front desk will inform the social service that a family member/ other visitors coming in with bag of items. If dropping it off, then social service will come down and search and if visitor is staying and coming in with bag of items then the reception will check the bag. On 3/21/24 at 10AM, V24 (Receptionist) stated that V4 will notify the nurse that a family member will bring a bag of snacks for the nurse to check in the nurses station. Because I do not know the residents diet. I will call the nurse and let them know that a family member is on their way with a bag of snacks. Outside deliveries, they come in they show us their phone and show us they are here to deliver something. Sometimes residents will come down and wait for the delivery person and wait for them on the other side of the door (receptionist area to facility floor unit). In regards to groceries, Social service will check. I will inform social service that a grocery is delivered or dropped off. Social service need to be present when handing the bag to the resident. Food delivery service, it has to be given unopened to the resident. We don't check if with the receipt and the bag is closed. On 3/28/24 at 3:30 PM, V17 (Substance Abuse Coordinator), stated that due to history of drug use while in the facility, R28 was counseled not to do drugs anymore. In general, a resident that tested positive for illegal drugs we will try to find out where they got the drugs from. We notify the MD. If they have a guardian we will notify the guardian. High level treatment which is inpatient was offered to R28. R28 refused. Our intervention was to continue with the current intervention in the care plan. No new specific intervention added at the time she tested positive for cocaine. Staff to encourage R28 to attend group meeting such as AA meeting. Increase one to one meeting. Nurses Notes dated 12/2/2023 05:45, reads in part: Upon rounds at this time, observed R28 in bed lying on Left side. Called her name, not easily aroused. Unresponsive verbally and tactile. Upon further assessment she appeared not to be breathing. Code blue immediately called, CPR Initiated. All staff Nurses responded. 911 Emergency was called and they arrived immediately. CPR (Cardio Pulmonary Resuscitation) continuous EMS (Emergency Medical Services) resumed CPR. Police present. Patient's mother already notified and in the facility as well as the Director of Nursing. EMS Continued CPR then called the Time of Death 6:18AM. Fire Department Runsheet dated 12/2/23, reads in part: Unit notified 12/2/23 at 5:56AM, Unit arrived at scene at 6:03AM, and patient contact at 6:04AM. Called for Cardiac Arrest. Found nursing home staff attempting CPR on [AGE] year old resident. Unknown PMH. Unknown last time patient was seen normal. Unknown what time patient was found not breathing. Exam, patient cyanotic from the neck up. Patient with full rigor throughout body. 4 lead applied confirmed asystole. Local ER call for medical control. Medical control confirmed DOA (Dead on Arrival) at 6:11AM. On 3/20/24 at 10AM, V60 (R28's complainant) Reported that after R28's death, they checked R28's text messages on her cellphone and R28 was in communication with somewhat an Uber driver stating that the drugs will be placed inside the hair coloring box. Was not specific what kind of drugs it was and was not able to give the date of this transaction conversation through text messages. V60 reported that R28 died of drug overdose. On 3/26/24 at 11:25AM, V61 (Coroner's office personnel) confirmed cause of death for R28 as written in R28's Death Certificate as combined drug toxicity: Drug fentanyl Acetyl despropionyl fentanyl. Physician Order sheet reviewed and there is no order for Fentanyl medication. Resident Handbook revision date 1/7/23, reads in part: Room, Personal and Body Searches. Staff members perform room checks every day. Staff will check each resident room to ensure a clean and safe environment. You may be present at the times of these room checks. Please be aware that staff will be checking all closets, dressers, suitcases and shelving. Certain items are not permitted in your room for your safety and safety of others. Some items not allowed in the facility, include but not limited to: Firecrackers or any kind of chemicals or flammable materials. Any poisonous materials. Guidelines for Community Access Determination dated 2/8/23, reads in part: Resident personal belongings will be searched upon entry and re-entry to the facility. June 2017 Alcohol/Substance Use/Abuse policy reads in part: Substance Use/Abuse Policy objective It is the policy of the nursing facility to provide a safe and healthy living environment. The facility recognizes that persons requiring long-term care present with significant physical and mental health problems. In some situations, the person may have a history of substance abuse. The facility recognizes that substance use/abuse disorders result in substantial physical and mental impairment disability and recognize the personal responsibility of the individual to seek and remain engaged in treatment. The facility shall work with the individual to provide appropriate treatment referrals to enable the individual to work on abstinence, sobriety, personal improvement and reducing chances of recidivism. Appropriate interventions are strongly recommended to persons with substance abuse problems. Each resident (and/or representative) is informed that facility policy prohibits the use of alcohol without a doctor's order. Facility policy prohibits use of illicit drugs. As a condition of residence, each person living in the facility acknowledges that he/she will not use alcohol