The facility reported a census of 43 residents, with six residents sampled and one resident reviewed for the right to be free from physical restraints. Based on interview and record review, the facility failed to ensure Resident (R) 3, who had a history of self-harm and physically and verbally aggressive behaviors, remained free of physical or chemical restraints when on 09/18/24, 09/19/24, and 09/20/24 the resident attempted to injure himself and became combative with staff and the facility staff chemically and physically restrained the resident. The facility failed to identify the resident's medical/behavioral symptoms that warranted the use of chemical restraint, physical restraint of five to six staff, and the use of a bedsheet to further restrain the resident. The resident's record lacked any physician orders related to the use of the restraints, any specific documentation related to assessment of the resident for restraint use and/or person-centered care planning, which included the use of a physical restraints or the least amount of restriction/time possible and/or ongoing evaluation. This deficient practice placed R3 in immediate jeopardy. Findings included: - The Medical Diagnosis tab for R3 included diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods) with psychotic features, major depressive disorder (major mood disorder which causes persistent feelings of sadness), attention deficit hyperactivity disorder (ADHD - a chronic condition including attention difficulty, hyperactivity, and impulsiveness), post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), and autistic disorder (a developmental disorder that impairs the ability to communicate and interact). The admission Minimum Data Set dated 08/21/24, revealed the facility did not assess R3's Brief Interview for Mental Status and did not complete the staff assessment for mental status. R3 did not have any hallucinations (sensing things while awake that appear to be real, but the mind created) or delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) during the assessment period, and no behavioral symptoms or rejection of care. R3 did not require restraints. The Psychotropic Drug Use Care Area Assessment (CAA) dated 09/11/24, revealed R3 had a baseline for delusions and hallucinations. R3 required psychiatric medications on a daily basis. R3 did not trigger for further development of the following CAA's: Cognitive loss/Dementia, Psychosocial Well-being, Mood, Behavioral symptoms, or Physical Restraints. The Care Plan dated 09/18/24, revealed R3 had behavior problems related to impulsivity and poor judgement. The staff were to monitor behavior episodes and attempt to determine underlying causes, provide a program of activities that was of interest, accommodate his status, and assist R3 to develop more appropriate methods of coping and interacting. R3's preferred activities were watching television, going on outings, and playing video games. He had the potential to be verbally aggressive and threatening others on social media related to ineffective coping skills, poor impulse control, and severe and persistent mental illness (SPMI - a group of mental health disorders that cause significant functional impairment). When R3 became agitated the staff were to intervene before agitation escalated, guide him away from source of distress, engage calmly in conversation, and if response was aggressive the staff were to walk calmly away and approach later. On 09/23/24, the facility added R3 was physically aggressive related to anger and poor impulse control and the trigger identified was anxiety related to legal issues and R3's behaviors were de-escalated by medication/sedation and physical restraint by personnel. On 09/18/24, R3 was upset about violating a PFA (protection from abuse) order and wanted to go to jail and turn himself in. The staff advised R3 it was still in the investigation stage, and he did not need to worry about it. R3 threw desk tools, a hole punch, and a water bottle that was in Administrative Nurse's D's office. R3 tried to stab himself and staff with a pen and made several threats he was going to harm himself and others. The event lasted three hours. The facility called the Sheriff to assist and had the resident screened for placement at a hospital, which treats adults diagnosed with psychiatric disorders. R3 calmed down with medications and placement was deferred as he did not meet current criteria for admission. The facility placed R3 on one-to-one monitoring and his medications were reviewed and adjusted by the psychiatric provider. On 09/19/24, R3 called 911 and stated he was going to blow up the (specified name) county courthouse. The facility advised R3 it was illegal to make threats like that and that it would not help his court case. R3 became aggressive stating he was going to hurt everybody. R3 threw items from the desk and five staff members restrained R3, sedated him, and four hours later he ceased trying to hurt other and himself. The facility called the Sheriff, had him screened for hospital placement and accepted, however, on a waiting list. After several hours the facility receive information that another local mental health facility would take R3 until he could be placed and required medical clearance. The facility took R3 to a local hospital where R3 was medically cleared, however the local mental health facility rejected the admission and R3 returned to the facility where he was placed on one-to-one and medicated with Haldol (antipsychotic - class of medications used to treat major mental conditions which cause a break from reality) and Ativan (antianxiety - class of medications that calm and relax people). On 09/20/24, R3 was medicated all day but was able to function, walk in the hall, go to meals, and watch television. R3 became angry and violent as he was upset another resident was on the phone he wanted to use and R3 stated he was going to hurt all the (explicit language) and called everyone a (explicit language). The care plan revealed the staff placed R3 in a chair and took him to Administrative Nurse D's office where he had to be physically restrained as he was biting, spitting in staff's face, head butting, and trying to punch, kick, and pinch. The facility called the Sheriff to assist, utilized intramuscular injection of Haldol and Ativan, and R3 was taken to the local hospital where he was admitted . Record review of R3's Electronic Medical Record (EMR) lacked a physician order to the facility to physically restrain R3. The Progress Notes dated 09/17/24 at 07:33 PM, by Administrative Staff A revealed the staff removed R3's PlayStation per the request of his Guardian since R3 violated the no contact order and emailed the person who had the no contact order against him over five times on 09/16/24 and 09/17/24, threatening that person and saying hateful things, and caused the facility she was at to be placed on lock down due to R3's threats. The facility staff and the Guardian spoke with R3 regarding complying with the no contact order and why the PlayStation had been removed. The Progress Notes dated 09/18/24 at 01:49 AM, by Administrative Nurse D revealed R3 was up in the hall pacing with repetitive motion of hands. R3 stated he did not want to go to jail. R3 was advised he needed to stop worrying about things in the world he cannot change. R3 stated he was stupid and did not know what to do. R3 continued to say over and over he did not know what to do while pacing the floor. Administrative Nurse D called Administrative Staff A, then administered lorazepam (Ativan) for agitation. The Progress Notes dated 09/18/24 at 01:59 AM, by Administrative Nurse D revealed resident was in bed sleeping and talking in his sleep. The Progress Notes dated 09/18/24 at 04:27 PM, by Licensed Nurse (LN) G revealed R3 paced a lot today and when he started talking to Administrative Nurse D, he became very anxious, started twisting his hands fast, crying, and picking at his arms. R3 became more agitated so Administrative Nurse D called Administrative Staff A who ordered clonazepam (benzodiazepine class of medication - depressant medication that produces sedation and can be used to treat anxiety), every evening at 04:00 PM, for seven days. The staff administered the medication. The Progress Notes dated 09/18/24 at 05:07 PM, by Administrative Nurse D revealed R3 was upset and believed there was a warrant out for his arrest, could not wait for them to come get him, could not go to prison, and stated he knew he did wrong. Administrative Nurse D asked the resident not to worry about what he cannot change and R3 stated he was so screwed. R3 then switched to being bored, needed his PlayStation stating his Guardian did not have the right to take his stuff, and stated he could not live without his gaming system. R3 stated he needed someone to give back the PlayStation, then said he was killing his Guardian and hated everyone. R3 was scratching his arm, making rapid movements back and forth and was given clonazepam, one milligram. After 15 minutes, R3 started to settle down, talking quietly, and stated he was hungry. Then R3 became loud, insisted he had nothing to live for, wanted to kill himself, became belligerent and combative, then started to hit his head with fist, bang his head on the wall, and hit his face with his knee. Five staff assisted to restrain R3 from hurting himself. R3 was crying, yelling, relentless to hurt self, and tried to staff himself with a paperclip. R3 was given Haldol, five milligrams (mg), intramuscular, for agitation. R3 slowed down after 15 minutes remaining awake and alert, continued to need someone to hang onto him, screened for aggressive behavior, with request it be rushed. The Progress Notes dated 09/18/24 at 05:12 PM, by LN G revealed R3 had been in Administrative Nurse D's office much of the afternoon talking about the consequences of his behaviors, worked up, and sobbing. He then started hitting himself and tried to injure himself and the staff tried to hold him. R3 required clonazepam, orally, and Haldol, IM this afternoon and was a little calmer now. Call made (specified name) for a screen (lacked what type) for him. The Progress Notes dated 09/18/24 at 07:03 PM, by Administrative Nurse D revealed a call back received from (specified organization) to advise because of R3's diagnosis of intellectual and developmental disability- (IDD- a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life), he did not qualify to go to the state hospital. The Progress Notes dated 09/18/24 at 10:33 PM, by LN I revealed R3 was one-on-one for behaviors, was in his bed, he was being monitored every 15 minutes sitting outside his door, and he was sleeping. The Progress Notes dated 09/19/24 at 07:09 PM, by LN G revealed a call received from Administrative Staff A on how R3 was doing now and told he was still sleeping. Administrative Staff A ordered haloperidol (Haldol), five mg, by mouth, every day, for seven days, for psychotic behaviors. The Progress Notes dated 09/19/24 at 04:19 PM, by LN G reveled R3 was calm today and had good insight on how things worked and could calmly discuss his situation with staff. R3 was currently resting in bed. The Progress Notes dated 09/19/24 at 06:01 PM, by LN H revealed R3 continued yelling out I am going to kill you (explicit language), I will find you and I will kill you. R3 stated he wanted to be like all the men in his family, they were in jail or the penitentiary and we were all going to pay. The Progress Notes dated 09/19/24 at 06:15 PM, by Administrative Nurse D revealed R3 called 911 and reported he was going to bomb the (specified place). R3 was confronted with calling in a terroristic threat, he became agitated, stated he was going to kill his (specified family member), myself, and other people. R3 stated he was in a gang and wanted to go to prison and he violated the PFA, so he deserved the death penalty. R3 became increasingly agitated and started to throw objects at staff such as water bottles and clipboards, then grabbed a pen and stabbed Administrative Nurse D in the leg. Other staff members (lacked names) responded while R3 was throwing things from the shelves and the desk, he tried to punch staff, pinch, kick, spit in staff's face, and tried to head butt. R3 was placed in a sheet restraint to protect self and others, hands restrained, resident very wild and not listening to anyone. Resident broke free of sheet restraint and slid to floor. Resident required several people to sit on his legs and arms to control resident from hurting himself and others. R3 was given Haldol, five mg, and Ativan, one