**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, pictures captured of video footage, record review, and staff, family member, resident, and Medical Director interviews, the facility failed to ensure the necessary supervision was provided to prevent a cognitively impaired resident who was care planned as having a history of attempting to leave the facility, had impaired safety awareness, and hearing loss and aphasia (a language disorder that affects a person's ability to communicate) from exiting the building without staff knowledge. On Saturday 09/06/25, Resident #1 entered a conference room area where the inside entrance doors had been propped open by the Dietary Manger. The Dietary Manger then went to the kitchen and the left the conference room area unattended. Resident #1 entered the conference room area and exited the facility through a wanderguard alarmed door at 1:45 PM. The wanderguard alarm system did not alarm or sound, which allowed Resident #1 to exit the facility without staff knowledge. Resident #1 walked down the main road to the facility and passed a security gate at 1:54 PM. He was found lying on the sidewalk near a very busy intersection of Park Road and Park South Drive that was a 4-lane highway with a posted speed limit of 35 miles per hour by a bystander at 2:02 PM who notified police. Resident #1 was transported to the hospital and assessed to have a contusion of the face and skin tear of the right hand. This deficient practice had a high likelihood of causing serious harm or serious bodily injury to Resident #1 including serious head injury, fractures, or internal injuries. The deficient practice affected 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Immediate jeopardy began on 09/06/25 when Resident #1 exited the facility unsupervised and without staff knowledge. Immediate jeopardy was removed on 09/12/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective and education is completed.Findings included: An interview was conducted with Family Member #1 on 09/22/25 at 1:10 PM. Family Member #1 stated that Resident #1 had memory issues and could not take care of himself. She stated when she visited Resident #1 in his independent living apartment prior to admission on [DATE], she would find burned pans and burned coffee machine, and he could not make food for himself. One time he went to the dining room and could not remember how to get back to his apartment. An interview with Family Member #1 on 09/10/25 at 3:01 PM revealed Resident #1 had previously lived on campus in an independent living setting; however the resident was becoming more forgetful such as leaving his coffee pot on during the day. Family Member #1 stated she did not feel comfortable with him living alone so the family decided to place him in a more assisted environment. Resident #1 was admitted to the facility on [DATE] from his independent living apartment on the same campus with diagnoses of aphasia, atrial fibrillation, hearing loss and mild cognitive impairment.Review of Clinical admission dated 07/21/25 at 12:50 PM revealed that Resident #1 wore hearing aids and indicated his level of cognitive impairment was mild impairment (some confusion) and was alert and oriented x 3 (fully aware of person, place and time), communicated verbally, speech is clear, is able to understand and be understood when speaking. The clinical admission was completed by Nurse #4. An Elopement Evaluation dated 07/21/25 at 1:07 PM revealed that Resident #1 had a history of elopement or attempted leaving the facility without informing staff, verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door, wandered, and had been recently admitted or readmitted . The evaluation gave him a score of 3 and any score 1 or higher indicated risk of elopement. The evaluation was completed by Nurse #4. Nurse #4 was interviewed via telephone on 09/23/25 at 10:10 AM and confirmed that she has completed the admission assessment and elopement evaluation risk assessment for Resident #1 on 07/21/25. Nurse #4 stated that Resident #1 used to live in the independent apartments on campus and would come daily to visit his spouse who lived on the skilled unit. Nurse #4 stated that she had seen a decline with Resident #1 during his visits with his spouse prior to his admission on [DATE]. Nurse #4 stated that Resident #1 even prior to admission on [DATE] while living in the independent living had a sitter and one day as the sitter was leaving she noted Resident #1 walking towards the health center where his spouse resided and called the family, the family then called the health center and asked the staff to make sure he got home safely because the family was worried he would wander off. Nurse #4 stated that during the admission process Resident #1 did not understand that he was going to be moving into the