**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A 2. On 8/13/24 at 9:15 A.M., an Indiana Department of Health Incident Report, dated 8/4/24, indicated Resident C was found walking up the road by a staff member. Facility was investigating how she got out. It was reported that a nurse left for lunch and resident may have followed the nurse out the front entrance door. Resident C was immediately returned to facility and placed on 1:1 for 2 hours and 15 minute checks for 72 hours. Facility immediately notified maintenance to check the doors and called (Name of Door Repair Company #1) to come and inspect the doors. On 8/13/24 at 9:30 A.M., Resident C's medical records were reviewed. admission date was 2/8/24. Diagnosis included, but were not limited to rheumatoid arthritis, coronary artery disease, hypertension, non-Alzheimer's dementia, seizure disorder, anxiety disorder, asthma, and hallucinations. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 5/8/24, indicated Resident C was moderately cognitively impaired, needed supervision of one for bed mobility, supervision with set up for transfers and eating and limited assistance of one for toilet use. Resident had no behavior of wandering, no hallucinations, no delusions, no physical or verbal behavioral symptoms, and used a wander/elopement alarm daily. Current physician orders, dated 7/25/24, indicated facility staff should monitor Resident C for behaviors including, but not limited to elopement and check placement and function of the WanderGuard every shift. A plan of care for risk of elopement/wandering, dated 7/8/24, included, but were not limited to, interventions for staff to use distraction techniques, structured and individual activities, music, quiet time, identify patterns of wandering, and a WanderGuard to prevent further elopement attempts. Care plan interventions were not updated after Resident C eloped on 8/4/24. Progress Notes included, but were not limited to the following: 7/18/24 5:46 A.M. Health Status Note Note Text: Resident pacing from room to lobby multiple times. c/o [complained of] being cold. Resident given a jacket and went back to room. 7/18/24 8:38 A.M. Health Status Note Note Text: Resident pacing from room to lobby. Snack given, went back to room. 7/20/24 12:20 P.M. Behavior Progress Note Note Text: Resident restless, walking up and down hallway, standing next to nursing cart, and following nurse from room to room. Resident laid down at noon for a nap. 7/25/2024 12:50 P.M. Behavior Progress Note Note Text: Resident has been pacing today and standing at the nurses [sic] station multiple times today. Resident is not causing any issues. Resident has brought some of her greeting cards from her room to the nurses [sic] station and has read them repeatedly to whomever is there at the nurses [sic] station to listen, otherwise resident stands there quietly. Resident has been asked if there are any unmet needs. Resident denies and unmet needs. 7/26/24 5:13 A.M. Health Status Note Note Text: Resident restless and pacing early in shift between 6 P.M. to 8 P.M. Once resident was assisted with getting ready for bed, rested well with C-Pap on. 8/4/2024 1:48 A.M. Health Status Note Note Text: OOF [out of facility]- Family went out with resident and to be returned to facility 5pm [sic] per report given. RSD [resident] has not been returned to facility at this time. Calls made to family via phone. Pending response back. 8/4/2024 1:33 P.M. Health Status Note Note Text: Resident has returned to facility at this time with son. 8/4/2024 2:29 P.M. Incident Note Note Text: This nurse received a phone call from employee who was leaving on lunch break that this resident was walking outside facility and he was assisting her back to front door. This nurse and CNAs [Certified Nurses Aides] ran to front door and assisted resident back into the facility where she was assessed. Temp [Temperature] 96.5, Resp [Respirations] 16, HR [Heart Rate] 99, BP [Blood Pressure] 120/95, 93% RA [Room Air]. Resident had just returned from overnight stay with son and stated that she was trying to get home to her son. Resident is currently on 1 on 1 supervision for 2 hours. Administrator, DON [Director of Nursing], PCP [Primary Care Provider], andfamily [sic] notified. 8/4/2024 4:41 P.M. Elopement Evaluation done by LPN 5 had an Elopement Score of 3 which indicated Resident C was an elopement risk and wandered. A progress note dated 8/5/24 8:38 A.M. indicated Resident C was on 15 minute checks for 72 hours. A Fifteen Minute Checks Form was completed every 15 minutes starting on 8/4/24 at 4:30 P.M. through 8/7/24 at 11:45 P.M. A progress note by Social Services, dated 8/5/24 3:55 P.M., indicated Social Services met with Resident C in her room and talked about the weekend. Resident C talked about other things not related to the elopement. No exit seeking had been reported. A progress note, dated 8/5/24 8:13 P.M., indicated Resident C had no exit seeking. She stayed in her room or stood at the nurse's desk. She went to the dining room for supper. She refused to wear bipap and had to be put to bed 4 (four) times. She will be monitored. A progress note, dated 8/7/24 5:19 P.M., indicated Resident C was very confused, wandering on the unit, almost blocked another resident's doorway. The other resident raised their voice to get her to move. Both residents were redirected successfully. A progress note, dated 8/11/24 11:48 A.M., indicated Resident C was seen wandering by the front door several times, pushing on the double doors by the front door. Alarm was applied to front door and Resident C was monitored for safety. The most recent Core Behavior Risk Assessment completed on 4/25/24 indicated Resident C was on psychotropic medications, was cognitively impaired, had no history of mental illness and no aggressive behaviors in the last 3 months. The August 2024 Medication Administration Record (MAR), dated from 8/1/24 through 8/13/24, indicated Resident C had no behaviors on any shift and the WanderGuard was checked for placement and function every shift, except for the evening of 8/3/24, which was blank. A handwritten note signed by LPN 5 indicated on 8/4/24 when she went to the front door to get Resident C from Dietary Aide 3, she noticed the front entrance door was not latched and the alarm was not sounding. A typed note by LPN 12, dated 8/4/24, indicated she went out the front entrance door to put belongings in her car. She heard the front entrance door slam. She helped Resident c through the second set of double doors by