or illicit drugs during residence in this building. Persons returning from the community who present with signs and symptoms of intoxication will be evaluated by the nurse on duty or charge nurse. The nurse is responsible for taking vital signs and assessing the person's present behavior. The nurse will be responsible for contacting the attending physician (A.P.) if the resident is determined to be in need of medical attention and/or a decision is required regarding withholding prescribed medications. Documentation will be placed in the chart regarding signs/symptoms of intoxication/inebriation. Documentation should include the resident's own admission of alcohol/drug use. The facility reserves the right to have the person submit to blood/urine testing at any time if policy violation is suspected. Follow-up interventions and treatment recommendations will be communicated to the resident/representative and documented in the medical record. Outside treatment sources will be utilized as appropriate. Residents with substance abuse disorders are expected to participate in acute/active treatment, sobriety counseling, or aftercare Persons who continually jeopardize their health and the health and safety of others will be evaluated for involuntary discharge. The Immediate Jeopardy that began on 12/2/23 was removed on 04/18/24 when the facility took the following actions to remove the immediacy. 1. A system to ensure contraband does not enter the facility and is removed from the resident will be achieved through staff education. Education will be provided by the Administrator, to registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager. This education will review the facility's contraband policy updated on 4/18/2024 and will include that residents may be asked to voluntarily empty and show the contents of their pockets at any time if reasonable suspicion exists. Reasonable suspicion includes frequent leaves of absence with or without facility knowledge, odors, new needle marks, and changes in resident behavior such as unexplained drowsiness, slurred speech, lack of coordination, mood changes, particularly after interaction with visitors or absences from the facility. Residents may be asked to voluntarily reach into concealed clothing areas and remove any items and place these items on a horizontal surface. Staff are instructed to have the resident hand items to the staff members or place the items on the horizontal surface. It is the objective of this policy that the above steps occur in plain sight of multiple witnesses (if possible) to afford appropriate protection to both the resident and the involved staff member(s). These steps are necessary to assure that the resident is treated with respect and dignity throughout the procedure. It is appropriate to ask the resident to empty his/her pockets and display their contents or roll down his/her socks. It is not appropriate to bring a resident into a room for a more specific search unless there is strong suspicion that the individual is attempting to bring in objects/items that may cause serious harm. If a more specific search is required the staff are to follow guidelines as set forth by the administrator or the administrative representative. This may even involve requesting professional assistance from the local police. Only outerwear articles of clothing including, but not limited to, jackets, coats, scarves, hats, gloves, and vests, shall be removed in plain site of staff. This policy recognizes that residents have attempted to hide/conceal contraband articles in undergarments in the past. If this appears to be the case and staff assess and suspect that these items may cause harm, staff are directed to contact the administrator or the administrative representative for instructions on how to proceed. The facility emphasizes treatment with dignity at all times. The facility reserves the right to remove locks from drawers, cabinets, closets, lockers, or any other object if there is reason to suspect that the resident possesses any item or items that may potentially harm other persons. The facility may choose, at its discretion, to involve drug-sniffing dogs (e.g., from a K9 company) if residents are suspected to be trafficking drugs inside the facility. A root cause analysis will be completed upon identification of contraband. This education began on 4/19/24 and will be completed by 4/22/24. Upon completion of the training, staff will sign an will contact agency staff before their scheduled shift to review staff education regarding the prevention of contraband from entering the facility and the removal of contraband from resident possession. A binder with staff education will be kept at the front desk and agency staff will be required to read and sign to validate their understanding of the information presented in the binder. If agency nurses have any questions regarding the information presented in the staff education binder, they will be instructed to contact the Director of Nursing for clarification prior to signing the record of education. In the absence of the Director of Nursing, the Assistant Director of Nursing will review the education requirements and answer any questions for agency nurses. The facility has identified five staff members who are on a leave of absence/vacation. These staff members will be contacted by the Administrator to review staff education regarding the prevention of contraband from entering the facility and the removal of contraband from resident possession. The staff education will be placed in a binder at the front desk and must be reviewed and signed by the staff member before returning to work. The staff