**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident (R2) from sexual abuse by another resident (R1) and failed to ensure a resident (R4) was free from physical abuse by another resident (R3) with a known history of verbal and physical aggression for two of four residents reviewed for abuse in a sample of six. This failure resulted in R3 verbally yelling and physically slamming his door on R4's hand. R4 sustained bleeding lacerations and fractures to three fingers on R4's right hand which required hospitalization evaluation where 12 sutures were placed to R4's fingers; further surgical intervention is pending. These failures have the potential to affect R4 and other dementia residents residing in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 9/24/24, the facility remains out of compliance at Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of the facility's removal plan and quality assurance monitoring. Findings include: 1. The facility's Abuse Prevention Program policy, dated 10/2022, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This policy continues with This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. This policy also states Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical hare, pain, or mental anguish to a resident .The term 'willful' in the definition of 'abuse' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility's undated Residents Rights Statement documents, All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. This facility will protect and promote the rights of each resident, including each of the following rights: 38. The resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion .47. The facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. R3's current Face sheet documents diagnoses including but not limited to Restlessness and Agitation, Acute Kidney Failure, and Cognitive Communication Deficit R3's Minimum Data Set/MDS assessment, dated 7/15/24, documents R3 as cognitively intact with behaviors including physical symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), rejection of cares, and wandering. R3's Documentation Survey Reports for behavior tracking, dated August 2024 and September 2024, document R3 displayed behaviors including yelling/screaming, kicking/hitting, grabbing, pinching/scratching/spitting, wandering, abusive language, threatening behavior, sexually inappropriate and rejection of cares. R3 had one or more of these type of behaviors on one or more shifts on the following dates: 8/4, 8/9, 8/10 - 8/12, 8/14 - 8/16, 8/19 - 8/22, 8/24, 8/25, 8/28 - 8/30, 9/1, 9/3, and 9/8/24. Also documented is (R3's) response to staff interventions including any one or more of these responses: Increased activity/mobility/agitation, Combative (physically and/or verbally), and Unable to redirect/engage. R3's Progress Note, dated 8/1/24 by V11 Licensed Practical Nurse/LPN, documents, Resident became combative upon room entry. R3's Progress Note, dated 8/11/24 by V12 Registered Nurse/RN, documents, Describe behavior: Patient (R3) slammed peer's (R4's) hands into his (R3's) door when she (R4) was standing in his doorway. Patient (R3) was cursing at peer (R4) stating 'get out of my f***ing room or I will hurt you.' Before staff could diffuse situation patient (R3) did slam both (R4's) hands into his door. Environmental, Physiological, Psychosocial factors/triggers: Patient (R3) is easily agitated with aggressive tendencies and stated after slamming peer's (R3's) hands into the door, 'I don't f***ing care if I hurt her (R4) or not, damn b**ch does not need to be in here.' While assessing peer (R4) out in the hall patient (R3) came out of room shouting that he did not cause this harm but rather staff. Patient (R3) was making false accusations against staff stating that they slammed her (R4's) hands into the door. Intervention: Reviewed with patient (R3) that we needed to take care of peer (R4) involved and that they needed to go back into their room which he (R3) slammed the door and told all staff 'We can go f*** ourselves.' Resident response: did not come out of room. Notifications made: Director of Nursing notified. R3's Progress Note, dated 8/22/24 by V3 Director of Nursing/DON, documents, Staff approached this nurse stating resident (R3) punched CNA (Certified Nursing Assistant/V11) in the stomach and the face. (V11) states when (V11) went into resident room to deliver room tray to resident (R3) when he (R3) punched her (V11) in the stomach and then the face. (V11) has notable red mark to her stomach where resident (R3) punched her. Police called and resident (R3) stated to police, 'I have told them I don't want their food.' Police took report. Report number 26-01054. Resident sent to (named hospital) for psych (psychiatric) eval (evaluation). R3's Nurse Practitioner Progress Note, dated 8/23/24, includes but is not limited to: Restlessness and agitation. Patient (R3) frequently having behaviors and agitation. He has made multiple attempts to harm staff and other residents. Staff injury reported today. Patient (R3) to be sent to the hospital for a psych evaluation. Patient (R3) is considered a threat to the safety of others and is not appropriate to reside in this long-term care setting. Patient refuses to see rounding mental health provider. HPI (History of Present Illness) Interval History: Staff report patient (R3) continues to have aggressive and harmful behaviors towards staff and other residents. Today, a staff member was providing patient with a meal tray and patient punched the staff member. He (R3) has had episodes of yelling while using profanity and hitting in the past. He often throws dishes in his room with the attempt to break them and subsequently poses risk to himself and staff members. Patient has previously slammed his door on another resident's fingers while yelling profanity at that resident. He has put other residents' safety at risk and vocalizes no remorse for injuring others. Patient is noncompliant with cares and medication orders despite frequent attempts to educate on the importance of bathing, eating, and taking medications as ordered. R4's current Face sheet documents diagnoses including but not limited to Unspecified Dementia, Unspecified severity, without Behavioral disturbance, Psychotic disturbance, Mood disturbance, and Anxiety; Chronic Kidney disease, stage 3; Displaced Fracture of middle phalanx of right middle, right ring, and right little finger; Presence of Cardiac Pacemaker; Syncope and collapse, and Weakness. R4's MDS assessment, dated 6/27/24, documents R4 is severely cognitively impaired and wanders. R4's current Care plan includes a focus of: (R4) has impaired cognitive function/dementia or impaired thought processes r/t (related to) Dementia with interventions including but not limited to (R4) requires approaches that maximize involvement in daily decision making and activity limit choices, use cueing, task segmentation, written lists, instructions. R4's Progress Note, dated 8/11/24 by V12 Registered Nurse/RN, documents Resident (R4) noted by staff walking into peers (R3's) room. Peer (R3) became immediately agitated and yelled 'get out of my f***ing room.' While staff was attempting to redirect resident (R4) out of peer's (R3's) room, Peer (R3) slammed the door and caught resident's (R4's) hands in the door. Immediate blood noted to right hand. Staff helped patient (R4) into chair and vitals started. Patient (R4) was found to be diaphoretic and very pale. Patient's (R4's) pulse ox (oximetry) was 76% upon assessment and patient (R4) was holding chest. Blood pressure was not palpable. Patient (R4) had head back in wheelchair .911 call placed for emergent transport to (named hospital). R4's Hospital After Visit Summary, dated 8/11/24, documents Reason for Visit: Loss of Consciousness; Diagnoses: Loss of consciousness, Crushing injury of right hand, initial encounter. R4's Progress Note, dated 8/11/24, documents, Resident brought back to facility by daughter (POA/Power of Attorney) around (3:00pm), resident assessed and vitals WNL (within normal limits), x-ray done to right hand done by (named hospital) with no break/fractures, resident has no c/o (complaints of) pain, resident in wheelchair at nurses' station, no concerns at this time. R4's Progress note, dated 8/12/24 by V17 Facility Nurse Practitioner, documents: HPI (History of Present Illness) Interval History: Resident returns to the facility after being assessed by the ER (Emergency Room) after a hand injury. Patient had her hand shut in a door of another resident's room. The ER ruled out any fracture. Patient denies pain at this time but due to dementia is not an accurate historian. Bruising and scabbing noted on her right hand. She is able to move all finger and wrist joints without difficulty. Patient has PRN (as needed) Tylenol available for pain relief. R3 and R4's Progress Notes, dated 9/8/24 and 9/9/24 respectively, by V11 LPN, document, (V11) was at the north nurse's station and had just hung up the phone with doctor about another resident and had started making notes. (V11) heard resident yelling 'get the f*** away from here, get the f*** out now.' (V11) slid (V11's) chair back away from the computer so that she could see where the commotion was taking place, (R4) was standing up in front of (R4's) wheelchair at (R3's) door with her (R4's) hand on the doorframe. (V11) jumped up from (V11's) chair at the north nurse's station and ran towards (R4) while trying to yell to (R3) that (V11) would get (R3), but before (V11) could finish the sentence and intervene, (R3) slammed the door shut while still yelling at (R4) saying 'stupid bitch, get the f*** away from here.' (R4's) hand was caught in the door and a loud crunching sound was heard. (R4) sat back in wheelchair and looked down at her hand which was bleeding and stated, 'that really hurts.' (V11) moved (R4) away from (R3's) room door to the north nurse's station and inspected (R4's) hand. (V11) could see visible open bleeding wounds to (R4's) right hand digits 3, 4 and 5. (V11) wrapped (R4's) hand with a towel to try and stop the bleeding. (V11) went to take a look into (R3's) room and (R3) started yelling for (V11) to 'get the f*** away from here nigger.' (R3) also stated 'I didn't do anything to (R4), she shouldn't have brung (sic) her ass into my room.' (V11) called out for help and started giving orders for an aide to stay with (R3) and for an aide to stay with (R4) while (V11) made necessary phone calls to the proper authorities, management, Dr. (doctor), and POA (Power of Attorney), resident was transported to (named) ED (Emergency Department), (V16 Medical Director), (V3) DON (Director of Nursing) and POA notified of incident. R3's Progress note, dated 9/8/24 by V17 Facility Nurse Practitioner, includes but is not limited to: HPI (History of Present Illness) Interval History: Provider notified of a repeated incidence of patient significantly harming another resident while slamming his room door on another resident's hand and using profanity to call that resident names and for them to get away from the door. This is not the first time he has injured another resident at the facility. He continues to have aggressive and harmful behaviors towards staff and other residents, with noted episodes of striking staff members. He still has episodes of yelling while using profanity and striking out at staff and other residents. He will throw dishes in his room with the attempt to break them and subsequently poses risk to himself and staff members. He once again puts other residents' safety at risk and vocalizes no remorse for the significant hand injury that occurred. Patient is noncompliant with cares and medication orders despite frequent attempts to educate on the importance of bathing, eating, and taking medications as ordered. He is to be sent to the hospital for a psychiatric evaluation due to continued outbursts of anger and physical aggression towards staff and other residents. R4's X-ray report of right hand, dated 9/8/24, documents Impression: 1. Acute posttraumatic fractures of the third-fifth digit middle phalanges. R4's Progress Note, dated 9/9/24 by V17 Facility Nurse Practitioner documents: HPI (History of Present Illness) Interval History: Patient returns to the facility after being evaluated at (named) ER (Emergency Room). Patient (R4) had her right hand slammed shut in the door of another resident's room. Per daughter, patient does have a fracture and is to follow up with ortho (orthopedics) tomorrow to discuss possible surgery. Patient denies any pain at this time but due to dementia, is not reliable with her ROS (Review of Systems). She does have noted stitches on the inside of her fingers. Multiple areas of dark bruising. Patient was started on a prophylactic antibiotic while at the ER to prevent infection. Patient also recently tested positive for COVID-19. She continues to have a clear runny nose, per baseline. No cough noted. On 9/18/24, at 12:04pm, R4 sat in her room then got up and walked over to the door entrance of her room. R4 showed this writer R4's right hand. R4's middle, index and pinky fingers are inflamed and purplish red in color with sutures noted across the first knuckle of all three fingers. R4 denies pain except when closes fist, R4 stated it doesn't feel too good. R4 is unable to recall how it happened and stated, did my family put me here? R4 then ambulated out of her room and wandered down the hall. On 9/19/24, at 9:28am, R4 sat in a wheelchair and self-propelled in the hallway. On 9/19/24, at 12:14pm, R4 stood in the hallway near the door of another resident's room. R4 ambulated a little further to the next resident's room and entered. On 9/20/24, at 9:59am, R4 self-propelled in her wheelchair up and down the hallway. R4 followed then caught up to this writer and stated, Did I go too fast? What's going on out there? while looking towards an exit door. On 9/19/24, at 9:31am, V13 Certified Nursing Assistant/CNA stated the following, (R4) is supposed to be in a wheelchair unless a CNA ambulates with her. She is a wanderer and has dementia. She wanders by self-propelling in her wheelchair. She goes in/out of resident rooms .She holds onto door frames as she peers into resident rooms looking, not always going in .She does it often and goes into a lot of rooms. After those two incidents we re-direct and try to keep her out of the center hallway especially if going towards his room in the center hallway. He usually left his door closed if he was in his room and leave it open when not in it. He was not a nice person .He was his own person, did not have dementia, refused cares and if we brought him water, he would bring it back out, slam it down and say I didn't want that. (R4) stops in doorways frequently