**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow advanced directives for 1 of 3 (R5) residents reviewed for advanced directives in a sample of 16. This failure resulted in an Immediate Jeopardy on [DATE] when staff performed unnecessary chest compressions, respiratory ventilation for 20 plus minutes, and intubation on R5 against his advanced directive status. On [DATE] at 9:22 AM V1, Administrator was notified of the Immediate Jeopardy. The Surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on [DATE], after abatement reviews dated [DATE] at 7:35 AM and [DATE] at 3:07 PM but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-servicing training and policies and procedures.Findings include:R5's Physician Order Sheet (POS), dated 7/2025, documented diagnoses of Chronic Obstructive Pulmonary Disorder, Chronic Diastolic Congestive Heart Failure, and Morbid (severe) Obesity with Alveolar Hypoventilation. It also documented an order dated on [DATE] DNR (Do Not Resuscitate).R5's Post Acute Care Transfer Report from the local hospital, dated [DATE], documented, Code Status Information: Limited: No CPR (cardiopulmonary resuscitation) Modified Resuscitation Specifics: Provide aggressive: No intubation.R5's Care Plan did not document R5's code status.On [DATE] at 9:56 AM, V7, Licensed Practical Nurse, (LPN), stated that at around 5:20 AM on [DATE], she was passing medications, and she stopped at R5's room, and took his medications in to him. She stated that she set them down on the table, called his name and he didn't respond, so she shook him, and he felt cold, and his color was pale. He did not respond, so she rubbed his chest and checked his neck for a pulse and did not feel anything. She stated she yelled for help, she checked her computer, that was right outside of R5's room, and there was not a code status in the computer. V7 was asked where she would find a code status on a resident in the computer, V7 stated that on the MAR (Medication Administration Record) by the resident's picture is their code status. V7 stated that the other nurse called 911, and she started Cardiopulmonary Resuscitation (CPR), had the bed flat. V7 stated that Emergency Management Services (EMS) arrived 15-20 minutes later and took over CPR. V7 stated that since she could not find the code status, she treated it as a Full Code. She also stated that while EMS was performing CPR, she went to the nurse's station and checked the BIG computer and there still wasn't a code status that could be found. She continued to state that she entered R5's room and EMS had stopped CPR at around 5:47- 5:50 AM and the MD (medical doctor) from the hospital called it (time of death). V7 stated that when the day shift nurse came in, she showed her where R5's code status was in miscellaneous in R5's electronic medical records. V7 stated that prior to her going into R5's room to give him medication at 5:20 AM, the last time she checked on R5 was around 12:30-12:45 AM. V7 stated that code status for all residents is on the home page and the Medication Administration Record (MAR), both located in the electronic medical record (EMR). On [DATE] at 2:00 PM, V8, Certified Nurse Assistant, (CNA) stated that she was not R5's CNA the night he passed away, but she was working so she went down to his room while CPR was in progress and before EMS came, and V7 had her perform CPR, because the nurse was getting tired. V8 stated that she couldn't answer where she would find a resident's code status.On [DATE] at 9:30 PM, V14, LPN, who was the day shift nurse on [DATE] that came in at 6:00 AM for her shift and assisted V7 with finding the code status, stated that when she came in, R5 was being coded by EMS, and that he was intubated. V14 stated that the DNR was in the miscellaneous section of his chart and that it was not on the computer screen where V7 could find it. V14 stated that she knew he was a DNR because she admitted him from the hospital on [DATE]. V14 also stated that there is a list of residents who are DNR at the nurse's station by the computer, but his name wasn't on it. V14 stated that EMS did intubate R5 and used the Ambu bag and that the doctor at the hospital told EMS to stop CPR. V14 was asked when a resident returns from the hospital, like R5 did, who gets the order from the doctor for the new code status? V14 stated that it is usually the admitting nurse, but she continued to state that she didn't think she got the order for R5's DNR nor did she put it in the computer and that was why it did not show up when V7 was looking for it. V14 stated that when she was helping V7 look for it, it was not on R5's home page in the electronic medical record and that was why V7 couldn't find it. On [DATE] at 11:55 AM, V17, Social Services Director, stated that she was not aware of R5's code status change when he returned from the hospital on [DATE]. V17 stated that no one notified her of the change of code status from full code to DNR, so a new POLST (Physician Orders for Life-Sustaining Treatment) was not made in June. V17 stated that when R5 returned from the hospital she went down to see him, and he gave her his will and the healthcare power of attorney, and she continued to state that in that paperwork there was no DNR, nor did it document a code status change. V17 then stated that you can't be a DNR and be comfort care and that she did not think this was a DNR, but she also did not approach R5 with a new POLST since she was not aware of his decision.On [DATE] at 12:25 PM, V2, Director of Nurses, stated that R5's code status was changed when he came back from the hospital on [DATE] and she did not know why an order was never written on that date. She continued to state that the social worker was given his living will, but she doesn't remember who