member will sign a record of education to validate their understanding of the information presented in the binder. If the staff have any questions regarding the education, they will be instructed to contact the Administrator before signing the record of education. In the Administrator's absence, the Director of Nursing will answer questions regarding the education. Additionally, this education will be provided to new staff upon hire during orientation training and will be repeated to all staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager annually. Record of continuing education sheet to confirm their knowledge and understanding of the topic presented. The Director of Nursing will contact agency staff before their scheduled shift to review staff education regarding the prevention of contraband from entering the facility and the removal of contraband from resident possession. A binder with staff education will be kept at the front desk and agency staff will be required to read and sign to validate their understanding of the information presented in the binder. If agency nurses have any questions regarding the information presented in the staff education biner, they will be instructed to contact the Director of Nursing for clarification prior to signing the record of education. In the absence of the Director of Nursing, the Assistant Director of Nursing will review the education requirements and answer any questions for agency nurses. The facility has identified five staff members who are on a leave of absence/vacation. These staff members will be contacted by the Administrator to review staff education regarding the prevention of contraband from entering the facility and the removal of contraband from resident possession. The staff education will be placed in a binder at the front desk and must be reviewed and signed by the staff member before returning to work. The staff member will sign a record of education to validate their understanding of the information presented in the binder. If the staff have any questions regarding the education, they will be instructed to contact the Administrator before signing the record of education. In the Administrator's absence, the Director of Nursing will answer questions regarding the education. Additionally, this education will be provided to new staff upon hire during orientation training and will be repeated to all staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager annually. 2. A system to prevent residents with a history of substance abuse from introducing contraband into the facility or obtaining contraband in the facility will be achieved through staff education. Education will be provided by the Administrator to registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager. This education will review the facility's policy on Alcohol/Substance Use/Abuse updated on 4/18/2024. The education will review that Each resident (and/or representative) is informed that facility policy prohibits the use of alcohol without a doctor's order. Facility policy prohibits the use of illicit drugs. As a condition of residence, each person living in the facility acknowledges that he/she will not use alcohol or illicit drugs during residence in this building. Persons assessed with an active substance abuse problem are offered appropriate treatment and rehabilitative services. While this policy addresses illicit drugs and alcohol, the same standards and expectations are in place for persons with a prescription narcotic addiction. These individuals are also responsible for engaging in appropriate treatment to reduce/eliminate dependency on opioids. Persons returning from the community who present with signs and symptoms of intoxication will be evaluated by the nurse on duty or charge nurse. The nurse is responsible for assessing the person's physical condition and present behavior. The nurse will be responsible for contacting the attending physician (A.P.) if the resident is determined to be in need of medical attention and/or a decision is required regarding withholding prescribed medications. Documentation will be placed in the chart emphasizing signs/symptoms of intoxication/inebriation (such as smell of alcohol, behavior changes, balance/gait problems, appearance of the eyes, and change in speech pattern). Documentation should include the resident's own admission of alcohol/drug use. The facility reserves the right to have the person submit to blood/urine testing at any time if policy violation is suspected. Persons who are evaluated as medically unstable will be transferred for appropriate medical care. Follow-up interventions and treatment recommendations will be communicated to the resident/representative and documented in the medical record. Outside treatment sources will be utilized as appropriate. Residents with substance abuse disorders are expected to participate in acute/active treatment, sobriety counseling, or aftercare interventions, as appropriate to their personal situation. The facility has the right to implement money management interventions pursuant to federal law if substance abuse continues. Persons who continually jeopardize their health and the health and safety of others will be evaluated for involuntary discharge. Education will include instruction on how to identify which residents have a substance abuse disorder and how to locate resident-specific interventions to prevent them from obtaining contraband while in the facility. This information will be kept in binders at the nurse's stations. The binders will include a list of residents with substance abuse disorders and information on resident-centered interventions