**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to hold warfarin, an anticoagulant medication (Coumadin, brand name for warfarin) following a documented International Normalized Ratio (INR) documented as 7.8 on 4/8/24 for one of one resident reviewed for warfarin administration (Resident #19). The resident received doses of warfarin on 4/8/24 and 4/9/24 when the medication was to be held. The resident's INR was documented as 9.3 on 4/10/24. The resident was found with blood on their arms and legs on 4/13/24. Resident sent to the hospital and admitted for INR of 8.2, Hemoglobin (Hgb) of 8.6, and treated with Vitamin K (antidote). This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident. The facility reported a census of 51 residents. Findings include: The State Agency informed the facility of the Immediate Jeopardy (IJ) on 9/25/24 at 4:20 PM. The IJ began on 4/8/24, when warfare administered to the resident following an INR of 7.8. Facility staff removed the IJ on 9/25/24 at 11:36 AM through the following actions: 1. The identified resident's Coumadin/warfarin was discontinued on 5/9/24 2. All other residents with Coumadin/warfarin orders were reviewed for accuracy on 9/25/24. 3. Implemented new procedure regarding Coumadin/warfarin administration 9/25/24. 4. Coumadin/warfarin Procedure New orders or New Admit with orders for Coumadin/warfarin the Nurse will: 4a. Enter Coumadin/warfarin order into Electronic Health Record. 4b. Nurse will document order on Coumadin/warfarin log located at each station. 4c. DON (Director of Nursing)/Designee will check all new Coumadin/warfarin orders and the log within 24 hours to ensure dosing and follow-up labs are entered as ordered on the log and in Electronic Health Record. 5. The Nurse who took the order to hold Coumadin/warfarin on 4/8/24 is no longer employed at the facility. 6. All nurses will be educated on the new procedure on 9/26/24. Additionally, all nurses will be educated on how to properly enter orders in Electronic Health Records. 7. New employees and agency staff will be trained on how to complete this procedure including entering orders in Electronic Health Records during their orientation. 8. Audit tool implemented to ensure nurses are administering Coumadin/warfarin according to physician orders. 9. Audits will be completed weekly for one month and then monthly ongoing as needed. 10. The audit results will be brought to the Quarterly QA (Quality Assurance) meeting. The scope and severity lowered from a J to a D during the survey. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #19 revealed the resident scored 14 out of 15 on a Brief Interview for Mental Status exam, which indicated intact cognition. Per this assessment, the resident took anticoagulant medication. On 9/24/24, review of the resident's Care Plan revised 7/18/23 revealed, The resident is on anticoagulant therapy; Coumadin. Review of the Intervention dated 7/18/24 revealed, Administer ANTICOAGULANT medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT (every shift). Review of Medical Diagnoses for Resident #19 revealed, in part, cardiac arrythmia. Review of the Health Status Note dated 4/1/24 at 4:16 PM revealed, Dr. [Name Redacted] aware of residents INR of 3.7 new orders given for Coumadin 3mg (milligram) on Thursday and Sundays and Coumadin 1.5mg on all other days, recheck INR on 4/8/24. The Physician Order present on Resident #19's MAR (Medication Administration Record) dated April 2024 revealed the following: a. (Start Date 4/1/24, with hold and discontinuation date 4/10/24): Coumadin Oral Tablet (warfarin sodium) Give 1.5 mg by mouth in the evening every Mon, Tue, Wed, Fri, Sat related to LONG TERM (CURRENT) USE OF ANTICOAGULANTS . 3mg on Thursday and Sundays recheck INR 4/8/24. The Orders-General Note from eRecord dated 4/8/24 at 3:03 PM authored by Staff L, Licensed Practical Nurse (LPN) revealed, [Lab Name Redacted] called with STAT lab results; Verbal report received from [Lab Name Redacted] staff [Name Redacted], PT (prothrombin, test for blood clotting): 73.4, INR: 7.8. Coumadin Clinic notified by this nurse. <sic>Comedian <sic> Clinc staff verbal response received from [Name Redacted]; Hold Coumadin for today and tomorrow. Check INR EARLY Wednesday. Watch out for bleeding. Any continuous bleeding, send resident out to the ER for further evaluation. Review of the fax sheet to Provider for Resident #19 dated 4/8/24 revealed, Please review labs. Coumadin clinic notified and gave orders to hold meds today & tomorrow. Draw labs early