**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and a record review, the facility failed to prevent an incident of staff to resident sexual assault and inappropriate exposure. This affected one of three residents (R1) reviewed for sexual assault and inappropriate exposure. This failure resulted in V6 forcibly pushing R1 down onto her back, grabbing her breast, undoing his clothing and exposed his penis to attempting to rape R1. R1 said, she felt hurt and wished for death. R1 said, she felt victimized, traumatized, and feared for her safety. The Immediate Jeopardy began on 04/09/24 when V6 exposed his penis and sexually assaulted R1. V1 (Administrator), V2 (Director of Nursing) and V14 (Chief Operating Officer) was notified of the Immediate Jeopardy on 04/18/24 at 11:40AM. The surveyor confirmed by record review and interview that the Immediate Jeopardy was removed on 04/18/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the interventions implemented. Findings Include: R1 was diagnosed with Huntington's disease. Brief interview for mental status dated 02/27/24 documents a score of thirteen which indicates cognitively intact. Screening Assessment to determine abuse/neglect dated 2/21/24 and 4/9/24 documents: a score of (0-2) low risk (risk measure for likelihood of previous/recent mistreatment and psychosocial/psychological symptoms related to history of abuse and or neglect.) On 4/11/24 at 1:08PM, V3 (CNA-Certified Nursing Assistant) said, R1 was her usually self after her lunch. V3 said, she went to lunch and returned, R1 was acting funny, terrible in her chair, moving like she was upset. R1 was anxious. R1 moves all the time based on her disease but R1 was moving more than normal. On 4/11/24 at 2:38PM, V2 (DON) said, he saw R1 after she mentioned the word rape. V2 said, normally R1 is very quiet. V2 said, that was the first time he saw R1 having that much anxiety. On 4/11/24 at 2:55PM, V1 (Administrator) said, he was informed by the V5 (nurse). R1 said, something about rape. R1 never used that language before. V1 said, he spoke with R1. R1 was sitting on the bed crying. R1 said, rape, black man. R1 couldn't give any more detail. V1 said, V6 was identified as that black male after reviewing the video footage. V1 said, V6 reported, he did his rounds and then checked on residents he has not seen throughout the day. V1 said, R1 threw a shoe at V6. V6 left the room, unable to determine why R1 threw the shoe. V1 said, maybe R1 was triggered by a past life event. On 4/11/24 3:15PM, V4 (CNA) said, R1 was agitated. V4 said, she worked with R1 in the past but has never seen R1 like that before. On 04/12/24 at 2:49PM, R1 was assessed to be alert and oriented to person, place and time. R1 was observed visibly distraught, crying, anxious and agitated. R1 said, while crying, red face, snot sniffling and increased body movement which included hitting bilateral heels hard on the floor multiple times, V6 came into her room and started to massage her shoulders. V6 forcibly pushed her down on her back by the shoulders, grabbed her breast on top of her clothing, undid his clothing and exposed his penis and tried to force her to have sex. R1 said, she couldn't yell. R1 said, she hit V6 with her phone then V6 left her room. R1 said, V6 tried to rape her. R1 said, she was hurt and would have rather death instead of being raped. R1 said, she felt victimized, traumatized and feared for her safety. On 4/12/24 at 10:06AM, V8 (Family) said, while crying, to watch R1 die from a debilitating disease is one thing but to watch R1 live through almost being raped and victimized was another level of trauma. R1 could not scream due her Huntington's disease. R1 reported, while in the hospital it would have been easier for her to die than to be raped. On 4/16/24 at 10:58AM, V6 (CNA) said, V6 said, he was compelled to check on R1 because he had not seen R1 in about a week to a week in a half. V6 said, he was concerned about R1. V6 said, it bother him to not see certain residents. V6 said, when he returned from an escort, ten of his residents were soaked in urine. V6 said, he did not report the ten residents to the nurse. V6 said, he changed five residents, then realized he had not seen R1 or R5. V6 said, he went into R1 and R5's room. R5 was sleeping/breathing. V6 said, he walked to R1's bed, R1 was sleeping, not moving and really still. V6 said, he stood in R1's room for one to two minutes to ensure R1 was breathing. R6 said, he had no idea who was R1's assigned CNA. V6 said, he did not notify the nurse when he thought R1 wasn't breathing. V6 said, after one to two minutes he saw R1 breathing he knew she was okay. V6 said, no one asked him to check on R1. V6 said, he was suspended pending an investigation for something, but not sure exactly what. V6 said, abuse should always be reported to V1 or the nurse immediately. Sexual, physical, mental, emotional, financial, involuntary seclusion and verbal are all forms of abuse. V6 said, he was not sure which abuse he was accused of but plan to stay away from all of them. V6 said, since he returned to work he