the entrance after explaining to the resident that her son had left. After Resident C was in the hallway, LPN 12 went to the [NAME] Hall. Since the door had slammed LPN 12 assumed it closed. When she left the facility, LPN 12 noticed the front entrance door was not closing all the way and was staying open. The door had to be pushed on to close it when leaving. A typed note, dated 8/4/24, by Maintenance Tech 26, indicated he was called by the Maintenance Supervisor that the front door was malfunctioning. He was unable to repair the door due to multiple damages. He let his supervisor know and the (Name of Door Repair Company #1) was contacted. Fire Watches were conducted every 15 minutes (from 6:40 P.M. through 7:10 P.M.) until (Name of Door Repair Company #1) arrived. (Name of Door Repair Company #1) was unable to repair the front entrance door due to multiple damages and recommended the code to enter and exit the front entrance door be changed for safety measures. The code was changed. A typed note by the Maintenance Supervisor, dated 8/4/24, indicated nothing was reported to her that the front entrance door had any problems. She was called about the door malfunctioning. When (Name of Door Repair Company #1) indicated they were unable to fix the door, she called the Administrator and he called (Name of Door Repair Company #2) to come and repair the front entrance door. Review of the (Name of Door Repair Company #1) invoice dated 8/4/24 indicated Technician called facility to inform of arrival time. Apon [sic] arrival technician met with facility and began troubleshooting front door. With nothing on door, door swings open 8 inches due to the bottom hinge rotting out. Technician tried to adjust two door closers to hold door shut for maglock to engage. Door closers do not have enough force to keep door from moving back out of range for maglock to engage. Technician spaced out bottom hinge to realign door. Spacing was unsuccessful and if we step up the spacing anymore it will blow the door out of what is remaining for the bottom hinge. The side and top of the door frame moves and shifts with the door. The bottom threshold has soft wood under it. Door is locked down until further work is done. Review of the (Name of Door Repair Company #2) work order, dated 8/5/24, indicated the front entrance door was not shutting all the way. Bottom pivot was busted and moving around. Replaced the bad pivots with a continuous hinge. We fabricated a brace for hinge side jams/top of frame. We also made a door stop for the bottom of the door. Door is short on width. Note: It was reported a resident busted out of the door and did some damage. During an interview 8/13/24 at 9:58 A.M., the DON (Director of Nursing) indicated Resident C was checked every two hours for check and change since she was incontinent. She was not followed by staff when ambulating in the hall since it was a locked building. The DON indicated Resident C wandered but did not have a history of exit seeking. From the time Resident C was admitted , she wandered the halls looking out the front double doors for her son's car in the parking lot but didn't try to go out the doors. She had a WanderGuard on, and staff redirected her away from the doors. She liked to hang out with the nurses. She was a jailer on night shift all her life and liked making rounds with the nurses. The DON indicated the son picked Resident C up on Saturday for an overnight stay and brought her back on Sunday. The son did take her to her room. The son indicated that he turned around to make sure the door was shut. The DON indicated that there were no problems with the alarm system on 8/4/24 and maintenance checked the doors and alarms routinely. Wander Guard would not trigger if a resident went out the front door. During an interview on 8/13/24 at 11:02 A.M., CNA (Certified Nurse Aide) 6 indicated Resident C did not have a history of elopement. Her son had dropped her off and she told CNA 6 after the elopement that she was going to whoop his butt because she was not done staying at home. Thirty minutes after Resident C was returned the elopement happened. CNA 6 heard the alarm but did not respond because she was on the end of the hall with a resident. Resident C was in the parking lot and had already been out there at that point. During an interview on 8/13/24 at 11:32 A.M., LPN (Licensed Practical Nurse) 5 indicated she usually worked on the [NAME] Hall but had worked with Resident C on 8/4/24. Resident C needed limited to extensive assistance with care, depending on what it is. She required her meat to be cut but could ambulate on her own. Elopement assessments were done quarterly and could be seen under assessments in the medical records. Resident C did not have a history of exit seeking but she wandered and wore a WanderGuard. At the time of the elopement on 8/4/24, LPN 5 indicated she was doing charting at the desk at the opposite end of the East Hall, not in view of the front entrance door. The son brought Resident C back at 1:30 P.M. About 1:50 P.M., kitchen employee called and said resident was walking outside. LPN 5 indicated she did not see Resident C go out the front door. When she got outside Resident C was in parking lot. She brought her inside and kept her at the nurse's desk for 1:1 for 2 hours. Resident C did go to the dining room for supper and had no further behaviors. LPN 5 indicated Resident C has had no other attempts of exiting the building. LPN 5 indicated the alarm at the front door went off anytime someone went in or out of the building. Each nurse's desk had box on the wall that indicated where the alarm was going off. Any employee could check an alarm to see if a resident was setting it off. During an interview on 8/13/24 at 2:01 P.M., CNA 4 indicated he was working the day Resident C eloped. He indicated the alarm would sound, but he always had to press the front entrance door back because you didn't know if it would stay closed. He indicated Resident C was warm when she came back into the facility. They had to put cool cloths on her and make sure her air conditioner unit was turned up in her room. During an interview on 8/13/24 at 2:12 P.M., Dietary Aide 3 indicated he went out the back door going on lunch break around 2:00 P.M. He indicated he was leaving the parking lot when he saw Resident C standing in the grass next to the facility sign facing Indiana Highway 62. He called the nurse to notify her the resident was outside and turned around as soon as possible. He parked his Jeep in the parking lot, called