unit, but he was essentially non-verbal so knowing for sure what he understood and did not understand was very difficult. She explained that she completed the elopement evaluation, and he was at risk and so a wanderguard bracelet (bracelet that causes the door to alarm if a resident exits a door that was equipped with wanderguard alarm sensor) was placed on his wrist like a watch in hopes that he would be compliant with it and was also placed on every 2-hour checks. Nurse #4 explained that when Resident #4 admitted on [DATE] he was placed in a room very near a door but soon after admission they swapped rooms with his spouse and Resident #1 was moved closer to the nurse's station and further away from the exit door. Nurse #4 stated that on the day of admission Resident #1 had intermittent confusion and at times would nod his head appropriately to questions and directions and at other times he had no response to questions and directions, and you could tell by the blank expression on his face that he did not understand what was being said to him. Nurse #4 added that Resident #1 attempted to exit any door he could find but did seem to focus on the main door of the facility and did not ever indicate where he wanted to go. Nurse #4 stated that the elopement risk assessment was a set of questions on the computer that she answered and generated a score, she could not recall what the questions were or if they were specific to his cognition or not as she did not have the assessment in front of her.An Elopement Evaluation dated 07/21/25 at 7:15 PM revealed that Resident #1 had a history of elopement or attempted leaving the facility without informing staff, had verbally expressed the desire to go home or packed belongings to go home or stayed near an exit door, wandered, goal directed wandered, and was recently admitted or readmitted . The risk assessment score was a 5 and any score 1 or higher indicated risk of elopement. The evaluation was completed by Nurse #5. Nurse #5 was interviewed via telephone on 09/23/25 at 10:32 AM and confirmed that he had completed the elopement risk evaluation on 07/21/25 at 7:15 PM. Nurse #5 stated that on the day Resident #1's admission [DATE] was the first time he had met the resident. Nurse #5 stated he was not familiar with Resident #1 or his baseline at that time; however, the staff reported to him that even prior to admission Resident #1 was at risk of elopement and that he often wandered off and staff had to watch him closely. Nurse #5 could not recall who had informed him of this, but he was aware on 07/21/25 that Resident #1 was an elopement risk. After reviewing the progress notes from 07/21/25 he recalled completing the elopement risk evaluation because Resident #1 continued to try to exit the facility from any door he could find and was constantly being redirected by staff. Nurse #5 stated that Resident #1 had no intelligible conversation that day to indicate where he wanted to go but continued to try and exit the door and required frequent redirection from staff. Nurse #5 again stated he was not familiar with Resident #1's baseline so it was difficult to ascertain if his confusion was acute due to the move or if this was his baseline. Nurse #5 again stated he did have an understanding that Resident #1 was a flight risk and a wanderguard bracelet had been initiated as well every 2-hour checks.A nursing progress note dated 07/21/25 at 4:04 PM written by Nurse #2 revealed Resident #1 attempted to exit the building however his wanderguard device alarmed the front door and he was easily redirected back to his room. Resident #1 was placed on every 2-hour safety monitoring.A Social Services note dated 07/21/25 at 7:59 PM written by the Social Worker revealed Resident #1 was observed walking outside of the building through the front doors despite the wanderguard alarm going off at the door. Resident #1 pushed through the emergency exit and stepped onto the sidewalk outside of the front door. A nurse and security guard met the resident, and it took a duration of 20 minutes to get Resident #1 to agree to reenter the facility.A Social Services note dated 07/22/25 at 12:41 PM revealed the Social Worker and Administrator spoke with the Medical Director in regard to Resident #1's adjustment to admission into the facility. The Medical Director recommended a room move to the facility's locked unit based on him being an elopement risk and independently ambulatory.On 09/10/25 at 1:00 PM an interview was conducted with the Social Worker. During the interview she stated Resident #1 was admitted as a long-term care resident at the end of July 2025 and had a hard time adjusting. She stated on 07/21/25, the same day he was admitted , Resident #1 pushed through the front door entrance and security had to assist him back into the building. She stated