the nurse was or what had happened to the hospital paperwork, but the DNR never was put into their computer system on [DATE]. V2 stated that the nurse started CPR on [DATE] on R5 because she couldn't find in the system where R5 was a DNR, so their protocol was to start CPR. V2, stated that 2 things happened during that code, 1. the paper was found that he was a DNR and 2. the daughter told them to stop CPR. V2 stated that the issue was that the nurse working did not see where the code status was. V2 stated that someone, could not recall which nurse, communicated with her that R5 was a DNR on [DATE], it's possible that that nurse is no longer employed at the facility, it is the responsibility of that nurse to write the order for the DNR and to make sure social services knows and then we follow up on it to make sure it was done. No one followed up on his DNR and that was why the order was written on [DATE] and back dated for [DATE]. V2 stated that R5 should not have been Coded on [DATE] but the agency nurse did not see he DNR and our protocol is to start CPR. V2 stated that agency nurses have access to the medical records system where it has code status and there was a list at the desk of who are do not resuscitate (DNR).On [DATE] at 2:00 PM, V1, Administrator, stated that what she is learning at this time was that at the hospital he decided to make that change and that paperwork, with the DNR and it was not given to social services. V1 stated that the nurse who admitted him on [DATE], should have put the DNR orders in when he was re admitted and then let social services know so a new POLST could have been done. V1 stated that she would expect the staff to know where to find a resident's DNR on the dashboard and in point click care (electronic medical records). V1 stated that R5 should have been reassessed upon readmission and the breakdown in communication was that social service was not being made aware by nursing of the change in code status and that the physicians order should have been written by the nurse. On [DATE] at 3:03 PM. V12, R5's daughter and Healthcare Power of Attorney (HCPOA), stated that her father did not want to be intubated but when they called her that morning and was told they were doing CPR, she stated that she told them to stop CPR because he was a DNR. V12 continued to state that the last time her father was in the ICU, which was the end of May and early June, they, her, her sister (V13) and the doctor had a serious talk about code status and that her dad wanted CPR but did not want to be intubated and that the doctor told him one could not be done without the other. V12 stated that they all had a concern that if her father was to be intubated, then he may never get off a ventilator and he did not want that, so he decided that he would be a DNR. V12 stated that early June is when the paperwork was done, and it went back to the nursing home with him that he would be a DNR.On [DATE] at 10:35 AM, V18, R5's Nurse Practitioner, stated that code statuses are updated in the files and when she looked this morning, in his file, he was a DNR. She continued to state that they, do not have a specific procedure with DNR, if it was signed at the hospital and that it was signed by a physician there. V18, stated that she would expect the facility to honor the residents wishes with their code status.R5's Progress Note, dated [DATE], at 6:35 AM, written by V7 documented, This nurse started CPR until (Local) police arrived with paramedics and this nurse was instructed to stop CPR. This nurse left out of the room and continued to find polst form for code status. Another nurse came in and went into computer and located DNR paperwork and this nurse went and took paperwork to medical staff assisting with the code. This nurse called POA, and she stated that the resident just signed DNR forms and to stop CPR. The physician that called time of death is (Hospital Doctor) with (local) hospital. Time of death called at 6:07 am. Daughter is in route to facility. DON called and informed of resident expiring awaiting daughter to arrive. This nurse spoke with coroner (County Coroner). Oncoming nurse aware that she will need to call coroner with name of funeral home once next of kin arrives.The Facility's policy, Advance Directives, undated, documented, 1. At the time of admission each resident will be asked if they have made advanced directives and provided educational information regarding state and federal law. 2. The Social Service and/or Admissions Director will be responsible for providing copies of state statutes, regulations, and information regarding Advanced Directive(s), to resident, legal representatives upon admission, and also to families who wish to receive such information and assistance regarding Advanced Directive(s) and decisions regarding life sustaining measures and in no event shall give legal advice on the need for medical care directives. 