Resident C's name and she walked to him. He assisted her to the front door where staff was waiting. During an interview on 8/14/24 at 8:59 A.M., Resident C indicated her son brought her back to the facility on 8/4/24 because he had to [NAME] the yard. She indicated her son's truck was broke down and didn't want her to have to deal with that as well. Resident C could not recall any specifics about the elopement incident. During an interview on 8/14/24 at 9:44 A.M., the DON indicated that care plans might be updated by MDS (Minimum Data Set) Coordinator, Social Services or Activities depending on what the care plan entails. As far as when care plans were to be updated, the DON indicated that usually that was done with quarterly MDS assessments, or if there was something that arose such as infection, injury, or something of an acute nature. On 8/14/24 at 11:55 A.M., the weather report for 8/4/24 at 1:53 P.M. to 2:53 P.M. found on TimeandDate.com/weather indicated the temperature was 91 degrees and the humidity was 52%. On 8/14/24 at 8:33 A.M., the DON provided an undated Elopement Policy and Procedure that indicated, .The facility team will assess the environment to identify potential risks associated with elopement and/or hazards associated with elopement. Elopement is defined as follows: When a cognitively impaired resident leaves the physical structure of the facility unattended and without staff knowledge and displays exit seeking behavior. [name of company] will implement individualized interventions to strive to prevent elopement .Complete Elopement Plan of Care as applicable .Review and evaluate assessments and risk factor data and make a determination of risk for elopement .Review and revise plan of care as needed .Review and correct deficiencies in practice as they relate to the following, including, .response to alarms, testing alarms .Validate that the resident is wearing an electronic/alarm device as indicated and check that electronic/alarms systems are functioning according to manufacturer recommendations. Record residents at risk for elopement on patient care guide/assignment sheets .If in the event a resident is found to be missing or suspected to be missing a FULL FACILITY head count will be completed and the Missing Resident Action Plan will be initiated .The interdisciplinary team will re-evaluate cognitively impaired residents who have attempted (unsuccessfully or successful) to elope from the facility. Individualized interventions will be developed and initiated to manage the elopement behavior .Review and update plan of care and evaluate risk factors identified . On 8/14/24 at 11:37 A.M., the DON indicated that the missing resident action plan was not completed after the incident, as per policy, as staff was not aware of where the forms were located, but she would expect the form to be completed in the event a resident was missing. On 8/14/24 at 8:33 A.M., the DON provided a Behavior Management Policy, dated 3/11/24, that indicated, A Behavior Risk Assessment will be completed on all residents upon admission, quarterly, and when new or worsening behavior occurs. All residents who score 3 or above on the behavior risk assessment may be deemed high risk for behaviors and may require a review of the current care plan by the IDT (Inter-disciplinary Team) and/or the medical provider. All residents will be monitored for behaviors every shift. If an identified behavior occurs, it will be documented in the medical record . On 8/14/24 at 11:37 A.M., the DON indicated that the missing resident action plan was not completed for Resident B and Resident C as staff was not aware of where the forms were located to complete it. The Immediate Jeopardy, that began on 8/4/24, was removed on 8/15/24 when the facility in-serviced facility staff on exterior door policy, revised elopement policy and identification, missing person action plan, use of Wanderguard system, additional updates to exterior doors, and wandering behaviors but the noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence.A. Based on interview and record review, the facility failed to ensure supervision of two cognitively impaired residents; and failed to follow the facility elopement policy resulting in elopements for 2 of 2 residents reviewed for accidents. Resident B exited the facility by a side door and walked 0.5 miles to a gas station. An hour later, the resident's brother notified the facility that Resident B had left the facility. Resident C exited the facility by the front door after being returned to the facility by the son after an overnight stay. Twenty minutes later the resident was found outside the facility walking in the grass away from the facility next to the road, Highway 62. (Resident B, Resident C) This deficient practice resulted in an Immediate Jeopardy. This Immediate Jeopardy began on August 4, 2024, when the facility failed to ensure a cognitively impaired resident was adequately supervised and was allowed to leave the facility by the front door. On August 5, 2024, another cognitively impaired resident left the facility by the side door. The second resident had a history of wandering and was not adequately monitored for these behaviors. The Administrator was notified of the Immediate Jeopardy on August 13, 2024 at 2:29 P.M. The Immediate Jeopardy was removed on 8/15/24 at approximately 3:30 P.M., but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. B. Based on observation, record review, and interview, the facility failed to develop and implement interventions to reduce the risk of falls, fall risk assessments were failed to be completed after falls, and neurological checks were not completed after unwitnessed falls for 2 of 7 residents reviewed for accidents, (Resident 18, Resident 33). Findings include: A 1. On 8/13/24 at 9:15 A.M., the Indiana Department of Health (IDOH) incident reports were reviewed and indicated on 8/5/24 at 4:51 P.M., Charge nurse called stated that resident called his brother and said I'm at a gas station come pick me up. Brother called facility and staff immediately went and picked him up. On 8/13/24 at 9:30 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, traumatic brain injury, epilepsy with status epilepticus, unsteadiness on feet, rheumatoid arthritis, dementia with behavioral disturbance, schizoaffective disorder, bipolar disorder, unspecified mood (affective) disorder, conversion disorder with seizures, anxiety, and unspecified psychosis. The most recent Annual MDS (Minimum Data Set) Assessment, dated 