he was just confused as to why he couldn't go back to his independent living apartment that he previously lived in. He would become frustrated with himself and others not being able to clearly understand him. The Social Worker explained she had spoken with his Family Members on the day of admission [DATE]) and the day after (07/22/25) about his attempts of elopement and the possibility of placing him on the locked memory care unit. She stated the Family Members did not want him on the locked memory care unit and offered to hire a private sitter to sit with the resident with hopes to minimize Resident #1's exit seeking behavior. She stated it was successful for some time however the Family Members knew if the exit seeking behavior continued, he would need to be placed in a secure area.A Social Services note dated 07/22/25 at 2:35 PM written by the Social Worker revealed the Social Worker, Assistant Director of Nursing (ADON), and Administrator observed Resident #1 attempting to exit the facility through the front door. He was able to be redirected but while walking down the hallway he was noted to aggressively shake his cane in the ADON's face. Family Members of Resident #1 arrived during the episode and agreed to provide a private sitter for one-on-one supervision beginning overnight.A nursing progress note dated 07/25/25 at 8:41 PM written by Nurse #2 revealed Resident #1 had walked out of the front door of the facility and was standing outside of the building with two staff members. The note revealed Resident #1 had manipulated the door to be able to exit the building despite having a wanderguard bracelet in place on the right wrist. He was redirected back into the building without incident.A current care plan initiated on 07/25/25 revealed a focus area for Resident #1 as an elopement risk/wanderer related to disorientation to place, history of attempts to leave the facility unattended, and impaired safety awareness. The goal was for Resident #1's safety to be maintained through the next review date. Interventions included engaging the resident in purposeful activity, identifying the pattern of wandering, increased supervision of a one-on-one sitter and a wanderguard bracelet to the resident's right wrist.Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired and was independent for ambulation, sit to stand transfers and chair to bed transfers. Wandering behavior was exhibited 4 to 6 days during the assessment reference period. Resident #1 used a cane as an assistive device and had no functional impairments with range of motion to the upper or lower extremities. He did not receive an anticoagulant during the assessment period. Resident #1 used a wander/elopement alarm daily. An elopement assessment dated [DATE] revealed Resident #1 to be a level 5 (high risk of elopement). Resident #1 was noted to have verbally expressed the desire to go home, wandered in the facility, had a pattern of wandering behavior and a history of elopement in the facility.A physician order dated 07/30/25 revealed Resident #1 had a wanderguard. Nursing staff were to check placement of the bracelet to right wrist every shift and monitor the wanderguard each shift.A nursing note dated 07/30/25 at 10:11 AM written by Nurse #2 revealed Resident#1 had cut off his wanderguard bracelet and had attempted to elope through the front door. He was redirected back to his room and a new wanderguard bracelet was placed on his right wrist.On 09/10/25 at 1:25 PM an interview was conducted with Nurse #2. During the interview he stated he had written the nursing progress notes dated 07/25/25 and 07/30/25 when Resident #1 had attempted to elope from the facility. The interview revealed Resident #1 was previously in the independent living housing on the facility campus and would come into the facility to visit his spouse. Nurse #2 indicated the resident was used to coming and going freely from the building and had a difficult time adjusting when he was admitted to the facility in July 2025 due to a decline in health. Nurse #2 explained each time Resident #1 went through the front door he was redirected back into the building accompanied by a staff member and was never outside of the building alone prior to 09/06/25. Nurse #2 stated the resident always attempted to walk out the front entrance of the facility during his shift and he had never seen him at the conference room door. Nurse #2 stated Resident #1 became frustrated with not being able to exit the facility and at one point obtained scissors in his room from an unknown source and cut off his wanderguard bracelet. The wanderguard bracelet was immediately replaced.A communication note dated 08/05/25 at 8:41 AM written by the Social Worker revealed the Administrator, Director of Nursing (DON) and Social Worker spoke with Resident #1's Family Member