Wednesday send resident to ER if any continuous bleeding noticed. Review of the Lab Report for Resident #19 dated 4/8/24 revealed INR result 7.8 and Hgb 9.9. The Lab Report noted standard anticoagulant INR range 2.0-3.0 INR, and aggressive anticoagulant range 2.5-3.5 INR. Review of the Coumadin Dosage Schedule chart dated 4/8/24 from the clinic managing the resident's Coumadin revealed the resident not to receive Coumadin on 4/8/24 or 4/9/24. The Medication Administration Record (MAR) dated April 2024 revealed Resident #19 was administered Coumadin 1.5 mg on 4/8/24 and 4/9/24. The Health Status Note dated 4/8/24 at 4:05 PM revealed, Response received from [Anticoagulation clinic name redacted] goes as follows: Continue same meds and follow up 4/30/24 as planned. Staff will continue to monitor. The Communication-with Physician note dated 4/10/24 at 10:59 AM revealed, Call received from [Name Redacted] at [Facility Redacted]/Coumadin clinic. Has concerns about Coumadin dosing/staff. Relayed to supervisor ([Name Redacted], ADON). The Lab Note dated 4/10/24 at 3:00 PM revealed, Call placed to Coumadin clinic RE: INR 9.3, PT 86.3. Spoke with [Name Redacted]. Has to speak to Dr. [Name Redacted] and will call back. The Order Note dated 4/10/24 at 3:30 PM revealed, ANY S/S (signs/symptoms) OF BLEEDING or FALLS - TO ER IMMEDIATELY. INR 9.3 PT 86.3 HOLD COUMADIN THROUGH SUNDAY RETEST INR 04/15/22. DO NOT GIVE COUMADIN UNTIL SPEAKING WITH CLINIC 04/15!!!!! every shift until 04/15/2024 18:00 (6:00 PM) Start Date: 4/10/2024 End Date: 4/15/2024 .Lab updated, wanted to d/c (discontinue) INR 04/11 and place the INR for 04/15. Pharmacy aware. The Health Status Note dated 4/13/24 at 5:25 AM revealed, Resident has a standing order to be sent to ED (emergency department) for eval (evaluation) if any bleeding. Resident found in bed with blood on her arms and legs. BP (blood pressure) 80/40. 02 (oxygen) sat 88% on room air. Placed on oxygen . Have standing order to be sent to ED for eval and treat for any bleeding. Left message with POA (Power of Attorney) daughter. Called medic for transport they are on their way. Paperwork prepared. Review of ED admission Paperwork from Resident #19's Hospital Records dated 4/13/24 at 6:43 AM revealed the following per Chief Complaint: pt (patient) arrived from [Facility Name Redacted] d/t (due to) staff finding dry blood, skin tear on left forearm, and INR 9.3. has gallbladder infection. Review of the resident's vital signs revealed blood pressure documented as 102/50 mm hg. Review of the Physician Progress Note dated 4/14/24 revealed the following documented Hemoglobin levels of 8.6 on 4/13 and 4/14, with INR documented as 8.2 on 4/13 and 2.6 on 4/14. The Progress Note dated 4/13/24 at 11:40 AM revealed, Spoke to nurse [Name Redacted] at [Name Redacted] ER. admitted for an INR 8.2. Positive for blood in stool. Hemoglobin 8.6. Administered Vitamin K in ER. Bp (blood pressure) low, and not moving very well due to weakness. Coumadin clinic faxed, [Facility Name] on-call made aware. On 9/24/24 at 8:31 AM, Resident #19 observed in their room. The resident was wearing a nasal cannula, with oxygen concentrator set to 4 Liters. On 9/25/24 at 12:54 during an interview with Staff K, Medical Assistant from anticoagulation clinic, Staff K explained the following about Resident #19: Per Staff K, the resident's INR on 4/8 was 7.8, and at that point guidance was to hold the resident's warfarin on 4/8 and 4/9, and test on 4/10. Per Staff K, test on 4/10 revealed INR 9.3, and the resident ended up taking the warfarin on those nights when was supposed to be held. Per Staff K, Dr.[Name Redacted] said to hold Wednesday through Sunday (4/10-4/14), and test on Monday (4/15). Staff K explained the clinic did not get test on 4/15 because the resident was in the hospital. Staff K further explained the clinic would call (facility) after every INR, every single one. When queried as to a set number for a critical value, Staff K responded it would depend on the person's range. Staff K explained for Resident #19, anything over 4.6 INR would hold the resident's warfarin. Staff K further explained she believed a lab would come in and draw the INR, and the clinic did not get it until the next day. Per Staff K, a schedule faxed with every INR which told whatever orders given. On 9/25/24 at 1:48 PM, interview conducted with Staff M, Licensed Practical Nurse (LPN). Staff M explained if INR was followed by the Coumadin clinic, the clinic would give the orders unless had an on-call for the weekend, but