every day. On 9/19/24, at 9:41am, V14 CNA stated the following, (R4) is a wanderer and has dementia. I was not working those days she got her hand caught in the door. She wanders in her wheelchair and sometimes leaves it and gets up to walk. I typically only work weekends so last weekend when I was working, I saw her hand with sore fingers. The nurse told me she got it slammed in the door and we were to keep her out of other peoples' rooms. I have seen (R4) go into resident rooms all the time. I kind of keep my eye on her and if she is going into another's room, I take her back to her room. She's got dementia so bad five minutes later she asks, 'where's my room.' When she walked, she braced herself by holding onto the doorframes. She does not get one on one supervision, but that would be a good idea. Can't have her in eyesight all the time. Keeping an eye on where she is all the time is impossible. She is here one minute and next minute she is down the hall. She's fast whether walking or in her wheelchair. On 9/19/24, at 10:29am, V11 LPN stated the following: I remember (R3 and R4's 9/8 incident). I was at nursing station on phone about another resident and hung up to write notes on the computer. I heard yelling so I swung my chair around and saw (R4) standing at (R3's) door but (R4) didn't go in. I could see (R4) peering into (R3's) room from the doorway standing up with (R4's) wheelchair behind (R4). I yelled out 'hey (R3)' but before I could finish the door went boom and I could hear (R4's) fingers crushing. Oh my god. (R4) sat down in her wheelchair and looked at her hand and said, 'wow that really hurts'. I don't think (R4) really understood. As I was going towards (R4) I could see the blood. I wheeled (R4) back towards the nurse's station while trying to call (V3 Director of Nursing/DON). The other nurse didn't know what to do. (R3) was still in his room yelling. He said, 'get away from here you nigger.' I said, 'you just smashed her fingers.' (R3) didn't care. (R3) said '(R4) shouldn't have brought her ass into my room.' (R4) is a wanderer and has dementia. She wanders in her wheelchair. (R4) likes to look around everywhere. We usually let her go about her business if she is in the wheelchair. She'll glide it around and look at things. (R4) just doesn't know what's going on. I thought (R4) would pass out or cry. (R3's) door is usually cracked open. I think (R4) may have gone into (R3's) room. (R4) was holding onto the doorframe when peering into (R3's) room. That is what (R4) would usually do and (R4) would do this when peering into other's rooms. I knew of their previous incident. I was on shift 8/11/24 and worked 2pm - 6:30am. That incident I did not see. I did see her fingers - her index finger and even more sore her thumb had skin torn off. We spoke with (R3) and explained (R4) doesn't know and is harmless so if (R4) comes to (R3's) door let us know and we will get (R4). (R3) is stuck in his ways. (R3) is aggressive and throws things and cusses. (R3) can be sweet when wants something. (R3) said, 'you keep (R4) out of here;' there is no reasoning with (R3). We try to keep an eye on (R4) as much as we can. There is only so much we can do while doing our job. It wasn't even five minutes that she had got away. (R4's) room is northeast and she was down the hallway and if there I know (R4) is okay down there and I show (R4) her room. (R4) had stopped at the nurses' station before I made the call then (R4) was gone .(R4) wanders into rooms often - she is looking for her room .(R3) punched a staff person in the stomach and (R3) has thrown things at staff. On 9/19/24, at 11:36am, V12 Registered Nurse/RN stated the following regarding R3 and R4's incident on 8/11/24: (R4) tends to wander and was in the doorway of (R3) and we heard yelling. Before we got there (R3) went to slam the door and (R4) had her hand in the door .Her hand was bleeding. We sent her out for chest pain, and we wanted her hand checked too. (R4) was on her feet from the minute she woke up and wandered a lot. There was constant redirection back to her hall. She had dementia .We were trying to redirect (R4) but it was difficult as she was going all over the place. I am not aware of anything (increased supervision/monitoring) in place. No increased supervision - I don't know how we would do that. We were already constantly going to get her .(R4) was not in eyesight 100% of the time but (R4) was never in her room. She was always staff asking, 'what do I do now.' It was so odd the way it happened because I was three doors down. (R3) is very vocal and (R4) was at (R3's) doorway. It happened so fast. (R3) is very private. (R3) is a strange character and knows more to what he plays on. (R3) is not nice. He may have arguments at times with residents but no other aggressive incidents that I know of. I stopped working about [DATE]th or so. I did not know it happened again. We didn't do anything different for (R4) or (R3). We asked (V18 Previous Administrator) about it and (V18) said 'this did not result in an injury and (V18) will handle it.' We felt (R3) needed a psychiatric evaluation to see if something was going on. I believe this was (R3's) first time it was an actual behavior harming someone. It is kind of hard to keep someone like (R4) safe. Breaks my heart that it happened again. On 9/19/24, at 12:54pm, V7 Social Service Director/SSD stated there was no increased supervision for (R4) or any care plan updates after the 8/11/24 for (R4's) wandering. V7 said, I wasn't in any discussion about it. I was in on discussion after the 9/9/24 incident and it happened so fast; the police were called. Everything was in place to get her out of that situation by redirecting. We don't usually have people in here that do things like slamming doors on others. V7 denies that any increased supervision or monitoring of (R4) was put into place. Confirmed that since a second similar incident occurred redirecting didn't really work. On 9/19/24, at 1:30pm, V3 Director of Nursing/DON stated the following: On the 8/11 incident I was not there. I received a call from (V12 RN) when it happened. (V12) said (R4) was by (R3's) room in the hallway. (R3) became angry and slammed (R4's) hand in the door. (R4) became diaphoretic and was pale so we sent (R4) out to see if any injury to her hand and there was not. As for (R4), we try to redirect her away and do our best and watching (R3) and staff approaching when (R3) is getting worked up. (R4) is a known wanderer and has dementia. (R4) hovers in a doorway, looks in, then keeps going. V3 confirmed redirecting was already in place for R4 prior to this incident. V3 stated, The 9/8 incident happened at night on 2nd shift. I got called by (V11 LPN). (V11) said (V11) was at the nurse's desk and could see (R3's) room. (V11) heard (R3) screaming and cussing at (R4). (V11) tried to get there but (R3) had slammed (R4's) hands on the door again. When (V11) got there (R4's) hand was visibly injured, cut open and bleeding. It appeared that (R4) had just used (R3s) doorframe to stand. (R4) sat right back down afterwards. We called the cops on (R3). (R4) was sent to a separate hospital for evaluation. (R4) had three fractured fingers and 12 sutures total to all three fingers, ring middle and pinky. (R4) has an ortho (orthopedic) referral for surgery. (R4) had COVID so will need to be rescheduled till clear of COVID. We