to discuss room placement. The interdisciplinary team recommended relocating the resident to a room closer to the nurses' station due to increased wandering behaviors and the resident's current room being in close proximity to an exit door. The Family member agreed to the relocation.A nursing progress note dated 08/07/25 at 7:38 PM written by Nurse #3 revealed Resident #1 was seen attempting to go out of the back door of the unit. The nurse quickly went and redirected the resident to his assigned room. Resident #1 had pushed onto the exit door until it alarmed.On 09/10/25 at 1:00 PM an interview was conducted with Nurse #3. During the interview she stated on 08/07/25 Resident #1 had gone through the back door of the dining area exiting into a courtyard area. She stated he would often be observed pushing on the exit doors until they would alarm. Nurse #3 stated the behavior slowed down when the private sitter was with him starting the day after he arrived on the unit (07/22/25) during first shift but on the other shifts he had to be closely monitored.A nursing progress note dated 08/11/25 at 9:04 AM revealed at approximately 8:30 AM Resident #1 was observed by the Administrator, ADON and Receptionist exiting the front door while pushing his spouse in a wheelchair. Staff made several verbal redirection attempts; however, the resident declined to return inside. A Nurse Aide (NA) accompanied Resident #1 for safety until he re-entered the building. The residents' wanderguard bracelet was confirmed to be in place.Review of Resident #1's Medication Administration Record dated September 2025 revealed an order for staff to check placement of the bracelet to right wrist every shift and monitor the wanderguard each shift. The order was initialed as completed on each shift by the nursing staff.A nursing note dated 09/06/25 at 1:02 PM written by Nurse #1 revealed Resident #1 was in his room with a private sitter.A nursing progress note dated 09/06/25 at 2:25 PM written by Nurse #1 revealed she was notified Resident #1 had been found on the road outside of the facility campus and was taken to the hospital for an evaluation.A nursing progress note dated 09/06/25 at 2:35 PM written by Nurse #1 revealed Resident #1's medical information was provided to Emergency Medical Services (EMS) with a police officer present at the facility. EMS stated Resident #1 was found at the corner of a busy intersection and sustained some lacerations and was immediately sent to the hospital for an evaluation. EMS provided pictures and Resident #1 was noted with a wanderguard bracelet on.An incident report dated 09/06/25 at 2:25 PM completed by Nurse #1 revealed the nurse was notified Resident #1 was found on the road outside of the facility campus and was immediately taken to the hospital for an evaluation. EMS/Police were noted to be on the unit and provided with Resident #1's medical information. EMS provided the nurse with a picture of Resident #1; it was noted he had a wanderguard on and appeared to have a laceration to his right cheek. Injuries noted on the incident report included laceration to left hand, laceration to right knee, laceration to left knee and laceration to face. Resident #1 was documented to be confused with impaired memory and an active exit seeker.On 09/11/25 at 9:32 AM the surveyor was able to speak with a representative from the Police Department who stated a police officer had responded to the incident on 09/06/25 at 2:02 PM however a formal police report had not been filed because the resident was sent to the hospital by EMS. The incident had been filed in the miscellaneous system, and no formal report could be obtained regarding the incident. The surveyor left contact information for the responding policer officer, but no additional communication was received.On 09/10/25 at 11:45 AM an interview was conducted with Nurse #1. During the interview she stated she was working on Resident #1's unit for the 7:00 AM to 3:00 PM shift on 09/06/25. She stated around 2:25 PM she had received a call from the security office that Resident #1 was found on the main intersection outside of the campus and was taken to the hospital for an evaluation. Nurse #1 confirmed she did not know Resident #1 was missing until she received the phone call, she thought he was asleep in his room. Nurse #1 stated she had last seen Resident #1 at 1:00 PM with his private sitter and at 1:15 PM the private sitter had stopped her in the hallway and stated she was leaving for the day. She stated she had not observed any exit seeking behaviors on that day however on previous shifts he had attempted to elope from the front entrance of the facility and the wanderguard system alarmed. Nurse #1 stated she had seen the double doors to the conference room open that morning, leading to the door Resident #1 was able