still should be the Coumadin clinic. Staff M explained the nurse would input the orders, usually would come with a print out and would have a calendar week with dosing and when to recheck. Per Staff M, the order would continue until the day of the INR, and would not give Coumadin that day until got orders. Staff M further explained needed to get the result (INR) to have orders, and not supposed to give Coumadin until go INR drawn. On 9/25/24 at 2:01 PM, the facility's Assistant Director of Nursing (ADON) queried about Resident #19's Progress Note which said the Coumadin clinic called with concerns, and phone call directed to the ADON. The ADON explained, in part, it was regarding the resident's high INR and she believed it was just an informative call. When queried if she was made aware of any Coumadin medication errors for Resident #19, the ADON responded no. When queried who would draw INRs at the facility, the ADON explained there was a lab, and that they would come in and draw. When queried how the Coumadin clinic communicated with the facility, the ADON responded sometimes sent a fax, and sometimes gave (facility) a call too. The ADON explained the following about critical lab values: The tab would call (facility), and a fax would come in from the lab after lab called. The ADON acknowledged staff should be on the phone and call any critical lab either to Coumadin clinic or PCP (Primary Care Physician). When queried how quickly INR results turned around to the facility, the ADON explained they had it now if the lab was not going to get back in a timely manner, the facility would take to a local lab. The ADON explained had not been doing too bad with INRs, and had not had to implement local lab process yet. The ADON explained INR supposed to be turned around and present before 3 PM because medication had to be given at 4 PM. The ADON explained unless result was critical, as would call immediately for those labs, and if not needed to be on the phone Dr, calling lab, and needed to be checking in on that. The ADON explained INRs were usually drawn about 5:00 AM/6:00 AM. When queried who would input the orders for Coumadin dosing, the ADON responded the nurses. Per the ADON, they would either get a fax back or if called, get a telephone order. The Coumadin clinic would give a telephone order and they would send a fax too. When queried about coordination between the Coumadin clinic and the provider, the ADON explained usually the nurses were the drivers, and they were going to make sure communication with the Coumadin clinic, info needed, and right dose. Per the ADON, they needed to make sure everything was in, everything on hold, and needed to be calling back, putting everything on hold, whatever the orders were. When queried if staff would wait until had the INR result to give the drug that day, the ADON acknowledged they would. Per the ADON, on INR days would not give until get those results, and waited until got the results which is why wanted by 3 (PM) or would call the doctor. Per the ADON, she had never had a doctor say to give without results. The ADON was asked to pull up Resident #19's MAR for 4/8/24 and 4/9/24. When queried if she had been made aware of any errors, the ADON responded no. On 9/25/24 at 2:45 PM during an interview with Staff L, former Licensed Practical Nurse (LPN) at the facility (who had charted the note to hold the medication on 4/8/24 and 4/9/24), Staff L explained she hardly worked down the hall where resident resided. Staff L explained she could not enter labs because she did not have access to labs. Per Staff L, the she was never given access to labs, and the facility kept turning over directors. Staff L explained she went by word of mouth to get lab results. When queried if she was able to put in orders, Staff L expressed the following: Like meds and stuff like that, [Staff L] didn't ever do any of those things there (facility), [Staff L] couldn't do anything. Staff L explained they emailed human resources with concerns. Staff L expressed being able to do the bare minimum with the electronic health record system. Per Staff L, the former Director of Nursing (DON) was supposed to work on her computer access, and Staff L further explained she would show (facility) things she (Staff L) could not do, and (facility) said they would do it. Staff L explained she currently knew how to get into the computer system and put (order) on hold due to other employment, and then (prior) didn't know how to do those things and would pass information on to the