to prevent them from obtaining contraband while in the facility. These binders will be updated by social services weekly and with resident changes in condition. This education began on 4/18/24 and will be completed 4/22/24. Upon completion of this education, staff will sign a record of continuing education to confirm their knowledge and understanding of the information presented. This education will be provided to new staff upon hire during orientation training and will be repeated to all staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager annually. The Director of Nursing will contact agency staff before their scheduled shift to review staff education regarding the prevention of residents with substance abuse disorders from introducing contraband into the facility or obtaining contraband in the facility. A binder with staff education will be kept at the front desk and agency staff will be required to read and sign to validate their understanding of the information presented in the binder. If agency nurses have any questions regarding the information presented in the staff education biner, they will be instructed to contact the Director of Nursing for clarification prior to signing the record of education. In the absence of the Director of Nursing, the Assistant Director of Nursing will review the education requirements and answer any questions for agency nurses. The facility has identified five staff members who are on a leave of absence/vacation. These staff members will be contacted by the Administrator to review staff education regarding the prevention of residents with substance abuse disorders from introducing contraband into the facility or obtaining contraband in the facility. The staff education will be placed in a binder at the front desk and must be reviewed and signed by the staff member before returning to work. The staff member will sign a record of education to validate their understanding of the information presented in the binder. If the staff have any questions regarding the education, they will be instructed to contact the Administrator before signing the record of education. In the Administrator's absence, the Director of Nursing will answer questions regarding the education. The procedure for developing resident-centered care plans to provide guidance to staff to prevent residents with a history of substance abuse from introducing contraband into the facility or obtaining contraband in the facility will be achieved through education provided by the Administrator to the Social Services department staff on the importance of identifying residents with substance abuse disorders and assessing their risk of introducing drugs/contraband and obtaining drugs/contraband while in the facility. This risk assessment is documented in the resident chart in the Social Service Initial Interview for SMI/Substance Abuse Disorder (SS) assessment. This risk assessment must be used by the social services staff to develop a resident-centered care plan to address the potential risks of the resident introducing drugs/contraband into the facility and obtaining contraband/drugs while in the facility. Care plan interventions will be based on the resident's personal risk factors and coping mechanisms and may include but are not limited to efforts outlined in the facility policy for Alcohol/Substance Use/Abuse such as outside treatment services, acute/active treatment, sobriety counseling, or aftercare interventions. The effectiveness of the care plan must be reviewed quarterly and with changes in condition and updated as indicated. A binder will be placed at each nurse's station with a list of residents with substance abuse disorders as well as information on the resident-centered interventions for preventing them from obtaining contraband while in the facility. These binders will be updated by the social services department weekly and with resident changes in condition. This education will begin on 4/18/24 and will be completed 4/22/24. Upon completion of this education, social services staff will sign a record of continuing education to confirm their understanding and knowledge of the topics presented. This education will be presented to new hire social services staff upon hire and will be reviewed with all social services staff annually. Agency staff is not utilized in the social services department. There are currently no social services staff on leave of absence or vacation. There have been no updates to facility policies. 3. A system to supervise residents from obtaining contraband and from having or obtaining illicit drugs in the facility will be achieved through staff education. The Administrator will educate staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and business office manager on the facility standard for providing adequate supervision for residents with substance abuse disorders to prevent them from obtaining contraband/ drugs. This education includes a review of the facility policy for safety and supervision which focuses on ensuring a facility-oriented approach to safety to address risks for groups of residents including residents with substance abuse disorders/history. Education will discuss the importance of identifying safety risks and environmental hazards on an ongoing basis. Staff will be educated that resident supervision is a core component of resident safety and that the type and frequency of supervision are determined by the individual resident's needs. Staff must intervene immediately whenever an unfavorable event between residents, staff, or visitors is noticed. Staff must decrease safety hazards as much as possible and provide redirection when neces