3. The resident, the legal representative, or the individual who has been authorized as the resident's health care representative will be asked if an Advanced Directive, as recognized under the state law, has been executed. Documentation concerning this inquiry, and the individual response shall include the date the entry was made and the individual making this inquiry. This information shall then be included in the resident's medical record. It continues, 6. Copies of the resident's Advanced Directive shall be made and maintained in the resident's clinical record and financial folder.The Immediate Jeopardy that began on [DATE] was removed on [DATE], when the facility took the following actions to remove the immediacy:1) A) Admin/SSD were in-serviced by the VP of clinical services on POLST forms, updating in medical records, timeliness of updating medical records. Completed [DATE].B) Admin will in-service IDT on POLST forms, expectations, where to locate code status of residents, and who can perform CPR, what to do when resident is found to be in distress. Completed [DATE].C) Current staff in-serviced on code status, where to find in residents' chart. Completed [DATE].D) Current licensed staff in-serviced on code status, where to find in residents' chart, who can perform CPR, and who to inform if a new code status when resident is admitted /readmitted . Completed [DATE].2) A) All residents that reside in the facility will have their POLST forms audited within the last 30 days. Completed on [DATE] by RNC & Administration. From [DATE]-[DATE]. Completed on [DATE]. B.) All residents will have a code status order and care plan updated within the last 30 days related to their POLST forms. Completed by RNC and Administrator on [DATE].C) Review of policy and procedure of advanced directives and system that is in place for updating code status. Residents that do not have a POLST form will remain a full code until POLST form can be obtained. Completed by VP of Clinical Services on [DATE]. 3) All working staff have been in-serviced on where to locate code status, who to give POLST forms to when a new admission or re-admission changes code status. Currently all staff on shift are in-serviced. Total facility will be 100% by 7.22.25. If staff are not in-serviced, they will be in-serviced prior to working their next shift.4) No staff will work before being in-serviced on code status. Ongoing being completed by IDT (Interdisciplinary team) or designed by start of next working shift. 5) A quality assurance tool was implemented; Daily audit will be completed of the 24-hour report to see if there are any new admissions &/or readmissions, POLST status will be reviewed, and if it a part of the medical record. Audit will continue daily x 4 weeks to ensure that code status is updated timely and located within the medical chart. Ongoing. Audits to be completed by Administrator/Designee.6) Root Cause Analysis Completed for POLST Forms.Deficiency: failed to follow POLST form that reflected residents wishes.Root Cause: Attached. Initiated on [DATE] and completed 100%.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were supervised to prevent elopement. This failure resulted in R2 eloping from the facility on 6/15/2025, unknown as being gone and spotted 0.2 miles from the facility, alone in a parking lot by V5 (Certified Nurse Assistant) who was returning from lunch. R2 was brought back to the facility but her return condition at the time of her return remains unknown, as she received no assessment for injuries and no longer resides in the facility. This failure also resulted in R22 eloping from the facility on 7/8/25 when R22's nurse (V30) noticed him missing between 9:30 AM to 10 AM. V30 stated R22 was returned to the facility at approximately 12:40 PM. The Immediate Jeopardy began on 6/15/25 when due to the facility's failure to provide adequate supervision for R2 who has a diagnosis of schizophrenia, periods of confusion with a physician order for memory diagnostic clinic for concerns for underlying neurocognitive disorder of which the facility failed to schedule following R2's recent hospitalization after she was found at an airport with confusion and claiming she had been kidnapped. R2's care plan did not document R2's risk of elopement nor was it updated following R2's elopement from the facility on 6/15/25. The facility failed to follow its policy and did not implement interventions after R2's facility elopement risk assessment deemed R2 at risk for elopement and R2's facility community survival skills assessment conclusion documented R2 does not appear to be capable of unsupervised outside pass privileges at this time. On 6/15/25 at approximately 11:20 AM a facility CNA (Certified Nurse Assistant) was returning to the facility from her lunch break and spotted R2 in an apartment parking lot approximately 0.2 miles from the facility without the facility's knowledge of R2 being gone from the facility. R2 was not assessed for injuries upon return to the facility after she eloped on 6/15/25. R2 remained at the facility until her family discharged her on 6/17/25. The facility did not update R2's care plan nor implement any risk reduction measures prior to nor following her 6/15/25 elopement. V1, Administrator, and V11, [NAME] President of Clinical Services, were notified of the Immediate Jeopardy on 6/25/25 at 12:30 PM. The facility then failed to implement elopement precautions for R22 after he was assessed as at risk for elopement. R22 has a diagnosis of paranoid schizophrenia and a history of elopement from his prior facility. R22's nurse V30 had previously cared for R22 at his prior facility and was aware of R22's history of elopement. V30 noticed R22 was not in the facility between 9:30 AM and 10 AM on 7/8/25 and was not returned to the facility until approximately 12:40 PM when the facility transportation CNA observed R22 approximately 0.2 miles from the facility. R22 stated he walked down to the city fountain which is located approximately 1 mile away from the facility. The Immediacy was removed on 7/8/25 but the facility remains out of compliance at a Level II. Findings Include: 1.R2's census sheet, print date of 6/18/25, documented R2 was admitted to the facility on [DATE]. R2's medical diagnosis sheet, print date of 6/18/25, documented R2 has diagnoses including schizophrenia, depression, heart failure, cardiomyopathy, coronary atherosclerosis, hypertension, pneumonia, type 2 diabetes mellitus, and depression. R2's elopement evaluation, dated 5/21/25, documented a score value of 1 or higher indicates risk of elopement. R2's elopement evaluation score was 