mg, to decrease agitation. R3 continued to fight and threaten to kill people. Sheriff officers arrived and assisted to keep R3 from hurting himself and others. After given Haldol, 15 mg, and Ativan, four mg, and three hours later R3 was calmer. After helped to a chair R3 complained of being thirsty, provided water and when water was gone, he threw ice and glass at Administrative Nurse D and tried to stab her with a pen. R3 was given another mg of Ativan and then began to calm down. R3 was screened by (specified organization), was awake and alert, answered questions, and tried again to stab a nurse (lacked name) with a pen. Police were still here assisting with restraining R3, who began to hit himself and police officers while calling them names. R3 banged head with knee several times stating he wanted to kill himself. R3 given Ativan, two mg at 10:30 PM, and then he asked to go to bed as he was very sleepy. R3 assisted to bed and was dozing with a one-to-one staff member. The Progress Notes dated 09/19/24 at 11:00 PM, by Administrative Nurse D revealed (specified organization) screener called to do screening and since R3 escalated to harming others as well as himself he was to be sent to the state hospital. The Progress Notes dated 09/20/24 at 01:19 AM by LN H revealed R3 left the facility and was being transported (lacked by who) to the local hospital. The Progress Notes dated 09/20/24 at 05:20 AM by LN G revealed R3 was out of control and was physically and verbally aggressive. Administrative Nurse D spent five hours in the screening process. R3 was taken to local hospital as instructed once made aware R3 was too acute, and they denied him. The Progress Notes dated 09/20/24 at 01:06 PM, by LN J revealed R3 rested in bed most of the day, continued to be a one-on-one at this time, and new orders were noted for Ativan, two mg, by mouth, every two hours. The Progress Notes dated 09/20/24 at 04:31 PM, by LN J revealed the order for Ativan changed to one mg tablet or 1 mg/0.5 milliliters (ml) IM, every three hours. The Progress Notes dated 09/20/24 at 06:30 PM, by Administrative Nurse D on 10/07/24 at 09:55 PM, revealed R3 was waiting for the phone and upset that another resident was using the phone. R3 yelled to the resident to get off the phone (explicit language) that he needed to use it. R3 was directed to Administrative Nurse D's office to use the phone and advised not to call names, the phone was a community phone, and needed to be shared. R3 picked up a hole punch and tried to hit Administrative Nurse D, and it was taken away by Certified Nurse Aide (CNA) O. R3 turned to hit CNA O and Administrative Nurse D, pushed (lacked name) an office chair underneath R3 to try and calm him. R3 stated he was going to kill everyone here, torture other (explicit language), stated he wanted to be a criminal like his biological family, and began to hit and bite staff. A speakerphone used to call 911 as R3 was hitting, kicking, spitting, pinching, biting staff and himself. R3 tried to raise his knee to his head to headbutt himself and continued to threaten to hurt staff and others. R3 made several connections that caused injuries to all six staff members. The staff placed a sheet over R3's arms and chest to prevent him from hurting himself and others. R3 continued to spit, a small corner of the shift placed over his face, and a Sheriff arrived and assisted to try and keep R3 safe as he was still trying to hurt himself and staff and call racist names. Administrative Staff A came to assess situation as we had been trying to find placement elsewhere all day. The Sheriff was unable to arrest or press charges and R3 stated they could not do anything and continued to try and injure the officer and the staff. Another state hospital was unable to take R3 because he was not in a catchment area and advised to have R3 arrested. The Sheriff suggested to take R3 to the local hospital as they can call another county Sheriff to arrest. Administrative Staff A took R3 to the local hospital. On 10/17/24 at 04:06 PM CMA R stated R3 was suicidal and very combative (could not recall date), spitting at us, kicking, and at one point he grabbed a pen and tried to stab Administrative Nurse D. CMA R stated R3 had a PFA order on him and R3 contacted the person the PFA was related to, we told R3 he could not do that, and we took the game system away so he could not contact that person. The next night, R3 would be okay one minute and the next minute he was going off the charts cussing (explicit language). CMA R stated R3 was in Administrative Nurse D's office .and he was trying to destroy the whole room. CMA R stated CNA M, Administrative Nurse D, and herself were in the office with R3 holding his hands down with ours so he could not hit us when two members from law enforcement came. CMA R stated R3 was sweaty from all the commotion, and we put a sheet across his arms, it was never tied, while sitting in a chair with his arms to his sides. CMA R stated the sheet went across his stomach and lower arms and kept in place for 15 to 20 minutes while Administrative Nurse D held it. CMA R stated at one point, R3 calmed down and they removed the sheet, he was calm and just sit there then all of a sudden, he would start throwing things. CMA R stated she was sitting on R3 in the chair, R3 was trying to get up, and we did not want him to get up and go where everybody else was. CMA R stated R3 tried to get up and scooted himself out of the chair and R3 and her both went to the floor and during that time he was kicking trying to destroy a monitor or television on a shelf and law enforcement held his feet down. CMA R stated she usually take her break at 06:00 PM and when she returned that night, she had heard the commotion and R7 stated they needed our help and at that time R3 and Administrative Nurse D was in Administrative Nurse D's office. After R3 was in the office for a while, he asked to go to his room and go to bed and law enforcement walked R3 to his room, one stayed and talked to R3 for a bit then he fell asleep, and we did one-on-one with him. On 10/07/24 at 04:35 PM, CNA N recalled a night when R3 was upset in Administrative Nurse D office, he would calm down for a little bit, then get agitated again. CNA N stated R3 started throwing things and Administrative Nurse D held a sheet in place so R3 would not hit while CNA N got him to calm down then the sheet was not used again. CNA N stated R3 was sitting in a chair and LN H and Administrative Nurse D tried to keep R3 from getting up by using their hands. On 10/07/24 at 04:48 PM, Administrative Nurse D stated on 09/19/24, every staff member she had on 09/19/24 and 09/20/24, held R3's hands, as it took 45 minutes for law enforcement to show up. Administrative Nurse D both days R3 came in my office, and you could see in his eyes, this kid go from Dr. Jekyll to Mr. Hyde and when asked if he was alright, he picked up a Stanley cup and threw it hitting my head and then started to tear everything off of my desk. Administrative Nurse D stated she thought the staff, CNA M, doing one-on-one was with him, and R3 went ballistic tearing things off my desk, throwing things after told to settle down, tried to stab at me, bit my finger. Administrative Nurse D stated the sheet I put across him. I held on to it, never tied. Basically, a band to keep his arms down. Administrative Nurse D stated R3 would try to hit them, and they did hold him with their hand on top of his and used the least amount of force we could then R3 struggled, for I don't know how long and we were having a terrible time trying to get R3 to calm down, he was given Ativan and Haldol. Administrative Nurse D stated she did not want R3 to hurt himself or her staff and he tried to bite himself, hit himself in the head, head butts against us, and on 09/20/24 he brought in an electric razor and was going to stab me, but law enforcement took it. R3 had cleared off the counter and grabbed different objects, throwing a stapler that hit my shoulder, and threw ice at me, calling us names. Administrative Nurse D stated at one point on 09/19/24 R3 was on the floor, law enforcement showed up, we let loose of the sheet, and R3 popped up and hit the officer and back down he went, where he was on the floor for about 15 minutes, hitting, scratching, kicking, clearing things off the desks in the room and basically the officer pinned him down. R3 tried to bite the officer, which did not work to well, and he tried to spit in my face. Administrative Nurse D stated on 09/20/24, she put sheets around R3's legs while he was sitting, so he would not kick us. Administrative Nurse D stated she did not have an order to use a sheet on R3. On 10/07/24 at 06:24 PM Administrative Staff B stated the facility did not have a policy for use of restraints. The facility failed to ensure Resident (R)3, who had a history of self-harm and physically and verbally aggressive behaviors, remained free of physical or chemical restraints when on 09/18/24, 09/19/24, and 09/20/24 the resident attempted to injure himself and became combative with staff and the facility staff chemically and physically restrained the resident. On 10/07/24 at 06:45 PM, Administrative Staff B was provided a copy of the Immediate Jeopardy template and notified of the facility's failure to ensure R3 remained free of physical or chemical restraints. The facility provided an acceptable plan for removal of the immediacy on 10/08/24 at 09:40 PM which included the following: 1. The facility completed a violence risk screening on all current residents by 10/09/24 at 12:30 AM. 2. The facility revised care plan for residents identified at high risk for assault identified in the screening tool. 3. The facility began educating staff on the Federal Guidelines on the use of restraints on 10/09/24. 4. The facility assigned online training on 10/07/24 and staff began training on 10/08/24 for Handling Aggressive Behaviors, Overview of Abuse and Neglect of Individuals with IDD, Understanding Wandering and Elopement, and the Meaning Behind Behaviors. The onsite surveyor verified the implementation of the above corrective actions on 10/10/24 at 09:45 AM and the deficient practice remained at a G scope and severity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 43 residents, with six residents sampled and one resident reviewed for treatment and services for mental/psychosocial concerns. Based on interview and record review, the facility failed to acknowledge and respond appropriately to Resident (R) 3's behaviors which aligned to treatment and services related to his psychosocial disorder and physical aggression related to his diagnoses. The resident made statements such as I will kill my guardian and comments regarding killing himself on 09/18/24 at 05:07 PM. The resident became loud, insisted he had nothing to live for and wanted to kill himself. R3 became very belligerent and combative. R3 stated he just wanted to die and then started to hit his head with his fist, banged his head on the wall, hit himself in his own face with his knee, and five staff assisted in restraining the resident from hurting himself. Resident was crying, yelling, and was relentless to hurt himself. R3 attempted to stab himself with a paperclip. On 09/19/24 at 06:15 PM, R3 became agitated stating he was going to kill his aunt, himself, and other people. His agitation increased and he started to throw objects at staff, stabbed at a nurse's leg with a pen, tried to punch staff, pinch, kick, spit in staff's face, and tried to head butt staff. The staff placed the resident in a sheet restraint to protect him and others and restrained his hands. R3 was very wild, was not listening to anyone, and broke free of a sheet restraint and slid himself to the floor. R3 required several people to sit on his legs and arms to control him from hurting himself and others. The police came and assisted in restraining R3. R3 banged his head with his knee several times, stating he wanted to kill himself. On 09/20/24 at 06:30 PM, R3 made further statements he was going to kill everyone here and was hitting, kicking, spitting, pinching, and biting staff and himself. The facility chemically and physically restrained R3 on 09/18/24, 09/19/24, and 09/20/24. With this deficient practice, the likelihood of harm could occur due to the aggressive behaviors related to the restraining of R3 placing him in immediate jeopardy. Findings included: - The Medical Diagnosis tab for R3 included diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods) with psychotic features, major depressive disorder (major mood disorder which causes persistent