8/3/24, indicated Resident B's cognition was severely impaired, supervision of 1 staff with set up for bed mobility, transfers, eating, and toileting, did not have behaviors of wandering or exit seeking, and wore a WanderGuard (device worn to prevent elopement) daily. The physician orders, dated, 10/11/23, (prior to 8/5/24 when Resident B eloped), indicated facility staff should monitor Resident B for behaviors including, but not limited to, elopement, wandering, and to check placement and function of the WanderGuard every shift. A plan of care for history of elopement, dated 7/28/24, included, but were not limited to, interventions for staff to use distraction techniques, structured and individual activities, music, Activities of Daily Living (ADL) care, and a WanderGuard to prevent further elopement attempts. The care plan did not include documentation to show the plan was revised with interventions to prevent another elopement. A plan of care for Psycho-Social Distress Risk, dated 11/3/23, included but were not limited to, intervention to monitor behavior episodes, attempt to determine underlying cause, and to document behavior and potential causes. An elopement risk evaluation, dated 7/30/24, indicated the resident did not have a history of elopement, did not wander, and was not at risk for elopement. The progress notes were reviewed from 8/1/24 through 8/13/24 and lacked documentation of exit seeking behavior. A nursing progress note, dated 8/5/24 6:00 P.M., indicated one-to one (continuous) supervision was provided for two hours followed by 15-minute checks per facility protocol that ended on 8/6/24 at 10:15 A.M. The August 2024 MAR (Medication Administration Record), dated 8/1/24 through 8/12/24, indicated Resident B demonstrated behavior of exit seeking on the evening shift of 8/5/24. The facility's investigation of Resident B's elopement on 8/5/24 included the following: Resident B approached LPN (Licensed Practical Nurse) 5 at approximately 4:48 P.M. and asked where he could get a meal. The report indicated LPN 5 told Resident B supper would be served in 10 minutes, but did not include documentation to determine interventions to prevent elopement were implemented in accordance with the plan of care. At approximately 5:45 P.M., LPN 5 answered the phone and the resident's brother said he got a phone call from Resident B telling him he was outside the facility at a gas station and he wanted to be picked up. A (Name of Door Repair Company) technician reported on 8/5/24 (time unknown) the hinges on the side door (employee entrance) were adjusted to so the door would close properly. Maintenance Employee 7 indicated on 8/5/24 (exact time unknown but after door repair company was there that day) inspected the side door and noticed the door was still not closing properly against the alarm sensor. A (Name of Door Repair Company) technician report about the side door dated 8/6/24 at 1:30 P.M., indicated upon arrival, maintenance stated that from time to time the Maglock would not engage when the door closed and the alarm would not sound when door was left ajar as expected. The technician identified a wiring problem that prevented the alarm equipment from functioning properly. During an interview on 8/13/24 at 9:49 A.M., LPN 5 indicated Resident B needed some supervision, had behavior of wandering up and down the halls, wore a WanderGuard, and had a very poor short term memory. At that time, she indicated he had eloped before but not for at least a year and was not exit seeking or voicing that he wanted to leave the facility. She indicated they do not document random wandering in his clinical record. It's only documented if he's intrusive to other residents. At that time, LPN 5 indicated the Elopement Risk Evaluation, dated 7/30/24, was filled out incorrectly. During an interview on 8/13/24 at 9:57 A.M., CNA (Certified Nurse Aide) 6 indicated Resident B was mainly independent, did wander in the halls, and staff only had to check on him every now and then. She indicated he had not eloped before that she knew of and she was not working the day he eloped but was told that Resident B wanted turkey for an evening meal and went to get one for himself. During an interview on 8/13/24 at 10:08 A.M., the SSD (Social Services Director) indicated Resident B had a history of elopement and vocalization that he did not want or need to be in the facility and he wanted to leave, but nothing recently. He had not been exhibiting exit seeking behavior prior to the elopement. He had a thought in his head at that minute, found a way out, and then left the facility to get what he wanted. At that time, she indicated he did wander, but they were not tracking wandering behaviors because it was considered his normal activity. During an interview on 8/13/24 at 10:16 A.M., the Administrator indicated Resident B has had exit seeking/wandering and aggressive behavior in the past but not recently. To keep the resident safe, they use a WanderGuard but it does not sound an alarm at any of the 3 exterior doors as you would expect. It only sounds when those residents enter and exit through the double doors from the dining room. During mealtimes and activities, the facility disables that alarm because so many residents pass through the doors at those times. At that time, he indicated on 8/5/24 he got a call from a nurse that Resident B went to the nurse's station and asked for a sandwich. Resident B was told to follow the CNA's to the dining room. Resident B went to the dining room, knocked on the kitchen door, asked for a turkey sandwich, and was told it would be on his meal tray. At that time, the resident sat down at a table, got up and walked down the hall, and went out of the side door near the dining room. The nurse was contacted at 5:45 P.M. by the resident's brother and notified that the resident had left the facility and was at a gas station. The staff only documented Resident B's behaviors if they were accelerated and since wandering was his normal, they don't document that. The Administrator indicated he would expect staff to provide interventions to prevent elopement in accordance with the care plan for a cognitively impaired resident at risk for elopement. During an interview on 8/13/24 at 10:35 A.M., the Maintenance Director indicated maintenance staff was not expected to randomly check the doors of the facility to make sure they were functioning properly. They were only checked when maintenance staff were alerted to a problem with them and staff did not keep any documentation about