6. R2's community survival skills assessment, dated 6/8/25, documented R2 is not sufficiently alert, oriented, coherent nor knowledgeable to be considered for independent outside pass privileges. This form documented R2 does not know the facility address nor how to ask for/seek help in an emergent or problematic situation. This form also documented R2 does not have the ability to adhere to pass privilege policies, e.g., getting permission to leave, signing out, respecting time parameters and curfews, and informing staff upon return. This assessment conclusion documented the resident does not appear to be capable of unsupervised outside pass privileges at this time. R2's MDS (Minimum Data Set), dated 5/29/25, documented R2 is cognitively intact although on 6/18/25 at 11:51 AM V10 (Social Service Director) stated she completed R2's cognitive assessment and that R2 was able to answer the questions on the assessment but R2 was absolutely not safe to go outside on her own and that R2 would not have known to sign herself out of the building. R2's care plan, print date of 6/18/25, does not document or address R2's elopement risk. R2's hospital H&P (history and physical), dated 5/6/25, documented Pt (patient) with psychosis that appears to be new, but it appears has not been evaluated by a medical professional. She is also having an acute on chronic systolic heart failure exacerbation. Diagnosis for cause of psychosis is unclear but there is suspicion for a dementia related diagnosis given the age of onset. R2's regional hospital inpatient Discharge summary, dated [DATE], documented principal problem pneumonia of right lower lobe due to infectious organism. Active problems: delirium. Resolved problems: no resolved hospital problems. Details of hospital stay per H&P on 5/6/25 R2 is a [AGE] year old F (female) w/ (with) PMH (past medical history) of dilated cardiomyopathy, CAD (coronary artery disease), HTN (hypertension), DM (diabetes mellitus), insulinoma s/p (status post) Whipple (surgical procedure of pancreas), depression who was brought to the hospital by ambulance for paranoia, found to have exacerbation of known heart failure. Per chart review, patient was BIBEMS (brought in by emergency medical services) as she came to the airport and told people there, she had been kidnapped. On arrival to the ED (emergency department) patient was combative, attempting to leave the emergency department. She was treated with Ativan, Zyprexa, and eventually IM (intramuscular) Haldol multiple times during ED stay. It continues, patient was evaluated by psych team in ED who noted unspecified schizophrenia and other psychotic disorder but given elevated BNP (B-type natriuretic peptide) concerning for HF (heart failure) exacerbation, not appropriate for psych admission at this time. Patient arrived to the floor agitated, kicking at staff, but on room air and with stable vitals. Unable to obtain medical or social history from patient. It continues, hospital course: delirium and agitation: patient brought to the ED by EMS for bizarre behavior. Initially combative and aggressive requiring multiple doses of IM Haldol and patient was placed on elopement precautions. Intermittently requiring physical restraints during the initial presentation, patient became more appropriate, with better insight as her admission progressed. This was in the context of a psychiatric consult and the initiation of scheduled PO (by mouth) Haldol for symptom management. Given acute presentation, infectious workup was completed which was negative, at which point antibiotics were discontinued. Treatment of acute heart failure exacerbation as below. Improvement in heart failure exacerbation coincided with improvement in mental status, but this is in conjunction with scheduled antipsychotic medication. Initial attempts to wean off Haldol coincided with increased confusion and irritability, so psychiatry was reengaged and recommended a taper off of Haldol and onto Seroquel. This taper was initiated inpatient, and instructions for further tapering were provided to skilled nursing facility at time of discharge (see below). Per psych the underlying diagnosis for this is agitation in the setting of delirium and Seroquel is scheduled to stop after 2 weeks on just Seroquel, with encouragement to follow up outpatient with memory diagnostic center and geriatric clinic. It continues, Haldol to Seroquel taper (instructions below), f/u w/ memory diagnostic clinic for concerns for underlying neurocognitive disorder. On 6/26/25 at 10:26 AM V25 Transportation CNA stated she took care of R2 a few times during her stay and R2 was confused and wandered around the facility. V25 stated she started doing transports about a month ago and she did not take R2 to any appointments nor know anything about her order for a memory diagnostic center. Surveyor asked V25 how she is notified of resident appointments and V25 replied the nurses are supposed to write it down for her although they have not been doing this, so she is being trained on how to check the EMR (electronic medical record) for appointments.On 6/26/26 at 10:42 AM V25 stated she started doing resident transports on 6/2/25 and stated the facility has agency nurses and they usually do not know the process therefore she is often not notified of appointments that are needed for residents. On 6/26/26 at 10:47 PM surveyor called the Memory Diagnostic Center where R2 was referred to and V26 office employee stated there was never an appointment made for R2.On 6/26/25 at 11:16 AM V1 Administrator stated the facility never made the appointment for R2's discharge to be evaluated at the Memory Diagnostic Center. V1 stated she does not know why it was not made because the prior transport aide quit with no notice.On 6/26/25 at 12:27 PM