did not have any training and nothing was newly implemented related to his suspension. V6 said, R1 did not throw a shoe at him. On 4/16/24 at 3:12pm, V9 (Nurse) said, R1 was alert and oriented to person, place and time. R1 has never made any false allegations. Health status note dated 4/9/24 documents: Around 3:07PM, nurse on duty observed the resident (R1) being wheeled by two female CNAs in the hallway to the nursing station. Resident was noted to restless and holding her phone with the flash light on. Resident was then approached and asked what is wrong with her but she kept swinging her arms. She was asked if she wanted the nurse to turn off the flash light and she nodded. Afterwards, resident was still noted to be anxious and was again asked if she wanted the nurse to call her son. Resident nodded and the nurse proceeded to call her son but to no avail. Resident was again asked if what is wrong with her and she made an allegation. V1 and V2 was called right away and they went check on the resident. One to one supervision for safety provided. Body assessment and police called. Facility reportable dated 4/9/24 documents: It was reported to V1 (Administrator) that R1 is alleging black male rape. Police were contacted and came to follow up on resident statement. Camera footage reviewed: One employee that entered room for a few minutes with door open has been suspended pending investigation. Police report dated 4/9/24 documents: R1 said, she was raped by a male/black (M/B) about one hour ago. Reviewed video briefly which showed at 1434 hours (2:34PM), a M/B, large build, afro style hair, full facial hair, and wearing all black entered R1's room. At 1438 hours (2:38PM), the M/B subject exits the room. At 1439 hours (2:39PM), R1 exits the room and then walks to a wheel chair. Hospital papers dated 4/9/24 documents: Assault was exposure and an attempt. Video seen on 4/16/24 at 1:15 pm shows V6 was observed entering R1's room whose door was open at 14:34:25 and coming out at 14:38:38 while pulling the door behind him which did not close completely. Abuse Policy dated 12/2020 documents: Our resident have the right to be free from abuse. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. Sexual abuse id defined as non-consensual sexual contact of any type with a resident. The Immediate Jeopardy that began on 04.09.24 was removed on 04.18.24 when the facility took the following actions to remove the immediacy. On April 18th, 2024, a State Surveyor informed the Administrator that an Immediate Jeopardy had been issued for Citadel of Skokie under F600. This abatement plan is being submitted without any prior knowledge of what specifically the Illinois Department of Public Health surveyor's citations will be. The following Plan of Abatement shall also serve as the Facility's written credible allegation of compliance that will be achieved by stated date of completion. Submission of this Plan of Abatement does not constitute in any way an admission of any facts and/or conclusions of law reflected in the alleged deficiencies, nor does it constitute a waiver of the Facility's right to contest the deficiencies and/or any remedies imposed as a result of this or future surveys. The facility reserves the right to contest the survey findings and the immediate jeopardy as allowed by applicable law and rules. The facility abatement plan includes the following: April 9th, 2024 Incident On April 9th, 2024 Facility Administrator was informed that R1 reported black man rape. In response, on that same day, April 9, 2024, the Administrator initiated action consistent with its abuse policy including: · Initiating a comprehensive abuse investigation · Notifying police immediately. Police came to facility and viewed the facility video footage and interviewed R1. R1 was sent to (local) hospital for evaluation. R1 was seen and assessed at the hospital and refused a complete rape kit. R1 had a partial rape kit done. R1 did change her initial statement to exposed his self to me. R1 was not admitted and was sent to another facility the next day. R1 has not returned to the facility. · Identifying and suspending the alleged employee pending investigation. Employee was suspended from April 9, 2024 until the conclusion of the investigation. The investigation as complete by April 11, 2024. Because the investigation could not substantiate that the alleged sexual abuse occurred, employee returned to work April 16, 2024 after Administrator confirmed employee was up to date on his abuse in-service training, including the in-service training referenced below that employee received on April 11, 2024. (No further allegations of sexual abuse were made or received between April 16 - April 18. Employee was suspended April 18 and subsequently terminated for an issue unrelated to the instant sexual abuse allegations.) · Notifying the Resident ' s MD (physician) and family. · Sending an initial report to (state agency) on 4/9/2024 · Sending a final report to (state agency) on 4/11/2024 Administrator completed a comprehensive abuse investigation that included: · Interview of facility employees. Administrator interviewed all employees who were observed to be near/outside the room at the time of the alleged incident and none heard, saw, or observed anything inappropriate from resident ' s room. All other employees were interviewed about their knowledge and experience with the alleged perpetrator and no employees have heard, seen, or otherwise observed anything inappropriate about the alleged perpetrator. · Interview of facility residents. No residents reported any inappropriate treatment or contact by staff, including the alleged perpetrator. · Review of video footage. Video footage that showed employee [NAME] enter R1's room for approx. 