sent (R3) for a psych (psychiatric) eval (evaluation). (R3) was deemed decisional. We called the hospital about (R3) being aggressive and noncompliant. (R3) has been sent out several times for psych evals and they send him back. I sent (R3) in once. (R3) became aggressive on staff when they went to change him. Cops were called and (R3) hit the cop . (R3) hit (V15 CNA) in the face and stomach when (V15) was taking his room tray in. We called the cops. All three incidents occurred within 30 days. We tried to reason with (R3). (R3) was mean on purpose. We don't have the staff to do one on one supervision. We are not a locked unit; no way to watch her every second. We do our best to keep our eye on her. It was a busy night, and everyone was busy right after dinner hour laying people down and the nurse was on the phone. There was a lot going on. Obviously, I want to protect (R4), but it could have been anybody. He was mean and impulsive all the time. I think (R3) was dangerous in general; not an (R4) thing. (R3) refused psych evals with our psych (psychiatric doctor) and refused meds (medications). On 9/20/24, at 1:36pm, V3 DON stated, (R3) was aggressive any chance he got. (R3) would break dishes, cuss us out or become aggressive. (R3) did this almost on a daily basis. It got to this point where (R3) started calling the cops. (R3) was decisional and knew what he was doing. (R3) was choosing these behaviors like threatening staff and residents so we started calling cops on him .(R3) refused a psychiatric evaluation and refused his medications frequently. The Facility Incident Report Form, regarding a Reportable Event, documents an abuse allegation occurred on 9/8/24 at 7:30pm involving R3 and R4. --- 2. The facility policy, Abuse Prevention Program, dated 10/2022 directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. The facility Incident Report Form, Date of Occurrence 8/19/24 at 7:30 P.M. Initial: Staff member (V6/Laundry Aide) reported to the Abuse Prevention Coordinator (V3/Director of Nurses) designee that R1 was allegedly touching R2 inappropriately in the dining room. R1 and R2 immediately separated. R2 assessed, no injuries noted. R1 being seen by psych (psychiatric services) and NP (Nurse Practitioner). Investigation initiated, final to follow. POA (Power of Attorney) of R2 notified. R1 is his own representative. MD (Medical Doctor) notified. Local Authorities notified. R1's facility admission Record documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Senile Degeneration of Brain, Chronic Kidney Disease and Adjustment Disorder. R1's Minimum Data Set Assessment, dated 6/12/2024 documents R1's cognitive status as 12 out of 15 (moderate cognitive impairment). R1's Nursing Progress Note, dated 8/20/2024 documents, Incident was reported to the writer by a staff member. Staff member reports seeing the resident in close proximity to a female resident in the dining room. Staff member saw resident's hand on the thigh of the female resident. R2's facility admission Record documents that R2 was admitted to the facility on [DATE] with the following diagnosis: Alzheimer's Disease. R2's Minimum Data Set Assessment, dated 7/4/20204 documents R2's cognitive status as 3 out of 15 (cognitively impaired). R2's current Care Plan includes the following Focus Area: (R2) has impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, Dementia, Delusional Disorders, Mood Disorder. Also included are the following Interventions: (R2) needs supervision and assistance with all decision making. The facility Incident Report Form dated August 26, 2024, documents, Final: Investigation completed. Interviews with staff and resident completed. Per interview with R1, resident adamantly denies allegations stating he is [AGE] years old and has no sexual desires and would not touch anyone in an inappropriate manner. R1 has resided at the facility for a long time and has not had any behaviors or inappropriate interactions. This would be completely out of character for him. R1 states he might touch a resident on the hand to offer comfort or greeting but would never do anything inappropriate. It must be noted that R1 has impaired vision and is almost blind. It is highly likely that he could have made contact accidentally. R1 is alert and oriented X 2 with a BIMS (Brief Interview for Mental Status) of 12 and a hospice patient. R2 is not interviewable due to advanced dementia. (R2) is alert and oriented X 1 with a BIMS of 3. V1 the staff member who reported this incident states she was cleaning the dining room. R2 was sitting with her back to V1 as she walked further into the dining room, she observed R1 and R2 sitting across from each other knee to knee. V1 reports she observed R1's hand on R2's thigh. It appeared to be near the groin area of R2. R2's hands were positioned beside her in her wheelchair. V1 then told R1 to remove his hands and went and got the nurse who separated R1 and R2. V1 stated R2 was wearing long pants which were fully intact. V1 reports that no other staff or residents observed the incident. Peer reviews done with other women on the unit, none of which mentioned any sexual misconduct during their stays. R2 was assessed and no injury or evidence of sexual interaction was found. IDT (Interdisciplinary Team) met and reviewed plan of care for both R1 and R2 and updated accordingly. R1 UA (urinalysis) is negative, was seen by NP (Nurse Practitioner) who did med (medication) review. R1 refused to have psych (Psychiatric) eval (evaluation). R1 will continue to be monitored for any inappropriate conduct. The investigation determined insufficient evidence to substantiate abuse due to lack of intent, physical or mental distress. On 9/18/2024 at 1:24 P.M., V6/Laundry Aide stated, On (8/19/24) around 7:15 in the evening, I saw (R1) touching (R2) in her crotch. They were sitting side by side in the ADR (Activity Dining Room). They were the only two in the room. I happened to be walking through. Their wheelchairs were side by side. (R1's) left hand was on (R2's) inner right thigh and (R1's) right hand was in (R2's) crouch. It was on the outside of (R2's) gray sweatpants. I was able to see the position of his hands clearly. Her hands were down by her side. (R2) wasn't saying anything. (R1) was talking really low to (R2). I could not make out what (R1) was saying to (R2). (R1) was very angry when he saw me. He yelled at me and said, 'I am very offended of your presence.' (R1) immediately withdrew his hand. I went to the nurse; I don't know what her name is. She is an Agency nurse. She still works here. The nurse came into the ADR and separated them and told (R1) to keep his hands to himself. (R1) was still very angry with me, telling me that I was a dirty person and had a dirty mind. The nurse had me come to the nurse's station and write a statement. V8/CNA (Certified Nursing Assistant) was standing at the nurse's station talking to V3/DON (Director of Nurses) on the phone. He took a picture of my statement with his phone and sent it to (V3). (R1) likes to flirt with all the ladies. (R1) says he is looking for a lover. On 9/19/24 at 9:20 A.M., R1 stated, I have lived here for a few years. (R2) is my friend. I love her. I have touched (R2) many times, on the hand and face. I don't see (R2) much anymore. I miss (R2). On 9/19/24 at 10:00 A.M., [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to