V1 Administrator stated all resident discharge orders from hospitals including orders for follow up appointments should be added the resident's physician orders upon admission.R2's hospital progress notes/referral documents, dated 5/15/25, documented CT (computed tomography scan) head without contrast. History: [AGE] year-old female presenting with altered mental status. Findings: encephalomalacia in the right occipital lobe. According to the National Institutes of Health (NIH.gov) encephalomalacia is the softening or loss of brain tissue after cerebral infarction, cerebral ischemia, infection, craniocerebral trauma, or other injury. According to NIH.gov symptoms of encephalomalacia include memory loss, difficulty concentrating, difficulty with reasoning and judgment, and impaired problem solving. NIH.gov noted brain tissue damaged by encephalomalacia cannot regenerate and results in permanent brain damage. It continues, assessment/plan: AMS (altered mental status) - patient is poor historian and unwilling to participate in interview but based on collateral from friend patient with 3-5 years of worsening delusions and paranoia, has filed multiple police reports against neighbors. It continues, unclear if this is patient baseline, or gradual worsening of chronic condition vs (versus) acute presentation at this time. It continues, delirium precautions, elopement precautions. R2's hospital internal medicine daily progress notes, dated 5/12/25, documented interval history: afebrile, hemodynamically stable. Remains intermittently confused, although cooperative with staff and exam. R2's facility admission notes, dated 5/21/25 at 3:43 PM, documented resident transferred to facility via ambulance. This nurse received report from (nurse) at (regional hospital). Resident is a [AGE] year-old female. Alert, confusion at times, early onset dementia. Resident was found at an airport. Resident didn't remember how she got to the airport; told hospital staff she was kidnapped. Resident noted to have delusions at times. R2's facility progress note, dated 5/22/25 at 12:38 AM, documented alert with intermittent confusion. High elopement risk. Staff has to monitor very closely. Resident approached side doors several times during the shift but easily redirected. R2's progress note, dated 5/27/25 at 5:34 AM, documented resident walked around all night with no recollection of previous encounters with staff seen within 30-minute time frame. Resident seemed angry and distressed. Resident stated that she was looking for something and stood in the dining area for one hour under supervision until moved back to room. Resident became very angry if touched all efforts redirected by letting resident move when ready. Sign has been placed on door to help resident identify living area. R2's Nurse Practitioner progress note authored by V22, dated 5/28/25, documented [AGE] year-old female presents to me today at NF (nursing facility) as new patient. She admitted from hospital after paranoia, AMS (altered mental status), and HF (heart failure) exacerbation. It continues, she is A&O (alert and oriented) to self. Cognitive status: confused. R2's progress note, dated 6/11/25 and authored by V22 Nurse Practitioner, documented R2 presents to me today at NF for nursing reports that R2 has been refusing medications and her sister is here and concerned about her edema. Her sister wants her to go to ER d/t (due to) the refusal of meds and her edema. She is adamant she does not wish to go. She is very agitated and paranoid this am. She will not answer ROS (review of systems) questions and only allows for limited exam. Sister wants me to give her something to be more compliant, explained that is not possible. She is also requesting (regional) hospital. Explained EMS makes that call. Also explained if she refuses when EMS arrives there is strong chance, they will not take her. She is up in chair. She is A&O (alert and oriented) to self. R2's behavior progress note, dated 6/9/25 at 3:20 AM, documented resident attempted several times to leave facility and had to be redirected multiple times. Resident states that she cannot stay here because her house is waiting for her. It continues, resident is starting to wander in the room of other residents. R2's progress note, dated 6/11/25 at 10:08 AM, documented resident out in dining room during breakfast with x2 family members present. Resident having increased behaviors, yelling, cursing, refusing medications and meal. DON (Director of Nursing), Administrator, ADON (Assistant Director of Nursing), and NP (Nurse Practitioner) present and aware. Orders received per NP to send resident to ER (emergency room) for evaluation. Resident refusing all care. Family requesting resident may need to be sent to psych (psychiatric) eval (evaluation) for AMS (altered mental status) and increased behaviors, plus refusal of medications and care. It continues, resident currently ambulating self around facility, staff supervision/monitoring continues. R2's next progress note following the 6/11/25 progress note was on 6/14/25 at 12:57 PM and it documented resident has refused all medications, including blood glucose monitoring/insulins for this nurse today. Several attempts to offer medications during scheduled times refused and resident stated, I don't take medicine.R2's initial psychiatric evaluation, date of service 6/13/25 and authored by V28, documented per staff patient wanders a lot and voice thoughts indicative of delusions and paranoia. Per staff patient voiced she was kidnapped and feels that she is not safe because someone wants to kill her. Patient also believes that her credit card was used to fund breakfast. Per staff patient believes she has been to jail and works at the airport. Patient appears to be exit seeking at times as she believes she needs to get to work at the airport. Per staff patient can be irritable and has been refusing to take her medication. She appears suspicious of staff and paranoid. Upon assessment today patient was not cooperative. She states, I already have a doctor I don't need to talk to you. Denied feelings of anxiety and depression. Denies concerns with sleep or appetite. When asked about hallucinations patient states I am done with you go on Per documentation/chart review patient was recently discharged from the hospital for bizarre behaviors, delusions, and agitation and was started on medication management. Per staff family would like for patient to get [NAME] (long acting injectable). Mental status examination documented Thought Process: disorganized, Associations: loosening associations, Thought Content: paranoia and delusions elicited, Mood: irritable, Attention: impaired, Insight: poor, Judgement: poor, Orientation: person. R2's progress note, dated 6/15/25 at 10:32 AM, with a created date of 6/16/25 at 10:34 AM, and authored by V1 Administrator, documented R2 exited the facility without signing out. This writer remined R2 of the importance of signing out with the nurses and showed her where the sign out book was located. R2 has a BIMS of 13 and voiced understanding. R2's incident progress note, dated 6/15/25 at 1:16 PM, documented resident exited building and went outside. Staff with resident and assisted resident back in facility. Resident educated and reminded to sign out when going outside of building and tell staff before exiting. Resident verbally agreed. Enhanced supervision provided. R2's behavior progress note, dated 6/16/25 at 5:39 AM, documented resident A/O X 2 did not sleep well in assigned area with consistent ambulating to dining hall and sleeping on couch. Pt (patient) was redirected several times to assigned living area. Pt is pleasant but confused on why she is living here. Pt is exit seeking and sleeps no more than three to four hours late nights. It continues, resident has been placed with safety protocols. Will continue with plan of care. R2's behavior progress note, dated 6/16/25 at 6 AM, documented resident attempted exit and redirected to unit 200. Returned to hallway seeking exit 5 per staff. R2's progress note, dated 6/17/25 at 1:35 PM, documented upon return from LOA (leave of absence), residents sisters voiced that resident will be leaving facility and not returning. Family refused to wait until MD (medical doctor) notified. Family also refuses to make facility staff aware of where resident is discharging to. On 6/18/25 at 8:25 AM V7 LPN (Licensed Practical Nurse) stated R2 discharged from the facility yesterday and R2's family did not say where she was going. V7 stated she was not working when R2 left the building, but she heard R2 eloped and was by the highway. V7 stated a CNA noticed R2 on her way back from lunch and picked her up. V7 stated the times she cared for R2 in the last 2 weeks R2 was paranoid and combative. On 6/18/25 at 8:30 AM V5 CNA approached surveyor and stated, I was working last weekend, I was returning from lunch around 11:20, and I saw (R2) down the street. V5 stated she did a u turn, stopped, and said to (R2) I will take you home. V5 said (R2) replied I know you from somewhere. and then got into the car with her and she brought her back to the facility. V5 stated she does not know how long (R2) was gone but she did see her at breakfast that day. V5 stated she called and reported the incident to the DON (Director of Nursing).On 6/18/25 at 8:45 AM V9, Activity Director, stated she was not at work when R2 eloped last weekend and stated R2 was confused at times during her stay at the facility.On 6/18/25 at 8:52 AM V10, Social Service Director, stated R2 was at the facility for 2 or 3 weeks, she was very confused, combative, and non-compliant. V10 stated she completed her community assessment, and she was not safe to be out of the facility by herself. V10 stated R2 could not have signed herself out because she came to the facility after she was found at the airport claiming she was kidnapped.On 6/18/25 at 8:57 AM V1, Administrator, stated she did not report R2's elopement because she looked at her (cognitive assessment) and she was a 13. Surveyor asked V1 if she looked at R2's community/elopement assessment and V1 stated no.On 6/18/25 at 9:03 AM V11, [NAME] President of Clinical Services, stated based on R2's (cognitive assessment) and cognition at that time they don't think it was an elopement.On 6/18/25 at 11:43 AM V12 CNA stated she was not at work last weekend when R2 eloped. V12 stated R2 was very much confused all the time when she saw her or took care of her during her stay at the facility. On 6/18/25 at 11:51 AM V10 Social Service Director stated she completed R2's cognitive test, and R2 could answer those questions but she was absolutely not safe to go outside on her own. V10 stated she does not know what door R2 exited the facility from, but she was in room [ROOM NUMBER] which is located 2 doors down from that hall exit door. V10 stated R2 never left the faciity on her own and she would not have known to sign herself out to leave the building.On 6/18/25 at 12:17 PM V1, Administrator, stated she believes R2 exited the front door when she left the facility. Surveyor asked how she reached that conclusion and V1 replied a nurse saw her by the front door around 11 AM on 6/15/25. V1 stated she did a timeline, and she thinks R2 was only out of the facility for approximately 5 minutes. Surveyor requested a copy of the timeline and V11, Regional Director, stated we are working on it. Surveyor asked if someone deactivated the door alarm without checking to see why it went off and V1 replied she assumes so.On 6/18/25 at 12:23 