it. During an interview on 8/13/24 at 2:01 P.M., CNA 4 indicated he was working at the time Resident B eloped and was working on the [NAME] Hall where Resident B's room was. CNA 4 indicated Resident B had a history of eloping from the facility. CNA 4 indicated when he went to pick up the resident from the gas station after they were notified Resident B was missing, the resident was confused and didn't know where he was but said he went to (name of restaurant) across the street from the gas station and got himself a drink and a sandwich. According to the Iphone map application, the restaurant where the resident went was 0.5 miles away from the facility and would take 11 minutes to walk there. The resident had to cross Indiana Highway 62 and [NAME] Street twice to get to the restaurant and then to the gas station where he was picked up by staff. B 1. On 8/14/24 at 9:55 A.M., Resident 18 was observed sleeping in bed with a fall mat placed on the ground. On 8/15/24 at 12:09 P.M., Resident 18's clinical record was reviewed. The diagnoses included, but were not limited to: non-traumatic brain dysfunction, seizure disorder, and depression. The most recent Quarterly and State Optional MDS (Minimum Data Set) Assessment, dated 6/21/24, indicated Resident 18 was an extensive assistance of two or more persons for: bed mobility, transfers, and toileting. The MDS indicated he had two or more falls since admission or the prior assessment. Care plans included, but were not limited to, I am at risk for falls r/t [related to] Psychoactive drug use, dementia, tremors, repeated falls, lack of coordination, unsteadiness on feet, restless leg syndrome, degenerative disease of nervous system, anemia, uses a wheelchair and uses walker at times for ambulation . revised 7/1/24. Resident 18's fall history included, but was not limited to: Fall 1: On 7/19/24 Resident 18 fell in the bathroom after breakfast. Resident 18's clinical record lacked an update to his care plan after that fall. Fall 2: On 7/24/24 resident was sitting in chair enjoying his activity and when he was done he just jumped up and started to try to walk across the floor. legs were weak and he fell to floor on buttock . did not hit his head. and received no injuries . Resident 18's clinical record lacked an update to his care plan and notification to his family and doctor. Fall 3: On 7/26/24 Resident 18 was leaning to his left side and fell when he tried to stand up. His clinical record lacked an update to his care plan after that fall. Fall 4: On 7/28/24 Resident 18 was found kneeling on his fall mat. His clinical record lacked a notification to his family. During an interview on 8/16/24 at 1:29 P.M., the MDS Coordinator indicated the care plan was not updated after every fall and the interdisciplinary team should update the care plans after a fall and family and the physician should be notified after a fall by the nurse on duty. B 2. On 8/19/24 at 10:57 A.M., Resident 33 was observed awake and in bed with both feet hanging off the right side of the bed and the wheelchair was placed by the bathroom door. The resident indicated he wanted to get up. The resident was asked to use his call light, but it was wrapped around the bed rail, hanging down, and stuck between the bedrail and mattress. The resident attempted twice but was not able to pull it out to use it. At that time, there was not a sign to call and don't fall observed in Resident 33's room. On 8/20/24 at 8:32 A.M., Resident 33 was asleep in his bed and the wheelchair was by the closet door. On 8/15/24 at 11:50 A.M., Resident 33's clinical record was reviewed. Diagnoses included, but were not limited to, stroke, dementia with behaviors, and schizophrenia. The most recent admission MDS Assessment, dated 6/12/24, indicated Resident 33 was cognitively intact, an extensive assist of 1 staff for bed mobility, transfers, and toileting. A current Risk for Falls Care Plan, dated 6/19/24, included, but was not limited to, the following interventions: Be sure the resident's call light is within reach, initiated 6/19/24 Follow facility fall protocol, initiated 6/19/24 Staff to ensure wheelchair is at bedside for self-transfers, initiated 7/15/24 Vision sign call don't fall for reminder, initiated 7/30/24 The following were the only Fall Risk Assessments documented in Resident 33's clinical record: 6/9/24 indicated resident was not a high risk to fall. 8/12/24 indicated resident was not a high risk to fall. On 8/19/24 at 9:36 A.M., the DON (Director of Nursing) provided the following Fall reports on Resident 33 that included, but were not limited to, the following falls: 7/11/24 at 6:40 P.M., Resident 33 was observed on the floor next to his bed on both knees and indicated he was trying to get to bed. A post Fall Risk Assessment was not documented in the clinical record. 7/21/24 at 7:30 P.M., CNA (Certified Nurse Aide) reported to nurse that Resident 33 fell in his room and was obse[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B.1. An incident report form, dated 7/22/23 at 5:01 A.M., indicated Resident G had reported to a CNA (Certified Nurse Aide) 8 that CNA 13 hit Resident E in the chest twice when care was provided. CNA 13 had been removed from the schedule until further notice. Social services staff interviewed other residents for abuse. A written letter was provided by CNA 13 that indicated Resident E did not wake up when CNA 13 called his name and told him what tasks were going to be performed. CNA 13 provided care and Resident E woke up agitated during care. During an interview on 7/24/23 at 9:15 A.M., Resident C indicated a staff member with the same name is mean and talked to him negatively. On 07/25/23 2:08 P.M., Resident C's clinical record was reviewed. The most recent quarterly MDS, dated [DATE], indicated Resident C was cognitively intact. On 7/25/23 at 1:32 P.M., Resident E's clinical record was reviewed. Diagnosis included, but were not limited to, dementia and anxiety. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 6/24/23 indicated Resident E's brief interview for mental status could not be assessed due to Resident E not being understood. Resident E was an extensive assist of 1 staff member for bed mobility, transfers, eating, and toileting. A current behavioral symptoms care plan dated 7/23/23 indicated to stop care if Resident E tried to hit staff and have the nurse assist with care. During the month of July, Resident E did not have any of the following behaviors documented: inappropriate behavior, mood changes, anxiety, anger, hitting, cursing, or screaming. On 7/25/23 at 2:17 P.M., Resident G's clinical record was reviewed. The most recent quarterly MDS, dated [DATE], indicated Resident G was cognitively intact. Resident G lacked a care plan related to fabricating stories. During the month of July, Resident G did not have any of the following behaviors documented: anxiety, cursing, fabricating, or refusing care. An untimed progress note dated 7/22/23 indicated .this morn [morning] around 5:00 A.M. [staff name] came in here et [and] she must have thought I was asleep because [Resident E] was giving her a hard time et [and] I know he can be difficult @ [at] times but still what she did is not right. He was not wanting her to change him et [and] he kept resisting et [and] she punched him twice in the chest et [and] I seen et [and] heard it et [and] she hit him hard .I asked [Resident E] if he had been hit et [and] he looked @ [at] me et [and] said yeah in my chest. This nurse then asked if I could see his chest et [and] he pulled his shirt up et [and] I assessed et [and] noted there to be an area pinkish in color to left side of his chest. Area is blanchable skin is intact. No other areas noted during head-to-toe assessment. I did tell housekeeper earlier this morn [morning] after breakfast that [Resident E] wasn't acting like his normal self et [and] she said he does not seem to be staying completely bent over for some reason . During an interview on 8/1/23 at 8:55 A.M., LPN (Licensed Practical Nurse) 29 indicated CNA 8 notified her that Resident G informed her that CNA 13 punched Resident E in the chest twice and she didn't realize that Resident G was awake. LPN 29 asked Resident E if he had been hit and Resident E stated, yea, in my chest. LPN 29 assessed Resident E and noted he had a pink area on his chest. During an interview on 8/1/23 at 9:02 A.M., Resident G indicated CNA 13 came in the room to provide incontinence care to Resident E and did not pull the privacy curtain. Resident G witnessed CNA 13 hit Resident E in the chest twice. Since Resident G notified staff, Resident G indicated he was told CNA 13 was not allowed back in his room and his call light gets ignored. CNA 13 walked by the door and does not notify other staff since she had returned to work and he felt like they had retaliated on him. During an interview on 8/1/23 at 9:12 A.M., the Administrator indicated CNA 13 did not have any restrictions on which rooms she can provide care in. During an interview on 8/1/23 at 10:04 A.M., Staff 16 indicated CNA 13 was not allowed to provide care in Resident G's room per the DON (Director of Nursing). During an interview on 8/1/23 at 12:41 P.M., LPN 29 indicated neither Resident E nor Resident G had behaviors. On 8/2/23 at 7:31 A.M., Resident E was observed in the common area slouched over in a wheelchair. A current abuse policy, dated 9/15/17, was provided 7/28/23 at 7:45 A.M. and indicated It is the policy of [facility name] to ensure that each resident is free of physical, mental, verbal and sexual abuse, corporal punishment, mental and physical neglect and involuntary seclusion. [name of facility] prohibits the mistreatment, neglect, abuse of residents and misappropriation of residents' property by anyone including staff, other residents, or persons from outside the facility . This Federal tag relates to complaint IN00412693. 3.1-27(a)(1) 3.1-27(a)(3) A. Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 1 resident reviewed for discharge. A resident (Resident B) with a court order to remain at the facility was allowed to leave and did not return. The resident was being monitored for suicide precautions at the time the resident was allowed to leave with an unknown female and has never returned. The resident's whereabouts was currently unknown. Legal authorities and the physician were not notified of the resident's departure from the facility or failure to return. As an endangered adult, the resident has the potential of harming himself if not under supervision. The resident had a history of being aggressive which has the potential of others being harmed as well. (Resident B) B. Based on observation, interview, and record review. The facility failed to protect each resident from physical and verbal abuse for 2 of 3 residents reviewed for abuse. A staff member struck a resident on his chest when perineal care was being provided. (Resident C, Resident E) This Immediate Jeopardy began on July 4, 2023 when the facility failed to implement a court order to ensure Resident B was under 24-hour supervision and allowed the resident to leave the facility. When the resident called the following day to inform staff he was not returning, staff failed to notify the physician or the Adult Protective Services (APS) representative handling his case. The Administrator was notified of the Immediate Jeopardy on July 28, 2023 at 8:35 A.M. The Immediate Jeopardy was removed on July 31, 2023, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: A. 1. On 7/26/23 at 8:42 A.M., Resident B's clinical record was reviewed. admission date was 6/29/23. Diagnosis included, but were not limited to, borderline personality disorder, schizophrenia, diabetes mellitus, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). On admission, Resident B was cognitively intact, alert and oriented to name, place, month, and time. A referral assessment tool form (not dated) indicated Resident B to be admitted from another long-term care facility. Resident B required assistance of one staff member for mobility and needed therapy. Handwritten notes included Schizophrenia COPD Cirrhosis CHF . refuses meds [at] times . plays music very loud . protective order from court to be in facility - cannot leave . court order to be in NH [nursing home]. Goes back to court 7/20/23 - APS involved . Wants to get out asap. admission records from the previous facility included the following information: Resident B was his own responsible party with emergency contact information for the APS representative handling his case, a friend, and a sister (with name listed). A new admit form, dated 6/29/23, indicated Will make up things about sister, family, APS etc. He will say it's OK to do this or that. He has a cell phone - be watchful that he does NOT take pictures of others. We can take away per court order if does. A resident information sheet indicated Resident B was admitted [DATE] at 11:30 A.M., the APS representative was listed as emergency contact #1, and Resident B was his own person, no guardian or power of attorney (POA). A 