properly prepare and administer medications to prevent a significant medication error for one resident (R3) and failed to prepare medications properly for three residents (R5, R6, and R8) of four residents reviewed for medication administration in a total sample of four. These failures resulted in R3 receiving the wrong medication and being hospitalized for low blood pressure and cardiac monitoring. These failures resulted in an immediate Jeopardy. While the immediacy was removed on 4/26/23. The facility remains out of compliance at severity level 2 while the Facility continues to educate the nursing staff on proper medication preparation and administration and conduct audits to ensure continued compliance. Findings Include: The Facility's Medication Administration Policy dated February 2014 documents Setting up of doses for more than one (1) scheduled administration is not permitted. The policy documents Residents will be positively identified prior to medication administration and shall not be left alone until the medication is consumed or refused. Policy also documents Medications errors, drug side effects and adverse drug reactions, including overdoses or poisoning, will be immediately reported to the attending physician, Director of Nursing, and pharmacist. The error or clinical symptoms will be documented in the clinical record and on the facility designated form. The Facility's Medication Error Investigation Summary dated 4/20/2023 documents Nurse reported to nurse supervisor of administering wrong medication to (R3). V9 (LPN) statement on 4/19/23: I grabbed the wrong cup of medications and administered the Seroquel and Trazodone to (R3). On 4/25/23 at 12:30 PM V3 (LPN/Acting Director of Nursing) stated that on 4/19/23 around 6:30 PM R3 received all of R4's 4PM and 8PM scheduled medications to include: Atorvastatin Calcium 80 mg (milligrams), Docusate Sodium 200 mg, Quetiapine 625 mg, Trazadone 150 mg, Eliquis 5 mg, Lactobacillus 1 capsule, Sennosides Tablet 8.6 mg, Topamax 100 mg and Gabapentin 300 mg. V3 stated, (V9) had pulled (R4)'s medication up and labeled the cup and gave them to (R3) by mistake. V3 stated, Medications should not be prepared and left in the top of the cart for administration later. R3's Progress Notes dated 4/19/23 at 6:55 PM documents, gave wrong medication, very tired, low bp (blood pressure) 72/44, did vitals called 911 notified md (Medical doctor) and called son but there was no answer sent to (Emergency Room) for evaluation. Resident was responsive and answering questions. R3's emergency room Record dated 4/19/23 at 8:00 PM, Poison Control initial note: Case # 5175395. Goals for labs: Mag 2, Potassium 4, Calcium 9. Combination of meds will cause hypotension (low blood pressure), drowsiness and lethargy. Titrate (Norepinephrine/blood pressure maintenance support) as needed. Repeat EKG (electrocardiogram/cardiac monitoring) in 6 hours. R3's emergency room Record documents admit to hospital due to hypotension due to drugs, accidental medication error. On 4/25/23 at 11:00 AM V14 (Nurse Practitioner) stated, That (medication error on 4/19/23) was definitely a significant medication error, R3 is in the hospital receiving treatment for low blood pressure directly related to the error. R3's Medical Record documented she was hospitalized from [DATE] until 4/26/23 for treatment of low blood pressure. On 4/26/23 at 10:45 AM V15 (Pharmacist) stated that R3 receiving R4's 4:00 PM and 8:00 PM medications on 4/19/23, certainly qualifies as significant. On 4/25/23 at 12:50 V10 (RN) had a medication cup with R5's name on it and a pill inside of it in the top drawer of her medication cart. V10 stated, That is (R5)'s Buspar. There was another empty cup with R7's name on it with Zoloft written on it. V10 stated that was to remind her to administer R7's medications. There was a medication cup with a small amount of crushed up pill noted in it with R6's name on it. V10 stated the crushed-up medication was R6's Eliquis. On 4/25/23 at 1:00 PM V11 (LPN) had a medication cup with R8's name on it and a pill inside of it in the top drawer of her medication cart. V11 stated, That is (R8)'s Gabapentin. The immediate Jeopardy began on 4/9/23 at 5:45 PM when V9 administered the wrong pre-prepared medications to R3. V1 (Administrator) was notified of the Immediate Jeopardy on 4/27/23 at 12:48 PM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R3's medical record confirms R3 was sent immediately to the emergency room for treatment of low blood pressure and remained in the hospital until 4/26/23. 2. On 4/19/23 the V2 (DON/Director of Nursing) immediately in-serviced the nurse involved in the medication error on proper medication pass procedures. 3. On 4/20/23 V3 (LPN/Acting Director of Nursing) completed all nursing staff training on proper med pass procedures and to never open medications prior to administering to residents. A whole house nursing staff training was repeated on 4/25/23 and 4/26/23 and all nursing staff reviewed proper procedure instructions and signed off. Anyone not signed off will review and signoff on training prior to their next scheduled shift. 4. On 4/25/23 an audit of all med carts to ensure no other medications were opened in advance of administering to residents was completed by V3 and continued 4/26/23. 5. DON or Designee will audit all med carts, 5 days a week, for 4 weeks to make sure no pills are opened in advance of administering to residents. 6. The facility will audit medication carts at least quarterly X 1 year to ensure that corrections are achieved. 7. On 4/25/23 V9 (LPN) confirmed that she had gotten immediate education on how to properly dispense medications. 8. On 4/27/23 V4 (LPN) V9 (LPN), V10 (RN), V11 (LPN), V12 (RN) and V13 (RN) confirmed they had received education and multiple trainings on proper medication preparation and administration procedures since 4/20/23. 9. On 4/27/23 V3 stated that she will be auditing all medication carts daily five times a week for 4 weeks to check for pre-prepared medications. Then the audits will be done at least quarterly for a year. 10. On 4/27/23 Medication Cart Audit completed by V3 (LPN) was reviewed with no concerns. 11. On 4/27/23 Education on Proper Medication Administration dated 4/25/23 and 4/26/23 sign in sheets and course material reviewed with no concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure exit doors were secure and the door alarm system was in working order, failed to properly assess residents at risk for elopement, failed to develop a care plan and implement interventions for residents at risk for wandering/elopement, failed to follow facility elopement policies, and failed to provide adequate supervision for three of three residents (R4, R8, R9) reviewed for elopement risk in the sample of nine. These failures resulted in cognitively impaired residents (R4, R8, and R9) who require extensive assistance with ADL's (Activities of Daily Living) exiting the facility without staff knowledge and being found on separate dates, wandering aimlessly, and confused, out in the west side of the building's parking lot approximately 50 feet from the exit doors. This parking lot is located next to a road that has high activity of traffic. R4 and R8 were found before dawn, in the dark, and the weather was chilly. R9 was found sitting on the end of a car bumper. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 1-25-23, the facility remains out of compliance at a severity Level II as the facility continues to audit all exit doors on a daily basis for six weeks and then weekly thereafter to make sure they are secure and that the alarms are present and in working order, audit all residents at risk for wandering on a weekly basis for six weeks and then quarterly thereafter, installs a new door alarm system, provides training to new staff on the elopement policy, and the quality assurance committee monitors the facility's performance to ensure that corrections are achieved. Findings include: The facility's Door Alarm Drill Policy dated 1-1-15 documents, It is the policy of this facility that the door alarm drill will function to assure exit doors are functioning properly and alert staff that a resident has left the building. It will also assure staff respond to door alarms immediately and follow the door alarm and elopement policy. The facility's Wandering Residents policy dated 08/2006 documents, Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. All residents who are at risk for harm because of wandering (elopement) will be assessed. 2. The resident's care plan will be modified to indicate whether the resident is at risk for elopement episodes. Staff will be informed at shift change of the modification to the resident's care plan. 3. Interventions for elopement episodes will be entered onto the resident's care plan and medical record. 4. Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the nurses' notes. 5. If a resident repeatedly wanders off the unit, a monitoring schedule will be implemented to ensure resident safety. The resident's care plan will be documented as to the implementation of the monitoring schedule. The facility's Elopement and Search Policy dated 02/2014 documents, Policy: To establish methods for protecting residents who are at risk for elopement and for conducting an organized search for a resident who cannot be located. 1. All nursing personnel are responsible for: a. Knowing the whereabouts of residents for which they are assigned. b. Department supervisors are responsible for conducting resident rounds. c. Staff are responsible for keeping the nurse informed of a resident's whereabouts. 3. Residents are not permitted to leave the building alone unless a physician order is present. 5. Residents who have been identified as cognitively impaired and who have been assessed as an elopement risk will be provided with an elopement prevention device or be placed in an area of the facility that has a door alarm device with audible sound, or on a secured/locked unit. 6. Facility exit door alarms are checked daily for function. All personnel are responsible for promptly reporting/replacing malfunctioning elopement prevention devices. Maintenance is responsible for fixing/replacing any exit doors that do not alarm. 8. When a resident makes repeated/continuous attempted to leave the building, the resident will be visibly observed every fifteen (minutes) until the behavior is resolved. 10. When the resident is found (after elopement) a licensed nurse will: a. Announce Code Pink All Clear over the paging system. b. Perform a clinical assessment of the resident's skin and functional status and determine if the resident requires medical interventions. g. Complete the appropriate observations/forms. h. Initiate/update the care plan to include interventions to prevent reoccurrence. 11. The Administrator/designee is responsible for notifying the State Department of Public Health and any other appropriate local authorities (Adult Protective Services, Ombudsman) of the occurrence when applicable according to state and federal requirements. 13. Appropriate security measures will be implemented to assure the resident is monitored to prevent reoccurrence. 14. All facility staff will be informed of residents at elopement risk. The facility's Doors, Locks, and Alarms Test Operation of Doors Logbook dated 11-1-22 through 1-24-23 documents the doors and alarms are only being checked once weekly instead of daily as required by the facility's Elopement and Search policy. On 1-24-23 from 8:40 AM through 9:15 AM tour was done at the facility. The North-West hallway activity exit door had a Velcro stop sign attached across and had a sign posted on the door stating, If you are caught turning off door alarms without (V1's/Administrator's) approval you will be subject to termination. Residents have been getting out of the facility because alarms have been shut off. The North Nurse's Station had a binder labeled Elopement Book. This Elopement Book contained pictures and identifying information for all residents at risk for elopement within the facility. This book did not contain pictures or identifying information of R4, R8, and R9. 1. On 1-24-23 at 10:15 AM R4 was standing up and walking around his room without assistance of staff. R4's wheelchair was located next to R4's bed. R4 was confused to person, place, and time. On 1-24-23 at 10:05 AM V17 (RN/Registered Nurse) stated, (R4) has always been disorientated and tries to open doors and leave. (R4) needs re-direction. On 11-26-22 sometime before 5:00 AM I had left the facility to go to the gas station. When I came back, I found (R4) walking out in the North-West employee parking lot. (R4) was confused. (R4) was walking without his wheelchair and had gone out of the end North-West activity door. It was chilly out and (R4) did not have a coat or shoes on. (R4) had on a t-shirt, sweatpants, and socks. (R4) was cold. I have no idea how long (R4) was in the parking lot. I brought (R4) back into the facility and notified the on-call supervisor (V19/LPN/Licensed Practical Nurse). I asked (V19) what I should do. (V19) said she would talk to (V3/Assistant Director of Nursing) and let me know. I never heard anything back from (V19) or (V3). I did not document the incident. I am not sure if any interventions were implemented to increase (R4's) supervision. I know (R4) was supervised every 15 minutes for around 24 hours, but no other interventions were implemented after that. No door alarms were alarming at the panel at the nurses' desk. The alarms did not work when (R4) went outside. I do not know how long (R4) was outside. (R4) needs staff assistance when walking. I am not aware of the facility having an elopement book with residents at risk of elopement. R4's current Electronic Diagnoses Listing documents R4 has diagnoses of Non-Traumatic Intracerebral Hemorrhage, Alcohol Abuse with Intoxication, Alcohol Dependence, Cognitive Communication Deficit, and Unsteadiness on Feet. R4's MDS (Minimum Data Set) assessment dated [DATE] and Care Plan dated 10-17-22 documents R4 is severely cognitively intact, has inattention and disorganized thinking, is totally dependent on staff for transfers, and requires extensive assistance of staff for locomotion on and off the unit. This same MDS documents R4 uses a wheelchair for locomotion. R4's Elopement Evaluation dated 1-2-23 documents, Does the resident have a history of elopement or attempted leaving the facility without informing staff? No. Does the resident wander? Yes. Is the wandering behavior a pattern, or goal-directed? No. Does the resident wander aimlessly or non-goal directed? Yes. R4's current Care Plan does not include a plan of care with interventions to address R4's wandering and