feelings of sadness), attention deficit hyperactivity disorder (ADHD- a chronic condition including attention difficulty, hyperactivity, and impulsiveness), post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), and autistic disorder (a developmental disorder that impairs the ability to communicate and interact). The admission Minimum Data Set(MDS) dated [DATE] revealed the facility did not assess R3's Brief Interview for Mental Status and did not complete the staff assessment for mental status. R3 did not have any hallucinations (sensing things while awake that appear to be real, but the mind created) or delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) during the assessment period, and no behavioral symptoms or rejection of care. The MDS indicated R3 did not require restraints. The Psychotropic Drug Use Care Area Assessment (CAA) dated 09/11/24, revealed R3 had a baseline for delusions and hallucinations. R3 required psychiatric medications on a daily basis. R3 did not trigger for further development of the following CAAs: Cognitive Loss/Dementia, Psychosocial Well-Being, Mood State, Behavioral Symptoms, or Physical Restraints. The Care Plan dated 09/18/24, revealed R3 had behavior problems related to impulsivity and poor judgement. The staff were to monitor behavior episodes and attempt to determine underlying causes, provide a program of activities that was of interest, accommodate his status, and assist R3 to develop more appropriate methods of coping, and interacting. R3's preferred activities included watching television, going on outings, and playing video games. He had the potential to be verbally aggressive and threatening others on social media related to ineffective coping skills, poor impulse control, and severe and persistent mental illness (SPMI - a group of mental health disorders that cause significant functional impairment). When R3 became agitated the staff were to intervene before agitation escalated, guide him away from source of distress, engage calmly in conversation, and if response was aggressive, the staff were to walk calmly away and approach later. On 09/23/24, the facility added R3 was physically aggressive related to anger and poor impulse control and the trigger identified was anxiety related to legal issues and R3's behaviors were de-escalated by medication/sedation and physical restraint by personnel. On 09/18/24, R3 was upset about violating a PFA (protection from abuse) order and wanted to go to jail and turn himself in. The staff advised R3 it was still in the investigation stage, and he did not need to worry about it. R3 threw desk tools, a hole punch, and a water bottle that was in Administrative Nurse's D's office. R3 tried to stab himself and staff with a pen and made several threats he was going to harm himself and others. The event lasted three hours. The facility called the Sheriff to assist and had the resident screened for placement at a hospital, which treats adults diagnosed with psychiatric disorders. R3 calmed down with medications and placement was deferred as he did not meet current criteria for admission. The facility placed R3 on one-to-one monitoring and his medications were reviewed and adjusted by the psychiatric provider. On 09/19/24, R3 called 911 and stated he was going to blow up the (specified name) county courthouse. The facility advised R3 it was illegal to make threats like that and that it would not help his court case. R3 became aggressive stating he was going to hurt everybody. R3 threw items from the desk and five staff members restrained R3, sedated him, and four hours later he ceased trying to hurt other and himself. The facility called the Sheriff, had him screened for hospital placement and accepted, however, on a waiting list. After several hours the facility received information that another local mental health facility would take R3 until he could be placed and required medical clearance. The facility took R3 to a local hospital where R3 was medically cleared, however the local mental health facility rejected the admission and R3 returned to the facility where he was placed on one-to-one and medicated with Haldol (antipsychotic- class of medications used to treat major mental conditions which cause a break from reality) and Ativan (antianxiety- class of medications that calm and relax people). On 09/20/24, R3 was medicated all day but was able to function, walk in the hall, go to meals, and watch television. R3 became angry and violent as he was upset another resident was on the phone he wanted to use and R3 stated he was going to hurt all the (explicit language) and called everyone a (explicit language). The care plan revealed the staff placed R3 in a chair and took him to Administrative Nurse D's office where he had to be physically restrained as he was biting, spitting in staff's face, head butting, and trying to punch, kick, and pinch. The facility called the Sheriff to assist, utilized intramuscular injection of Haldol and Ativan, and R3 was taken to the local hospital where he was admitted . The Electronic Medical Record (EMR) lacked a physician order for the facility to physically restrain R3. The Progress Notes dated 09/17/24 at 07:33 PM by Administrative Staff A revealed the staff removed R3's PlayStation per the request of his Guardian since R3 violated the no contact order. R3 had emailed the person who had the no contact order against him over five times on 09/16/24 and 09/17/24, threatening that person and saying hateful things, and caused the facility she was at to be placed on lock down, due to R3's threats. The facility staff and the Guardian spoke with R3 regarding complying with the no contact order and why the PlayStation was removed. The Progress Notes dated 09/18/24 at 01:49 AM by Administrative Nurse D revealed R3 was up in the hall pacing with repetitive motion of hands. R3 stated he did not want to go to jail. R3 was advised he needed to stop worrying about things in the world he cannot change. R3 stated he was stupid and did not know what to do. R3 continued to say over and over he did not know what to do, while pacing the floor. Administrative Nurse D called Administrative Staff A, then administered lorazepam (Ativan) for agitation. The Progress Notes dated 09/18/24 at 01:59 AM, by Administrative Nurse D revealed R 3 was in bed sleeping and talking in his sleep. The Progress Notes dated 09/18/24 at 04:27 PM by Licensed Nurse (LN) G revealed R3 paced a lot today and when he started talking to Administrative Nurse D, he became very anxious, started twisting his hands fast, crying, and picking at his arms. R3 became more agitated so Administrative Nurse D called Administrative Staff A who ordered clonazepam (benzodiazepine class of medication - depressant medication that produces sedation and can be used to treat anxiety), every evening at 04:00 PM, for seven days. The staff administered the medication. The Progress Notes dated 09/18/24 at 05:07 PM by Administrative Nurse D revealed R3 was upset and believed there was a warrant out for his arrest, could not wait for them to come get him, could not go to prison, and stated he knew he did wrong. Administrative Nurse D asked the resident not to worry about what he cannot change and R3 stated he was so screwed. R3 then switched to being bored, needed his PlayStation stating his Guardian did not have the right to take his stuff, and stated he could not live without his gaming system. R3 stated he needed someone to give back the PlayStation, then said he was killing his Guardian and hated everyone. R3 was scratching his arm, making rapid movements back and forth and staff administered clonazepam, one milligram. After 15 minutes, R3 started to settle down, talking quietly, and stated he was hungry. Then R3 became loud, insisted he had nothing to live for, wanted to kill himself, became belligerent and combative, then started to hit his head with fist, bang his head on the wall, and hit his face with his knee. Five staff assisted to restrain R3 from hurting himself. R3 was crying, yelling, relentless to hurt self, and tried to staff himself with a paperclip. The staff administered Haldol, five milligrams (mg), intramuscular (IM), for agitation to R3. The resident slowed down after 15 minutes remaining awake and alert, continued to need someone to hang onto him, and screened for aggressive behavior, with request it be rushed. The Progress Notes dated 09/18/24 at 05:12 PM by LN G revealed R3 had been in Administrative Nurse D's office much of the afternoon talking about the consequences of his behaviors, worked up, and sobbing. He then started hitting himself and tried to injure himself and the staff tried to hold him. R3 required clonazepam, orally, and Haldol, IM this afternoon and was a little calmer now. Call made (specified name) for a screen (lacked what type) for him. The Progress Notes dated 09/18/24 at 07:03 PM by Administrative Nurse D revealed a call back received from (specified organization) to advise because of R3's diagnosis of intellectual and developmental disability- (IDD- a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life), he did not qualify to go to the state hospital. The Progress Notes dated 09/18/24 at 10:33 PM by LN I revealed R3 was one-on-one for behaviors, was in his bed, he was being monitored every 15 minutes sitting outside his door, and he was sleeping. The Progress Notes dated 09/19/24 at 07:09 PM by LN G revealed a call received from Administrative Staff A on how R3 was doing now and told he was still sleeping. Administrative Staff A ordered haloperidol (Haldol), five mg, by mouth, every day, for seven days, for psychotic behaviors. The Progress Notes dated 09/19/24 at 04:19 PM by LN G revealed R3 was calm today and had good insight on how things worked and could calmly discuss his situation with staff. R3 was currently resting in bed. The Progress Notes dated 09/19/24 at 06:01 PM, by LN H revealed R3 continued yelling out I am going to kill you [explicit language, I will find you and I will kill you. R3 stated he wanted to be like all the men in his family, they were in jail or the penitentiary and we were all going to pay. The Progress Notes dated 09/19/24 at 06:15 PM by Administrative Nurse D revealed R3 called 911 and reported he was going to bomb the (specified place). R3 was confronted with calling in a terroristic threat, he became agitated, stated he was going to kill his (specified family member), myself, and other people. R3 stated he was in a gang and wanted to go to prison and he violated the PFA, so he deserved the death penalty. R3 became increasingly agitated and started to throw objects at staff such as water bottles and clipboards, then grabbed a pen and stabbed Administrative Nurse D in the leg. Other staff members (lacked names) responded while R3 was throwing things from the shelves and the desk, he tried to punch staff, pinch, kick, spit in staff's face, and tried to head butt. R3 was placed in a sheet restraint to protect self and others, hands restrained, resident very wild and not listening to anyone. Resident broke free of sheet restraint and slid to floor. Resident required several people to sit on his legs and arms to control resident from hurting himself and others. R3 was given Haldol, five mg, and Ativan, one mg, to decrease agitation. R3 continued to fight and threaten to kill people. Sheriff officers arrived and assisted to keep R3 from hurting himself and others. After given Haldol, 15 mg, and Ativan, four mg, and three hours later R3 was calmer. After helped to a chair R3 complained of being thirsty, provided water and when water was gone, he threw ice and glass at Administrative Nurse D and tried to stab her with a pen. R3 was given another mg of Ativan and then began to calm down. R3 was screened by (specified organization), was awake and alert, answered questions, and tried again to stab a nurse (lacked name) with a pen. Police were still here assisting with restraining R3, who began to hit himself and police officers while calling them names. R3 banged head with knee several times stating he wanted to kill himself. R3 given Ativan, two mg at 10:30 PM, and then he asked to go to bed as he was very sleepy. R3 assisted to bed and was dozing with a one-to-one staff member. The Progress Notes dated 09/19/24 at 11:00 PM by Administrative Nurse D revealed (specified organization) screener called to do screening and since R3 escalated to harming others as well as himself he was to be sent to the state hospital. The Progress Notes dated 09/20/24 at 01:19 AM by LN H revealed R3 left the facility and was transported (lacked by who) to