ADON. Per Staff L, the ADON was aware Staff L could not access things. On 9/25/24 at 3:21 PM, interview conducted with the facility's DON. The DON explained she started in the position on 4/8/24. When queried if there were any concerns with Coumadin (warfarin) in April, the DON responded no. When queried if notified about blood on resident's arms/legs, the DON responded no. When queried if she was made aware of any concerns with Resident #19's Coumadin, the DON responded no. When queried about the situation, the DON acknowledged the following expectation: write the order to stop the Coumadin, stop the Coumadin, signs/symptoms of bleeding go the the ER (emergency department), watch for INR in 2 days, and make sure to discontinue on the MAR (Medication Administration Record), absolutely. When queried if she was aware of computer access concerns, the DON responded no, and the DON knew agency staff did not have access to lab. During the interview, the DON was made aware of the resident's INR of 7.8 followed by Coumadin administration, INR of 9, then hospitalization. The DON acknowledged the situation could have ended very poorly. When queried if the orders would be handled by the anticoagulation clinic if resident saw them, the DON acknowledged they would be, and further explained would usually do a verbal asked to fax them, they would do either. The DON further explained she would really think with 7.8 (INR) would send the resident out because facility was not a hospital. The DON further explained they would have sent the resident out that day with the INR of 9. On 9/26/24 at 10:47 AM the ADON queried about any computer issues, and responded the [electronic health record] system was kind of new for the facility, and the facility had only been using it for a year at present time. When queried if Staff L, LPN had computer issues, the ADON responded she did. The ADON explained she remembered Staff L received education on a few things. The ADON further explained Coumadin levels were kind of hard to put in too, and wanted to make sure right dose each day. Per the ADON, everyone got education on the first day they came and as needed. Review of the Facility Policy dated Administering Medications, dated 2001 and revised 4/19, revealed the following: Medications are administered in a safe and timely manner, and as prescribed.

Based on observations, clinical record review, and resident and staff interviews the facility failed to identify and respond to an elopement in a timely manner for 1 of 1 residents reviewed for elopement (Resident #1). Resident #1 eloped from the facility on 7/20/24 at approximately 3:00 a.m., was found at 7:20 a.m. by facility staff on a neighboring business property approximately 100 yards from the facility. Facility staff initially identified the resident was missing at 6:50 a.m., notified management staff at 7:08 a.m., and staff went outside and looked for the resident at 7:15 a.m. The facility failed to follow appropriate precautions when a door alarm sounded on 7/20/24, they did not assess the area around the door for residents and did not take action to ensure that all residents were accounted for that resulted in a resident's elopement and fall with injuries. Residents that were cognitively impaired but independently mobile could potentially have been impacted by the facility's failure. The facility reported a census of 51 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/6/24 at 2:00 p.m. The IJ began on 7/20/24. The facility staff removed the IJ on 8/6/24 by implementing the following actions: 1. Staff educated to account for all residents when a door alarm is sounded, effective 2:00 p.m. on 7/20/24. All door alarms were checked for correct operation; concerns were identified on the Station 2 door and beauty shop door, and a staff member was positioned by the doors and designated as a door watch until the security alarm company arrived on 7/22/24 and assessed alarm functions on all exit doors. Adjustments to the alarm sensitivity were made at that time, replacement parts ordered, the company returned on 7/24/24 and completed repairs on the effected exit doors. The door watch was discontinued after alarm functions were verified on all WanderGuard alarmed doors. 2. Staff educated on 7/22/24, 7/23/24, 7/24/24, 7/25/24, 7/26/24 and 7/30/24 regarding proper head counts of residents when the door alarm sounds, including visual confirmation that they are present in the facility. Additionally, staff were educated to respond to every door alarm. If there is an unwitnessed alarm activation staff have been educated to check the area around the door on both sides of the door and surrounding areas within proximity of the door that alarmed, and initiate an immediate headcount if the resident is not found near the door and completed prior to deactivating the alarm. 