3-4 minutes with door left open and exiting R1 ' s room. · Administrator reviewed R1's statements about the alleged incident. Completion Date: 04-09-24 On April 10 and April 11, 2024, Administrator met with corporate office to review Administrator's investigation where it was confirmed that abuse allegation could not be substantiated. Legal counsel confirmed unsubstantiated investigation was insufficient to support employee termination. (Should this reviewer have questions about this determination, we request you meet with our legal counsel for a discussion.) Completion Date: 04-11-2024 On April 9, 2024, Administrator, DON, Regional Nurse began educating all employees on the facility's abuse /neglect policy with emphasis on sexual abuse-physical-reporting. All employees on duty received education before their shift ended. The remaining facility employees have been educated before to their next scheduled shift and education will continue until 100% of facility employees have been educated. The Administration will be at the facility to conduct education at the start of their shifts. Completion Date: 04-19-2024 The Facility Quality Assurance team (which includes Administrator, Director of Nursing, Medical Director, and Facility Directors met on April 18, 2024 to review R1's incident and will meet monthly to review abuse and neglect policies related to sexual abuse. DON will conduct ongoing audits including any risk management reports to ensure compliance once week on each shift for the next 60 days. QAPI will discuss and revise ABUSE policy as needed through the QAPI process. Completion Date: 04-19-2024 Facility SSD (Social Service Director) audited all resident records on April 18 and April 19, 2024 to ensure all residents have an up-to-date abuse assessment. Completion Date: 04-19-2024 R1 was discharged to another facility 4/10/24. Facility has confirmed R1 is stable according to emergency room report dated 4/9/24. Completion Date: 4-19-2024

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have effective system in place to prevent a resident from leaving the facility unauthorized on two different occasions. This affected one of three residents (R1) reviewed for supervision and elopement. This failure resulted in R1 being buzzed out of the facility with a visitor without staff knowledge on 01/05/24, and R1 able to leave the facility without staff knowledge on 03/11/24 after a staff member failed to ensure the door was closed securely after entering. The Immediate Jeopardy began on 01/05/2024 when R1 left out the facility when V14 buzzed visitors out of the facility and was found disorient and falling on the ground by local police, R1 also left the faciity on [DATE] and found disoriented and falling on the ground by the local police. V12 (Administrator) was informed of the immediate jeopardy and the immediate jeopardy template was presented on 03/21/2024 at 9:16 am. The surveyor confirmed by onsite observation, interview and record review the immediacy was removed on 3/22/24 but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the education and in-service training. Findings include: R1 face sheet shows diagnosis of unspecified dementia, severe with other behavioral disturbance. R1 MDS (Minimum Data Set) dated 2/21/24 denotes in part section C for cognitive patterns a BIMS (Brief Interview Mental Status) of 2 (cognitively impaired). Police report dated January 5, 2024, denotes in part on 05 January 24 at approximately 2:11pm hours, I (officer) was dispatched to the (street name) intersection for a public fall on the northeast corner. Upon arrival, I spoke with (fire department) who stated a passing motorist (V2- concern citizen), noticed an elderly male, later identified as R1, walking eastbound on the north sidewalk. V2 stated the male was walking with an unsteady and unbalanced walk and stated he continued to watch the male because he thought R1 was going to fall. V2 stated as R1 turned to go north on the sidewalk, he lost his balance and fell onto the grass parkway. V2 stated he could not tell if R1 lost his footing and fell or if he tripped over the sidewalk. V2 stopped his car and checked on R1. I contacted (police department) Communications and advised them to send an Evidence Technician. E.T. (Officer) arrived on location and photographed the scene and R1. See his report for further. Transported R1 to (local) Hospital for treatment as they could not determine