the local hospital. The Progress Notes dated 09/20/24 at 05:20 AM by LN G revealed R3 was out of control and was physically and verbally aggressive. Administrative Nurse D spent five hours in the screening process. R3 was taken to the local hospital as instructed, and once made aware R3 was too acute, and they denied admitting him. The Progress Notes dated 09/20/24 at 01:06 PM by LN J revealed R3 rested in bed most of the day, continued to be a one-on-one at this time, and new orders were noted for Ativan, two mg, by mouth, every two hours. The Progress Notes dated 09/20/24 at 04:31 PM by LN J revealed the order for Ativan changed to one mg tablet or 1 mg/0.5 milliliters (ml) IM, every three hours. The Progress Notes dated 09/20/24 at 06:30 PM by Administrative Nurse D, a late entry on 10/07/24 at 09:55 PM, revealed R3 was waiting for the phone and upset that another resident was using the phone. R3 yelled to the resident to get off the phone [explicit language] that he needed to use it. R3 was directed to Administrative Nurse D's office to use the phone and advised not to call names, the phone was a community phone, and needed to be shared. R3 picked up a hole punch and tried to hit Administrative Nurse D, and it was taken away by Certified Nurse Aide (CNA) O. R3 turned to hit CNA O and Administrative Nurse D pushed (lacked name) an office chair underneath R3 to try and calm him. R3 stated he was going to kill everyone here, torture other (explicit language), stated he wanted to be a criminal like his biological family, and began to hit and bite staff. The staff used a speakerphone to call 911 as R3 was hitting, kicking, spitting, pinching, biting staff and himself. R3 tried to raise his knee to his head to headbutt himself and continued to threaten to hurt staff and others. R3 caused injuries to all six staff members. The staff placed a sheet over R3's arms and chest to prevent him from hurting himself and others. R3 continued to spit, and staff placed a small corner of the sheet over his face. The Sheriff arrived and assisted to keep R3 safe as R3 continued to try and hurt himself and staff and called out racist names. Administrative Staff A came to assess the situation as we had been trying to find placement elsewhere all day. The Sheriff was unable to arrest or press charges and R3 stated they could not do anything and continued to try and injure the officer and the staff. Another state hospital was unable to take R3 because he was not in a catchment area and advised to have R3 arrested. The Sheriff suggested to take R3 to the local hospital as they can call another county Sheriff to arrest. Administrative Staff A took R3 to the local hospital. During an interview on 10/17/24 at 04:06 PM, CMA R stated R3 was suicidal and very combative (could not recall date), spitting at staff, kicking, and at one point he grabbed a pen and tried to stab Administrative Nurse D. CMA R stated R3 had a PFA order on him and R3 contacted the person the PFA was related to. CMA R said the staff told R3 he could not do that, and staff took the game system away so he could not contact that person. The next night, R3 would be okay one minute and the next minute he was going off the charts cussing (explicit language). CMA R stated R3 was in Administrative Nurse D's office, and he was trying to destroy the whole room. CMA R stated CNA M, Administrative Nurse D, and herself were in the office with R3, holding his hands down so he could not hit us when two members from law enforcement came. CMA R stated R3 was sweaty from all the commotion, and the staff put a sheet across his arms, noting it was never tied, while R3 sat in a chair with his arms to his sides. CMA R stated the sheet went across his stomach and lower arms and was kept in place for 15 to 20 minutes while Administrative Nurse D held it. CMA R stated at one point, R3 calmed down and they removed the sheet, he was calm and just sat there, and all of a sudden, he would start throwing things. CMA R stated she was sitting on R3 in the chair, R3 was trying to get up, and the staff did not want R3 to get up and go where everybody else was. CMA R stated R3 tried to get up and scooted himself out of the chair and R3 and her both went to the floor. CMA R said, during that time he was kicking trying to destroy a monitor or television on a shelf and law enforcement held his feet down. CMA R stated she usually took her break at 06:00 PM and when she returned that night, she had heard the commotion and R7 stated they needed our help, and at that time R3 and Administrative Nurse D were in Administrative Nurse D's office. After R3 was in the office for a while, he asked to go to his room and go to bed and law enforcement walked R3 to his room, and one officer stayed and talked to R3 for a bit, then he fell asleep, and the staff did one-on-one with him. During an interview on 10/07/24 at 04:35 PM, CNA N recalled a night when R3 was upset in Administrative Nurse D office, he would calm down for a little bit, then get agitated again. CNA N stated R3 started throwing things and Administrative Nurse D held a sheet in place so R3 would not hit while CNA N got him to calm down then the sheet was not used again. CNA N stated R3 sat in a chair and LN H and Administrative Nurse D tried to keep R3 from getting up by using their hands. During an interview on 10/07/24 at 04:48 PM, Administrative Nurse D stated on 09/19/24, every staff member she had on 09/19/24 and 09/20/24, held R3's hands, as it took 45 minutes for law enforcement to show up. Administrative Nurse D said both days R3 came into her office could see in his eyes this kid go from Dr. Jekyll to Mr. Hyde and when asked if he was alright, he picked up a Stanley cup and threw it, hitting Administrative Nurse D's head and then started to tear everything off of her desk. Administrative Nurse D stated she thought the staff, CNA M, doing one-on-one was with him, and R3 went ballistic tearing things off her desk, throwing things after being told to settle down, tried to stab at her, and bit her finger. Administrative Nurse D stated the sheet I put across him. I held on to it, never tied. Basically, a band to keep his arms down. Administrative Nurse D stated R3 would try to hit them, and they did hold him with their hand on top of his and used the least amount of force we could then R3 struggled, for I don't know how long and we were having a terrible time trying to get R3 to calm down. She stated the staff administered Ativan and Haldol to R3. Administrative Nurse D stated she did not want R3 to hurt himself or her staff and he tried to bite himself, hit himself in the head, head butts against the staff, and on 09/20/24 he brought in an electric razor and was going to stab her, but law enforcement took it. She said R3 had cleared off the counter and grabbed different objects, throwing a stapler that hit her shoulder, and threw ice at her, and called staff names. Administrative Nurse D stated at one point on 09/19/24 R3 was on the floor, law enforcement showed up, staff let loose of the sheet, and R3 popped up and hit the officer and back down he went, where he was on the floor for about 15 minutes, hitting, scratching, kicking, clearing things off the desks in the room and basically the officer pinned him down. R3 tried to bite the officer, which did not work to well, and he tried to spit in Administrative Nurse D's face. Administrative Nurse D stated on 09/20/24, she put sheets around R3's legs while he sat, so he would not kick us. Administrative Nurse D stated she did not have an order to use a sheet on R3. On 10/07/24 at 06:24 PM, Administrative Staff B stated the facility did not have a policy for use of restraints. The facility failed to acknowledge and respond appropriately to Resident (R) 3's behaviors which aligned to treatment and services related to his psychosocial disorder and physical aggression related to his diagnoses, who had a history of self-harm and physically and verbally aggressive behaviors, remained free of physical or chemical restraints when on 09/18/24, 09/19/24, and 09/20/24 the resident attempted to injure himself and became combative with staff and the facility staff chemically and physically restrained the resident. On 10/07/24 at 06:45 PM, Administrative Staff B was provided a copy of the Immediate Jeopardy template and notified of the facility's failure to ensure R3 remained free of physical or chemical restraints, placed R3 in immediate jeopardy. The facility provided an acceptable plan for removal of the immediacy on 10/08/24 at 09:40 PM which included the following: 1. The facility completed a violence risk screening on all current residents by 10/09/24 at 12:30 AM. 2. The facility revised care plan for residents identified at high risk for assault identified in the screening tool. 3. The facility began educating staff on the Federal Guidelines on the use of restraints on 10/09/24. 4. The facility assigned online training on 10/07/24 and staff began training on 10/08/24 for Handling Aggressive Behaviors, Overview of Abuse and Neglect of Individuals with IDD, Understanding Wandering and Elopement, and the Meaning Behind Behaviors. The onsite surveyor verified the implementation of the above corrective actions on 10/10/24 at 09:45 AM and the deficient practice remained at a G scope and severity.

The facility reported a census of 45 residents. The six sampled residents included three reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). The facility identified six residents at risk for elopement. Based on observation, interview, and record review the facility failed to provide appropriate supervision, implement interventions, and identify elopement behaviors to prevent the elopement of Resident (R)1, who remained on 30-minutes checks from a prior elopement, eloped again from the facility on 01/28/24 at 04:36 PM, with staff present. The facility staff did not realize R1 was missing until another staff member saw R1 walk past a window outside the building, on 01/28/24 at 05:30 PM. almost an hour after the resident eloped. Review of the 30-minute check log revealed the facility staff failed to check and log on the resident's whereabouts since 01/28/24 at 04:30 PM. This deficient practice placed the resident in immediate jeopardy. Findings included: - The Electronic Health Record (EHR) documented R1 had diagnoses, which included unspecified schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), cannabis (marijuana) abuse, and insomnia (inability to sleep). The 03/01/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 hallucinated (sensing things while awake that appear to be real, but the mind created). R1 had no behaviors directed towards self or others during the seven-day look-back period and was independent for all cares. The resident took an antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) daily during the seven-day look-back period. The 12/02/23 Quarterly MDS documented a BIMS score of 13, which indicated intact cognition. The resident hallucinated and had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The resident had other behavioral symptoms not directed at others one-to-three days and wandered four-to-six days in the look back period. R1 received antipsychotic medication during the assessment look-back period. The Care Plan documented that the resident was a high elopement risk and documented the following: On 10/14/20, staff were to assess the resident for fall risk. On 10/14/20, staff were to identify patterns of wandering and to intervene as appropriate. On 10/14/20, staff were to place a Wander Guard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on R1's right ankle. On 03/04/21, staff were to monitor the resident's location several times a day and document wandering behavior. On 01/05/24, staff placed a Wander Guard on R1's right wrist after assessment and elopement, where R1 broke out a bedroom window. The Wandering Risk Scale assessments revealed a low risk on 08/24/22, 11/24/22, 02/24/23, 05/25/23, 05/25/23 and 11/27/23. Further documented a high risk to wander on 01/15/24 and 01/28/24. The Progress Notes documented the following: From 12/19/23 to 01/28/24, R1 displayed 19 episodes where he had wandering behaviors and/or paced near the main entrance with and without talking to himself. On 01/05/24, R1 eloped from the facility where he sustained injuries that required sutures (a medical device used to hold wound edges together to promote healing after an injury). On 01/12/24, the facility discontinued 1:1 staff supervision and initiated staff observations of the resident's whereabouts every 15 minutes. On 