elopement. R4's Electronic Medical Record dated 11-1-22 through 1-24-23 does not include any documentation, nurse assessment, or investigation regarding R4's elopement on 11-26-22. On 1-24-23 at 10:00 AM V10 (Registered Nurse/RN) stated, (R4) tries to open exit doors frequently. We (facility staff) cannot always hear the alarm going off at the nurses' station when we are at the end of the hallways. The alarms do not alarm at the doors, only at the nurses' station. On 1-24-23 at 12:35 PM V3 (Assistant Director of Nursing) stated, (R4's) record has no documentation about (R4) being found out in the parking lot unattended on (11-26-22) and (R4) has not had care plan developed or implemented regarding (R4's) elopement/wandering. There is no documentation of (R4's) family being notified of the incident. (R4's) incident has not been investigated. On 1-24-23 at 12:40 PM V22 (CNA/Certified Nursing Assistant) stated, (R4) wanders constantly and tries to get to the doors and leave. We try to re-direct him. 2. On 1-23-23 at 4:35 PM V15 (RN/Registered Nurse) stated, I was working on 1-7-23 the Northeast hallway. (R8) was found outside unattended in the employee parking lot by the garbage cans (approximately 50 feet from the exit door) around 5:00 in the morning. (R8) had gone out of the activity room door to the outside. I do not know how long (R8) was outside. The door alarm did not work at the door or at the panel by the nurses' station. (R8) tries to leave the facility all of the time. (R8) goes up to the exit doors and tries to push them open. I called the on-call supervisor (V19/LPN/Licensed Practical Nurse) and informed her that (R8) was found outside, and the door alarm did not work. I was not (R8's) nurse that day. I am not sure who was the nurse. (V14/Activity Assistant) was called in to check the doors. (V14) told me that the door alarm was working. (V18/Maintenance Director) has been told numerous times that the door alarms do not work correctly and do not alarm at the panel like they should. Nothing is ever done about it. I know (R4) has gotten out of that same door unattended before and was found in the parking lot. I do not know if the facility has an elopement book. R8's current Electronic Diagnoses Listing documents R8 has diagnoses of Drug Induced Subacute Dyskinesia, Schizophrenia, Mental Disorder, Difficulty in Walking, Muscle Weakness, Cognitive Communication Deficit, Dementia, Unspecified Severity, with other behavioral disturbance, Restlessness, and Agitation. R8's MDS assessment dated [DATE] and current Care Plan documents R8 is severely cognitively impaired, has disorganized thinking, and requires extensive assistance of staff for transfers and walking, and limited assistance of staff for locomotion. R8's current Care Plan does not include a plan of care with interventions to address R8's wandering and elopement. R8's Electronic Medical Record dated 1-1-23 through 1-24-23 does not include any documentation, nurse assessment, or investigation regarding R8's elopement on 1-7-23. On 1-23-23 at 4:10 PM V13 (Activity Director) stated, (R8) comes to the activity exit door and tries to push it open. I was told that (R8) got out into the parking lot without staff knowing. I am not sure what date that was. On 1-24-23 at 9:00 AM V20 (R8's Family Member) stated, I came in the facility on 1-8-23 and was told by the staff that (R8) had gotten out of the building unattended on Saturday (1-7-23). I am concerned that they facility is not watching (R8) close enough and (R8) will get lost. (R8) is very confused and cannot be outside. I called the Administrator (V1) on Monday (1-9-23) and told him about my concerns with (R8) getting out of the building and not being watched closely. On 1-24-23 at 10:32 AM V1 (Administrator) stated, (V20/R8's Family Member) called me on Monday (1-9-23) and reported that she was upset because (R8) had been found outside unattended and nobody had notified her. I brought (R8's) incident to morning meeting the next day to be investigated by the nurse managers. I am not sure if anyone investigated the incident (R8's elopement). I know the investigation was never reported to IDPH (Illinois Department of Public Health). On 1-24-23 at 11:25 AM V3 (Assistant Director of Nursing) stated, I was not aware that (R8) had gotten out of the facility unattended (1-7-23). No one had reported that to me. (R8's) record has no documentation about the incident and (R8) has not had an elopement risk assessment done or a care plan developed or implemented regarding (R8's) high risk of elopement/wandering. There has been no investigation completed. (R8's) family was not notified of the incident according to (R8's) medical record. The elopement book should contain all residents at risk for elopement and is located at the nurses' stations, and social service office. The elopement book has not been updated for a long time. (R4, R8, R9) information and pictures are not in the elopement book and should be. The Social Service Director (V21) is responsible to keep the elopement book updated. On 1-24-23 at 12:12 PM V19 (LPN) stated, (V15/RN) called me around 4:56 AM on 1-7-23 and reported that the staff had found (R8) outside in the employee parking lot, unattended by staff. (V15) reported to me that the door alarm did not alarm at the panel, so the staff did not know (R8) had sent outside. I told (V15) to notify (R8's) family, the physician, and (V2/Director of Nursing), and to perform an assessment of (R8). I also reported the incident in the morning meeting on Monday (1-9-23). I contacted (V18/Maintenance Director) and let him know the door alarms were not working and needed looked at. On 1-24-23 at 11:05 AM V14 (Activity Director) stated, I was called on 1-7-23 to go in and check the Northwest Activity Exit door alarm to make sure it was working because (R8) had gotten out of that door and staff found her in the parking lot. When I went in the door alarm was working. The day before I was working in activities and took Christmas supplies out to the shed. I turned the toggle on the door off so the alarm would not sound when I opened that door. I guess I am not supposed to use that door. I believe on Monday (1-9-23) V18 (Maintenance Director) zip tied the box so that the toggle switch could no longer be turned off. 3. On 1-24-23 between 9:45 AM and 10:30 AM R9 was wandering aimlessly in her wheelchair up and down the north hallways. On 1-24-23 at 1:10 PM V7 (Wound Nurse) stated, On 1-10-23 around 7:00 AM I was arriving to work and saw dietary staff talking about an old lady sitting on the end of a bumper of a blue car and was not sure who it was. I went to talk to the lady and noticed it was one of our residents (R9) sitting on a bumper of a car. (R9) stated, I am not going back. I want to go home. (R9) did not have her wheelchair with her and was cold. I then went and got a wheelchair and had the CNA's take her back to the floor. On 1-24-23 at 1:20 PM this surveyor and V7 viewed the west side parking lot that (R9) was found in on 1-10-23, (R4) was found in on 11-22-22, and (R8) was found in on 1-7-23. The parking lot exits onto Newcastle Road, [NAME] Illinois. This road has a high level of traffic with a central school and multiple businesses located on this road. V7 confirmed that R9 was found sitting on a bumper of a car approximately 50 feet from the exit doors in this parking lot. R9's