PM V11, [NAME] President of Clinical Services, stated she knows the facility did have elopement risk binders for the residents at risk for elopement because she is the one who put them together. V11 stated she does not know if R2 had an elopement risk binder or not. V11 stated R2 was cognitively intact based on her cognition score and with resident rights she had the right to leave if she wanted to. Surveyor questioned V11 regarding the reason R2 was admitted to long term care after she was found at the airport with confusion and claiming she was kidnapped. V11 replied R2 had a hospitalization following that. Surveyor then questioned if V1 and V11 had reviewed R2's chart as it documented R2 had confusion throughout her stay at the facility and her community assessment documented she is unsafe to be out on her own. V11 replied I am confused at times and residents still have rights.On 6/18/25 at 12:43 PM V1, Administrator, provided R2's elopement evaluation dated 5/21/25 with a score of 6. Surveyor asked V1 if a score of 6 indicates R2 was at risk for elopement. V1 replied let me look and left the room. This form documented score value of 1 or higher indicates risk of elopement. On 6/18/25 at 12:46 PM V1 returned and stated it doesn't say she is high risk for elopement. Surveyor asked V1 if a score value of 1 or higher as documented on the elopement evaluation indicates R2 was at risk of elopement and V1 replied yesOn 6/18/25 at 2:34 PM V13 LPN stated she did not write a written statement regarding R2's elopement from the facility but she did document it in her progress notes. V13 stated she was R2's nurse on 6/15/25 and she last saw her before she started her medication pass before 11 AM on 6/15/25. V13 stated she did not see R2 again until she was returned to the facility by a CNA around 11:20 AM. V13 stated she did not document an assessment of R2 upon her return to the facility. V13 stated R2 was confused on the morning of 6/15/25, was carrying some of her belongings around in bags, and stated she was leaving. V13 stated she had previously cared for R2 on 2 other shifts at the facility and R2 was also confused during those shifts.On 6/18/25 at 2:53 PM V1 Administrator stated R2 did not have a photo taken during her admission to the facility nor did she have an elopement risk binder per the facility missing resident/elopement policy.On 6/18/25 at 3:13 PM surveyor asked V1 what enhanced precautions were put into place for R2 as documented in R2's progress notes upon her return to the facility after being found walking up the street and V1 replied we just checked on her frequently, I don't know if it was documented or if her care plan was updated. I will checkOn 6/24/25 at 10:37 AM V11 Regional Clinical Director stated if residents are at risk for elopement, then they do not have an elopement binder but if they are high risk then they do have an elopement binder. V11 stated the facility did have binders for the high-risk residents but they were misplaced when surveyor requested them, so she redid them. V11 stated she does not know why R2 did not have an elopement binder and was unaware of her history of wandering.V11s tated she would expect all staff to immediately respond to door alarms except the dining room door because there is usually a staff member outside with the residents and it is fenced in. Surveyor asked if the gate is locked as it is a fire egress and V11 stated she does not know if it is locked or not. On 6/24/25 at 10:40 AM surveyor asked V2 DON if she considered R2 high risk for elopement and V2 replied R2 wanted to go home, she went to the doors and looked out. Surveyor then asked V2 if R2's memory diagnostic appointment was completed as documented in R2's facility admission orders from the regional hospital and V2 replied she does not know if the appointment was made or not. Surveyor asked if a physical assessment of R2 was completed following R2's elopement from the facility and V2 stated she would look and see if there is one in R2's medical record. On 6/24/25 at 11:01 AM V13 LPN stated she was R2's nurse when R2 left the building on 6/15/25 without the knowledge of staff and she does not know how long she was gone from the facility although she recalls seeing her 15 to 20 minutes prior to the CNA bringing her back in. V13 stated she did not complete nor document a skin nor any type of assessment on R2 after R2 eloped. V13 stated R2 was absolutely unsafe to go out of the facility on her own due to her psychiatric issues, periods of confusion, and poor safety awareness and stated when she cared for R2 she was fixated on wanting to leave the facility. V13 stated she does not know what door R2 left from, but she would guess door 10 as her room was just 2 doors down from that exit. V13 stated R2 didn't recall leaving and stated she didn't leave when she got back. On 6/24/25 at 2:24 PM V1, Administrator, stated R2 does not have an incident report, nursing assessment, nor skin assessment for the day she exited the building alone.On 6/25/25 at 8:59 AM V22 Nurse Practitioner stated she assessed R2 on two separate dates during her stay at the facility. V22 stated R2 was very paranoid and when she saw her on 6/11/25 she wanted to send R2 to the hospital but R2 refused. V22 stated R2 was tearing up V22's papers while she was assessing her and that R2 had been refusing medications. V22 stated R2 was confused both times she assessed her and R2 was not safe to leave the facility on her own.On 6/25/25 at 11:06 AM V5 CNA stated R2 was standing on the corner of the parking lot of the apartment building on Pawnee drive and north Illinois street when she spotted R2 as she was returning from her lunch break. V5 stated R2 seemed confused when she gave her a ride back to the facility.On 6/26/25 at 10:23 