who the male was or his injuries. The elderly male could not provide a name or if he was uninjured. Once at Hospital, he was seen by the emergency room staff and (physician name). I was unable to speak with R1 as he only spoke Spanish. R1 stated to the emergency room nurses, that he was not injured and was transported to the emergency room by the ambulance. While I (officer) was on scene at (the location of the fall), employees from the (nursing facility), stopped and asked if we had seen one of their residents, but did not provide a description. I advised them the ambulance took an elderly male to the hospital, but the male would not provide a name. It was later determined R1 was a walk away from the (nursing facility). The (nursing facility) was contacted, and they arrived to pick up R1. The employees from the (nursing facility) requested R1 be checked out by the hospital staff. Police report dated 3/11/24 denotes in part, on 11 March 2024, at 8:24 hours, I (Officer) was dispatched to the north entrance area of (store name) on (street name) for a report of a public fall. (Local police department) Communications received a call from V15 (concern citizen), stating she was with an elderly male who seems disoriented and appeared to have fallen. Upon arrival, I briefly spoke with V15 who advised she was driving (west bound) on (street name) when she observed an elderly male with a walker on the parkway area of the sidewalk. She pulled into the (store name) lot and assisted the elderly male up and called (local police department). The area was the grass between the sidewalk and (street name). The elderly male was identified as (R1 name). R1 was unable to explain where he had fallen. (R1) did not have any visible injuries on his person. (R1) was wearing a fleece jacket which the right elbow part of the jacket appeared to have grass debris. R1 was unable to answer (local fire departments) questions and was transported to (local) Hospital. The parkway area of the sidewalk had no objects that may have caused R1 to fall. R1 was walking with a walker and appears to have trouble walking due to his medical illness/age. R1 had no visible injuries. (R1) did not have any identification on his person and (local fire department) recognized R1 due to a previous public fall, RD #24-00110. Per the report, (R1) was a patient at (local) nursing (facility), (facility address). I went to (nursing facility) and spoke with the front desk receptionist who advised R1 was a patient. She briefly spoke with the nurse in charge who advised they did not know that (R1) had left the property. I advised staff that R1 had fallen and was taken to (local) Hospital. I spoke with Director of Nursing, (V10) (number listed) who was advised of the incident and stated he was going to review camera footage to see how R1 was able to leave the property. I went to (local) Hospital emergency room #1 and spoke with R1 in Spanish. (R1) stated the following: (R1) was going for a walk and advised he has trouble walking. He did not want to walk on the sidewalk as it was dirty, so he began to walk on the grass. R1 lost his balance as he was walking on the grass with his walker and fell. (R1) advised he was walking on (street name) and advised they just repaved the road, so he was unfamiliar with the street. I advised (R1) he was not on (street name) and not in Chicago. I spoke with R1's daughter/emergency contact, (V1- R1 family) via (telephone) (number listed). V1 stated the following: I advised V1 of the incident and the status of R1. V1 advised R1 has dementia and should not be walking alone. V1 was frustrated that the nursing staff did not notice R1 had left the property. V1 advised R1 has left the nursing home unsupervised approximately three (3) different times. R1 advised she was on her way to Hospital. I provided (nursing facility) and V1 with a incident referral card. On 3/12/24 at 3:24pm V1 (R1 family) said she was R1 power of attorney, V1 said R1 has dementia and uses a walker for ambulation. V1 said R1 should not be out of the facility alone and unsupervised. V1 said she did not give permission for R1 to leave the facility on 1/5/24 and 3/11/24. V1 said the police notified her that R1 was found on 3/11/24 and she rushed to the hospital to see R1. V1 said R1 left the facility a total of 2 times. V1 said R1 does not wear a wander guard band. On 3/14/24 at 10:29am R1 observed resting in bed, awake, alert, orient to name, R1 observed to speak Spanish language. V4 (Registered Nurse) assisted with translation, R1 said he left the facility, R1 said he did hear the door alarms. R1 said no one was at the front desk. R1 complain of pain in his back. R1 laid in the bed to get some rest. Facility incident report labeled unwitnessed fall, dated 1/5/24 at 3:11pm am denotes in part, R1 name, incident location outside. Resident was observed kneeling on the ground. Thorough physical assessment done, no injury, denied hitting head, full range of motion to all extremities. Resident unable to give description. Head to toe and pain assessment done, denied pain complaints, 911 was