**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's physician was notified of significant changes that required treatment to be altered for 1(#1) of 3 (#1, #2, and #3) residents reviewed for falls with injury. The facility failed to ensure nursing staff notified the physician when Resident #1 fell, had new onset complaints of pain, and required increased assistance with transfer. The deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a cognitively impaired resident, beginning on 01/02/2025 at 5:00 a.m., when S7CNA failed to report Resident #1 fell during transfer, hitting his wheelchair. From 01/02/2025 at 5:00 a.m. through 01/03/2025 at 7:30 a.m., Resident #1 had multiple complaints of new onset pain and required increased assistance with transfers from staff. Staff did not report the pain or decline in status to the physician during this time for new interventions or treatment. On 01/03/2025, x-ray results revealed the resident had a displaced comminuted intertrochanteric femur fracture that extended through the greater and lesser tuberosities. Resident #1 was then transferred to the hospital on [DATE] where he received 4 mg of morphine and was diagnosed with a Left femur fracture requiring multimodal pain control and surgical intervention. Due to Resident #1's cognitive impairment he was unable to appropriately communicate the affects the fall and delayed treatment caused him. It can be assumed a reasonable person would have suffered psychosocial harm and severe pain when staff failed to ensure he received treatment of a femur fracture. S1ADM was notified of the Immediate Jeopardy situation on 02/06/2025 at 6:10 p.m. The Immediate Jeopardy was removed on 02/07/2025 at 5:59 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for all cognitively impaired residents with communication deficits. Findings: Cross Reference: F697, F600 Review of the facility's Policy titled, Falls, undated revealed the following: Procedure: 1. Resident will not be moved until a Licensed Nurse has ascertained resident's condition. 5. Notify physician for further orders. 8. Fill out accident/incident form Review of the facility's Policy titled, Accident/Incident Reports: Resident, undated revealed the following: Policy: When an accident or incident involving a resident occurs, any witnessing staff will offer immediate assistance. An accident/incident report and the appropriate documentation will be completed by the end of the shift. Purpose: To assure appropriate follow-through on all accidents/incidents. Procedure: 1. Do not move the resident until a Licensed Nurse evaluates the condition. 2. Notify the nurse in charge 7. Notify the resident's physician 9. Complete an accident/incident report. Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included, in part, the following: Muscle Wasting and Atrophy, Age Related Osteoporosis, Dementia, Alzheimer's disease, Aphasia, and Cognitive Communication Deficit. Further review revealed Resident #1was diagnosed with a Left Femur Fracture resulting from a fall on 01/02/2025. Review of Resident #1's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/03/2024, indicated the resident had a Brief Interview of Mental Status (BIMS) of 3, which indicated severe cognitive impairment. Further review revealed the resident had no pain. Review of Resident #1's current Care Plan revealed the following interventions: Dated 11/15/2024 - Physical mobility impaired: Transfer assist x 1 Dated 01/02/2025 - X-Ray of Left hip/pelvis and knee Dated 01/02/2025 - Send to local hospital emergency room for eval Dated 01/07/2025 -Transfer status to 2-person assist Review of Resident #1's Imaging Results, dated 01/03/2025, revealed, in part, the following: Exam - CT left hip without contrast Findings - Displaced comminuted intertrochanteric femur fracture with surrounding soft tissues swelling. Fracture planes extend through the greater and lesser tuberosities. Review of the local hospital records dated 01/03/2025 revealed the following: admit date : [DATE] Chief complaint: Left hip pain The hip was noted to be outwardly rotated and shortened on x-ray with intertrochanteric left femur fracture. Consulted Orthopedics. Plan: Orthopedic Admit, with surgical plans pending CT results. Multimodal pain control. Further review of hospital record revealed Resident had a Left Femur Intertrochanteric Fracture Surgical Repair procedure performed on 01/05/2025. On 01/29/2025 at 1:38 p.m., an interview was conducted with S7CNA. S7CNA stated on 01/02/2025 at approximately 5:00 a.m. she transferred Resident #1 in his room. She explained during the transfer, the resident began to struggle and she had to lower the resident to the ground. As he was being lowered he hit his left side on the wheelchair. She stated she then called S12CNA into the room and they picked the resident up off the floor placing him back in his wheelchair. She stated she did not report the fall to the nurse or her supervisor. She stated later that day, at 1:15 p.m., Resident #1 complained of pain during transfer into bed. She stated she reported the pain to S4LPN, but did not report the resident fell. S7CNA stated she did not report the fall because Resident #1 did not complain of pain and did not have any obvious injuries. She stated she did not report the fall and should have. On 01/30/2025 at 8:35 a.m., an interview was conducted with S12CNA. S12CNA stated on the morning of 01/02/2025, S7CNA asked her to assist with transferring Resident #1. She stated she walked into Resident #1's room and found him on the floor in front of his wheelchair. She stated she did not know how he ended up on the floor, but she helped S7CNA move him from the floor to his wheelchair and went back to her assigned unit. She stated she did not report that resident was found on the floor to anyone. On 01/30/2025 at 12:24 p.m., an interview was conducted with S4LPN. S4LPN stated on 01/02/2025 at approximately 1:00 p.m. S7CNA notified her Resident #1 complained of pain, but did not report the resident had fallen earlier in the day. She stated if a resident had a fall it should be reported to the nurse or supervisor. She stated she did not administer pain medication or report the new onset of pain to her supervisor or the NP. On 01/30/2025 at 7:10 a.m., an interview was conducted with S6LPN. S6LPN stated at approximately 4:45 a.m. on 01/02/2025 she heard Resident #1 yell from his room. She stated by the time she got to Resident #1's room he was sitting on the side of his bed. She stated S7CNA was in the room and did not report the resident fell. She did not assess the resident at that time. She stated before Resident #1's injury he was able to stand and would sometimes get into his wheelchair without assistance. She stated Resident #1 did not normally complain of pain. On 01/29/2025 at 2:17 p.m., an interview was conducted with S8CNA. She stated Resident #1 was able to stand, pivot, and transfer with 1 person assistance with transfers before going out to the hospital. On 01/29/2025 at 2:43 p.m., an interview was conducted with S9CNA. She stated before his injury, Resident #1 was able to stand and pivot to the wheelchair with 1 person assistance. She stated on 01/02/2025, she worked the 2:00 p.m.