AM V24 RN (Registered Nurse) stated R2 was very confused and exit seeking every time she was R2's nurse. V24 stated she was R2's nurse multiple times. V24 stated she did not know anything about R2's order to be seen at a memory diagnostic center.On 6/26/25 at 12:31 PM V28 PMNHP (Psychiatric Mental Health Nurse Practitioner) stated she evaluated R2 on 6/13/25 and based on that evaluation and information provided by facility staff R2 was not safe to leave the facility on her own. V28 stated R2 was oriented to self only on 6/13/25, R2 did not want to speak to her, and R2 was very paranoid. V28 stated the facility staff reported R2 had been delusional, confused, exit seeking, and non-compliant with PO (by mouth) medications.On 6/26/25 at 12:48 PM V11, [NAME] President of Clinical Services, stated she did not review R2's hospital records prior to R2's admission to the facility. V11 stated based on what she knows about R2 now, R2 should have had elopement risk interventions, R2's care plan should have been updated, the hospital discharge orders for R2 to follow up with specialists should have been put onto R2's physician orders, and those appointments should have been made. Surveyor asked V11 why R2 was placed in a room [ROOM NUMBER] doors down from an exit as the facility elopement policy documents room placement close to common area and away from exits. V11 replied based on what she knows now R2 should have been placed in a room closer to the nurse's station.Facility plans to remove immediacy: Description of Occurrence:Facility failed to ensure residents were supervised to prevent elopement.Action Taken Completion Date1) R2 is no longer in the facility 6.25.252) a) Admin/ DON were in-serviced by the VP of clinical services. a) Completed 6.25.25b) Admin in-serviced the IDT team. b) Completed 6.25.25c) Current staff in-serviced on elopement policy and procedure. c) Completed 6.25.25 EOD by IDT team.3) a) All residents that resided in the facility will have an elopement risk assessment completed within the last 30 days. a) Completed by VP of clinical services, DON, & administrator by 6.25.25b) Elopement Binder will be updated based on those risk assessments. b) Completed by VP of clinical services, DON, & administrator by 6.25.25c) Review of policy and procedure completed to reflect current practice. c) Completed by VP of clinical services by 6.25.25. 4) All working staff have been in-serviced on elopement, monitoring, and procedures on what to do if a resident is at risk. Currently all staff on shifts are in-serviced. Total facility staff will be 100% by 6.25.25.On-going- being completed by IDT team or designee by start of next working shift.5) No staff will work before being in-serviced on elopement procedures.6) A quality assurance tool was implemented; daily audit of the 24 hour report for wandering/elopement risks. Daily audit for elopement risk assessments completed within 72 hours of admission. Audits to continue daily x 4 weeks to ensure that elopement risk is documented. On-going. Audits completed by: Admin/ Designee 7) Root Cause Analysis completed for elopement.Deficiency: Failed to prevent elopement. Root Cause: Attached. Initiated- 6.25.25 Completed 100% Completed by:[NAME]- VP of Clinical ServicesYehuda [NAME]- CEOMonica [NAME]- AdministratorTracey Berry- DON2.)R22's clinical census sheet, print date of 7/8/25, documented R22 was admitted to this facility on 7/1/25. R22's medical diagnosis sheet, print date of 7/8/25, documented R22 has diagnoses of paranoid schizophrenia, muscle weakness, gastro-esophageal reflux disease, primary generalized osteoarthritis, and drug induced subacute dyskinesia. R22's MDS, dated [DATE] at 12:53 PM, documented R22 is moderately cognitively impaired. This assessment was completed by V10 Social Service Director. R22's progress note, dated 7/8/25 at 1:02 PM and authored by V9 Activity Director, documented a second cognitive assessment with a higher score indicating R22 is cognitively intact. R22's clinical resident profile/face sheet, print date of 7/8/25, does not have R22's photo. R22's care plan, print date of 7/8/25, documented R22 is at risk for wandering/elopement with goals of the resident will not leave facility unattended and the resident's safety will be maintained. Interventions are schedule time for regular walks/appropriate activity. R22's care plan, undated, documented 7/8/25 actual elopement: placed on 1:1, will be supervised when outside, elopement risk assessment reassessed. Placed in elopement binder. Date initiated: 7/8/25. Elopement risk assessment will be completed within 72 hours of admission, readmission, and quarterly. Engage resident in purposeful activity, identify if there are triggers for wandering/eloping, provide reorientation to surroundings, and schedule time for regular walks/appropriate activity. R22's fall risk evaluation, dated 7/8/25 at 8:39 PM, documented R22 has intermittent confusion.On 7/8/25 at 10:32 AM two surveyors observed facility staff walking at a fast pace up and down the halls looking for a resident. At 10:38 AM V1 Administrator was in the conference room with the surveyors and unaware other facility staff were looking for a resident. Surveyor then alerted V1 that staff were looking for a resident. The facility does not have an overhead paging system, so surveyors did not hear any facility employees including the leadership team announce code pink per the facility policy when a resident is missing. At 10:43 AM V2 DON was observed walking at a fast pace down the 200-unit corridor, surveyor asked what resident is missing, and V2 replied (R22). At 11:00 AM surveyor checked the facility elopement binders and R22 did not have an elopement binder nor a photo in his EMR (electronic medical record). Multiple employees wer