called. Resident taken to (hospital emergency room) for further medical evaluation. Taken to hospital Y. Mental status orientated to person. Facility incident report labeled other, dated 3/11/24 at 8:25am denotes in part, R1 name, incident location out of facility, Resident went out to walk outside and was picked up by the (local) police officer (name noted) Resident was taken to (local) hospital for evaluation. Resident description I was just walking. Immediate action, taken to ER (emergency room). DON (Director of nursing) and administrator went to see resident right away. He was resting well in bed. He denied pain, no objective signs of pain or discomfort, no facial grimacing, moaning, etc. taken to hospital Y. Mental status, orientated to person, orientated to place. Agency /person notified family member and nurse practitioner. On 3/14/24 at 11:43am V10 (Director of nursing) said R1 did not elope from the facility on 3/11/24 and that R1 went for a walk. V10 said R1 did not inform any staff at the facility that he was going for a walk, V10 said the staff did not know R1 was going for a walk, V10 said R1 did not have an order to leave the facility unsupervised and go for a walk. V10 said he do not know where R1 was going walk to. V10 said he do not know if R1 is at risk for elopement and he will get back to the surveyor. On 3/15/24 at 1:47pm during a follow up interview, V10 said R1 was at risk for elopement. V10 said R1 eloped from the facility twice. V10 said on 1/5/24 he received notification from a staff member that the neighboring facility notified them (male staff member) that the fire department had picked a male up from the ground. V10 said himself and a staff member went to the scene and the police informed them that the male was sent to the hospital. V10 said himself and the staff member went to the hospital and identified that R1 was the resident that the fire department had picked up from the ground. V10 said on 1/5/24 the receptionist pressed the button to allow visitor to leave the facility and R1 left the facility behind the visitors. V10 said the receptionist was not at the front desk monitoring the entry door but instead was sitting behind the nurse's station on the first floor when she pressed the button. V10 said she pressed the button and sat back down; she did not look to see who was leaving the facility. V10 said the receptionist did not see R3 leave behind the visitors. V10 said the receptionist should be at the front desk/ front lobby monitoring that area and door. V10 said the interventions was to monitor R1. V10 said on 3/11/24 R1 left the facility after V3 (CNA- Certified Nursing Assistant) entered the facility. V10 said the door has a delay before it locks. V10 said he watched the video. V10 was asked why didn't V3 redirect R1 front the front lobby area as mentioned in the care plan. V10 said V3 was a newer CNA, and she did not know R1 well, she did not know R1 was an elopement risk. V10 said R1 daughter did contact him on 3/11/24 and express her concerns of R1 leaving the facility unsupervised, V10 said R1 daughter said, what if my father had been hit by a car. V10 did not give response when asked if the monitoring was effective if R1 was able to leave the facility on 3/11/24. Observation of the Nurse station, there is a green square button located on the wall behind the nurse station. V26 (CNA) observed to press this button when door alarm sound. V26 (nursing aide) said this button is used to unlock the front door and to shut the door alarm off. On 3/14/24 at 1:41pm V3 (CNA-Certified Nursing assistant) said on 3/11/24 she came inside the facility, she saw R1 in the front lobby, R1 had his jacket on and R1 had his walker, R1 was standing between the door and the front desk (V3 drew a picture demonstrating R1 position). V3 said she greeted R1 and went downstairs to punch in for the day. V3 did not respond when asked if she was aware that R1 was an elopement risk. V3 denied redirecting R1 from the front lobby area when she observed him with his jacket on. V3 said there were no staff in the front lobby on 3/11/24. V3 did not give response when asked about her understanding of elopement risk, and how do she know who are the residents that are at risk for elopement. Review of V3 timecard denotes V3 punched in at 8:09am on 3/11/24. On 3/15/24 at 10:09am, V7 (social worker) said R1 is at risk for elopement. V7 said R1 cannot go out of the facility without supervision. V7 said R1 has dementia, poor safety awareness, unsteady gait, and is at risk for falls. V7 said R1 cannot go out without supervision for safety reason. V7 said due to R1 dementia, R1 may not know how to return to the facility, R1 may not know how to contact his family and or the facility, R1 may not be able to cross the street safely. V7 said R1 eloped from the facility on January 5, 2024, and recently on 3/11/24. R1 elopement risk assessment dated [DATE] reviewed with V7. V7 said she completed R1 elopement risk assessments and may have documented in error that R1 did not have history of elopement. V7 said she checked No for is the resident