48-hour care plan, dated 6/29/23, lacked information related to a court case, or APS. The care plan did not indicate that Resident B was to stay in the facility. A care plan, dated 6/30/23, indicated Resident B had potential to fabricate stories related to a sister and others. Physician orders included, but were not limited to, the following: LOA (leave of absence) with responsible party as needed, dated 6/30/23. Send to ER (emergency room) for psych evaluation and treatment, dated 7/2/23. A current court order, filed 5/8/23, indicated the following: IN THE MATTER OF PROTECTIVE SERVICES FOR [RESIDENT B] . That [Resident B] is an endangered adult as defined by I.C. 12-10-3-2 .That [Resident B] is in need of the proposed emergency protective services . IT IS NOW ORDERED, ADJUDGED, AND DECREED by the Court all as follows . That the objectives of the Emergency Protective Order are to secure the safety and well Being and person of [Resident B] . That the medical provider delivers the lease restrictive protective services necessary to attain the objective of the Adult Protective Services Protective Order. The medical provider shall place the endangered adult [Resident B] in a medical facility/nursing facility that specializes in geriatric psych if needed or recommended by physician with 24-hour care. Facility may restrict the use of cellular device at their discretion for the duration of sixty (60) business days or until the order is terminated by the petitioner . The healthcare provider shall maintain custody of the endangered adult for a period of not less than sixty (60) business days unless the order is terminated by the petitioner . A report triage note, dated 7/2/23 and signed by the Nurse Practitioner (NP), indicated a request to have an order to send Resident B to the ER for evaluation and treatment. She indicated he was off the chain and refuses all his meds. She indicated she was not aware of Resident B's admission and knew nothing about him. Staff did not notify her of his admission to the facility. Police had been called to get a handle on him because he was scaring the other residents. She indicated the Administrator was going to work on having him sent somewhere else that week. A history and physical form, dated 7/4/23, indicated Patient seen today for admission to [name of facility] for continued care and rehab. He has been in and out of behavioral inpatient facilities, held on ED [emergency detention] holds several times, due to his schizophrenia that is often unmanaged. In addition to this dx [diagnosis], he also has medical conditions such as CHF, DM [diabetes mellitus], HTN [hypertension] that are often unmanaged as well due to not taking medications. He believes he is healthy as an ox and his medical records are incorrect. He went as far as to steal his medical record (MAR) this weekend and attempt to hide it from staff. He also became aggressive with staff, yelling and cursing at staff and other. He was refusing medications and was sent to the ER. Police had to be called to get him to go with EMS [emergency medical services]. ER evaluated him and then sent him back with no new orders. He is under APS yet is still adamant that he is his own person. Very high thoughts of himself, that he has tons of money and lots of resources. Told me several inaccurate accounts of what has transpired over the years to him. He is on a diabetic diet and 2000 ml [milliliter] fluid restriction. He currently has a tooth abscess and is on ATBs [antibiotics] for this. Recently went to dentist for this. He uses a walker and wc [wheelchair] for ambulation but states he can walk independently just fine. SS [social services] is attempting to locate a behavioral health center to transfer him to as this is not the appropriate environment for him at this time. He needs more psych management than this facility will be able to provide . He tells me that he is going to a family function this afternoon with his sibling. Unsure if this is a delusion or a correct statement. Staff is unsure as well. I have been able to locate his prior records in EPIC [electronic medical record system], although it is not comprehensive view given, he has been in numerous facilities over the years that are not part of that EHR [electronic health record] system or integrated onto it. The form indicated Resident B had a confused cognitive status and was signed by the NP. Progress notes included, but were not limited to, the following: 7/3/23 (no time listed) . Judge does not want him released to community. Resident risk to self and others. APS reported they are able to give consent for treatment and sign paperwork. Homeland security called D/T [due to] resident called SS [social security] office threatening to commit suicide if they didn't help him. They wanted to make sure he was not living [sic] or had access to leaving . Resident was informed that APS is in charge and able to handle his affairs and can sign . Primary notified d/t [due to] reports that he made threats to commit suicide . Resident B was currently on 15-minute checks. 7/3/23 (no time listed) Received order for inpatient psych eval 7/4/23 5:00 P.M. Resident's sister and brother-in-law picked resident up at 4:30 P.M. that day, signed by LPN 7. 7/5/23 (no time listed) Resident went LOA with a female who he reported was family on 7/4/23. Resident did not return. Administrator communicating with APS. Resident did call SSD to report he was okay and proceeded to report reasons why he left. All a fabrication, signed by the SSD. On 7/28/23 at 9:25 A.M., a 15-minute check form was provided for Resident B. Checks began 7/3/23 at 11:30 A.M. and the last one was completed 7/4/23 at 4:30 P.M. A blank form was already filled out with the resident's name for 7/5/23. A sign out sheet indicating Resident B was signed out by a person accepting responsibility was dated 7/4/23. On 7/26/23 at 10:02 A.M., the Social Services Director (SSD) indicated she was aware of a court order that Resident B was supposed to be in a nursing home until his court date but did not know that date. She indicated he had a history of using his cell phone inappropriately and it could be taken if needed. The court order was included in all the other information given to staff when Resident first came to the facility, but there was nothing in the court order that said he could not leave the building and go LOA. APS told her that he was not supposed to be discharged to the community and needed to be in a long-term care facility. He did not have a wander guard. She indicated