01/20/24, the facility discontinued every 15-minute checks and initiated 1:1 staff supervision due to the resident calling 911 and requesting to be taken to a county jail. On 01/21/24, the facility discontinued 1:1 staff supervision and initiated staff observations every 15 minutes. On 01/23/24, the facility discontinued every 15-minute checks and initiated staff observations every 30 minutes as ordered by Physician Extender F. On 01/28/24 at 07:38 PM, Certified Nurse Aide (CNA) C and Certified Medication Aide (CMA) D observed R1 outside the facility at 05:30 PM, when R1 attempted to enter the building through the main doors. CMA D let R1 into the building and took him to the nurses' station where she notified Licensed Nurse (LN) E. LN E assessed R1 for injuries, then notified administration (Administrative Staff A, Administrative Nurse B, Physician Extender F) and R1's guardian. It further documented Law Enforcement notified by Physician Extender F at an unknown time. Review of the undated facility investigation revealed the following: On 01/28/24 at 04:30 PM, R1 went out the back patio door with CNA C and other residents to smoke. On 01/28/24 at 04:36 PM, R1 went over a six-foot wooden privacy fence surrounding the courtyard. On 01/28/24 at 05:00 PM, the Wandering Resident Monitor log lacked documentation of the staff 30-minute required check. On 01/28/24 at 05:30 PM, (one hour after staff last seen R1, and 54 minutes after R1 left the facility), documented R1 returned to the facility and R1's Wander Guard was intact on the resident's right wrist. R1 stated that he walked to the store (approximately 4000 feet or three-quarters of a mile from the facility and approximately 200 feet from a heavily traveled highway which includes semi-trucks and a speed limit of 55 miles per hour [mph]) to ask someone to light his previously lit cigarette, then he walked back to the facility. Review of weather data for the facility area from Weather Underground (www.wunderground.com), on 01/28/24 at 04:56 PM (20 minutes after the elopement and 34 minutes before R1 returned to the facility), the temperature was 52 degrees Fahrenheit (°F) with south winds at 8 mph, and the sunset was at 05:49 PM (19 minutes after R1 returned to the facility). Observation of the area around the facility revealed a highway approximately one-third of a mile north with heavy traffic that included semi-trucks and a speed limit of 55 mph. On 01/31/24 at 09:30 AM, Administrative Staff A was unable to provide an explanation as to why the 05:00 PM entry on the Wandering Resident Monitor log was blank and incomplete. Administrative Staff A had no further information to provide as her investigation of the elopement was ongoing. On 01/31/24 at 10:08 AM, CNA C stated that at the time R1 eloped, she had taken several residents out to smoke and another unidentified resident started an unknown disturbance that occupied her attention. When the residents and CNA C returned inside the building, she failed to recognize that R1 was not among the group of residents. Additionally, she stated that after the smoking period, residents would congregate in the dining area for the evening meal and neither her nor CMA D noticed R1 was not present. On 01/28/24 at 05:30 PM, CNA C and CMA D observed R1 through the dining room windows, walking up the sidewalk to the main entrance. He wore jeans, a shirt, a medium-weight coat, and shoes. CMA D let R1 in though the main entrance. On 01/31/24 at 10:14 AM, CMA D was unavailable for comment in the investigation. Review of facility investigation witness statements revealed that the investigation lacked a witness statement from CMA D. On 01/31/24 at 10:21 AM, LN E revealed that R1 had gone out to the patio with CNA C to smoke and sometime during that time, eloped over the fence in the courtyard. LN E revealed R1 had been pacing in the front lobby near the main doors earlier. LN E stated that she failed to perform the 05:00 PM observation of the resident because she thought that R1 had come in with CNA C and was in the dining area with the rest of the residents, so she had gone to the kitchen for a refreshment, utilized the bathroom, and then chatted with Physician Extender F in her office and lost track of the time. LN E realized that she failed to perform the 05:00 PM observation. LN E was advised at 05:30 PM when CMA D brought R1 to the nursing station and was informed R1 eloped. LN E stated that she notified Physician Extender F who then notified the remaining members of the administrative team (Administrative Nurse B and Administrative Staff A) and Law Enforcement. On 01/31/24 at 10:54 AM, Administrative Nurse B stated that CNA C failed to perform adequate supervision during the smoking period due to another resident had caused a disturbance. Administrative Nurse B stated that LN E failed to recognize that R1 had eloped from the building when she failed to perform the 05:00 PM observation of R1 and that her investigation was incomplete and ongoing. Administrative Nurse B stated that corrective actions that had been implemented since R1 eloped on 01/28/24 included: suspension of LN E pending an investigation, staff education that had been initiated but had not been completed, implementation of a sign out/in log for residents who smoke, implementation of 1:1 observation of R1 and that R1 had been screened for placement at a more appropriate facility. Administrative Nurse B stated that LN E failed to perform the appropriate notifications after R1's elopement and that Physician Extender F notified her. Administrative Nurse B stated that she feared that LN E would not have notified the administrative team if Physician Extender F had not been physically present in the building at the time of the elopement. On 01/31/24 at 11:48 AM, Law Enforcement G revealed that 911 dispatch received a call regarding R1's elopement on 01/31/24 at 06:49 PM (two hours and 13 minutes after the resident left the facility and one hour and 19 minutes after the resident returned to the facility) and that an officer responded to the facility at 06:54 PM and contacted Physician Extender F filed a report. The facility's undated Accident Prevention policy documented that all staff members of the facility will ensure that the environment remains as free from accident hazards as possible and will receive adequate supervision to prevent accidents. The facility's undated Elopement Policy documented that the facility wishes to ensure the safety of residents identified as being a risk for elopement and to take precautions to ensure safety and well-being. Upon discovering an unaccountable absence of a resident by a staff member, they will inform the nurse, record the time that the resident was discovered missing and where the resident was last seen. The nurse will contact law enforcement, perform a resident roll call, and direct other staff to search the facility and grounds. The facility failed to provide appropriate supervision, implement interventions, and identify elopement behaviors to prevent the elopement of R1, who eloped from the facility on 01/28/24 at 04:36 PM, with staff present, but without staff knowledge. The facility staff did not realize R1 was missing until another staff member saw R1 outside through a window, on 01/28/24 at 05:30 PM. The facility was notified of the IJ for F689 for R1 on the prior 2567 dated 01/16/24. Upon investigation into the second elopement of R1 on 01/28/24 at 04:36 PM, revealed the facility remained out of compliance and the failure to prevent the additional elopement of R1, and placed R1 back in immediate jeopardy. On 01/31/24 at 02:50 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) Template for failure to provide adequate supervision to prevent elopement. The facility provided an acceptable plan for removal of the IJ on 02/01/24 at 09:15 AM and the following corrective measures were verified by the surveyor on-site during the investigation on 02/01/24 at 10:00 AM. 1. On 01/29/24 at 06:00 AM, R1's care plan was updated with interventions to protect R1 and other residents to monitor outside while smoking and ensure that R1 signs in and out during scheduled smoking periods. 2. On 01/28/24 at 05:47 PM, Administrative staff B placed R1 on 1:1 observation at all times, even during scheduled smoking periods. 3. On 01/31/24 at 09:00 AM, all staff were required to participate in a tabletop scenario and write out the process for what to do in the event of an elopement prior to returning to work. 4. On 01/28/24 at 09:00 PM, the facility created sign out and sign in sheets for residents who go outside to smoke. 5. On 02/01/24 at 09:15 AM, the daily staffing sheet was modified to include an assignment for 1:1 observation of R1. 6. On 01/29/24 at 06:00 AM, the charge nurse would document every two hours to reflect the 1:1 observation of R1. The surveyor verified the facility implemented the corrective actions to remove the immediacy, while onsite on 02/01/24 at 10:00 AM. The deficient practice remained at a scope and severity of G after removal of the jeopardy.

The facility reported a census of 45 residents, with one resident sampled for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). The facility identified six residents at risk for elopement. Based on observation, interview, and record review, the facility failed to provide adequate supervision, identify likely avenues of exit (including windows), and failed to ensure the windows were secured after Resident (R)1 broke the window out in his room, to prevent elopement. On 01/05/24, R1, who suffers from delusions/hallucinations and wandering, broke the window out in his room and reported he was scared and wanted to leave. Certified Nurse Aid (CNA) D did not provide the supervision of R1, as directed by Licensed Nurse (LN) C. At 08:00 PM, unsupervised R1 went to his room unaccompanied. At 08:01 PM, R1 climbed through the known broken window and eloped from the facility and injured his leg. The staff did not realize R1 was gone until 08:02 PM. At 08:16 PM the facility called local law enforcement to report R1 missing. At 08:39 PM the resident returned to the facility with law enforcement and the left leg wounds were discovered then. R1 required 13 stitches to his left leg. This deficient practice placed R1 in immediate jeopardy. Findings included: - The Electronic Health Record (EHR) documented that R1 had diagnoses which included unspecified schizophrenia (a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), cannabis (marijuana) abuse and insomnia (inability to sleep). The 03/01/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 had hallucinations (sensing things while awake that appear to be real, but the mind created). R1 had no behaviors directed towards self or others during the seven-day look-back period and was independent for all cares. The resident took an antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) daily during the seven-day look-back period. The 12/02/23 Quarterly MDS documented a BIMS of 13 which indicated intact cognition. The resident had hallucinations and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The resident had other behavioral symptoms not directed at others one-to-three days and wandered four-to-six days in the look back period. R1 received antipsychotic medication during the assessment look-back period. The Care Plan documented the following: On 10/14/20, staff were to assess the resident for fall risk. On 10/14/20, staff were to identify patterns of wandering and to intervene as appropriate. On 10/14/20, staff were to place a WanderGuard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on R1's right ankle. On 03/04/21, staff were to monitor the resident's location several times a day and document wandering behavior. The Wandering Risk Scale assessments revealed a low risk on 08/24/22, 11/24/22, 02/24/23, 05/25/23, 05/25/23 and 11/27/23. The Progress Notes documented the following: From 12/19/23 to 01/01/24 R1 displayed nine episodes where he had wandering behaviors and/or paced near the main entrance with and without talking to himself. On 01/02/24 at 12:12 PM, R1 requested to speak to a representative from pastoral services. On 01/03/24 at 02:48 AM, R1 displayed wandering behavior, talked to himself and occasionally yelled out. On 01/05/24 at 07:30 PM, R1 self-reported to CNA D he broke out the window in his room, and he expressed fear and his desire to leave the facility. CNA D reported the incident to LN C and LN C instructed R1 to stay out of his room. The EHR lacked documentation of any injury. R1 self-reported the incident to local law enforcement officers (LEO) who responded to the facility at approximately 07:50 PM. On 01/05/24 at 08:04 PM, staff were engaged with two different residents causing two different crisis events and R1 was not observed in the lounge area where he had been previously. Staff initiated a search of the facility and upon searching R1's room, staff noticed footprints in the snow on the ground outside R1's broken window. The footprints led to a six-foot wooden privacy fence on the south end of the courtyard. Staff then initiated a resident rollcall which revealed that R1 was missing and staff called 911 to notify LEO of the elopement. On 01/05/24 at 08:30 PM, R1 was brought back to the facility by LEO. There was snow on the ground and the resident wore a coat, shoes, socks and appropriate winter clothing. A skin assessment completed upon R1's return to the facility, identified lacerations (wounds to the skin) and were documented on the front and the back of R1's lower left leg. LN C cleansed the wounds and covered the wounds with a dry dressing. Documentation revealed the lacerations required sutures. On 01/05/24 at 09:40 PM, staff sent R1 to the Emergency Department (ED) in the facility-owned vehicle with staff assistance for treatment of injuries sustained during the elopement from the facility. On 01/06/24 at 02:24 AM, R1 returned from the ED where he received 13 sutures to his wounds with instructions to keep the sutures clean and dry and monitor wounds for signs of infection. Further documented that R1 was placed on 1:1 observation with a staff member. On 01/06/24 at 10:11 PM, R1 approached staff holding a hospital identification bracelet and asked when he had gone to the hospital. R1 had no memory of the events of the elopement on the previous day. Review of the facility investigation and video recordings revealed the following: On 01/05/24 at approximately 07:30 PM, R1 informed CNA D that he had kicked out the window in his room. CNA D then notified LN C who instructed CNA D to maintain visual contact with R1 and instructed R1 to stay out of his room. On 01/05/24 on 08:00:16 PM, via video recording timestamp, CNA C left R1 unattended in the common's area. On 01/05/24 at 08:00:38 PM, via video recording timestamp, R1 got up from the common area and walked calmly down the hall to his room. On 01/05/24 at 08:01 PM, via video recording timestamp, R1 exited the building through the broken window in his room and ran to the six-foot wooden privacy fence on the south edge of the courtyard. On 01/05/24 at 08:02 PM via video recording timestamp, R1 observed going over the six-foot wooden privacy fence on the south edge of the courtyard. Review of weather data for the facility area from Weather Underground (www.wunderground.com) on 01/05/24 at approximately 07:00 PM (approximately one hour prior to the elopement) was 33 degrees Fahrenheit (?) with winds 3-5 miles per hour (mph) out of the North-North-West (NNW), sunset was at 05:25 PM (approximately two and a half hours before the elopement) with approximately one inch of snow on the ground from snowfall earlier that day. Observation of the area around the facility revealed a highway with heavy traffic including semi-trucks and speed limit of 55 mph approximately 2100 feet (approximately one-third mile) to the north. On 01/10/24 at 12:29 PM, CNA H was unavailable for comment in the investigation. Review of facility investigation witness statements revealed that the investigation lacked a witness statement from CNA H. On 01/10/24 at 12:31 PM, Certified Medication Aide (CMA) I was unavailable for comment in the investigation. Review of facility investigation witness statement revealed that CMA I was passing medications at the time of the elopement and assisted with the rollcall of residents and subsequent search for R1 who was missing. The witness statement documented that after R1 was returned to the facility by LEO that CMA I performed 1:1 observation until the completion of her shift. On 01/10/24 at 12:40 PM, Administrative Nurse B revealed that approximately 15 minutes before the incident where R1 broke the window in his room, he seemed like his usual self. After R1 broke his window but before he eloped from the facility, staff reported to the provider (Physician Extender G) and Administrative Nurse B that R1 displayed psychotic behaviors and Physician Extender G ordered a one-time dose of Haldol (haloperidol - an antipsychotic) 5 milligrams (mg) by mouth (PO) for one dose, Ativan (lorazepam - a benzodiazepine - a class of medication used to treat anxiety, insomnia and temporary situational stress) 2mg, PO for one dose, and Zyprexa (olanzapine - an antipsychotic) 15mg PO for one dose. Since Law Enforcement F was in the facility because he had responded to the facility for the broken window Law Enforcement F helped staff persuade resident to take the medication. After R1 had kicked out his window, staff removed R1 and his roommate from their room and LN C directed them to stay out of their room. LN C also directed CNA D to stay with R1. Administrative Nurse B stated that per video footage CNA D was observed following R1 up and down the hallway due to R1's pacing. Further stated that at the time of the elopement there were two other residents having two individual crises and confirmed that CNA D left R1 unattended to respond to another crisis elsewhere in the facility. On 01/05/24 at around 08:02 PM, per video footage, staff noticed that someone was missing and called Administrative Nurse B who directed staff to perform a roll-call census of all residents. Staff then noticed the footprints in the snow leading from R1's room to the six-foot wooden privacy fence on the south edge of the courtyard. Additionally stated that upon the R1's return to the facility with LEO, R1 had blood on R1's pant leg and injuries of unknown origin were discovered on R1's left leg. Administrative Nurse B stated that the LN sent R1 to the ED for treatment of his wounds. Administrative Nurse B also stated that all residents get a WanderGuard on admission for the first 30 days and the WanderGuard is removed if the residents are not at risk for elopement. Further stated that R1 had not been at risk for elopement since admission. On 01/10/24 at 01:00 PM, Physician Extender G revealed she was also the owner of the facility and supplied video footage of the incident to establish the timeline of the elopement. Physician Extender G revealed at the time of the elopement R1 was not an elopement risk but was having a psychotic episode (a period in which an individual behaves in a confusing and unpredictable way, may harm themselves or become threatening or violent towards others, and may be experiencing hallucinations and/or delusions). On 01/10/24 at 01:23 PM, CNA D revealed on 01/05/24 at approximately 07:30 PM, she was walking another resident when R1 stopped her in the hallway and reported he had broken the window out in his room and R1 stated he was scared for his life/safety but would not let staff assess him for wounds. CNA D stated she immediately reported the broken window to LN C who removed R1 and his roommate from their room and told them to stay in the common area. CNA D stated that LN C directed her to perform 1:1 observation of R1. CNA D stated that she was performing 1:1 observation of R1 at a distance. CNA D confirmed that she failed to maintain visual contact with R1 when another disturbance in the facility erupted. CNA D stated that when she returned to where R1 had been seated that he had gone. CNA D reported this to LN C who ordered a rollcall of all residents. CNA D revealed that when she searched R1's room she observed the footprints in the snow and notified LN C. On 01/10/24 at 01:29 PM, LN C revealed that prior to the incident where R1 broke out the window in his room, R1 appeared to be normal for him. When R1 broke out the window, he told CNA D who reported it to LN C. LN C then directed CNA D to stay with R1 and initiate 1:1 observation. R1 was ambulating with a limp and allowed LN C to assess him for injuries and none were found. LN C revealed that around the same time as the assessment of R1 that two different residents were having two different crises and LN C confirmed that she left CNA D with R1 with instructions to CNA D to perform 1:1 observation to go assess the other situations in progress elsewhere in the facility. LN C stated that an unknown time later, CNA D reported that the resident was not able to be found and that there were footprints outside the broken window. LN C stated that she then notified Administrative Nurse B and LEO. LN C stated that she then performed a rollcall of all residents and R1 was not accounted for. The LEO were able to locate him and bring him back. LN C stated that upon R1's return to the facility he was limping, and there was blood on his pants and left leg. LN C then performed a skin assessment and discovered a quarter-sized wound on the front of his left leg with adipose (subcutaneous [below the skin] fat) exposed and two one-to-two-inch wounds on the back of his leg with adipose tissue exposed. LN C stated that she cleaned and placed dry dressings on his wounds, then sent him to the local ED for evaluation and treatment of his wounds. When R1 returned from the hospital, LN C placed R1 back on 1:1 observation and a CNA was to be with him at all times. On 01/10/24 at 02:31 PM, Law Enforcement F revealed that 911 dispatch received the call regarding R1's elopement on 01/05/24 at 08:16 PM (15 minutes after the resident left the facility) and R1 was located by LEO on 01/05/24 at 08:27 PM (26 minutes after the resident left the facility) and that R1 was returned to the facility by facility staff in facility vehicle on 01/05/24 at 08:39 PM (38 minutes after the resident left the facility). Law Enforcement F revealed that the area where R1 was found was approximately 2800 feet (approximately one-half mile) from the facility and approximately 400 feet from a highway with heavy traffic including semi-trucks and speed limit of 55 miles per hour (mph). Law Enforcement F revealed that in his contact with the resident, when R1 was located, he did not appear to be acting or behaving abnormally. On 01/11/24 at 04:00 PM, Administrative Nurse B revealed the WanderGuard for R1 was removed on 11/14/20 after R1 was assessed for elopement and deemed to not be an elopement risk. The facility's undated Accident Prevention policy documented that all staff members of the facility will ensure that the environment remains as free from accident hazards as possible and will receive adequate supervision to prevent accidents. The facility's undated Elopement Policy, documented that the facility wishes to ensure the safety of residents identified as being a risk for elopement and to take precautions to ensure safety and well-being. Upon discovering an unaccountable absence of a resident by a staff member they will inform the nurse, record the time that the resident was discovered missing and where last seen. The nurse will contact law enforcement, perform a resident roll call and direct other staff to search the facility and grounds. The facility failed to provide adequate supervision, identify likely avenues of exit, including windows, and failed to ensure the windows were secured after R1 broke the window out in his room, to prevent elopement when CNA D did not provide the supervision of R1, as directed by LN C. At 08:00 PM, unsupervised R1 went to his room. At 08:01 PM R1 climbed through the known broken window and eloped from the facility and injured his leg. This deficient practice placed R1 in immediate jeopardy. On 01/10/24 at 05:07 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) Template for failure to provide adequate supervision to prevent elopement. The facility provided an acceptable plan for removal of the IJ on 01/11/24 at 02:33 PM and the following corrective measures were verified by the surveyor on-site during the investigation on 01/16/24 at 12:05 PM: 1. R1 was placed on 1:1 upon return to facility from the ED after receiving sutures and will remain on 1:1 until deemed stable by Physician Extender G. 2. Plywood sheeting placed over broken window 01/05/24 at 08:39 PM. 3. A contractor was contacted by the facility about a permanent window replacement. The contractor responded on 01/11/24 at 12:56 PM and documents reveal that there is no set date for repair, but facility is placed on waiting list for repairs to be completed as soon as practical. 4. Staff education related to the elopement policy was initiated on 01/08/24 at 08:00 AM and completed on 01/11/24 at 02:06 PM 5. Computer learning module titled Understanding Wandering and Elopement was initiated on 01/10/24 at 06:00 PM and completed on 01/11/24 at 11:26 AM The surveyor verified the facility implemented the corrective actions to remove the immediacy, while onsite on 01/16/24 at 12:05 PM. The deficient practice remained at a scope and severity of G after removal of the jeopardy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 45 residents with two residents reviewed for behaviors/resident-to-resident abuse. Based on observation, interview, and record review, the facility failed to provide adequate supervision and care planned interventions to prevent Resident (R)2, with a history of sexual behaviors since admission [DATE]), from sexually assaulting and harassing female residents in the facility. On 12/25/23, R2 grabbed R3's breast and masturbated in a public area, and the facility failed to place any interventions to protect R3 and other residents from R2's unwanted sexual advances/touching. R2 again on 12/25/23 masturbated in a public area. On 01/02/24, R2 attempted to grab R3's breast with no interventions in place. This deficient practice placed R3 and all other residents in immediate jeopardy. Findings included: - R2's Electronic Health Record (EHR) revealed a diagnosis of unspecified schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R2 had delusions (untrue persistent beliefs or perception held by a person although evidence shows it was untrue) and physical and verbal behaviors directed towards others, rejection of care and wandering behaviors one-to-three days in the seven-day look-back period that were disruptive of the living environment and/or social interactions. R2 took antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) medications daily in the seven-day look back period. The Quarterly MDS dated 11/27/23 documented a BIMS of 14, which indicated intact cognition. R2 had delusions and displayed physical behaviors towards others, other behaviors not directed at others, and rejection of care one-to-three days in the seven-day look-back period. R2 had wandering behaviors four-to-six days in the seven-day look-back period and took antipsychotic medication. The 08/27/23 Delirium Care Area Assessment (CAA) documented R2 exhibited several episodes of disorganized thinking. The 08/27/23 Psychosocial Well-Being CAA documented R2 did not attend activities or socialize with other residents and could be physically aggressive. The 08/27/23 Behavioral CAA documented the resident displayed several behaviors daily. The 01/11/24 Care Plan documented on 09/13/23, the resident displayed behavior problems of not following directions, inappropriate conversation, and screaming at staff. The care plan included the following: On 09/13/23, staff were to administer medications as ordered and monitor for effectiveness. On 09/13/23, caregivers were to provide an opportunity for positive interaction and attention. On 09/13/23, caregivers were to discuss the resident's behavior and explain/reinforce why behaviors were inappropriate or unacceptable. On 09/13/23, caregivers were to intervene as necessary to protect the rights and safety of others by diverting attention and removing from situation to alternate location as needed. On 09/13/23, caregivers were to praise indications of progress or improvement in R2's behavior. On 09/13/23, caregivers were to provide a program of activities of interest to R1. The care plan lacked interventions specific to R1's sexual behaviors to prevent further inappropriate sexual advances toward other residents, statements, and/or behaviors. The Progress Notes documented the following: 1. On 08/30/23 at 10:00 AM, R2 made inappropriate sexual advances and statements to staff when R2 wanted a female staff member to kiss him and touch his penis. 2. On 08/31/23 at 09:05 AM, R2 made inappropriate sexual advances and statements to staff when R2 asked a female staff member to undress and engage in sexual intercourse with him. 3. On 09/02/23 at 01:20 PM, R2 made inappropriate sexual advances to an unidentified female resident who had fallen asleep in a chair in the common area. R2 kissed the (unidentified) female resident on the lips without consent. 4. On 10/27/23 at 12:33 AM, R2 made inappropriate sexual statements to staff that he could have sex with children or any woman he wanted to because Santa Claus had told him to. 5. On 10/28/23 at 12:39 AM, R2 made inappropriate sexual statements to staff about having sexual relations with children. 6. On 11/08/23 at 06:08 PM, R2 made inappropriate statements to (unidentified) female residents. 7. On 11/25/23 at 06:35 PM, an unknown Certified Nurse Aide (CNA) reported to Licensed Nurse (LN) C that R2 purposefully urinated in the shower of the men's shower room and when confronted by staff, R2 claimed he had masturbated in the men's shower room. 8. On 12/12/23 at 11:57 PM, R2 made inappropriate sexual statements to (unidentified) female residents. R2 told the (unidentified) female residents that he was waiting for sex. 9. On 12/25/23 at 04:15 AM, R2 masturbated in a public area. LN J redirected R2 to his room. 10. On 12/25/23 at 04:40 AM, R3 reported to LN J that R2 grabbed her breast. When questioned about the incident by LN J, R2 admitted to grabbing R3's breast and stated that he did not know why he grabbed her breast. 11. On 12/25/23 at 05:01 AM, LN J observed R2 masturbating in a public area. LN J attempted to redirect R2 to the privacy of his room when R2 stated he could not help it and he got so horny around her (R3). 12. On 01/02/24 at 06:22 PM, R2 attempted to grab R3's breasts, but was redirected by staff. 13. On 01/04/24 at 02:33 PM, R2 made inappropriate sexual statements to an (unidentified) female resident. R2 asked the female resident if she wanted to be raped. Review of the facility's investigation and witness statements revealed no additional information. However, the investigation did have date stamp, by Administrative Staff A, on 12/25/23 that she had notified local law enforcement. On 01/11/24 at 10:41 AM, R3 reported she did not feel safe in her current environment, however, would not elaborate on why she felt unsafe. She reported she was uncomfortable with R2's sexual actions and did not want to further discuss any details. On 01/11/24 at 03:00 PM, Law Enforcement E revealed that no reports were on file related to the resident-to-resident sexual abuse that occurred on 12/25/23. Additionally, Law Enforcement E stated local law enforcement should be notified anytime there is an incident of unwanted sexual contact. On 01/11/24 at 03:39 PM, CNA D, CNA M, and CMA L revealed that if two or more residents were involved in an altercation of any type, they had been trained to physically separate the residents in question and to tell the licensed nurse on duty, then to follow the instructions given by the nurse. They further revealed if R2 and R3 got too close to each other, staff were to redirect one or both residents. On 01/11/24 at 03:45 PM, LN K revealed that if two or more residents were involved in an altercation of any type staff should separate the residents then investigate what happened, then relay the information to administration (Administrative Staff A, Administrative Nurse B and Physician Extender G). Administrative Nurse B was responsible to develop care plan interventions and instructions for staff to follow. Further stated that R2 has not made any unwanted sexual advances towards any peers other than R3. On 01/11/24 at 03:47 PM, Administrative Nurse B revealed staff were expected to keep R2 and R3 always separated per the communication notice in the EHR. Administrative Nurse B confirmed no interventions on the resident's care plan specific to inappropriate sexual contact/speech, sexual aggression, or sexual touching and stated that the staff have walking rounds after an incident and were to relay information from shift to shift with new interventions or that the new interventions placed on the communication notice in the EHR. Administrative Nurse B revealed that in the event of two or more residents being involved in an altercation of any type, staff were to separate the residents involved. The residents should be assessed by the LN on duty and investigate what happened. The LN was to notify all members of administration (Administrative Staff A, Administrative Nurse B, and Physician Extender G) who would then handle the remainder of the investigation and make the appropriate notifications of family/guardians, and if warranted, local law enforcement. On 01/11/24 at 03:58 PM, Physician Extender G stated the care plan entry dated 09/13/23 related to inappropriate speech addresses inappropriate sexual advances/speak/groping made towards peers or staff. R3 had attempted to go into R2's room since the incident on 12/25/23 but noted no documentation in R2 or R3's EHR to support this claim. Stated that law enforcement was not notified because R2 had the ability to call 911 herself and would have if she felt it necessary. On 01/11/24 at 04:00 PM, Administrative Staff A confirmed that she did not inform law enforcement on 12/25/23 as documented in the facility report. Stated that she did not notify local law enforcement because the resident and the resident's guardian did not want law enforcement involved. The undated facility policy Right to Consensual Sexual Activities documented that each resident has the right to a dignified existence, self-determination, and communication with persons/services inside and outside the facility and have all the rights provided to all citizens and residents of the United States of America, which includes affording all residents with privacy to engage in safe, consensual sexual expression. The policy defined sexual expression to include, but not limited to, hugs, kisses, masturbation, intimate touch, and intercourse. Further documented that sexual abuse was a non-consensual sexual contact of any type with a resident including but not limited to unwanted intimate touching of any kind especially of breasts or genitals, all types of sexual assault or battery, forced observation of masturbation and/or pornography. Further defined nonconsensual sexual contact as any resident who appears to want to contact to occur but lacks the cognitive ability to consent, or a resident who does not want the contact to occur. The facility failed to address steps for staff to take in the event of unwanted sexual contact. The undated facility Abuse, Neglect and Exploitation Policy documented that facility would prohibit and prevent abuse and that residents of the facility would remain free from abuse which may include verbal, mental, sexual, or physical abuse while residing at the facility. Documented that any staff that becomes aware of abuse should immediately report to the administrator who would report the abuse per state and federal requirements. Further, defined sexual abuse as non-consensual sexual contact of any type with a resident that included, but not limited to, unwanted intimate touching of any kind especially of the breasts or genitals and forced observation of masturbation. Additionally documented that willful abuse is defined that the individual must have acted deliberately, whether or not harm or injury was inflicted. Additionally documented that the administrator will file a report with the State Regulatory Agency immediately within 24 hours of the incident and any suspicion of abuse resulting in injury will be reported to the State Regulatory Agency within two hours and local law enforcement. Further documented that residents' sexual rights to not extend to acts which are non-consensual, acts with minors, or acts that impact negatively on the resident community as a whole through public display. Additionally documented that if there is any evidence of an incident that meets the definition of assault, battery, or other crime against a person that local law enforcement would be notified by the administrator or designee immediately. Additionally documented that if the alleged perpetrator of abuse is a facility resident, that a staff member will stay with the alleged perpetrator and wait for further instruction from administration. Further documented that all sexual assaults of a resident will be reported to local law enforcement immediately. The facility failed to provide a safe and secure living environment for the residents of the facility by the failure to provide adequate supervision and care planned interventions to prevent Resident (R)2, with a history of sexual behaviors since admission [DATE]), from sexually assaulting and harassing female residents in the facility. On 12/25/23, R2 grabbed R3's breast and masturbated in a public area, and the facility failed to place any interventions to protect R3 and other residents from R2's unwanted sexual advances/touching. R2 again on 12/25/23 masturbated in a public. On 01/02/24 R2 attempted to grab R3's breast with no interventions in place. These failures placed R3 and all other residents in immediate danger. On 01/11/24 at 05:30 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template for failure to provide adequate supervision to prevent and care planned interventions to prevent Resident (R)2, with a history of sexual behaviors since admission [DATE]), from sexually assaulting and harassing female residents in the facility, placing them in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 01/12/24 at 06:09 PM which included the following: 1. On 01/12/24 at 08:00 PM, the facility updated care plans for residents with sexually inappropriate behaviors by 01/16/24 completed for the four identified residents. 