considered to be at risk and no for elopement risk because R1 behavior had slowed down from going to the front lobby area. V7 said the elopement risk assessment helps with identifying residents that are at risk for elopement. V7 said the information is used to develop a care plan and interventions to prevent elopement. V7 said R1 elopement risk assessment is not accurate, it does not reflect that R1 is at risk for elopement. V7 said R1 assessment should be answered accurately, so that interventions can be put in place to help prevent R1 from getting out of the facility. V7 said she has observed R1 with exit seeking behaviors like standing around the door, looking around to see if people are going to leave out. V7 said sometimes she monitor the front door, and she have observed R1 with exit seeking behaviors. On 3/14/24 at 11:43am V12 (Administrator) said the facility video camera was not available for surveyor to review. During a follow up interview, on 3/15/24 at 11:14am V12 (Administrator) said he reviewed the facility video and observed R1 leave the facility with his walker on 3/11/24 after V3 entered the facility. V12 said the police notified the facility that R1 was found in the community. V12 said the department was not notified of R1 elopement on 1/5/24 or the elopement on 3/11/24. V12 said he thought the police would report the elopement to the state agency. V12 said the police do not work for the facility. V12 said he should have reported R1 elopement to the State agency (IDPH). On 3/14/24 at 10:32am V13 (Receptionist) said she was running late on 3/11/24, and she was not in the facility monitoring the front desk. V13 said the residents that are at risk for elopement have pictures in the computer, V13 said everyone that monitor the front desk don't have a login for the computer. V13 was asked how the staff will know who are at risk for elopement if they don't have access to the pictures in the computer. V13 said she's trying to start a folder for the pictures. On 3/21/24 at 11:11am V24 (Medical Doctor) said the facility made him aware that R1 left the facility, V24 was made aware of survey findings that on January 5, 2024, a staff member buzzed out a visitor and R1 left behind the visitor and on 3/11/24 R1 left the facility after a staff member entered the facility before the door locked per facility. V24 said he was not there, maybe staff wasn't paying attention. V24 said it's an unfortunate situation. V24 said the facility mention something about a wander guard, he's not sure. V24 said the elopement could have been avoided. On 3/21/24 at 12:16pm V22 (Nurse Practitioner) said R1 is on her caseload, V22 said she sees R1 for routine visits, V22 said she was not aware of R1 elopement on 1/5/24, the facility did not make her aware, V22 was made aware of survey findings related to R1 elopement on January 5, 2024. V22 and the facility made her aware of the 3/11/24 elopement on 3/14/24. V22 said the facility told her that a staff member heard the alarm sounding, or something. V22 said she was not aware that the police found R1 in the community and notified the facility that R1 was out of the facility. V22 said the facility should have made her aware of both elopements. V22 said she request R1 to have a wander guard bracelet. V22 said she did not see anything in R1 notes about the elopements. R1 community survival assessment dated [DATE] denotes in-part, the resident is sufficiently alert, oriented, coherent, and knowledgeable allowing him/her to be considered for independent outside pass privileges, No is checked. Conclusion, the resident does not appear to be capable of unsupervised outside pass privileges at this time. The resident cannot have unsupervised outside pass privileges, at this time. Signed by V7 (social services). R1 elopement risk assessment dated [DATE] denotes in-part, R1 name, score 3, is the resident cognitively impaired with impaired decision-making skill, yes is checked. Does the resident have diagnosis /symptoms of any of the following: dementia, Alzheimer's, yes is checked. Does resident ambulate independently with or without assistive devices including wheelchair, yes is checked. Does the resident have a history of elopement from home or facility, no is checked. Is the resident having difficulty accepting placement, no is checked. Does the resident verbally express a desire to go home, no is checked. Does the resident pace expressing a desire to locate a family member, no is checked. Has the resident been observed standing at the exit door waiting for someone to let them out, or verbalized a plan to exit, no is checked. Total score (a score of 5 or more is considered to be at risk for elopement). Is resident considered to be at risk, no is checked. Elopement risk, 4 is checked for not at risk. Observation of the first-floor nurses' station, the nurse's station has a high countertop, when sitting behind the nurse's station, the person must come to a standing position to see who is exiting the front door, which is greater than 15 feet away. R1 plan of care with initiated date of 3/11/24 denotes in part