-10:00 p.m. shift. She stated at approximately 2:00 p.m. she went in to change resident's brief. She stated Resident #1 usually stood up to transfer, but did not stand on his own at this time. She stated she had to extensively assist him into his wheelchair, which was not his normal. She stated she did not report the increased need for assistance to anyone. On 01/29/2025 at 3:45 p.m., an interview was conducted with S5LPN. She stated she worked on 01/02/2025 from 2:00 p.m. -10:00 p.m. shift. She stated no one reported Resident #1 fell. She stated on 01/03/2025 at approximately 7:00 a.m., she overheard S10CNA report to S4LPN Resident #1 had complained of leg pain. She said at this time an assessment was done by herself and S4LPN of Resident #1's leg and the resident grimaced when his left leg was moved. She stated the NP was notified and x- ray was ordered. She stated before his injury, Resident #1 was able to stand and pivot with transfers and did not normally complain of pain. On 01/30/2025 at 10:00 a.m., an interview was conducted with S13NP. S13NP stated she was not notified Resident #1 had a fall on 01/02/2025 and should have been. She stated if she had known about the fall and subsequent complaints of pain an x-ray would have been ordered sooner or she would have assessed the resident herself. On 01/30/2025 at 12:29 p.m., an interview was conducted with S3RN. She stated S7CNA did not report to her Resident #1 fell on [DATE]. S3RN stated if a resident had a fall she should be notified so the resident could be assessed by the nurse and the doctor would be notified. She stated Resident #1 did not normally complain of pain. On 01/30/2025 at 12:39 p.m., an interview was conducted with S2DON. S2DON stated she was not aware Resident #1 fell on [DATE]. She stated if a resident fell to the floor the CNA should not move the resident and notify the nurse immediately. The surveyors confirmed the following had been initiated and/or implemented prior to exit: 1. All residents who were identified as cognitively impaired were assessed to see if they showed any signs or symptoms of pain. A thorough review of each of the cognitively impaired residents fall risk assessment was completed by the Clinical Care Coordinators. 2. All staff were trained by the Administrator, DON, or designee to report any observed or verbalized pain or any change of condition immediately to a nurse or an administrative team member. The nurse or an administrative nurse will follow the standing or PRN orders and will follow up with their MD (Started 01/03/2025). 3. Nursing staff were trained by DON or designee on proper pivot transfers for one-person assist residents. Training emphasized that if a resident is combative, staff should not transfer the resident alone and should seek assistance (Started 01/03/2025). 3. Staff were educated by administrator, DON, or designee on the corporate policy for identifying and reporting incidents and accidents. The in-service also included the reporting process of when an incident/accident occurs (Started 01/06/2025). 4. Staff were educated by administrator, DON, or designee that covered definitions and examples of abuse and neglect. (Started 01/06/2025). 5. Nursing Staff were educated on identifying high fall risk residents, using assistive device markers and wall indicators - Falling Star Program (Started 01/06/2025). 6. All nurses were in-serviced to ensure a proper pain assessment was completed when a resident reports or shows any signs of pain to a staff member (Started 02/03/2025). 7. Monitoring was implemented on 01/06/2025 to assess and observe one-person pivot transfers conducted by the DON or designee 3 times a week for 6 weeks and monthly thereafter for 3 months (Started 01/06/2025). 8. Monitoring was implemented to assess resident pain with interviews of a random sample of nurses 3 times a week for 6 weeks and monthly thereafter including a specific section asking residents about pain during transfers (Started 01/30/2025). 9. Evaluation of staff knowledge, using a questionnaire, on handling incidents and accidents. Random audits conducted on 10 staff members per week for 6 weeks, followed by periodic checks (Started 02/06/2025). 10. Daily huddles with administrative staff in random facility sections asking nurses and CNAs about any observations of pain or incidents that occurred during their shift. These huddles started on 02/07/2025 and will be conducted daily for 2 weeks, then monthly thereafter for 3 months. As of 02/07/2025, the facility asserts the likelihood for serious harm to any recipient no longer exists.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's right to be free from neglect for 1 (Resident #1) of 3 (Residents #1, #2, and #3) sampled residents. The facility failed to ensure Resident #1 received needed services and treatment when CNA staff neglected to report a fall, which resulted in a left femur fracture. The deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a cognitively impaired resident, beginning on 01/02/2025 at 5:00 a.m., when S7CNA failed to report Resident #1 fell during transfer, hitting his wheelchair. From 01/02/2025 at 5:00 a.m. through 01/03/2025 at 7:30 a.m., Resident #1 had multiple complaints of new onset pain and required increased assistance with transfers from staff. Staff did not report the pain or decline in status to the physician during this time for new interventions or treatment. On 01/03/2025, x-ray results revealed the resident left femur fracture. Resident #1 was transferred to the hospital on [DATE] where he received 4 mg of morphine and was diagnosed with a Left femur fracture requiring surgical intervention. Due to Resident #1's cognitive impairment he was unable to appropriately communicate the affects the fall and delayed treatment caused him. It can be assumed a reasonable person would have suffered psychosocial harm and severe pain when staff failed to ensure he received treatment of a femur fracture. S1ADM was notified of the Immediate Jeopardy situation on 02/06/2025 at 6:10 p.m. The Immediate Jeopardy was removed on 02/07/2025 at 5:59 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for all residents residing in the facility. Findings: Cross Reference: F697 and F580 Review of the facility's policy, Abuse/Neglect Policy Statement, dated 12/11/2018 revealed the following, in part: The facility will not condone any form of resident neglect Each resident has the right to be free from neglect. Abuse/Neglect Reporting Definitions 9. Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish . Identification: Possible indicators of Potential Abuse and Neglect 1. Injuries of unknown origin 3. Changes in the behavior pattern of the resident 6. New onset of physical concern (pain) 23. Complaints of pain or injury that have not been addressed by facility staff 26. Medical conditions that have not been addressed by nursing personnel .evaluations based on the individual's needs 27. Inability of the resident to access medical personnel Review of the facility's undated policy, Falls, revealed the following, in part: Policy: To provide emergency care. Procedure 1. Resident will not be moved until a Licensed Nurse has ascertained resident's condition. 2. Assess resident for any abnormalities: i.e., a. deformed, discolored or painful body parts c. Vitals 3. Ascertain extent and type of injury. 4. Make resident as comfortable as condition permits 5. Notify physician for further orders. Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, in part, the following: Muscle Wasting and Atrophy, Age Related Osteoporosis, Dementia, Alzheimer's Disease, Aphasia, and Cognitive Communication Deficit. Further review revealed Resident #1 was diagnosed with a Left Femur Fracture resulting from a fall on 01/02/2025. Review of Resident #1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/03/2024, revealed a Brief Interview of Mental Status (BIMS) of 3, which indicated severe cognitive impairment. Further review revealed no indication Resident #1 had pain upon assessment completion. Review of Resident #1's current Care Plan revealed the resident had impaired cognition and communication related to Alzheimer's Disease and Expressive Aphasia. Further review of Resident #1's Care Plan revealed the following interventions: Start date: 01/02/2025 - X-Ray of L hip/pelvis and knee Start date: 01/02/2025 - Send to local hospital emergency room for eval Review of Resident #1's January 2025 Medication Administration Record (MAR) revealed the following: X-ray left hip, femur, and knee for complaint of increased of pain to area for left hip/leg pain - Start date 01/03/2025 Review of Resident #1's Imaging Results, dated 01/03/2025, revealed, in part, the following: a CT without contrast of the left hip was performed which showed a Displaced comminuted intertrochanteric femur fracture with surrounding soft tissues swelling. Fracture planes extend through the greater and lesser tuberosities and mild degenerative change. Review of Resident #1's local hospital record notes revealed an admit date of 01/03/2025 at 2:38 p.m. Resident's chief complaint was hip pain with a pain score of 4. Resident was administered 4 mg of Morphine at 5:00 p.m. Resident was admitted to the hospital on the same day with a Left femur fracture. Orthopedics was consulted and surgery was performed on 01/04/2025 to surgically repair a Left Femur Fracture. On 01/30/2025 at 12:37 p.m., an interview was conducted with S11SW. She stated she was responsible for completing BIMS assessments. She stated Resident #1 was able to respond to limited questions. She stated he was oriented to person only and could not identify the month and year. She stated he was not able to recall events that occurred 5 minutes ago. On 01/29/2025 at 1:38 p.m., an interview was conducted with S7CNA. She stated, on 01/02/2025 at approximately 5:00 a.m., she transferred Resident #1 in his room. She explained during the transfer, the resident began to struggle and she had to lower the resident to the ground. She stated, as he was being lowered he hit his left side on the wheelchair. She stated she called S12CNA into the room and they picked the resident up off the floor placing him back in his wheelchair. She stated after getting the resident into his wheelchair, he did not complain of pain or show nonverbal signs of pain, and there were no visible injuries. She stated Resident #1 did fall to the floor and she did not report the fall to the nurse or her supervisor. She stated later that day, at 1:15 p.m., she transferred the resident into bed and the resident complained of pain. She stated she reported the pain to S4LPN, but did not report the resident fell. On 01/30/2025 at 8:35 a.m., an interview was conducted with S12CNA. She stated on the morning of 01/02/2025, S7CNA asked for help with transferring Resident #1. She stated when she walked into the room Resident #1 was on the floor in front of the wheelchair with his legs straight out in front of him. She stated he did not complain of any pain. She stated she helped S7CNA move him to his wheelchair and went back to her assigned unit. She did not know how resident ended up on the floor and she did not report the resident was found on the floor. On 01/29/2025 at 2:17 p.m., an interview was conducted with S8CNA. She stated around lunch time on 01/02/2025, she assisted S7CNA with transferring Resident #1 from his bed to the wheelchair. She stated, during the transfer, Resident #1 cried out in pain when his left leg was moved. She stated she was not aware of Resident #1 having a fall. On 01/29/2025 at 2:43 p.m., an interview was conducted with S9CNA. She stated on 01/02/2025 at approximately 2:00 p.m., she went into Resident #1's room to change his brief. She stated the resident had been lying on his right side and did not want to roll to his back. She stated she asked Resident #1 what was wrong and he responded my leg. She stated she continued to change the resident's brief, sat him up on the side of his bed, and transferred him into his wheelchair. She stated prior to the Left Femur Fracture, Resident #1 was able to stand and pivot for transfers, but on this day he did not stand on his own. She stated she had to extensively assist him into the wheelchair, and this was not his normal. She stated she was not aware of Resident #1 having a fall. On 01/29/2025 at 3:45 p.m., an interview was conducted with S5LPN. She stated on 01/02/2025 she worked the evening shift on Resident #1's hall. She stated she did not receive a report or a fall regarding Resident #1 during her shift on 01/02/2025 by the CNA staff. She stated before his Left Femur Fracture, Resident #1 was able to stand and pivot with transfers and did not normally complain of pain. On 01/30/2025 at 8:52 a.m., an interview was conducted with S10CNA. She stated on 01/03/2025, she and S7CNA were bringing Resident #1 back to his room via wheelchair, when Resident #1 complained of leg pain. She stated before his injury, Resident #1 was able to get himself out of his wheelchair and onto the sofa without assistance. She stated she was not aware of Resident #1 having a fall. On 01/30/2025 at 12:24 p.m., an interview was conducted with S4LPN. She stated at approximately 1:00 p.m. on 01/02/2025, S7CNA notified her Resident #1 had complained of pain. She stated the CNA did not notify her that the resident had fallen earlier in the day. She stated on 01/03/2025 at approximately 7:00 a.m. Resident #1 was in his wheelchair being pushed through the dining room. She stated she and S5LPN overheard S10CNA state Resident #1 could not stand on his leg and he had complained of pain. She stated she and S5LPN completed an assessment on Resident #1 by moving his left leg. She stated when the left leg was moved, Resident #1 grimaced. She stated the charge nurse and Nurse Practitioner (NP) were notified, x-ray was ordered, and Tylenol was given. She stated Resident #1 was oriented to self only. She stated due to his cognitive impairment, he was only capable of reporting pain he currently felt, not pain from an earlier time. She stated Resident #1 did not normally complain of pain and this was a new complaint for him. On 01/30/2025 at 12:29 p.m., an interview was conducted with S3RN. She stated on 01/02/2025 S8CNA called the nurse's station and informed her of Resident #1's complaint of pain but did not report the resident had fallen earlier in the day. S3RN stated Resident #1 was oriented to self only and could not answer questions appropriately. She stated he would not be able to communicate pain unless he was feeling pain at that moment. She stated Resident #1 did not normally complain of pain. She stated a cognitively impaired resident's pain assessment would include the following; asking verbally, moving resident and observing for grimacing, and speaking with staff that reported the pain for more information. She stated she would expect a reasonable person with a fracture to express pain with movement or manipulation. On 01/30/2025 at 12:39 p.m., an interview was conducted with S2DON. She confirmed she was not aware Resident #1 had a fall on 01/02/2025. She stated a cognitively impaired resident's pain assessment would include the following: observing for grimaces and checking for limited range of motion. She stated Resident #1 would not be able to communicate pain unless he was currently experiencing pain. She stated if a resident had fallen to the floor, expressed pain, and no report of fall was made she would consider this neglect. On 01/29/2025 at 3:00 p.m. an interview was conducted with S1ADM. He stated he was not aware Resident #1 had a fall to the floor on 01/02/2025. He stated a CNA withholding information about a resident's fall that would delay necessary care would be classified as neglect. The surveyors confirmed the following had been initiated and/or implemented prior to exit: 1. All staff were in-serviced on resident pain and change of condition reporting (Conducted on 01/03/2025) 2. Nursing staff were in-serviced on proper transfers (Conducted on 01/03/2025) 3. All staff were in-serviced on abuse and neglect policies (Conducted on 01/06/2025) including different types of abuse and neglect and how they can occur in the facility and corporate policies identifying, preventing, and reporting abuse or neglect. 4. In-service conducted on incident and accident reporting including definitions and reinforcement of the need for immediate documentation and notification of supervisory staff. 5. Daily huddles performed with CNAs and nurses, randomly picking a section of the building and asking if any reported falls or if any issues of abuse/neglect have been reported. (Started 02/07/2025 and to continue for 2 weeks and randomly thereafter. 6. QA monitoring of one person assist transfers and assessment of pain and reporting of falls. An administrative nurse or designee will randomly monitor transfers 3 times a week for 6 weeks and monthly thereafter (Implemented on 01/06/2025). 7. Implementation of a questionnaire regarding abuse and neglect: A questionnaire will be implemented randomly monitoring all staff members of their knowledge of abuse/neglect. Ten staff members will be randomly selected and questioned weekly for six weeks. The questionnaire will bring up specific types of abuse/neglect and if the staff members know and understand what they are. Random checks will continue after the initial six-week period to ensure continued compliance (Implemented on 02/06/2025) 8. Incident and accident Questionnaire - A questionnaire will be implemented randomly monitoring staff members for their knowledge of incident and accident reports. The questionnaire gives specific examples of what to do if a resident is on the floor and how to report those instances to administration (Implemented on 02/06/2025) As of 02/07/2025, the facility asserts the likelihood for serious harm to any recipient no longer exists.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide pain management consistent with professional standards of practice for a cognitively impaired resident, following a fall, for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for pain. Nursing staff failed to assess and treat Resident #1 after multiple complaints of new onset pain. The deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a cognitively impaired resident, beginning on 01/02/2025 at 5:00 a.m., when S7CNA failed to report Resident #1 fell during transfer, hitting his wheelchair. From 01/02/2025 at 5:00 a.m. through 01/03/2025 at 7:30 a.m., Resident #1 had multiple complaints of new onset pain and required increased assistance with transfers from staff. Staff did not report the pain or decline in status to the physician during this time for new interventions or treatment. On 01/03/2025, x-ray results revealed the resident had a displaced comminuted intertrochanteric femur fracture that extended through the greater and lesser tuberosities. Resident #1 was transferred to the hospital where he received 4 mg of morphine and was diagnosed with a Left femur fracture requiring multimodal pain control and surgical intervention. Resident #1 was not treated or appropriately assessed for pain even though he reported pain multiple times to staff. Due to Resident #1's cognitive impairment he was unable to appropriately communicate the affects the fall and delayed treatment caused him. It can be assumed a reasonable person would have suffered psychosocial harm and severe pain when staff failed to ensure he received treatment of a femur fracture. S1ADM was notified of the Immediate Jeopardy Situation on 02/07/2025 at 3:10 p.m. The Immediate Jeopardy was removed on 02/07/2025 at 6:37 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for all cognitively impaired residents, with communication deficits, experiencing pain. Findings: Cross Reference: F580 and F600 Review of the facility's undated policy, Falls revealed the following, in part: Policy: To provide emergency care. Procedure 1. Resident will not be moved until a Licensed Nurse has ascertained resident's condition. 2. Assess resident for any abnormalities: i.e., a. deformed, discolored or painful body parts c. Vitals 3. Ascertain extent and type of injury. 4. Make resident as comfortable as condition permits 5. Notify physician for further orders. Review of the facility's undated policy, Accident/Incident Reports: Resident Purpose: To provide appropriate follow-through on all accidents/incidents. To study the cause of accidents and incidents and to give guidance for corrective/preventive action. Procecure: 1. Do not move the resident until a Licensed Practical Nurse evaluated the condition. 2. Notify the nurse in charge. 3. Licensed Nurse - .Complete a thorough head -to-toe assessment of the resident for possible injury, including range of motion. 6. Make the resident comfortable. 7. Notify the resident's physician-receive orders for follow-through. 10. Note the location and the time of the incident, and the exact circumstances of the incident. Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included, in part, the following: Muscle Wasting and Atrophy, Age Related Osteoporosis, Dementia, Alzheimer's disease, Aphasia, and Cognitive Communication Deficit. Further review revealed Resident #1 was diagnosed with a Left Femur Fracture resulting from a fall on 01/02/2025. Review of Resident #1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/03/2024, revealed a Brief Interview of Mental Status (BIMS) of 3, which indicated severe cognitive impairment. Further review revealed no indication Resident #1 had pain upon assessment completion. Review of Resident #1's current Care Plan revealed the resident had impaired cognition and communication related to Alzheimer's Disease and expressive aphasia. Further review revealed the resident had chronic pain. Review of Resident #1's January 2025 Medication Administration Record (MAR) revealed no documentation the resident received medication for the treatment of pain until 01/03/2025 at approximately 7:30 a.m. when Resident #1 was administered Tylenol after S4LPN assessed him to find pain with movement of his left leg. Review of Resident #1's Imaging Results, dated 01/03/2025, revealed, in part, the following: a CT without contrast of the left hip was performed which showed a Displaced comminuted intertrochanteric femur fracture with surrounding soft tissues swelling. Fracture planes extend through the greater and lesser tuberosities and mild degenerative change. Review of Resident #1's local hospital record notes revealed an admit date of 01/03/2025 at 2:38 p.m. Resident's chief complaint was hip pain with a pain score of 4. Resident was administered 4 mg of Morphine at 5:00 p.m. Resident was admitted to the hospital on the same day with a Left femur fracture. Orthopedics was consulted and surgery was performed on 01/04/2025 to surgically repair a Left Femur Fracture. On 1/30/2025 at 12:37 p.m., an interview was conducted with S11SW. She stated she was responsible for completing the BIMS assessments on residents. She stated Resident #1 was able to respond to limited questions. She stated he was oriented to person only and could not identify the month and year. She stated he was not able to recall events that occurred 5 minutes ago. On 01/30/2025 at 7:10 a.m., an interview was conducted with S6LPN. She stated at approximately 4:45 a.m. on 01/02/2025, she heard Resident #1 yell from his room. She stated when she got to Resident #1's room he was dressed and sitting on the side of the bed. She stated S7CNA was in the room with the resident and S7CNA said everything was ok. She stated she asked Resident #1 if he was ok and the resident did not respond. She said she did not assess the resident at this time. She stated Resident #1 did not get up on the night of 01/02/2025 and slept. She further stated Resident #1 did not often complain of or show signs of pain. She stated before his injury, Resident #1 was able to stand and would sometimes get into his wheelchair without assistance. On 01/29/2025 at 1:38 p.m., an interview was conducted with S7CNA. She stated, on 01/02/2025 at approximately 5:00 a.m., she transferred Resident #1 in his room. She explained during the transfer, the resident began to struggle and she had to lower the resident to the ground. As he was being lowered he hit his left side on the wheelchair. She stated she called S12CNA into the room and picked the resident up off the floor placing him back in his wheelchair. She stated after getting the resident into his wheelchair, he did not complain of pain or show nonverbal signs of pain, and there were no visible injuries. She stated she did not report the fall to the nurse or her supervisor. She stated later that day, at 1:15 p.m., she transferred the resident into bed and the resident complained of pain. She stated she reported the pain to S4LPN, but did not report the resident fell. On 01/30/2025 at 12:24 p.m., an interview was conducted with S4LPN. She stated at approximately 1:00 p.m. on 01/02/2025, S7CNA notified her Resident #1 had complained of pain. She confirmed she did not complete a full pain assessment on Resident #1 on 01/02/2025 when the complaint of pain was reported to her. She stated on 01/03/2025 at approximately 7:00 a.m. Resident #1 was in his wheelchair being pushed through the dining room. She stated she and S5LPN overheard S10CNA state Resident #1 could not stand on his leg and he had complained of pain. She stated at that time she and S5LPN completed an assessment on Resident #1 by moving his left leg. She stated when the left leg was moved, Resident #1 grimaced. She stated the charge nurse and NP were notified, x-ray was ordered, and Tylenol was given. She stated Resident #1 was oriented to self only. She stated due to his cognitive impairment, he was only capable of reporting pain he currently felt, not pain from an earlier time. She stated Resident #1 did not normally complain of pain and this was a new complaint for him. She stated a reasonable person with a femur fracture would express pain with incontinent care. She stated a cognitively impaired resident's pain assessment would include the following; asking if they had pain, observe for pain indicators, such as grimacing, pulling away or favoring a certain area. She confirmed on 01/02/2025 she only asked the resident if he was in pain. On 01/29/2025 at 2:17 p.m., an interview was conducted with S8CNA. She stated around lunch time on 01/02/2025, she assisted S7CNA with transferring Resident #1 from his bed to the wheelchair. She stated, during the transfer, Resident #1 cried out in pain when his left leg was moved. She stated she notified S3RN, who then notified S4LPN about the resident's complaint of pain. On 01/29/2025 at 2:43 p.m., an interview was conducted with S9CNA. She stated on 01/02/2025 at approximately 2:00 p.m., she went into Resident #1's room to change his brief. She stated the resident had been lying on his right side and did not want to roll to his back. She stated she asked Resident #1 what was wrong and he responded my leg. She stated she continued to change the resident's brief, sat him up on the side of his bed, and transferred him into his wheelchair. She stated prior to the left femur fracture, Resident #1 was able to stand and pivot for transfers, but on this day he did not stand on his own. She stated she had to extensively assist him into the wheelchair, and this was not his normal. She stated she notified S5LPN that Resident #1 had complained of pain. On 01/29/2025 at 3:45 p.m., an interview was conducted with S5LPN. She stated on 01/02/2025 she worked the evening shift on Resident #1's hall. She stated he did not complain of pain while he was up in his wheelchair, and did not appear to be in pain when she was in his room. She stated she did not receive a report of pain regarding Resident #1 during her shift on 01/02/2025. She stated on 01/03/2025, S9CNA reported the resident had pain. She stated before his left leg fracture, Resident #1 was able to stand and pivot with transfers and did not normally complain of pain. On 01/30/2025 at 8:52 a.m., an interview was conducted with S10CNA. She stated on 01/03/2025 she and S7CNA were bringing Resident #1 back to his room via wheelchair with S8CNA, when Resident #1 complained of leg pain. She stated she reported this to S3RN. She stated before his injury, Resident #1 was able to get himself out of his wheelchair and onto the sofa without assistance. On 01/30/2025 at 10:00 a.m. an interview was conducted with S13NP. S13NP stated she was not notified Resident #1 had a fall on 01/02/2025 and should have been. She further stated she had not been made aware of Resident #1's complaints of pain until 01/03/2025. She stated if she had known about the fall and subsequent complaints of pain she would have ordered an x-ray sooner or waited until she could assess the resident herself. On 01/30/2025 at 12:29 p.m., an interview was conducted with S3RN. She stated on 01/02/2025 S8CNA called the nurse's station and informed her of Resident #1's complaint of pain. She stated she informed S4LPN within minutes. She stated S4LPN went to Resident #1's room, came back and reported to her Resident #1 denied pain. S3RN stated Resident #1 was oriented to self only and could not answer questions appropriately. She stated he would not be able to communicate pain unless he was feeling pain at that moment. She stated Resident #1 did not normally complain of pain. She stated CNA should have reported that resident was having pain in leg while performing transfer or incontinent care. She stated a cognitively impaired resident's pain assessment would include the following; asking verbally, moving resident and observing for grimacing, and speaking with staff that reported the pain for more information. She stated she would expect a reasonable person with a fracture to express pain with movement or manipulation. On 01/30/2025 at 12:39 p.m., an interview was conducted with S2DON. She stated a cognitively impaired resident's pain assessment would include the following: observing for grimaces and checking for limited range of motion. She stated the assessment would be based on who it was and based on the clinical presentation. She stated Resident #1 would not be able to communicate pain unless he was currently experiencing pain. She stated Resident #1 would not be able to communicate pain unless it was current. She further stated Resident #1 would not be able to communicate pain 5 minutes after it had occurred. The surveyors confirmed the following had been initiated and/or implemented prior to exit: 1. All residents who were identified as cognitively impaired were assessed to see if they showed any signs or symptoms of pain. A thorough review of each of the cognitively impaired residents fall risk assessment was completed by the Clinical Care Coordinators. 2. All staff were trained by the Administrator, DON, or designee to report any observed or verbalized pain or any change of condition immediately to a nurse or an administrative team member. The nurse or an administrative nurse will follow the standing or PRN orders and will follow up with their MD (Started 01/03/2025). 3. All nurses were in-serviced to ensure a proper pain assessment was completed when a resident reports or shows any signs of pain to a staff member (Started 02/03/2025). 4. Monitoring was implemented to assess resident pain with interviews of a random sample of nurses 3 times a week for 6 weeks and monthly thereafter including a specific section asking residents about pain during transfers (Started 01/30/2025). 5. Daily huddles with administrative staff in random facility sections asking nurses and CNAs about any observations of pain or incidents that occurred during their shift. These huddles started on 02/07/2025 and will be conducted daily for 2 weeks, then monthly thereafter for 3 months. As of 02/07/2025, the facility asserts the likelihood for serious harm to any recipient no longer exists.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure there was adequate supervision and monitoring for 1 (#47) of 4 (#21, #47, #74, and #83) residents who was assessed as an elopement risk. This deficient practice resulted in an immediate jeopardy situation on 02/12/2023 at 2:44 p.m., when Resident #47, who had a BIMS of 3, indicating she was severely cognitively impaired, was taken out of Unit a to attend a parade by S10CNA. Resident #47 had diagnoses, which included Dementia and Memory Deficit following Cerebrovascular Disease. Additionally, Resident #47 was assessed as being at high risk for elopement. Resident #47 wandered from the facility unnoticed by staff. Resident #47 was found on 02/12/2023 at 10:00 p.m. by an off duty staff member 1.7 miles away from the facility at a heavily traveled intersection. S1ADM was notified of the Immediate Jeopardy on 02/17/2023 at 2:10 p.m. The Immediate Jeopardy was removed on 02/17/2022 at 3:45 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal prior to the survey exit, which included: 1. All staff In-serviced on the following topics: a. All activities must be approved by administration. No unauthorized activities are to be provided at any time. b. All residents who exit the unit must have increased supervision and be signed out using sign out sheet. c. Code W: Refreshing staff members on definition and proper response when activated. d. All activities will be held in their designated units. No activities will be crossed over between units at this time. e. Q 15-minute checks ordered and are to be performed on the residents in the unit. This should be done to ensure resident's location and safety. f. *QA Monitor in place for administrative designee to ensure completion of logs g. If residents from either unit are to attend an event/activity off their designated unit, they must be approved to leave by the Administrator/DON, or floor nurse working. h. All new hires will attend extensive training on above stated topics. i. A monitor has been developed to be done by administrative staff to ensure that 15 minute visual checks are being done. This will be completed on a random sample of residents 3 times per week for 6 weeks. j. A monitor has been developed to be done by administrative staff to ensure that the resident sign in-sign out log is being completed in both secure care units. This will be completed on a random sample of residents 3 times per week for 6 weeks. k. QAPI team is discussing the process in the meeting daily to ensure that compliance is maintained and education is continued. 2. A Competency Questionnaire was developed and implemented to review the above In-service topics to make sure that the staff understands and they are being implemented. 3. We have begun to implement a sign in/sign out log on the units. All nurses, aides and therapist have been instructed on how to properly utilize this form. 4. Facility's Elopement binder has been updated to contain up to date colored photos and face sheets for each resident. Three different binds were created for each unit for easy access for all staff members. All new hires will attend extensive training on above stated topics. 5. A monitor has been developed to be completed by administrative staff to ensure that 15-minute visual checks are being completed. This will be completed on a random sample of residents 3 times per week for 6 weeks. 6. A monitor has been developed to be completed by administrative staff to ensure that the resident sign in-sign out log is being completed in both secure care units. This will be completed on a random sample of residents 3 times per week for 6 weeks. 7. QAPI team is discussing the process in the meeting daily to ensure that compliance is maintained and education is continued. 8. An audit of all residents residing in both secure care units was completed by administrative nurses to ensure that all residents had a current wander data collection tool completed and reviewed each residents' plan of care to ensure that at risk for wandering was included in their interventions. An additional review was completed of all residents residing outside of the secure care units to ensure all residents had a current wander data collection tool. A list was compiled of all residents that score at a level to be considered at risk for elopement based off of the assessment tool. Residents identified will be reviewed by the Interdisciplinary Team to determine a plan of action needed for each resident. This deficient practice had the potential for more than minimal harm for the 2 residents who were taken off of Unit a by S10CNA to attend the Mardi Gras parade. Findings: A review of the facility's Wandering or Missing Resident Policy revealed, in part: Procedure: Resident Missing From Designated Area of Facility: 3. If the resident is not located in the buildings or the grounds within a reasonable time, the charge nurse shall notify the Director of Nursing and the Administrator to implement the plan to locate the resident. A review of Resident #47's clinical record revealed she was admitted to the facility on [DATE] with diagnoses including: Paranoid Type Schizophrenia, Memory Deficit following Cerebrovascular Disease, Dementia, and Bipolar Disorder. A review of Resident #47's Assessment Type 5 day MDS with ARD of 12/08/2022 revealed a BIMS of 3, which indicated Resident #47 was severely cognitively impaired. A review of Resident #47's Physician Orders dated February 2023 revealed, in part: 07/28/2022-Visual check for resident's location every 30 minutes 07/28/2022-Admit to secure until for diagnosis of dementia and wandering behaviors A review of Resident #47's care plan, revealed, in part: Problem: Wandering: Potential for elopement. 02/12/2023-Resident wandered off of facility grounds (was outside at parade) Interventions: Place resident in area where frequent observation is possible; monitor and document target behaviors; instruct visitors to inform staff when they are leaving the designated area with the resident; designate staff to account for resident whereabouts throughout the day; alert staff to wandering behaviors; implement facility protocol for locating an eloped resident; visual checks for resident's location every 30 minutes; complete room/bathroom search of facility; Administrator, DON, and CNA Supervisor notified and arrived to facility to implement plan to locate resident; head to toe assessment was performed, NP notified, q 1 hour vital signs initiated, investigation report opened; In-service completed to ensure all activities must be approved by administration; In-service for all staff that all residents who exit the unit must have increased supervision and be signed out using the new sign out sheet with QA monitor for log completion 3times\week for 4 weeks; In-service for Code W refreshing the staff on what this is and how to respond when this is activated; In-service with staff that all activities will be held in their designated units. No activities will be crossed over units at this time; In-service with staff (Nurses and CNA's) that q 15 minute visual checks are to be performed on residents in the unit to ensure safety and nurses to check off on log provided with QA monitor log completion; In-service with staff that residents on unit are to attend an event\activity off their designated unit that they must be approved A review of Resident #47's Nurse's Notes revealed, in part: 02/13/2023 at 2:34 p.m.- On 02/12/2023 at 7:15 p.m., DON notified by S7LPN of staff's inability to locate resident after being taken outside on the facility grounds by CNA for a local Mardi Gras parade. S7LPN also reports that a complete room/bathroom search of the facility has been performed. S6LPN (LPN-nurse on duty) reports the last time resident was seen is between 2:00 p.m. and 3:00 p.m. Administrator notified of missing resident by DON. Administrator, Assist. Admin., DON, and CNA Supervisor arrived to facility to implement the plan to locate resident. NP notified of missing resident. Resident has no personal contacts listed to notify of occurrence. Local hospitals and fire depts. were contacted. The local police department was notified, and a missing person report was filed. The local/surrounding areas near the facility were searched. During the search, Administrator received a call from local police dept. stating they had picked up a female fitting the description of the resident and taken her to the local emergency room around 3:45 p.m. Upon further investigation with police department and hospital, it was explained that there were no medical indication to keep/treat resident and she was unable to provide information so she was released. Search of the local vicinity continued-resident was located by CNA near a main intersection, and she notified CNA Supervisor. Resident brought back to facility by CNA and arrived at 10 p.m., where she appeared in stable condition wearing clothing appropriate for weather. Resident stated she was hungry and was provided dinner. Resident noted in good spirits with pleasant affect-exhibits no signs of fear, anger, and depression. She was escorted back to her room where a complete head-to-toe assessment was performed with her permission- skin smooth, warm, and dry with an abrasion noted to her nose and minimal swelling and discoloration noted to her upper lip. Resident unable to give clear account for injury to nose but does deny any altercation. PEERLA, ROM WNL x 4 without difficulty. Temperature 97.0, Heart rate 78, Respiration rate 20, Blood pressure 128/74, pain 2/10 to upper lip. DON contacted NP that resident had been found-no new orders received at this time, NP plans to see resident in the morning. Abrasion to nose cleansed with wound cleanser and antibiotic ointment applied. Q 1hour vital signs per standing orders. An investigation report was opened.- Signed by S2DON. 02/13/2023 at 2:22 p.m.- LATE ENTRY-According to S6LPN: On 02/12/2023, resident was escorted off the Secure Unit to watch the Mardi Gras parade after lunch. Then while passing medications between 4:15 p.m.-4:30 p.m., she did not see resident in Secure Unit. S6LPN states that when she asked the CNAs where the resident was, she was told in the beauty shop getting her hair done. S6LPN reports that she then moved on to the next resident with intent to administer this resident's medication upon her arrival back to the Secure Unit. After completing her 4:00 p.m. medication pass, S6LPN states she realized she had not given resident her medication yet, so she walked to the beauty shop noting it was closed. S6LPN states she then walked into the main dining area of the facility to look for resident. She reports at that time, the staff began a room search of the facility and notified Administration around 7 p.m. after completing the room search and deeming the resident missing. Signed by S2DON. A review of the facility's Incident Report for Resident #47 revealed she went missing after being removed from the Secure Unit and taken outside to watch a Mardi Gras parade on 02/12/2023 by staff. The resident was last seen between 2:00 p.m. and 3:00 p.m. at the facility and was found and brought back to the facility at 10:00 p.m. A review of the facility's video camera footage revealed Resident #47 exited facility with S10CNA on 02/12/2023 at 12:40 p.m. On 02/12/2023 at 2:44 p.m., staff members and residents were seen entering facility from the same door they exited earlier. Resident #47 was not seen entering facility with staff and other residents. S10CNA was seen looking outside after all residents and staff were inside, and then closing the door behind her. On 02/16/2023 at 11:44 a.m., an interview was conducted with S4LPN. She stated she was responsible for resident's elopement risk assessments. She stated the last elopement risk assessment for Resident #47 was completed on 01/31/2023. She stated Resident #47 was a definite risk for elopement, meaning she was at the highest risk for elopement. She stated Resident #47 had not attempted to elope from the facility before the recent incident, however, Resident #47 made comments stating it was time for her to go to work and would stand at the door saying she was waiting on her ride. On 02/16/2023 at 12:14 p.m., an interview was conducted with S6LPN. She stated she was Resident #47's nurse on 02/12/2023. She stated on 02/12/2023, she noticed Resident #47 was not on Unit a during her 4:00 p.m. medication pass. She stated she asked one of the CNAs where Resident #47 was, and she was told Resident #47 was at the beauty shop. She stated she just started working at the facility and did not know all the names of the staff members. She stated she did not know who told her Resident #47 was at the beauty shop. S6LPN stated she was going to finish her medication pass then go back and give Resident #47 her medications. S6LPN stated she sat down at 7:00 p.m. to document, and she remembered Resident #47 had not received her medications. She stated she checked Resident #47's room and she was not there; then she went to the beauty shop and the beauty shop was closed. She stated she and other staff began to search the facility for Resident #47 and she notified administration. She stated she did not know who took Resident #47 off of the unit. She stated she heard staff talking about bringing a couple of residents to a parade earlier that day but was never notified by anyone they were taking Resident #47 out of Unit a. She stated she did not know what time the parade was. She stated shift change was at 2:00 p.m. for the CNAs so it had to have been before 2:00 p.m. when Resident #47 was taken off Unit a. She stated she was at the facility when Resident #47 was found. She stated an employee was driving down the street, saw Resident #47 on the road, and returned her to the facility around 10:00 p.m. She stated Resident #47 had a mark on her lip and on the bridge of her nose. She stated if Resident #47 went outside unsupervised, she would not be safe. She stated Resident #47 should have never been left unattended. On 02/16/2023 at 12:42 p.m., an interview was conducted with S11CNA. She stated on 02/12/2023 she worked the 6:00 a.m. to 6:00 p.m. shift. She stated she knew S10CNA took Resident #47 to get her hair done but was unsure if S10CNA took Resident #47 outside. She stated Resident #47 was always at the side door but had never attempted to leave the facility. She stated Resident #47 was first discovered missing by all staff around the same time. She stated Resident #47 could not and should not be outside of the facility on her own. On 02/16/2023 at 1:14 p.m., an interview was conducted with S7LPN. She stated she was working on Unit b on Sunday, 02/12/2023. She stated between 7:05 p.m. and 7:08 p.m. the nurse on Unit a told her she was unable to find Resident #47. She stated staff began to search for Resident #47 and notified S2DON. She stated staff performed a room search and a completed a headcount of all the residents after notifying S1ADM Resident #47 was missing. She stated a staff member who was not on the clock found Resident #47. She stated Resident #47 returned to the facility that night with a scrape to the bridge of her nose. She stated Resident #47 was at risk for elopement and would not be safe outside of the facility by herself. On 02/16/2023 at 1:41 p.m., an interview was conducted with S10CNA. She stated around 1:40 p.m. on 02/12/2023 she took Resident #47 outside for a parade. She stated she was standing by Resident #47 and another resident from Unit a during the parade. She stated she picked these two residents to take outside because they didn't get agitated like other residents on Unit a. She stated the parade lasted for about an hour and there were a lot of people at the parade. She stated after the parade, all of the residents who were by the door went in first. She stated one of the residents was blocking the entrance and she had to move him. She stated she did not pay attention to see if the two residents she took out of Unit a made it back inside, and she did not see Resident #47 walk back inside. She stated she left the facility at 3:50 p.m. assuming Resident #47 was inside, and the facility called her at 7:00 p.m. to notify her Resident #47 was missing. She stated she was responsible for taking Resident #47 out of Unit a and she should have made sure Resident #47 made it back inside safely. She stated Resident #47 could have been hit by a car when she wandered from the facility. She stated she was not at the facility when Resident #47 was found but was told Resident #47 had an abrasion on her nose. On 02/16/2023 at 2:33 p.m., an interview was conducted with S12SocS. She stated she was working on 02/12/2023. She stated she stepped outside between 1:50 p.m. and 2:00 p.m. to watch the parade with the residents and staff members. She stated there were three or four other families out watching the parade by where the residents were at. She stated she did not remember seeing Resident #47 when she walked outside. She stated the intersections had been blocked, so there were people walking around and parade floats passing by. She stated the parade lasted until about 2:50 p.m. and she clocked out and went home. She stated Resident #47 resided on Unit a and would stand by the door and try to put the code in to get out. She stated S2DON called her at 7:29 p.m. on 02/12/2023 to notify her Resident #47 was missing. She stated she stopped and prayed that no one would pick Resident #47 up and she would be found. She stated Resident #47 would not be safe unsupervised outside of the facility. On 02/17/2023 at 8:45 a.m., an interview was conducted with S2DON. She stated on 02/12/2023 around 7:15 p.m. S7LPN called her and stated Resident #47 was missing. She stated S7LPN told her they immediately began to search all rooms. S2DON stated she called S1ADM. S2DON stated she got to the facility and unlocked all of the locked offices to check for Resident #47. She stated staff performed a headcount of the residents to make sure everyone else was accounted for. She stated S1ADM called local hospitals and the police department to give them Resident #47's information. She stated she got in her car and drove around the facility to see if she could find Resident #47. She stated she did not find Resident #47 and went back to the facility. She stated S1ADM got a call back from the police department and they stated they had picked up Resident #47 and taken her to a local hospital earlier that day. She stated a staff member went to the hospital and Resident #47 was no longer there. She stated Resident #47 did not require medical attention, the hospital assumed she was homeless, and they released her. S2DON stated an off duty CNA heard Resident #47 was missing, drove around looking for her, and was able to locate Resident #47 at an intersection down the road from the facility. S2DON stated Resident #47's lip was swollen and she had an abrasion on the bridge of her nose. S2DON stated residents on the locked units had never been approved to leave a locked unit for activities. S2DON confirmed Resident #47 should not have been taken outside of the facility. S2DON confirmed since S10CNA took Resident #47 off Unit a, she should have made sure Resident #47 made it safely back on Unit a. On 02/17/2023 at 9:12 a.m., an interview was conducted with S1ADM. He stated around 7:15 p.m. on 02/12/2023 he received a call from S2DON stating Resident #47 was missing. He stated a search of rooms had already been initiated. He stated he called the local hospitals and filed a missing person report with the police department. He stated the police department called him and stated they had taken someone with a similar description to one of the local hospitals earlier that day. He stated the hospital said Resident #47 was no longer there. He stated Resident #47 was found by an off duty CNA around 9:30 p.m. on a local highway. He stated the nurse should have noticed Resident #47 was not on Unit a earlier than she did. He stated Resident #47 was a dementia patient and should not have been taken off Unit a. He confirmed since S10CNA took Resident #47 off of Unit a, she should have made sure Resident #47 made it back to Unit a.