2. On 01/11/24 at 08:00 PM the facility educated staff on the policy Abuse, Neglect and Exploitation and completed 01/12/24 at 04:40 PM. 3. On 01/11/24 at 08:00 PM, the facility educated staff on the policy Sexual Consent and completed 01/12/24 at 04:40 PM 4. On 01/11/24 at 08:00 PM, the facility initiated an online training module for staff to complete on Relias with the topic of Preventing, Recognizing and Reporting Abuse and completed 01/13/24 at 03:08 AM 5. On 01/11/24 at 08:00 PM, the facility initiated an online training module for staff to complete on Relias with the topic of Abuse, Neglect and exploitation and completed 01/13/24 at 03:08 AM 6. On 01/11/24 at 08:00 PM, the facility initiated an online training module for staff to complete on Relias with the topic of Ethical Issues of Sexuality and the Older Adult and completed 01/13/24 at 03:08 AM 7. On 01/16/24 at 10:00 AM the facility initiated a process through which the Social Services Designee (SSD) would conduct resident interview questions related to abuse, neglect and exploitation 45 residents in the first week and had completed three of the 45 resident interviews on 01/16/24 at 12:05 PM with the remaining resident interviews ongoing. 8. On 01/11/24 at 08:00 PM the facility placed R2, with concerns of unwanted sexual advances under 1:1 observation until LEO investigated and resident would been assessed by Physician Extender G and/or Administrative Nurse B. Policy/procedure reviewed on 01/16/24 at 11:56 AM with Administrative Staff A. 9. On 12/22/23 at 05:00 AM the facility instructed staff to redirect/intervene/distract/encourage self-soothing activities in the privacy of R1's room and is an ongoing intervention. 10. On 01/12/24 at 08:00 PM, the facility instructed all staff instructed to maintain visual contact with R2 when out of his room and updated on care plan with this intervention. 11. On 01/12/24 at 05:51 PM, the facility placed a door alarm on R2's door to alert staff when R2 left his room and will be maintained for minimum of 30 days and reviewed at next QAPI meeting. 12. On 01/02/24 (at unknown time) R2 was seen by psychological provider for medication follow up and will be seen on an as needed basis until the 30 day review period, this included medication changes with Lithium (an antipsychotic medication) increased to 600 milligrams (mg) orally (PO) twice daily related to schizophrenia and started on trazodone (an antidepressant medication that is sometimes used to help with sleep) 100 mg po every night at bedtime related to insomnia. The surveyor verified the facility implemented the above corrective measures on-site during on 01/16/24 at 12:05 PM. The deficient practice remained at a scope and severity level of a E, following the implementation of the removal plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 45 residents with 13 selected for review, which included one resident reviewed for elopement. Based on observation, interview, and record review, the facility failed to prevent an elopement when the Resident (R)5 exited the facility unsupervised, through an employee exit on 12/30/22 at 07:52 PM, and remained outside of the building without staff knowledge for 16 minutes. When R5 exited the facility, the door alarmed and Certified Nurse Aide (CNA) M, looked outside of the door, but did not see the resident and shut the sounding alarm off. CNA M failed to notify any other staff members of the alarm sounding. The facility failed to immediately initiate a head count of the residents until the resident returned unaccompanied to the facility front door and knocked. While out of the facility unsupervised, the resident crossed the street, walked into a barbed wire fence, sustained scratches to the legs, and required a tetanus vaccine (a vaccine for a bacterium that enters the bloodstream from a wound on the skin from contaminated objects, which may cause serious muscle problems such as lockjaw). The facility failure to determine who went out the exit door when the alarm sounded placed this resident in immediate jeopardy. Findings included: - Review of Resident (R)5's Physician Order Sheet, dated 05/26/23, revealed diagnoses included schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), bipolar disease (major mental illness that caused people to have episodes of severe high and low moods), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), restlessness, and agitation. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive status and no behaviors or wandering. The resident was independent with activities of daily living. The Activity of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 05/22/22, assessed the resident required reminders and cueing for completion of self-care. The Quarterly MDS, dated 11/22/22, assessed the resident with normal cognitive function and no behaviors or wandering. The Care Plan, dated 10/22/22, instructed staff to complete a wandering assessment every 30 days. Staff were to monitor the location several times a day and document wandering behaviors. Staff were to attempt diversional interventions located in the behavior log. The care plan indicated the resident had a moderate elopement risk. The Wander Risk Scale assessment scores (0-8 low risk, 9-10 at risk, and 11 and greater at high risk) were noted as follows: On 11/01/22 staff assessed the resident with a score of 6 (low risk). On 12/05/22 staff assessed the resident with a score of 3 (low risk). On 12/31/22 staff assessed the resident with a score of 4 (low risk). A Nurse Progress Note, dated 12/30/22 at 09:20PM, documented the resident eloped from the facility and walked into a fence resulting in several scratches on her right lower leg. A Nurse Progress Note, dated 12/31/22 at 02:02AM, documented the scratches as 5 centimeters (cm), 17.5 cm and 5.5 cm with no depth to the scratches. Nursing staff cleansed the areas with wound cleanser and applied antibiotic ointment and applied a small sterile dressing to the 5.5 cm scratch. Interview on 06/13/23 at 08:13 AM, with R5 revealed the resident needed to get fresh air at times as a coping mechanism for anxiety and did remember exiting the building several months ago by pushing on the exit door by the laundry room, which set the alarm off. R5 did not ask staff to accompany them outside and began walking by themselves, crossed the street and went over a barbed wire fence, which caused cuts on their legs. The resident explained the decision to return to the facility and knocked on the front door to signal staff to let them back inside of the building. Interview on 06/13/23 at 11:02 AM, with Previous Administrative Staff B, stated the resident was not considered at high risk for elopement when the resident left the building unattended in December 2022. Previous Administrative Staff B explained the resident returned to the facility on their own after approximately 15 minutes. All staff were in-serviced and completed education on elopement, but Previous Administrative Staff B was not sure of the date of completion for the education. Interview on 06/13/23 at 11:10 AM, with Licensed Nurse (LN) R, revealed the resident did not currently have wandering behaviors, but did several months ago when R5 walked out of the facility, across the street, and fell into a barbed wire fence. Interview on 06/13/23 at 03:00PM, with Certified Medication Aide (CMA) S, revealed she worked in the kitchen the night R5 set off the alarm and exited the building unsupervised. CMA S stated another staff member shut off the alarm. CMA S stated staff should look for the person that set off the alarm, if not found, notify the charge nurse to do a head count of the residents to determine who was missing. Interview on 06/13/23 at 03:30 PM, with Administrative Nurse E, confirmed R5 left the building without staff knowledge by pushing on the exit door by the laundry and setting off the alarm on 12/30/22. Administrative Nurse E stated previous Certified Nurse Aide (CNA) M, shut off the alarm without looking around the building for the person who set off the alarm and did not notify the charge nurse of the elopement until approximately 16 minutes later when the resident returned to the facility and knocked on the front door for staff to let them back into the facility. Administrative Nurse E stated she thought the resident tried to follow a cat and walked across the street and over a fence and obtained scratches on her legs, which required cleansing, antibiotic ointment, and a tetanus vaccine. Administrative Nurse E stated she expected staff to look beyond the door and around the building when the exit door alarm sounded. She expected staff to notify the charge nurse immediately, perform a head count, and begin searching for the missing resident. She confirmed CNA M shut off the alarm without a thorough search and did not notify the charge nurse. Interview on 06/14/23 at 06:50 AM, with LN H, confirmed the elopement incident took place on 12/30/22 at approximately 09:00 PM. LN H further explained CNA M shut the exit door alarm off without looking past the door for the resident and did not notify her that he did not find the resident. LN H stated the resident exited the building by pushing on the exit door by the laundry because R5 wanted fresh air then, once outside, followed a cat across the street and over a barbed wire fence. LN H stated the resident was gone approximately 15 minutes before she returned to the facility on her own and sustained scratches on her legs from the fence. LN H stated upon return she placed a Wander Guard (a device that sounds to alert staff when resident approached an exit door) device on the resident's wrist. The undated facility policy titled Elopement, , instructed staff that under no circumstance will a door alarm be de-activated until the source of the activation has been determined. The nurses should immediately perform census verification and resident roll call to determine if there are any other missing residents. The facility failed to ensure R5 remained free of accidents when the resident exited the building, which activated the alarm system and staff failed to determine who exited the facility and shut off the alarm. The staff went on without searching for the resident and initiating elopement protocol. The resident who was injured after walking into barbed wire fence, returned to the facility after 16 minutes and knocked on the front door to notify staff they were back. These failures placed the resident identified as at risk for elopement in immediate jeopardy. The facility identified and implemented the following corrective actions beginning on 12/31/22 at 03:00 PM: 1. LN H performed a resident head count on 12/30/22 when notified of the resident return to the facility. LN H performed a skin assessment, treatment to scratches sustained, and education to the resident regarding leaving the building without supervision. The physician was notified of the elopement and injury to the resident with instruction given to LN H to obtain a tetanus vaccine as soon as possible (administered on 01/02/23.) 2. On 12/31/22 staff moved the resident to a room closer to the nurses' station. 3. On 01/02/23 Staff updated the resident's Care Plan to included moderate elopement risk and a wander guard was placed on the resident 4. On 01/06/23 all staff education and competency testing on the facility's Elopement Policy begun. 5. On 01/31/23 at 03:00PM last staff member completed the education and competency. During the survey on 06/14/23 the surveyors validated the completion date of the above items as of 01/31/23 at 03:00 PM, which deemed the deficient practice as past non-compliance.