while here, Resident B displayed a lot of socially inappropriate behavior, blaring of music on his phone, verbal cursing of the staff, and refusing care. She indicated Resident B said that was how he was going to act, and he would not change his behavior. She indicated he was educated about his behavior and would apologize and then do it again. Other residents complained of his behavior. She indicated Resident B had gone to the ER on [DATE], and on his way back on 7/3/23, he called the social security office in (city name) and threatened to commit suicide in their office if they did not make him the payee of his social security. Because of the threat, Resident B was placed on a suicide watch when he returned to the facility, but the next day was a holiday and administrative staff were all off. She indicated nursing staff should have documented the suicide watches, and should not have let him leave while on the watches, as they were to remain in effect until an evaluation was completed by psych. She indicated she questioned that decision, but the nurse on duty thought the person that came was family, so she allowed him to leave. Upon her return to the facility on 7/5/23, she had an inpatient facility for him to be transferred to, but he was gone. On 7/26/23 at 10:15 A.M., the Administrator indicated the information provided from Resident B's previous facility included, but were not limited to vaccine information, diagnosis information, medication information, and allergies. She was also notified that Resident B had behaviors of playing music very loud and had a court order to take his phone as needed. Resident B had an order to be in a facility and had no guardian or POA. On 7/28/23 at 7:53 A.M., Licensed Practical Nurse (LPN) 3 indicated if a resident expressed suicidal ideation she would document in the resident's chart as a behavior and report to the SSD. Staff should also notify the resident's family and physician. Staff should initiate 15-minute checks as an immediate intervention and document those checks on a form for at least 48-72 hours, possibly longer depending on if the resident continued with the suicidal comments or behaviors and may be placed on 1:1 supervision. She indicated staff should then implement whatever the physician or psych services ordered. The resident may be sent out for a psych evaluation. If a resident were on 15-minute checks due to suicidal ideation, staff should absolutely not allow them to go LOA without approval from the physician, administrator, etc. The following information was provided by confidential correspondence: The facility accepted Resident B from another long-term care facility. APS had a current order related to Resident B that he was not to leave the facility. APS was trying to find him a guardian due to a doctor deeming him incompetent. APS notified the facility of Resident B's court order and behaviors on 7/28/23 prior to admission, as well as Resident B would try anything to leave the facility. APS was assured by the facility there were other residents with mental health concerns and their staff could handle Resident B. It was made very clear that Resident B was not to leave the facility for any reason and the court order indicated he was to remain in a 24-hour facility. The facility indicated Resident B had already called them about a sister he wanted to visit with. The facility was then informed Resident B did have a sister, but they did not have contact with each other, and he could not leave the facility for any reason. It was requested that if Resident B wanted to visit with anyone, that they needed to come to the facility to see him. On 7/5/23, the APS office indicated Resident B had called them from a different state and had paid someone from a social media account to claim they were his sister and brother in law to come pick him up from the facility the day before. APS was not notified that Resident B was missing and failed to follow a court order signed by a judge. Resident B was in extreme danger to himself and others. The facility spoke with the APS office on 7/3/23 about looking into moving Resident B into another facility. The facility did not want him as a resident after only a few days related to his behaviors and manipulations which they had indicated prior they were equipped to handle. The court order for Resident B indicated he was to remain in a 24-hour facility, as when it was originally executed, Resident B was found on his floor unable to get up and was hours from passing away. A welfare check was done to the individuals that came to pick up Resident B from the facility, but Resident B could not be located. Both individuals had a criminal record. A current non-dated missing resident action plan was provided 7/28/23 at 9:17 A.M. and indicated when a resident was missing, staff should notify police, the Director of Nursing (DON), family or responsible party, the physician, the facility Administrator, and the state agency. A current abuse policy, dated 9/15/17, was provided 7/28/23 at 7:45 A.M. and indicated It is the policy of [facility name] to ensure that each resident is free of physical, mental, verbal and sexual abuse, corporal punishment, mental and physical neglect and involuntary seclusion. [name of facility] prohibits the mistreatment, neglect, abuse of residents and misappropriation of residents' property by anyone including staff, other residents, or persons from outside the facility . Neglect can also be ab [sic] action or lack of action that places one or more residents in a life-threatening situation. A current non-dated suicidal precautions policy was provided 7/26/23 at 10:04 A.M. and indicated It is the policy of the facility to protect the rights of the residents but keep the resident safe. When a resident makes statements to cause harm to self or attempts to cause harm to self the resident must be immediately placed on precautions. At first the resident must be placed on 1:1 until the incident has been assessed and determined if the resident needs sent out. A current non-dated notification of change policy was provided 7/28/23 at 9:28 A.M. and indicated The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Circumstances requiring notification include . A transfer or discharge of the resident from the facility The Immediate Jeopardy, that began on 7/28/23, was removed on 7/31/23 when the facility in-serviced facility staff on abuse, neglect, and elopement identification, reporting, and behaviors, but the noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence.