**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview, and staff interviews, the facility failed to provide a safe discharge for 1 out of 1 resident reviewed (Resident #2). On 7/3/25 at approximately 6:15 PM, Resident #2 exited the building to go see his support animal without staff knowledge. On 7/4/25 around 3:00 AM, Resident #2 requested to return to the facility. Due to the frustration of not being able to get a ride back to the facility, Resident #2 used his electric wheelchair and transported himself to a convenience store at 3:00 AM. At 5:30 AM the police notified the Administrator they found Resident #2. On 7/4/25 at 5:50 AM, the Administrator went to the convenience store and had Resident #2 sign a form indicating he left the facility against medical advice (AMA). The facility lacked documentation of education provided to Resident #2 for leaving AMA.On 7/23/25 at 3:30 PM, the Iowa Department of Inspections and Appeals and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on 7/25/25 at 1:30 PM, after the staff competed the following:The facility updated their Point of Contact form on 7/17/25 to include additional resident emergency contacts to reach if an emergency situation occurs, such as elopement, or a potentially unsafe resident-initiated discharge.The facility provided staff education on 7/23/25 regarding the Point Of Contact form and the process regarding the chain of command if a resident refused to return from an elopement or their therapeutic leave including calling law enforcement if the resident left the premises and refused to return.The facility added administrative oversight regarding every facility or resident initiated discharge (including AMA) must be reviewed and cosigned by an administrative leader (i.e. Administrator, DON, SW, MDS or designee) before the resident leaves or AMA paperwork is initiated to verify full compliance with the Federal Regulations regarding notice and discharge planning requirements. The administrative team leader would verify the following checklist: Administrative Reviewer -Unplanned Discharge Checklist prior to resident discharge from facility:Right to remain: Verify resident (and representative, if any) was clearly told they may stay at the facility and receive continued care; discussion is documented. Offer root cause analysis and appropriate alternatives concerning their desire to leave the facility in order for the facility to encourage the resident to stay at the facility.Refusal captured: If the resident still chooses to leave, ensure refusal / AMA form is completed and scanned into the record.Medication safety: Confirm medication reconciliation is done and an adequate supply-or prescription-plus written instructions were offered/provided.Post-discharge supports: Confirm offers to arrange / initiate:Home-health or other appropriate community care services.b. A safe place to stay (e.g., confirmed address, shelter, family).Transportation: Ensure safe transportation to the chosen destination is arranged or offered and documented (method, driver, address). The facility educated the nursing staff and social services on 7/25/25 regarding a safe return escort:Any resident off premises who calls or appears without transport is met by facility staff and escorted back in a facility vehicle if available, family member, authorized representative, law enforcement, or emergency services.Staff must immediately notify the facility administrative staff to ensure no resident reentered the facility alone or is stranded and they complete an unplanned discharge checklist to ensure the resident's safety.The scope was lowered from an IJ to a G (harm that is not immediate) on 7/25/25 after ensuring the facility implemented the removal plan. The facility identified a census of 51 residents.Finding include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #2 required partial to moderate assistance with transfers. In addition, listed Resident #2 as dependent with dressing and personal hygiene. The MDS included a diagnosis of need assistance with activities of daily living (ADLs). The MDS indicated Resident #2 didn't smoke.Resident #3's Clinical Census listed an admission date of 7/3/25.The BIMS evaluation conducted 7/3/25 listed a score of 15.Resident #2's admission assessment dated [DATE] at 3:04 PM identified a BIMS score of 15. The assessment listed Resident #2 as dependent with activities of daily living and used a motorized wheelchair mobility. The assessment included diagnoses of diabetes mellitus, muscle weakness, need for assistance with personal cares, anxiety, chronic atrial fibrillation (an irregular often rapid heart rate that commonly causes poor blood flow), bilateral (both sides) below knee amputation, and substance abuse.The Care Plan included the following Focuses initiated7/3/25 indicated Resident #2 used tobacco. The Goal listed he would adhere to the smoking policy. The Interventions directed:7/14/25: Complete a smoking evaluation as needed.7/14/25: Inform Resident and/or Responsible party of the smoking policy.7/14/25: Must keep smoking accessories secured when not in use by the facility staff.7/18/25: Dependent SmokerStaff to assist him to smoke in the designated areas at the designated smoking times.Staff to supervise while smoking.If needed must wear a protective smoking vest or apron.Resident #2 had a risk for ineffective breathing related to wheezing (caused by tightness in the lungs that make breathing difficult). The Intervention directed to provide medications as ordered.Resident #2 required assistance with ADLs. The Interventions directed the following:Assist with showers/bathing per scheduleDependent on staff for dressing, grooming, transferring, and bed mobility.Resident #2 received an anticoagulant (blood thinner) medication. The Intervention instructed to monitor for signs and symptoms of bleeding, bruising, headaches, bloody stool, bloody emesis or sputum.Resident #2 received psychotropic medications related to an anxiety disorder related to the targeted behaviors of restlessness, irritability, muscle tension, and sleep problems. The Intervention directed to provide medications as ordered.Resident #2's July 2025 Medication Administration Record (MAR) lacked documentation to reflect Resident #2 received the following medications on the evening of 7/3/25:Ramelteon (a medication used to help with sleep),Simvastatin (a medication used to help reduce the risk of a heart attack and stroke),Eliquis (medication to reduce risk of stroke or blood clots)Gabapentin (medication used to prevent and control partial seizures and reduce nerve pain).On 7/21/25 at 11:30 AM, observed Resident #2 lying in bed with a fan on him and covered with a sheet. He had his motorized wheelchair next to his bed and his blinds closed to the outside for privacy. Resident #2 stated he left the faciity on 7/3/25 around 6:15 PM, to go see his dog at a friend's house. He didn't know how long it took him to get to his friend's house or the direction he went but he got there. He told his friend he didn't want anyone to know where he was at until he had time with his dog. On 7/4/25 at 3:00 AM Resident #2 told his friend to call the facility to tell them he'd like to return to the facility because he got to see his dog. His friend called and told someone at the facility about him being ready to return to the facility. Resident #2 reported he waited, attempted to use the bathroom and became incontinent with stool. He added this made him mad as he had to clean his friend's bathroom and sit in his own stool. He started to make his back to the facility on his electric wheelchair. He got to a convenience store around 5:30 AM, as he already had the cops looking for him, they found him there. The next thing he knew, the Administrator came and got upset with him because he left the facility without telling anyone where he went. Resident #2 reported he got upset because he felt like the Administrator tried to make him feel bad for wanting to see his dog. The Administrator then told him if he didn't want to come back, he could sign the AMA paperwork. At this point, they told him he wouldn't come back to the facility. By that time, he reported being so angry sitting in his own stool and being unable to get clean, he just signed the paper work. Resident #2 explained after he calmed down for a little while, he realized he needed to go back to the facility for their help. Resident #2 added if someone would have gone to his friend's house and picked him up when his friend called, he would have returned to the facility. Resident #2 explained he left because he got so upset because he couldn't see his dog and no one came outside to help him while he smoked, so he left on his electric wheelchair to go to his friend's house. Resident #2 verified he didn't receive medications on 7/3/25 during the evening shift and he had orders to get medications at that time.On 7/16/25 at 12:30 PM, Resident #7 reported she knew about Resident #2 being out of the facility for 2 hours and the staff didn't even realize he left. She added it happened twice and the facility just wanted to cover it up and not do anything about it.On 7/16/25 at 2:20 PM, Staff L, Certified Medication Aide (CMA), stated she didn't know Resident #2 left the premises until staff came around and asked if anyone saw the new resident (Resident #2) on 7/3/25 at 8:30 PM. Staff L said she didn't see him at all since he ate in the dining room at a table by himself around 5:30 PM. Staff L explained she knew Resident #2 from high school and they knew some of the same people. Staff L attempted to contact a few of the mutual people. Staff L explained she attempted to call Resident #2's friend around 3 times without an answer. At 10:46 PM, Staff L sent him a text message to see if he saw Resident #2. At 2:43 AM, Staff L received a message back from Resident #2's friend about him being at his house and that he called the facility to report Resident #2 wanted to come back to the facility. Staff L explained they went home at 10:00 PM that night but knew Staff O, Licensed Practical Nurse (LPN), received the call about Resident #2 wanting to return to the facility.On 7/16/25 at 2:45 PM, Staff D, Certified Nurse Aide (CNA), said she last saw Resident #2 at the dining room table on 7/3/25 at 5:30 PM when he ate supper. When Staff D, took Resident #5 outside to smoke around 5:45 PM, she saw Resident #2 already out there smoking.On 7/16/25 at 3:00 PM, Staff E, CNA, said she last saw Resident #2 at 5:30 PM, in the dining room eating supper before she went back to her hallway to start passing room trays.On 7/16/25 at 3:15 PM, Resident #5 said when he went outside to smoke in the front of the facility on 7/3/25 at 5:45 PM, he saw Resident #2 already outside smoking. Resident #5 said around 6:00 PM, he came back in the facility and Resident #2 stayed outside still smoking.On 7/17/25 at 1:30 PM inquired with the Administrator and DON in regard to how the AMA came up with Resident #2 at the convenience store, the Administrator replied she got a phone call from the police stating they located Resident #2 at the convenience store. The Administrator went to the convenience store and Resident #2 told her he didn't want to go back to the facility, that it was a prison. The Administrator called the DON and told her to get a AMA form to fill out so that the facility didn't have any responsibility for Resident #2 leaving. Then around 9:23 AM on 7/4/25, Resident #2 showed up at the facility and wanted to come back so they readmitted him. When questioned about what happened related to the notes documenting Resident #2 called the facility 2:00 AM on 7/4/25 and wanted to come back, the Administrator replied that she and the DON were exhausted. She verbalized excuse her if she went to bed, let the police handle the situation, and didn't hear her phone go off when Staff O called that Resident #2 wanted to come back. She added when the police called her she went to the convenience store, she got very upset about the questioning of her chain of command with the nurse that attempted to call her at 3:00 AM to have Resident #2 come back. The Administrator then said well the facility didn't have transportation to bring him back at that time of the morning and asked what were they supposed to do. When questioned again and asked if he could transfer into a car and have the electric wheelchair stay there until someone could get it back to the facility, she got very upset and asked if she could leave to get someone else. The DON said they should have stayed up and kept looking for Resident #2. She added the nurses needed to have a chain of command so that another staff member could of went and got Resident #2 from his location. Staff R, Corporate Staff, came in and discussed the situation, she responded she understood and would look into it and get back.On 7/22/25 at 10:30 AM attempted to call Staff O, no answer voicemail left to return call. On 7/22/25 at 515 PM, Staff P, Corporate Staff, and Staff Q, Corporate Staff, reported they couldn't contact Staff O and thought she couldn't return the call in regards to a personal situation. Staff P said she had questions also in regards to how come no one went to Resident #2's friend's house to pick him up and why did the facility sign him out AMA if he wanted to return to the facility at 3 in the morning. Staff P added someone could of went and picked him up in a car, left the electric wheelchair at his friend's house and he would have been back safe. Staff P felt the Administration and Resident #2 must have had a confrontation, and Resident #2 felt they blamed him for leaving the facility. Staff P added the Administrator probably accused Resident #2 of leaving. This probably upset Resident #2, resulting in him saying he didn't want to come back to the facility and agreeing to sign the AMA form to live his life the way he wanted. Staff P said she got a telephone call from the Administrator stating Resident #2 returned to the facility at 9:30 AM and wanted to come back. Staff P told the Administrator to do everything she could to get him back and readmit him. They agreed the facility could have handled the incident better, adding someone from the facility could of went and got Resident #2 to bring him back when he called. They agreed the facility lacked documentation of the physician being involved in the AMA, the staff could have handled the education differently and Resident #2 would of came back.On 7/23/25 at 8:15 AM, the facility's physician verified that he was not involved with the education portion of Resident #2 discharged AMA. The Administrator told him Resident #2 signed out AMA. The physician said he expected the facility to follow the policy/procedure for discharging residents.On 7/23/25 at 9:10 AM Resident #2 stated he heard his friend talk to someone at the facility, he didn't know who he talked to but, his friend told them that he wanted to come back. He explained he waited and waited and got pissed off because no one came and got him so he left his friend's house. He went to the convenience store where the cops found him. He reported the Administrator came and had him sign AMA paperwork.On 7/23/25 at 12:45 AM, Resident #2 reported he became angry, upset, pissed off, that no one would listen to him about pooping his pants, being incontinent of urine and bowel. He added he felt embarrassed at his friend's home and that no one came to get him when he called at 3 AM. Resident #2 verbalized being scared, fearful, and upset that he had nowhere to go when Administrator had him sign the AMA papers. He calmed down while riding his electric wheelchair around town and realized he had nowhere to go, so he went back to the facility hoping that they would take him back, and he had somewhere to stay. On 7/23/25 at 5:00 PM, Staff M, Licensed Practical Nurse (LPN) explained Resident #2 came back to the facility on 7/4/25 about 9:30 AM. He had an odor of body sweat, bowel, and bladder incontinence. Staff M reported Staff H gave Resident #2 a shower.A review of an online map service for directions, reflected walking from the facility to Resident #2's payee's house via the east south street and south 7th avenue would take 1 hour and 14 minutes for 3 miles.The undated and untitled facility timeline of attempts to contact Resident #2, documented:7/3/25 at 8:50 PM, Administrator aware of inability to locate Resident #27/3/25 at 8:52 PM, the Administrator notified the DON Resident #2 left the building. The staff last saw Resident #2 when he went out to smoke. Resident #2 never came back in the facility.7/3/25 at 8:56 PM - 9:51 PM, the DON and Administrator left in vehicles to look for Resident #2 at various addresses familiar to him (mother's previous address, payee home).7/3/25 at 9:26 PM, the Administrator notified the [NAME] President of Operations.7/3/25 at 9:52 PM - 10:22 PM, the Administrator notified the police. The DON and Administrator regrouped at the facility and spoke to the police. The police posted an updated photo of Resident #2 on their Facebook page. The police reported they would perform their own search. The Administrator provided the police department with her business card for any contact needed. The police assigned a case number and completed a welfare check at the of Resident #2's payee. Resident #2's payee only allowed the police in the front living room of their home and denied Resident #2 being there.7/3/25 at 10:22 PM until 7/4/25 at 1:30 AM, the DON and Administrator returned to their vehicles to continue looking for Resident #2 in his familiar locations.The DON and Administrator couldn't locate Resident #2 and made a decision to stop the search. The DON and Administrator believed Resident #2 stayed at his payee's house, a handicap accessible house where Resident #2's therapy dog resided. 7/4/25 at 2:00 AM, Resident #2 called the facility to request a ride from his brother's home where staff looked for him several times.7/4/25 at 5:30 AM, the police notified the Administrator they located Resident #2 at a gas station7/4/25 at 5:50 AM, when the Administrator and DON arrived at gas station, Resident #2 stated he wanted to live his life and he wouldn't go back to the center. Resident #2 signed AMA paperwork.7/4/25 at 9:23 AM, Resident #2 returned to facility, apologized for his behavior on 7/3/25 and went to his room.7/5/25 at 9:33 AM, after arriving at the facility, the Administrator to speak with Resident #2 about expectations of living in the nursing facility. Resident #2 agreed he would follow the facility's expectations. The facility readmitted Resident #2 to the facility.The Police Department Report dated 7/3/25 at 9:53 PM, documented the facility reported a missing person, Resident #2. The note reflected they found Resident #2 and closed the case on 7/7/25 at 6:51 PM.The untitled typed statement from the Administrator dated 7/18/25 at 1:40 PM, indicated Staff L, Registered Nurse (RN), notified the Administrator that the staff couldn't find Resident #2 at the facility on 7/3/25 at 8:50 PM. The Administrator immediately notified the DON. They met at the facility and initiated a search for Resident #2 at 8:56 PM, in familiar places to him in town. The Administrator notified the police department to assist with searching for a resident. When the Administrator and DON regrouped at the facility at 1:30 AM, they spoke with the police department who stated they would continue to search for Resident #2 and notify them if they located Resident #2. On 7/4/25, the police notified the Administrator per phone at 5:30 AM, they found Resident #2 located at a gas station. The Administrator and DON went to the gas station to speak with Resident #2. The Administrator spoke with Resident #2. They discussed options for Resident #2 and offered him to return to the facility, which he declined. The Administrator discussed Resident #2's safety and best placement options for him. The Administrator attempted to convince Resident #2 several times to return to the facility and Resident #2 declined. Resident #2 told the Administrator and DON, he wanted to live his life, and he wouldn't go back to the center. The Administrator and DON offered a detailed explanation of discharging AMA and the possible consequences of the decision. Resident #2 chose to sign the AMA paperwork, and before leaving the gas station, Administrator told Resident #2, Be careful, if you need anything, please reach out to the facility. On 7/4/25 at approximately 9:30 AM, the Administrator returned to facility after the staff notified her Resident #2 returned to facility, apologized for his behaviors, and wanted to readmit to the facility. The Administrator went to Resident #2's room and spoke with him about the rules of living in a facility, and the rule of leaving the facility grounds, and the requirements if he wanted to do that. The conversation included, signing out at nurses' station in the sign out book, notifying nursing staff he wished to leave, letting the nursing staff know where he'll visit. Resident agreed to the said rules and wished to continue to stay in the facility. The staff readmitted Resident #2 to the facility. The facility policy title Discharge Against Medical Advice revised February 2024, instructed staff to ensure they followed the standard procedures for residents who choose to discharge against medical advice. The staff should provide the appropriate attention and make a reasonable effort to prevent a resident from leaving AMA. The staff must call the physician to notify of the pending AMA discharge. If the resident requested to leave facility against the advice of the attending physician, the facility should document a resident's discharge AMA order in the clinical record. In addition, the facility should assist in arranging post-discharge planning and care to the extent possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff and resident interviews, and facility policy, the facility failed to ensure residents safely returned to the building from smoking for 3 of 5 residents reviewed (Residents #1, #2, and #5). On 7/7/25 around 8:00 PM Resident #1 went outside to smoke. After smoking, she couldn't get back into the to the building and remained outside on 7/7/25 at 8:00 PM until 7/8/25 at 6:00 AM. The staff failed to do visual checks on Resident #1 for 10 hours. During the time Resident #1 couldn't get back into the building, the weather had a forecast of heavy rain shower with thunder and lightning. The rain began at 5:00 AM to 6:00 AM, this resulted in a temperature drop from 90 degrees Fahrenheit (F) to 72 degrees F. At that Resident #1 began to panic, became fearful, scared, and crying. Resident #1 reported she wouldn't go out alone to smoke in the evening in fear of it happening again. Resident #1 experienced serious actual psychosocial harm due to being left outside overnight and refused to go outside without another person. While touring the facility and courtyard with the Administrator, the door from the courtyard back in the building failed to open without excess force to move the handle on the door. This resulted in a serious likelihood of serious injury, impairment, or death to occur due the weather conditions and hazards in the courtyard. In addition, on 7/17/25 at 12:40 PM, observed Resident #5 yelling at staff because he couldn't open the courtyard door to come back in from smoking. He reported he rang the doorbell and no staff responded. The incident resulted in an immediate jeopardy situation to the safety of residents who went out to the courtyard.On 7/17/25 at 1:45 PM, the Iowa Department of Inspection, Appeals, and Licensing (DIAL) staff notified the facility staff the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility placed a doorbell in the courtyard area that can be heard at both nurses' stations. The designated smoking area has been moved from this courtyard.The facility changed the designated smoking area to the front of the building.The facility completed checks on all entrance/exit doors to ensure functionality. The front door functioned and any resident who couldn't independently open the door would have staff escort or supervision.The facility identified like residents who resided in the facility that smoke. The facility completed a smoking program on 7/17/25 and updated the residents' Care Plans. The facility completed assessment on safety with their ability to exit and enter the designated smoke area independently. The facility deemed any resident who couldn't enter or exit the door independently to the designated smoke area as a dependent smoker and would be supervised by staff during the designated smoking hours.The facility started to educate staff on 7/17/25 specific to visual rounds of residents, the smoking policy, and the change to designated smoking area.The courtyard door continued to have a functioning door alarm system to alert staff if any resident attempted to exit.In addition, the facility failed to ensure the safety of a cognitive resident (Resident #2) who left the facility unsupervised. When the Resident #2 attempted to call the facility to return, the facility failed to ensure he returned safely to the facility. The facility didn't go to Resident #2 until the police called around 5:30 AM. Due to Resident #2 not returning to the facility independently until around 9:30 AM, he missed his evening medications. The investigation determined Resident #2 used his electric wheelchair to go approximately 3 miles to return to the facility. The incident resulted in an immediate jeopardy situation.On 7/23/25 at 3:30 PM, the Iowa Department of Inspections and Appeals and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on 7/25/25 at 1:30 PM, after the staff completed the following:The facility updated their Point of Contact form on 7/17/25 to include additional resident emergency contacts to reach if an emergency situation occurs, such as elopement, or a potentially unsafe resident-initiated discharge.The facility provided staff education on 7/23/25 regarding the Point of Contact form and the process regarding the chain of command if a resident refused to return from an elopement or their therapeutic leave including calling law enforcement if the resident left the premises and refused to return.The facility added administrative oversight regarding every facility or resident-initiated discharge (including AMA) must be reviewed and cosigned by an administrative leader (i.e. Administrator, DON, SW, MDS or designee) before the resident leaves or AMA paperwork is initiated to verify full compliance with the Federal Regulations regarding notice and discharge planning requirements. The administrative team leader would verify the following checklist: Transportation: Ensure safe transportation to the chosen destination is arranged or offered and documented (method, driver, address). The facility educated the nursing staff and social services on 7/25/25 regarding a safe return escort:Any resident off premises who calls or appears without transport is met by facility staff and escorted back in a facility vehicle if available, family member, authorized representative, law enforcement, or emergency services.Staff must immediately notify the facility administrative staff to ensure no resident reentered the facility alone or is stranded and they complete an unplanned discharge checklist to ensure the resident's safety.The scope was lowered from a J to a G on 7/25/25 after ensuring the facility implemented the removal plan. The facility identified a census of 51 residents.Finding include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented Resident #1 didn't have behaviors during the lookback period. The MDS listed Resident #1 as independent with activities of daily living (ADLs). The MDS included diagnoses of non-Alzheimer's dementia, anxiety, depression and dizziness.The Care Plan Focus related to tobacco use initiated 5/16/25 included the following Interventions:5/16/25: Smoking evaluation will be completed as needed.7/14/25: As of 7/8/2025 Independent Smoker: Must keep smoking accessories secured when not in use control of facility staff.7/14/25: Resident would check in and out and carry a cell phone while smoking.5/16/25: Independent Smoker: Must smoke only in designated areas/designated times (unless able to independently get to and from the designated areas).The Concern Form dated 7/8/25 reflected Staff A, Dietary Aide, heard pounding on the courtyard door. When she opened the door, Resident #1 told her she got locked outside all night. The Administrator and Director of Nursing (DON) visited with Resident #1, who educated her the facility didn't have the door locked. Resident #1 described the door as heavy and she couldn't open it fully to get back in facility. The form labeled Resident #1 as cognitively intact. The form reflected they educated Resident #1 to take her cellphone when she went out to smoke moving forward. Additionally, they installed a doorbell with receivers at each nurses' station. They educated the staff and smoking residents. They ordered the doorbell on 7/11/25 and installed it 7/16/25.The General Progress Notes dated 7/8/25 at 2:00 PM, documented Resident #1 reported she had difficulty opening the door. She described herself as too weak to pull it open as she normally had before. The nurse notified the doctor of her reported weakness. The nurse waited for a call back from the doctor to see if he would like to complete any labs for Resident #1.The handwritten document completed by Staff F, Licensed Practical Nurse (LPN), on 7/8/25 at 6:30 AM, reflected Resident #1 didn't have injuries to her head, her pupils reacted equally on both sides to light, she had speech clear, she didn't have any redness, bruising, or other injuries. The note described her skin as pink, warm, and intact. Resident #1 could bend and straighten extremities without difficulty. She denied pain. The assessment showed clear lung sounds, a strong unremarkable apical (a location on the chest over the heart) pulse. The note described Resident #1 as alert and walked with a wheelchair. When Resident #1 entered the facility, she voiced concerns that the door wouldn't open. She denied discomfort. The staff escorted her to her room where Staff F completed a thorough exam. Resident #1 changed her clothes and requested to go to dining room for breakfast. The nurse documented Resident #1's mood improved as she socialized with her peers. The Local Conditions Report from the localconditions.com website for Marshalltown printed 7/15/25 at 4:25 PM, documented the weather on 7/7/25 as an overcast with a high of 82 degrees and a low of 69 degrees Fahrenheit (F). The report listed the wind as moderate, blowing around 11 miles per hour (mph) and a gust of 14.1 mph at 12:00 AM. The report detailed the average humidity as higher around 79%, the maximum being 93% at 7:00 AM. The review of the hourly conditions reflected the following:8:00 PM, temperature 78 degrees, felt like 81 degrees with wind speeds at 3.1 mph out of the southeast and gusts up to 5.8 mph.9:00 PM, temperature 76 degrees, felt like 79 degrees with wind speeds at 4.9 mph out of the southeast and gusts up to 10.3 mph.10:00 PM, temperature 73 degrees, felt like 76 degrees with wind speeds at 6 mph out of the southeast and gusts up to 12.7 mph.11:00 PM, temperature 73 degrees, felt like 76 degrees with wind speeds at 6.7 mph out of the southeast with gusts up to 14.1 mph.The Local Condition Report for Marshalltown dated 7/15/25 at 4:25 PM, for 7/8/25 documented the weather had moderate or heavy rain shower with a high of 76 degrees F and a low of 68 degrees. The overall forecast listed rain as having 100% chance of a rainfall total of 1.8 inches. The report identified the wind as light at 8 mph at times with gusts up to 13.8 mph at 3:00 AM. The review of the hourly conditions reflected the following:12:00 AM, temperature 72 degrees, felt like 76 degrees with wind speeds at 5.6 mph out of the southeast and gusts up to 11.7 mph.1:00 AM, temperature 72 degrees, felt like 76 degrees with wind speeds at 5.4 mph out of the south and gusts up to 11.3 mph2:00 AM, temperature 72 degrees, felt like 76 degrees, with wind speeds at 4.5 mph out of the south with gusts up to 9.4 mph.3:00 AM, temperature 72 degrees, felt like 76 degrees, with wind speeds at 6.9 mph out of the west south west with gusts up to 13.8 mph.4:00 AM, temperature 72 degrees, felt like 76 degrees, with wind speeds at 4.9 mph out of the southwest with gusts up to 9.6 mph.5:00 AM, temperature 72 degrees, felt like 76 degrees, with wind speeds of 6.5 mph out of the east south east with gust up to 13.1 mph and a precipitation of 0.02 inches of rainfall.6:00 AM, temperature 72 degrees, felt like 77 degrees with wind speeds of 4 mph out of the east northeast with gusts up to 7.2 mph and precipitation of 0.03 inches of rainfall.On 7/14/25 at 3:30 PM, observed Resident #1 sit on her bed with the head of bed elevated, doing a word puzzle and watching jeopardy on the television, dressed in capris, shoes, short sleeve t-shirt, wheelchair outside of the door to her room, and walker next to her bed.On 7/16/25 at 1:30 PM, the Administrator, Director of Nursing and the Surveyor went out to the courtyard on the east side of the dining room. Noted the door going to the courtyard didn't completely shut all the way, so staff asked over the walkie if anyone went outside and to make sure and check the dining room door, the Administrator pushed the door shut so that the alarm would stop sounding. During the walk through the courtyard, observed various hazards in the courtyard. The facility had a disconnected and nonfunctioning white button doorbell with a new black doorbell placed on the outside of the door frame of the door to the courtyard. In the yard, noted a white gate that didn't allow any resident to leave the facility from the outside courtyard. When attempting push down on the top of the door handle to open the door to go back in the facility, the door failed to open. The Administrator explained the door shouldn't have locked and verified the difficulty of opening the door. On 7/14/25 at 3:30 PM, Resident #1 said that on 7/7/25 at 7:00 PM, she went outside to have her last cigarette. She went out by herself through the dining room doors to the patio area designated for smoking. She said after she completed smoking, she proceeded to pull on the door to come in the facility but couldn't pull the door open. She saw a door bell and she rang it, but no one came. She rang it and pulled on the door again, and still no one came. She reported she stayed outside all night long in her wheelchair until someone from the kitchen came at 6:00 AM on 7/8/25. They saw her pounding on the door and asked her what she was doing outside. Resident #1 told her that she went out for a smoke and couldn't get back into the facility. She added she stayed out in the thunderstorm/lightning soaking wet. Staff A, Dietary Aide, let her in and took her to the nurse. She changed her clothes and got warm. At the time she wore shorts, shoes, and a t-shirt, as sat in her wheelchair outside. In order to keep warm, she pulled her arms inside of her shirt and tried to bring her knees up to her chest and still couldn't keep warm. Resident #1 explained being so scared and cold. She sat by the gas grill but didn't want to touch it due to the lightening. She just tried to huddle against the door to keep warm. Resident #1 reported they told her the door opened easy, it didn't lock, and she could get back in. Resident #1 declared well that didn't happen. She couldn't pull on the door to get it to open. She kept pushing on the door bell, she later learned that door bell was broken and it didn't work. Across from her bed had a calendar on the wall with blue dots on the date 7/7/25. The space had writing, that said outside all night long.On 7/16/25 at 1:10 PM, Staff A said that on 7/8/25 at 5:50 AM, she came into work in the kitchen. When she opened the double doors into the dining room, went over and turned on the lights to the dining room, she heard pounding on the window/door, and looked around the dining room and saw Resident #1 standing up at the door pounding on the window on the back-patio area where the smokers went. Staff A, went to the door and let Resident #1 inside. The door usually had a Velcro stop sign across, but it wasn't attached to the frame of the door. Staff A explained the alarm box with the code inside was turned off so the alarm didn't sound. Staff A explained Resident #1 was crying and shaking from being wet, scared, visibly upset, and shaking from being cold. Staff A explained when she came to work it was thundering and lightening outside.On 7/16/25 at 5:20 PM, Staff F, Licensed Practical Nurse (LPN) verified worked 6:00 PM - 6:00 AM on 7/7/25 to 7/8/25. She said around 8:00 PM, on 7/7/25, she looked outside and noticed Resident #1 sitting outside underneath the gazebo having a cigarette. She noted the Velcro side of the stop sign was down. She went to the lock box and opened it, finding the alarm off. She thought she should turn the alarm on, but with Resident #1 being outside she left the alarm off. On 7/8/25, at 6:00 AM, Staff A, brought Resident #1 to the east nurses' station. She reported Resident #1 was outside all night long and was cold, shivering, scared, frightened, and was hysterical. Staff F, LPN, and Staff G, LPN, proceeded to take Resident #1 to her room to put warm clothes on. They completed vitals and did a head-to-toe assessment.On 7/17/25 at 7:45 AM, Staff G verified on 7/8/25 at 6:00 AM, Resident #1 was left outside from 8:00 PM, on 7/7/25 until 6:00 AM, 7/8/25, when Staff A brought her to the east nurses' station. Staff G, added Resident #1 was soaking wet, cold, shivering, frightened, scared, and upset about being left outside in the thunderstorm, lightning, and rain. Staff G described Resident #1 as emotionally and psychosocially devasted about being outside all night long in the cold rain, with thunder and lightning. On 7/16/25 at 4:25 PM, Staff L, Certified Nursing Assistant (CNA), reported on 7/15/25, when they took Resident #18 out to smoke in the courtyard, they attempted to come back into the facility, but couldn't open the door and started to panic. Staff L, didn't know what to do and just about started pounding on the window in hopes someone would come and let them in. Staff L started to pound on the latch on top of the door handle and it finally let loose, letting her back in. Staff L reported being scared.2. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #2 required partial to moderate assistance with transfers. In addition, listed Resident #2 as dependent with dressing and personal hygiene. The MDS included a diagnosis of need assistance with activities of daily living (ADLs). The MDS indicated Resident #2 didn't smoke.Resident #3's Clinical Census listed an admission date of 7/3/25.The BIMS evaluation conducted 7/3/25 listed a score of 15.Resident #2's admission assessment dated [DATE] at 3:04 PM identified a BIMS score of 15. The assessment listed Resident #2 as dependent with activities of daily living and used a motorized wheelchair mobility. The assessment included diagnoses of diabetes mellitus, muscle weakness, need for assistance with personal cares, anxiety, chronic atrial fibrillation (an irregular often rapid heart rate that commonly causes poor blood flow), bilateral (both sides) below knee amputation, and substance abuse.The Care Plan included the following Focuses:Resident #2 required assistance with ADLs. The Interventions directed the following:Assist with showers/bathing per scheduleDependent on staff for dressing, grooming, transferring, and bed mobility.Resident #2 received an anticoagulant (blood thinner) medication. The Intervention instructed to monitor for signs and symptoms of bleeding, bruising, headaches, bloody stool, bloody emesis or sputum.Resident #2 received psychotropic medications related to an anxiety disorder related to the targeted behaviors of restlessness, irritability, muscle tension, and sleep problems. The Intervention directed to provide medications as ordered.Resident #2's July 2025 Medication Administration Record (MAR) lacked documentation to reflect Resident #2 received the following medications on the evening of 7/3/25:Ramelteon (a medication used to help with sleep),Simvastatin (a medication used to help reduce the risk of a heart attack and stroke),Eliquis (medication to reduce risk of stroke or blood clots)Gabapentin (medication used to prevent and control partial seizures and reduce nerve pain).On 7/21/25 at 11:30 AM, observed Resident #2 lying in bed with a fan on him and covered with a sheet. He had his motorized wheelchair next to his bed and his blinds closed to the outside for privacy. Resident #2 stated he left the faciity on 7/3/25 around 6:15 PM, to go see his dog at a friend's house. He didn't know how long it took him to get to his friend's house or the direction he went but he got there. He told his friend he didn't want anyone to know where he was at until he had time with his dog. On 7/4/25 at 3:00 AM Resident #2 told his friend to call the facility to tell them he'd like to return to the facility because he got to see his dog. His friend called and told someone at the facility about him being ready to return to the facility. Resident #2 reported he waited, attempted to use the bathroom and became incontinent with stool. He added this made him mad as he had to clean his friend's bathroom and sit in his own stool. He started to make his back to the facility on his electric wheelchair. He got to a convenience store around 5:30 AM, as he already had the cops looking for him, they found him there. The next thing he knew, the Administrator came and got upset with him because he left the facility without telling anyone where he went. Resident #2 reported he got upset because he felt like the Administrator tried to make him feel bad for wanting to see his dog. The Administrator then told him if he didn't want to come back, he could sign the AMA paperwork. At this point, they told him he wouldn't come back to the facility. By that time, he reported being so angry sitting in his own stool and being unable to get clean, he just signed the paper work. Resident #2 explained after he calmed down for a little while, he realized he needed to go back to the facility for their help. Resident #2 added if someone would have gone to his friend's house and picked him up when his friend called, he would have returned to the facility. Resident #2 explained he left because he got so upset because he couldn't see his dog and no one came outside to help him while he smoked, so he left on his electric wheelchair to go to his friend's house. Resident #2 verified he didn't receive medications on 7/3/25 during the evening shift and he had orders to get medications at that time.On 7/16/25 at 12:30 PM, Resident #7 reported she knew about Resident #2 being out of the facility for 2 hours and the staff didn't even realize he left. She added it happened twice and the facility just wanted to cover it up and not do anything about it.On 7/16/25 at 2:20 PM, Staff L, Certified Medication Aide (CMA), stated she didn't know Resident #2 left the premises until staff came around and asked if anyone saw the new resident (Resident #2) on 7/3/25 at 8:30 PM. Staff L said she didn't see him at all since he ate in the dining room at a table by himself around 5:30 PM. Staff L explained she knew Resident #2 from high school and they knew some of the same people. Staff L attempted to contact a few of the mutual people. Staff L explained she attempted to call Resident #2's friend around 3 times without an answer. At 10:46 PM, Staff L sent him a text message to see if he saw Resident #2. At 2:43 AM, Staff L received a message back from Resident #2's friend about him being at his house and that he called the facility to report Resident #2 wanted to come back to the facility. Staff L explained they went home at 10:00 PM that night but knew Staff O, Licensed Practical Nurse (LPN), received the call about Resident #2 wanting to return to the facility.On 7/16/25 at 2:45 PM, Staff D, Certified Nurse Aide (CNA), said she last saw Resident #2 at the dining room table on 7/3/25 at 5:30 PM when he ate supper. When Staff D, took Resident #5 outside to smoke around 5:45 PM, she saw Resident #2 already out there smoking.On 7/16/25 at 3:00 PM, Staff E, CNA, said she last saw Resident #2 at 5:30 PM, in the dining room eating supper before she went back to her hallway to start passing room trays.On 7/16/25 at 3:15 PM, Resident #5 said when he went outside to smoke in the front of the facility on 7/3/25 at 5:45 PM, he saw Resident #2 already outside smoking. Resident #5 said around 6:00 PM, he came back in the facility and Resident #2 stayed outside still smoking.On 7/17/25 at 1:30 PM inquired with the Administrator and DON in regards to how the AMA came up with Resident #2 at the convenience store, the Administrator replied she got a phone call from the police stating they located Resident #2 at the convenience store. The Administrator went to the convenience store and Resident #2 told her he didn't want to go back to the facility, that it was a prison. The Administrator called the DON and told her to get a AMA form to fill out so that the facility didn't have any responsibility for Resident #2 leaving. Then around 9:23 AM on 7/4/25, Resident #2 showed up at the facility and wanted to come back so they readmitted him. When questioned about what happened related to the notes documenting Resident #2 called the facility 2:00 AM on 7/4/25 and wanted to come back, the Administrator replied that she and the DON were exhausted. She verbalized excuse her if she went to bed, let the police handle the situation, and didn't hear her phone go off when Staff O called that Resident #2 wanted to come back. She added when the police called her she went to the convenience store, she got very upset about the questioning of her chain of command with the nurse that attempted to call her at 3:00 AM to have Resident #2 come back. The Administrator then said well the facility didn't have transportation to bring him back at that time of the morning and asked what were they supposed to do. When questioned again and asked if he could transfer into a car and have the electric wheelchair stay there until someone could get it back to the facility, she got very upset and asked if she could leave to get someone else. The DON said they should have stayed up and kept looking for Resident #2. She added the nurses needed to have a chain of command so that another staff member could of went and got Resident #2 from his location. Staff R, Corporate Staff, came in and discussed the situation, she responded she understood and would look into it and get back.On 7/22/25 at 515 PM, Staff P, Corporate Staff, and Staff Q, Corporate Staff, reported they couldn't contact Staff O and thought she couldn't return the call in regards to a personal situation. Staff P said she had questions also in regards to how come no one went to Resident #2's friend's house to pick him up and why did the facility sign him out AMA if he wanted to return to the facility at 3 in the morning. Staff P added someone could of went and picked him up in a car, left the electric wheelchair at his friend's house and he would have been back safe. Staff P felt the Administration and Resident #2 must have had a confrontation, and Resident #2 felt they blamed him for leaving the facility. Staff P added the Administrator probably accused Resident #2 of leaving. This probably upset Resident #2, resulting in him saying he didn't want to come back to the facility and agreeing to sign the AMA form to live his life the way he wanted. Staff P said she got a telephone call from the Administrator stating Resident #2 returned to the facility at 9:30 AM and wanted to come back. Staff P told the Administrator to do everything she could to get him back and readmit him. They agreed the facility could have handled the incident better, adding someone from the facility could of went and got Resident #2 to bring him back when he called. They agreed the facility lacked documentation of the physician being involved in the AMA, the staff could have handled the education differently and Resident #2 would of came back.On 7/22/25 at 10:30 AM attempted to call Staff O, no answer voicemail left to return call.On 7/23/25 at 8:55 AM, Staff H, CNA, verified Resident #2 received a shower on 7/4/25, due to have an odor of sweat, bladder, and bowel incontinence. Staff H reported Resident #2 appreciated the shower.On 7/23/25 at 9:10 AM Resident #2 stated he heard his friend talk to someone at the facility, he didn't know who he talked to but, his friend told them that he wanted to come back. He explained he waited and waited and got pissed off because no one came and got him, so he left his friend's house. He went to the convenience store where the cops found him. He reported the Administrator came and had him sign AMA paperwork.On 7/23/24 at 12:45 AM, Resident #2 reported he became angry, upset, and pissed off, that no one would listen to him about pooping his pants, being incontinent of urine and bowel. He added he felt embarrassed at his friend's home and that no one came to get him when he called at 3 AM. Resident #2 verbalized being scared, fearful, and upset that he had nowhere to go when Administrator had him sign the AMA papers. He calmed down while riding his electric wheelchair around town and realized he had nowhere to go, so he went back to the facility hoping that they would take him back, and he had somewhere to stay. On 7/23/25 at 5:00 PM, Staff M, Licensed Practical Nurse (LPN) explained Resident #2 came back to the facility on 7/4/25 about 9:30 AM. He had an odor of body sweat, bowel, and bladder incontinence. Staff M reported Staff H gave Resident #2 a shower.The undated and untitled facility timeline of attempts to contact Resident #2, documented:7/3/25 at 8:50 PM, Administrator aware of inability to locate Resident #27/3/25 at 8:52 PM, the Administrator notified the DON Resident #2 left the building. The staff last saw Resident #2 when he went out to smoke. Resident #2 never came back in the facility.7/3/25 at 8:56 PM - 9:51 PM, the DON and Administrator left in vehicles to look for Resident #2 at various addresses familiar to him (mother's previous address, payee home).7/3/25 at 9:26 PM, the Administrator notified the [NAME] President of Operations.7/3/25 at 9:52 PM - 10:22 PM, the Administrator notified the police. The DON and Administrator regrouped at the facility and spoke to the police. The police posted an updated photo of Resident #2 on their Facebook page. The police reported they would perform their own search. The Administrator provided the police department with her business card for any contact needed. The police assigned a case number and completed a welfare check at the of Resident #2's payee. Resident #2's payee only allowed the police in the front living room of their home and denied Resident #2 being there.7/3/25 at 10:22 PM until 7/4/25 at 1:30 AM, the DON and Administrator returned to their vehicles to continue looking for Resident #2 in his familiar locations.The DON and Administrator couldn't locate Resident #2 and made a decision to stop the search. The DON and Administrator believed Resident #2 stayed at his payee's house, a handicap accessible house where Resident #2's therapy dog resided. 7/4/25 at 2:00 AM, Resident #2 called the facility to request a ride from his brother's home where staff looked for him several times.7/4/25 at 5:30 AM, the police notified the Administrator they located Resident #2 at a gas station7/4/25 at 5:50 AM, when the Administrator and DON arrived at gas station, Resident #2 stated he wanted to live his life and he wouldn't go back to the center. Resident #2 signed AMA paperwork.7/4/25 at 9:23 AM, Resident #2 returned to facility, apologized for his behavior on 7/3/25 and went to his room.7/5/25 at 9:33 AM, after arriving at the facility, the Administrator to speak with Resident #2 about expectations of living in the nursing facility. Resident #2 agreed he would follow the facility's expectations. The facility readmitted Resident #2 to the facility.The Police Department Report dated 7/3/25 at 9:53 PM, documented the facility reported Resident #2 missing. The report reflected they found Resident #2 and closed the case on 7/7/25 at 6:51 PM.A review of an online map service for directions, reflected walking from the facility to Resident #2's payee's house via the east south street and south 7th avenue would take 1 hour and 14 minutes for 3 miles.The website titled timeanddate.com reflected weather information from CustomWeather. The website indicated on 7/3/25 at 6:35 PM, the city of Marshalltown had a temperature of 90 degrees Fahrenheit (F) with sunny skies and wind at 10 miles per hour. In addition, on 7/4/25 at 8:55 AM the website showed a temperature of 81 degrees F with sunny skies and wind at 8 miles per hour.The untitled typed statement from the Administrator dated 7/18/25 at 1:40 PM, indicated Staff L, Registered Nurse (RN), notified the Administrator that the staff couldn't find Resident #2 at the facility on 7/3/25 at 8:50 PM. The Administrator immediately notified the DON. They met at the facility and initiated a search for Resident #2 at 8:56 PM, in familiar places to him in town. The Administrator notified the police department to assist with searching for a resident. When the Administrator and DON regrouped at the facility at 1:30 AM, they spoke with the police department who stated they would continue to search for Resident #2 and notify them if they located Resident #2. On 7/4/25, the police notified the Administrator per phone at 5:30