Investigation Report dated 1-10-23 and unsigned documents, (R9) states that she was leaving and going home. (V17/RN) states that she took (R9) back to the Northwest desk (earlier that morning) and informed (V23/RN) that (R9) was attempting to go out the door on maintenance hall. (V23) was unaware of situation when questioned but is increasing monitoring at this time. Summary: (R9) was observed sitting on a bumper outside in the parking lot. (R9's) wheelchair was observed sitting in maintenance hallway. Maintenance cage door was unlocked which goes out into back parking lot. R9's current Electronic Diagnoses Listing documents R9 has diagnoses of Altered Mental Status, Chronic Respiratory Failure with Hypoxia, Cognitive Communication Deficit, and Unsteadiness on Feet. R9's MDS assessment dated [DATE] documents R9 requires extensive assistance of staff for transfers, walking, and locomotion off the unit. R9's Care Plan dated 1-20-23 documents R9 is at risk for falls due to confusion, deconditioning, gait/balance problems, incontinence, impaired mobility, and being unaware of safety needs. R9's Care Plan dated 4-14-22 through 1-9-23 did not include a plan of care to address R9's wandering behavior. R9's Elopement Evaluation dated 1-10-23 documents, Does the resident have a history of elopement or attempted leaving the facility without informing staff? No. Is the resident's wandering behavior likely to affect the safety or well-being of self/others? Yes. On 1-23-23 at 4:35 PM V15 (RN/Registered Nurse) stated, (R9) wanders in her wheelchair around all hallways. On 1-24-23 at 10:05 AM V17 (RN) stated, I know a few weeks ago (R9) was found outside in the parking lot. (R9) had went out of the door of the service hallway which is in the middle of the building between the North and South hallways. (R9) has always wandered and states she wants to go home. (R9) gets confused and would not be safe outside unattended by staff. On 1-24-23 at 1:30 PM V3 (Assistant Director of Nursing) stated, (R9) was found in the parking lot on 1-10-23. It was determined that (R9) had exited out of the middle service hallway, out of the maintenance cage (maintenance supply room) exterior door. Someone had left the cage door unlocked and (R9) was able to leave out of the exterior door. That door has no alarm on it, so staff were unaware of (R9) getting out of the facility. (R9) did not have a care plan developed for wandering or elopement risk prior to her exiting the building on 1-10-23. (R9's) Elopement Evaluation dated 1-10-23 is inaccurate and should have been coded as Yes to the question asking if (R9) has a history of elopement or attempted leaving the facility without informing staff. On 1-24-23 at 11:15 AM V18 (Maintenance Director) stated, I got a call from (V15/RN) on 1-7-23 early in the morning that (R8) was outside, and the door alarm did not work. I went in to check the alarm and (V14) said the alarm was working. The North hallway exit doors do not have alarms on the doors. When these doors are opened, they alarm at the nurses' station alarm panel (located in the center of the Northwest and Northeast hallways). There is a toggle switch on the doors that employees can use to turn off the alarms at the nurses' panel. Staff should never turn that toggle switch off. After the incident with (R8) I zip tied the toggle switch compartment shut so employees could no longer turn the alarm off. Employees are not supposed to use the end of the hallway exit doors. There are times the panel alarms for no reason. If it is really cold outside the door alarms malfunction at the panel. I have not called any alarm company in to check these door alarms for malfunctioning. I check the door alarms weekly. When (R9) got outside (1-10-23) and was found in the parking lot my cage (maintenance supply door) was unlocked. Dietary staff were trying to open the hallway door for a delivery and could not get in the hallway door, so they used a key and unlocked the maintenance room door. The dietary staff did not make sure the door was locked after they used it. When that door is left unlocked the residents can get out of the facility through the cage and out of the exterior door. The exterior door off of the maintenance room is not alarmed. On 1-24-23 at 1:38 PM V21 (Social Service Director/SSD) stated, I did not know I was in charge of updating the elopement book with information and pictures of residents at risk for elopement. I have not been updating the book. The Immediate Jeopardy started on November 26, 2022, when the facility failed to provide R4 with adequate supervision and implement elopement interventions which resulted in R4 being found outside of the facility, unattended by staff, and R4 was cold and did not have a coat or shoes on. V1 (Administrator), V3 (Assistant Director of Nursing), and V25 (Director of Operations) were notified of the Immediate Jeopardy on 1-25-23 at 12:05 PM. On 1-26-23 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 1-24-23 V21 (SSD) completed an updated Elopement Risk Assessment for R4, R8, and R9. 2. On 1-24-23 V28 (MDS Coordinator) developed an elopement care plan with interventions for R4, R8, and R9's. 3. On 1-24-23 (V1/Administrator) sent an initial report to IDPH (Illinois Department of Public Health) to investigate R4, R8, and R9's elopement and an investigation of these elopement was started. 4. On 1-25-23 a whole house review of elopement assessments was done and updated by V28 and V7 (Wound Nurse). 5. On 1-24-23 V18 (Maintenance Director) installed new battery-operated door alarms on the Northwest door, Northeast door, and Maintenance door to ensure staff could hear the door alarming at the location of the doors as well as at the nurses' station. 6. On 1-24-23 V1 ordered a new alarm system to put at the doors with a keypad to silence the alarms was ordered on 1.24.23 and should reach the facility by next week. 7. On 1-24-23 and 1-25-23 V18 in-serviced all staff on the proper function of door alarms. 8. On 1-24-23 on first shift, and 1-25-23 on second and third shift V18 held elopement drills with all staff. 9. On 1-24-23 and 1-25-23 V3 (ADON) re-educated all staff on the facility's alarm policy and the elopement Policy. This education included information that residents do not have to leave the property to be considered an elopement. A second education was provided electronically on 1-24-23 and 1-25-23 via the company website for all staff to log in and complete training. 10. On 1-25-23 V2 re-educated all nurses on proper documentation when a resident gets outside the building and notifying the power of attorney, doctor, and administration when a resident gets outside of the building. 11. V18 Maintenance Director/Designee will audit all exit doors on a daily basis for 6 weeks to make sure they are secure and that the alarms are present and in working order. After 6 weeks, he will do this on a weekly basis. An audit will be turned in to Administrator at the end of each week. 12. V3 ADON/Designee will audit all residents at risk for wandering on a weekly basis for 6 weeks to be sure that their Elopement Assessment and Care Plan are up-to-date with accurate information and interventions in place. After 6 weeks, they will be audited on a quarterly basis. The Quality Assurance Committee will monitor the facility's performance to ensure that corrections are achieved. Completion Date: 1-25-23.