resident (R1) is high risk for wandering/elopement identified, resident safety will be maintained will not leave facility unattended through next review. Close monitoring of residents whereabouts at least hourly. Provide resident picture at reception desk and at nurse station. Engage resident on all floor activities to redirect/divert attention to deescalate elopement ideas. Encourage family visits as often as needed. Involve family to help redirect resident in a meaningful conversation to mitigate unsafe notion to leave unattended. Ensure doors are secured alarmed. R1 plan of care for cognitive loss dated 5/3/2023 revised on 3/11/24 denotes in part, I (R1) am an older adult functioning with dementia. I may respond coherently at times, other times I may display cognitive challenges. My concentration and attention-span may be affected. I have reduced cognitive processing speed and deficits in executive functions such as abstract reasoning, planning, problem solving, impaired conversational skills, and lack of initiation. My strengths include my enjoyment of physical movement, exercise (including walking) and keeping busy. I have periods of lucidity and greater awareness. I will accept interventions to avoid complications/decline concerning my cognitive loss and I will be provided care/activities/interventions to help strengthen and promote my cognitive skills. Emphasize keeping R1 busy and engaged. Review his favorite and preferred activities which often include movement, exercise, physical tasks; solicit additional ideas for engagement from his family. Offer opportunities to 'move with music.' Cue, reorient and supervise as needed. R1 plan of care for falls denotes in part, R1 is at risk for falls r/t (related /to) gait/balance problems, poor communication/comprehension, unaware of safety needs. Facility policy titled Wandering, Unsafe Resident revised dated of 8/2014 denotes in part the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at risk individual for potentially correctable risk factors related to unsafe wandering. The resident care plan will indicate the residents is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as detailed monitoring plan will be included. Facility policy titled Care plans, comprehensive person centered with revised date of 12/2016 denotes in part a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Incorporate identified problem areas, incorporate risk factors associated with identified problems. The Immediacy Jeopardy that began on 01/05/24 was removed on 03/22/24 when the facility took the following actions to remove the immediacy. January 5, 2024 Incident On January 5th Facility V12 Administrator educated V14 on the elopement policy. V12 Administrator has verbal discussion with receptionist at the time to confirm understanding of elopement policy, including door buzzer process: 1. When door alarm is activated- go outside and check surroundings to identify root cause, if you do not actually see who activated alarm. 2. Ensure door closes and alarm activates prior to leaving door unattended. 3. Do not buzz any resident out of facility unless you 100% know who the resident is and that they have permission to leave premises. 4. Immediately respond to all alarms and assist residents back into facility. 5. Always stop and ask visitors if a resident is walking with them- where are they going and confirm with Nurse that they have properly signed out prior to allowing them to leave. V 14 Receptionist involving in the incident resigned. No other reports or incidents of residents able to exit with visitors/staff with other reception staff. Completion Date: 1/5/24 R1 was seen and assessed at the hospital. R1 was not admitted and returned to the facility the same day. Upon his return, Facility recommended relocation to second floor where Wander guard could be implemented. Family declined and preferred R1 remain on first floor. Educated on risks. Behavior monitoring completed every shift for R1 throughout January, February, and March. Neuro checks were implemented upon return to facility for close assessment for 72 hours. Completion Date: 1/5/24 On January 5th, 2024, V19 Maintenance Assistant, V19 performed a check of all facility doors and alarms to confirm they were working, secure and in good operation. Maintenance department performed weekly checks thereafter with no issues identified. Completion Date: 1/5/24 March 15, 2024, Incident R1 has been assessed with care plan updated to address elopement risk. Facility recommended relocation to second floor where Wander guard can be implemented immediately. Family declined and preferred R1 remain on first floor. Educated on risks and care plan update. R1 was placed on close monitoring 15 min checks, hourly checks, close monitoring. Facility resident head count conducted and confirmed all residents were accounted for on 03-11-24. Completion Date: 3/15/24 All facility staff: Nursing, activities, housekeeping, dietary, Bus driver. Maintenance staff, office staff, are educated annually on elopement policy and procedure, and safety and supervision of residents. Training