3. Nursing staff were educated that all residents should be accounted for, including visual verification, on the change of shift rounds at every shift change 4. Responsible staff have been educated to complete door alarm checks every shift. 5. Nursing staff educated they are required to verify placement of the WanderGuard bracelet on each of the resident's that have them, on every shift, and document on the resident's Treatment Administration Record (TAR). The WanderGuard alarm bracelets are also checked to ensure proper working order daily on the night shift using the remote checking device, also documented on the TAR. The IJ was removed on 8/6/24 at 5:30 p.m., the scope was lowered from a J to a G verified by onsite survey. Findings include: The Minimum Data Set (MDS) Assessment tool dated 6/4/24 revealed Resident #1 had short and long term memory deficits and severe cognitive impairment, had a diagnosis of non-Alzheimer's dementia, was able to make himself understood and understood others, able to ambulate independently and required staff supervision to maintain his safety. A Wandering Risk Scale assessment form completed 6/6/24 revealed the resident scored between 0 and 8 points, in the low risk category for wandering. A score of 9-10 indicated the resident was at risk for wandering, and a score of 11 or greater indicated the resident was at high risk for wandering. A Risk for Wandering/Elopement problem initiated 6/15/23 on the resident's Nursing Care Plan directed staff: 1. Engage resident in purposeful activity, initiated 7/15/23. 2. Identify if there is a certain time of day when wandering/elopement attempts occur, initiated 6/15/23. 3. Resident wears a WanderGuard bracelet (a device that activates an audible alarm when it is near an exit door). Staff to check placement every shift and 3rd shift to check if working properly, initiated 6/11/24. 4. Clearly identify resident's room and bathroom, initiated 6/15/23. The resident's July, 2024 Treatment Administration Record (TAR) revealed staff were directed to check for placement/confirmation that the WanderGuard bracelet was on the resident every shift (3 times a day, on the day shift, evening shift and night shift). Staff were also directed to check the functioning of the resident's WanderGuard bracelet daily on the night shift. The July, 2024 TAR revealed staff did not check for placement of the WanderGuard bracelet on the evening shift on 7/19/24, and the night shift on 7/20/24, and staff did not check the functioning of the WanderGuard bracelet on the night shift on 7/20/24. The posted daily schedule for 7/19/24 revealed scheduled employees on the night shift that started at 10 p.m., and ended at 6 p.m. on 7/20/24 included Staff D, CNA, Staff E, CNA, Staff F, LPN (Licensed Practical Nurse) through a staffing agency, and Staff G, LPN, also through a staffing agency. The posted daily schedule for the 6 a.m. to 2 p.m. day shift on 7/20/24 revealed Staff J, CNA, assigned to the resident, Staff A, CNA, also assigned to the resident's station, Station 3, and Staff C, RN assigned to Station 2. A Nursing Progress Note transcribed by Staff C, Registered Nurse (RN) on 7/20/24 at 1:33 p.m. stated: Alerted by staff that the resident was not in his room and staff unable to find the resident. All the CNA's (Certified Nursing Assistants) went around the facility to look for the resident, this nurse went around the health center looking for the resident door to door, at 7:08 a.m. notified the manager on call that the resident was missing and was advised to call the police if the resident could not be located. This nurse took their car and drove around the facility campus looking for the resident, while driving staff called and notified this nurse the resident was located by staff (Staff A, CNA and Staff B, CNA) at 7:20 a.m. at an adjacent property. This employee notified the manager on call the resident was located and drove to the resident's location. The 2 CNA'a were with the resident, reported they found him face down on the pavement facing the direction of the facility. Staff A said the resident was bleeding; this employee knelt down and assessed the resident, his eyes were open, he was breathing, his pulse was racing, blood was on the pavement approximately 12 inches away from where he was laying. The resident was able to move, turned him over to his back for comfort and let him rest his head on the employee's leg. The resident did not did not cry or yell out in pain, appeared anxious and his hands were shaking. His forehead had a laceration, nose had dried blood and had debris covering his face. This nurse asked the resident if he was okay, the resident kept looking at this employee and did not respond (the resident's normal status due to his dementia) and called EMS right away (Emergency Medical Services). The 3 staff remained with the resident until EMS arrived at 7:37 a.m. and transported the resident to hospital. A hospital Discharge Summary report dated 7/22/24 revealed the resident presented to the Emergency Department on 7/20/24 after a fall that resulted in: 1. A right sided triquetral fracture (bone in the wrist) that required application of a splint to be worn at all times, and follow-up with an orthopedic physician. 2. Forehead and facial abrasions from fall. The facility's Wandering and Elopement policy, dated as last revised March, 2019 directed staff: 1. The facility will identify residents who are at risk of unsafe wandering. 2. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety plan. 3. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner, b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. 4. If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and c. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies. 5. When the resident returns to the facility, the director of nursing services or charge nurse shall: a. examine the resident for injuries; b. contact the attending physician and report findings and conditions of the resident; c. notify the resident's legal representative; d. notify search teams that the resident has been located; e. complete and file an incident report; and f. document relevant information in the resident's medical record. Observations revealed: 8/1/24 at 3:15 p.m. revealed Staff H, Support Services Coordinator had a WanderGuard testing device by the Station 2 exit doors, the first set of exit doors alarmed when the device was near the door, and allowed the doors to open, as intended. The alarm continued to sound until a passcode was entered by staff. The second set of doors were equipped with magnetic locks, when the WanderGuard device activated the door alarm, the door became locked and required continuous pressure applied to the bar for 15 seconds in order for the door to open, also as intended. The alarm continued to sound until a passcode was entered by staff. The second set of doors opened to a hall that led directly to an unalarmed exit door. Staff H stated at that time she checked all door alarms daily from Monday through Friday, the doors alarmed with the device she used to check the alarms, but they found the alarms didn't always work with a resident that wore a WanderGuard bracelet. 8/1/24 at 3:24 p.m. the first set of exit doors by Station 1 alarmed when a WanderGuard device was near it, and continued to sound until a passcode was entered by staff. The second set of exit doors had a magnetic lock activated when a WanderGuard device was near, and required 15 seconds of continuous pressure on the bar for the door to open, as intended. The alarm continued to sound until reset by staff. The 2nd set of exit doors led to an area between administrative offices and an attached independent living facility, both areas led to unalarmed exit doors to the outside. 8/2/24 at 11:41 a.m., Resident #1 ambulated independently in the hall with regular gait, had shoes on and wore a splint on the right lower arm. Staff interviews revealed: 8/1/24 at 2:56 p.m., Staff D, CNA, stated he worked the night shift that started at 10 p.m. on 7/19/24 and ended at 6 a.m. on 7/20/24, there was usually 3 CNA's on the night shift but that night 1 of them had called in, and the other one (Staff E) arrived late, around 10:45 p.m. Staff D stated he was the only aide there for the night shift until Staff E arrived, he took report on all residents and saw Resident #1 laying down in his bed around 10:30 p.m. Once Staff E arrived, she had the Station 3 residents (the resident's area), Staff D had Station 2 residents, and the 2 aides split the Station 1 residents. The resident was still in his bed between 10:50 p.m. and 11 p.m. when he gave report to Staff E, CNA and rounded with her. He went past his room around 12 a.m. and the resident was still in bed. Between 2 a.m. and 2:30 a.m., he heard water running in the sink in the resident's bathroom and the resident was in there. Around 3 a.m. he went to Station 3 to assist Staff E, saw Staff G, LPN (Licensed Practical Nurse) as she came back from break and the door alarm at Station 1 was going off. Prior to that time that night, Resident #3 was up in her wheelchair, self-propelled and wandered throughout the facility, a usual activity for her, and activated the WanderGuard alarms at both Station 1 and Station 2 as she wandered. He followed Staff G, LPN to Station 1, Resident #3 self-propelled her wheelchair away from the exit door area and towards Station 2, Staff G told him to turn the door alarm off because she didn't know how to. Staff D stated he went out the first set of exit doors to turn the alarm off, the alarm on the 2nd set of doors was not activated, he didn't know the code to reset the alarm and silenced the alarm by inserting an ink pen into a whole located on the bottom of the alarm box, that was the only way he knew to silence the alarm. Staff D stated he thought Resident #3 had activated the door alarm because she was moving away from the door as they came down the hall from the Station 3 area. Staff D stated he had not seen Resident #1 out of his room that night. 8/1/24 at 3:44 p.m., Staff E, CNA, stated when she worked the night shift on 7/19/24 to 7/20/24, she saw the resident in bed in his room around 2 a.m. The resident will get up by himself and use the bathroom, she thought she saw the bathroom light on with the bathroom door shut around 4:30 a.m. and thought the resident was in the bathroom. Resident #3 was up in her wheelchair that night, she goes around in her wheelchair and sets the door alarms off and had been doing that on that night. When she made rounds with the day shift that morning, she thought the resident was in the bathroom because the bathroom door was shut, the bathroom light was on, and did not see the resident at that time. She did not see the resident out of his room that night, and did not know the resident got out of the facility until she got a call that day about it. 8/2/24 at 9:36 a.m., Staff F, LPN from a staffing agency, stated when she worked on the 7/19/24-7/20/24 night shift the resident was assigned to her, she saw him around 2 a.m., he was lying in his bed. She didn't see him in the halls that night. 8/1/24 at 5:06 p.m., Staff G, LPN from a staffing agency, stated the door alarm at Station 1 was going off that night (7/20/24), as she returned from break at approximately 3:00 a.m. There was a resident that self-propels in her wheelchair throughout the night and had set door alarms off earlier that shift, she was going towards Station 2 from Station 1 at the time (Resident #3). The agency staff received little instruction on specifics to the facility, she did not know the passcode or how to reset the door alarm, Staff D knew how to reset the alarm and did. Staff G stated she wasn't assigned to the resident that night, had no observations of him and had not seen him in the hall that night. 8/2/24 at 5:42 a.m., Staff I, CNA, stated she had worked on the night shift for several years, knew Resident #1 well, he didn't sleep very good and was up and down at night. He usually came out of his room, sat in a recliner across from the Nurse's Station, he ate a snack and has something to drink, then goes back to bed. He always puts his shoes on or had his shoes on when he came out of his room, she has seen him wander towards Station 2 and will get to the door if staff don't intervene and redirect him back to Station 3. She had not seen him go towards Station 1. 8/2/24 at 3:40 p.m., Staff J, CNA, stated he worked the day shift on 7/20/24. When he got report from the night shift, the resident wasn't in his bed, the bathroom door was shut, the light was on in the bathroom, and the staff that gave report to him said he was in the bathroom. As he assisted his residents that morning he could not find the resident in his room, he wasn't in the bathroom and he couldn't find him in the area, so he asked his coworker if she had seen him, she had not, and everyone started looking for him. 8/6/24 at 11:32 a.m., Staff A, CNA, stated she worked the day shift on 7/20/24, around 6:50 a.m. Staff J came to her and asked if she had seen the resident, she had not, she told him they needed to alert all staff and she notified staff at Station 2, then went to Station 1 and alerted them. Staff looked from room to room and she even went to the attached Assisted Living facility and did not see the resident. She went outside, saw 1 of the other aides outside looking for the resident (Staff B, CNA) who said she hadn't found him in the area, they went to the road that went around the facility, the gate on the fence line by the road was open so they went through it, she thought she saw someone in the distance on the ground, moved toward them and as she got closer she knew it was the resident. He was on the pavement, face down, he had dried blood on his face and on the ground by him, he was awake, his eyes were open, and she called the facility to tell them where he was. They stayed with the resident, the nurse, Staff C, RN, came in her car, she assessed him and called 911. Staff A stated she knew the resident well, he had walked towards Station 1 a couple of times but was easy to redirect. 8/5/24 at 11:34 a.m., Staff C, RN, stated she worked the day shift on 7/20/24, around 7 a.m. that day staff said they couldn't find the resident and they all started looking for him. They didn't find him in the facility, she called the manager on call to notify her, and got in her car to drive around the property to see if she could find him. She got a call that he was found in a business parking lot and drove there. The aides that found him were with him, he was laying on the ground face down, there was dried blood on his face and on the ground near him. He was awake, his eyes were open, she tried to talk to him, he didn't respond but that was normal for him. He could move everything and didn't act like he was in pain so they turned him to his back so he would be more comfortable, she didn't see injuries other than cuts/abrasions on his face. She called 911 and the manager on call. Prior to that day, she had seen the resident walk to Station 2 a couple of times in the last year, and when he was first in the facility he had gone to the Station 1 door. He was always easy to redirect. 8/2/24 at 2:20 p.m., the Director of Nursing (DON) stated staff called her on the morning of 7/20/24, notified her the resident had eloped, she went to the facility immediately, spoke with staff and implemented education that day on the expectations of what staff were supposed to do when a door alarm went off. They also assigned a staff member to each of the exit doors to monitor the doors in case there was an alarm malfunction until their service provider could inspect the alarm system. The facility was equipped with several surveillance security cameras and she thought she could review how the resident exited and the time, however, it was right after the computer software crash on 7/19/24, and their security cameras did not function because of that. One of the employee's there had connections to a neighboring business and how the facility had access to their security surveillance videos, that showed the resident walked across the parking lot at 3:13 a.m., headed south, to the corner of a business, then he turned, walked towards the facility, walked along a fence line that separated the parking lot from a business, the resident fell where staff found him that morning. The DON didn't know if the time on the video was correct, but she didn't think the resident was in the bathroom or in the building when staff said he was at 4:30 a.m., she thought the resident left through the Station 1 door when it alarmed at 3 a.m. and staff didn't check to see if anyone had gone out the door, or check for missing residents when the door alarmed and staff should have done that. All staff were educated to look on both sides of the door and around the area when a door alarm sounded, to make sure a resident hadn't left, do a headcount and make sure all residents were accounted for before the door alarm was reset. Staff were also educated to account for all residents, visually see each one when they gave the shift to shift report, and staff had not done this on that day. 8/2/24 at 10:33 a.m., a representative from the facilities contracted WanderGuard service provider was interviewed and stated they were at the facility on 7/23/24 to assess the system. They found all door alarms functioned but had to adjust the sensitivity of the signal on 1 of the doors due to electrical interference in the area. He stated the doors/alarms were normally set to alarm when a WanderGuard was within 6 feet of the door, but due to the interference at that door, it was sensitive and alerted when the WanderGuard was within 2 feet of the door. They returned on 7/25/24 and made additional adjustments to the sensitivity settings for the alarms, all alarms worked.