has been reviewed and confirmed to have been up to date for all staff. Completion Date: 3/15/24 All Facility staff including all receptionists were trained on: elopement risk binder kept at facility reception desk/nurses' station desk. R1 as elopement risk as identified in the elopement risk binder. door buzzer system and procedures to prevent residents from exiting and preventing unauthorized entries. ensuring residents are not near/trying to access doors when staff enter exit. All training was completed with open discussion among participants to maximize participation and demonstrate understanding. Completion Date: 3/15/24 Facility V 12 Administrator, V 20 Corporate Nurse Consultant/Nurse Administration and V11 Chief Operating Officer /Chief Nursing Officer immediately educated all facility employees on the following topics: 1. Elopement procedures, including securing doors to prevent unauthorized exits-facility and the door buzzer system process. 2. Elopement policy including reporting/proper notification policy and Identification of high-risk elopement residents through the use of the elopement risk binder that identifies high risk elopement risk residents at the receptionist /nurse's stations. 3. Policy and procedure to immediately notify nursing supervisor/designee when new exit seeking behaviors or high-risk behaviors are identified so that: a. Nursing supervisor/designee will assess behaviors. b. Nursing supervisor/designee will investigate root cause of behaviors. c. Elopement assessment and community survival skills will be reassessed. d. IDT will implement new interventions. 4. Facility V10 and V 12 will be the facility designees that will be responsible for staff training and evaluation of staff knowledge of elopement policies/procedures/door buzzer system/exiting doors with visitors. The education was completed between 3/11/24 and 3/15/24 for all facility staff. All training was completed with open discussion among participants to maximize participation and demonstrate understanding. Completion Date: 3/15/24 The Facility Quality Assurance team, which includes V12 Administrator, V10 Director of Nursing, V21 Medical Director, and Facility Directors met on 3/15/24 to review R1's incident and then will meet monthly to review Elopement policies and reporting, door buzzer, and exiting door with visitors. V20 will conduct ongoing audits including any risk management reports to ensure compliance once week on each shift for the next 60 days. QAPI will discuss and revise elopement policy as needed through the QAPI process. Completion Date: 3/15/24 All residents receive comprehensive assessments on admission and annually thereafter. All residents are assessed as needed for condition change, and when exit seeking behaviors or high-risk behaviors are identified. R1 is the only exit-seeking resident on the first floor. Completion Date: 3/15/24 Facility has audited all resident records to ensure all residents have an up-to-date elopement risk assessment and community survival assessment. Completion Date: 3/15/24 V19 Director of Maintenance or designee is performing door checks 3-5 times a week to ensure doors secured per facility policy/procedure. Completion Date: 3/15/24 All staff education provided and 1:1 V3 training provided on elopement policy and procedures- Identification of high-risk elopement risk residents through the assessment and the use of elopement risk binder process. Door buzzer process-door entry/exit closure/locking after being entered by staff/or visitor's process. Facility did not employ agency workers during this timeframe. If in the future agency is used, they will receive training prior to working their shift by V10 Director of Nursing or V12 Administrator. Staff that were on vacation received training via phone. Staff that were out sick received training via phone. If staff are unable to be contacted, they will receive training prior to next scheduled day of work by V10 Director of Nursing or V12 Administrator. All new facility employees will be trained during orientation process. Completion Date: 3/15/24 Quality Assurance meeting held 3-15-24 to review elopement issue and interventions. QA tool implemented for monitoring processes. Completion Date: 3/15/24 New Wander guard system was quoted 3/15/24 and will be installed and tested upon receipt. Completed installation confirmed that it's working on 3/22/24. Wander guard applied to R1. Completion Date: 3/15/24 Door egress delay was changed from 18 second delay to 5 second delay to prevent residents from using doors after staff enter/exit. During hours that receptionist is not clocked in at facility. The first floor Charge Nurse and first floor staff will monitor entrance. Completion Date: 3/15/24 Elopement books confirmed to be up to date including door buzzer/alarm and in place at reception desk. R1 is only elopement risk on the first floor and all receptionists familiar with R1 to watch for exit seeking. V7 Social Services Director will oversee new admissions risk elopement assessments and the assignment of wander guards. Completion Date: 3/15/24