to exit through but that the Dietary Manager was in her office, so she did not think anything about it. Nurse #1 explained when the incident happened the Dietary Manager was in the kitchen and did not see Resident #1.On 09/10/25 at 10:08 AM an interview was conducted with Nurse Aide (NA) #1. During the interview NA #1 stated she worked in the facility as the Medical Record's staff member, however had picked up an extra shift on 09/06/25 and was responsible for Resident #1 during the 7:00 AM to 3:00 PM shift. The interview revealed Resident #1 had a private sitter that arrived at the facility shortly after breakfast and remained with the resident until around 1:45 PM. NA #1 stated Resident #1's private sitter came into the dining room and stated she was leaving for the day, and Resident #1 was asleep in his room. NA #1 stated approximately 5 minutes later NA #2 entered the dining room returning from her meal break and stated to NA #1 she could now take her meal break. NA #1 did not recall telling NA #2 Resident#1's private sitter had left the facility for the day prior to clocking off shift for her meal break. She stated she went into the facility break room to warm up her food and eat. Around 2:25 PM Nurse #1 entered the break room and told her Resident #1 was found off campus and sent to the hospital. NA #1 stated she immediately went onto the unit to see what was happening. When she got to the nurses' station, she saw EMS and Police in the hallway. The police officer had a picture of Resident #1 sitting in a wheelchair with a laceration on his face and his wanderguard bracelet on his right wrist. NA #1 stated at that point she left the conversation and returned to caring for her assigned residents. She stated Resident #1's room was on the ground level floor and the side door which he exited the facility through was directly down the hall from his room. NA #1 stated, it would have taken him less than 5 minutes to get there. Resident #1 was independent with walking and transfers. She stated he had not shown any signs of exit seeking or wandering that morning because he had a private sitter with him. NA #1 stated the facility was completing every 2-hour rounding on Resident #1 and the last time she saw him was around 1:15 PM. The interview revealed the staff typically did not communicate when Resident #1's private sitter arrived at the facility or left because the resident was on every 2-hour monitoring regardless of her presence.On 09/11/25 at 10:26 AM an interview was conducted with NA #2. During the interview she stated she was working on the adjoining hallway Resident #1 resided on 09/06/25 during the 7:00 AM to 3:00 PM shift. She stated she had just returned from her meal break around 1:45 PM and told NA #1 she would watch her residents. NA #2 stated NA #1 did not tell her Resident #1's private sitter had left for the day but told her Resident #1 was asleep in his room. NA #2 stated she passed by Resident #1's room at 2:00 PM and his door was halfway closed; she could not see inside of the door but that was not unusual because his door was typically closed. NA #2 stated she did not go inside of the room to check on him because his next 2 hour rounding time would have been 3:00 PM and she thought he was asleep. NA #2 stated the last time she physically saw him was around 12:50 PM he was sitting in the dining room with his private sitter. She stated around 2:20 PM she was in the hallway completing rounding when Nurse #1 came to her and stated Resident #1 was found outside of the facility. She stated she was shocked because most of the time the doors to the conference room were locked on the weekends and she had never seen Resident #1 attempt to exit the facility through those doors. She stated he was alert at times but had confusion and was used to coming/going freely in the facility because he was once in the independent living section and would come to the unit to visit his spouse and leave.The surveyor reviewed pictures captured video footage of the incident with the DON on 09/10/25 at 11:40 AM. The pictures of the video footage revealed Resident #1 dressed in a light blue polo shirt, tan shorts and tennis shoes exiting the conference room door at 1:45 PM. A second view showed Resident #1 walking up the sidewalk without difficulty passing the security guard gate at 1:54 PM.An observation and interview were conducted on 09/10/25 at 10:29 AM with NA#1. The observation started at Resident #1's room that was observed to be directly down the hall from a set of double doors leading to a conference room with an exit door. The double doors were noted to be unlocked during the observation with two offices located inside of the room for the Dietary Manager and Business Office Manager who was noted to be in his office at the time of the observation. The exit door was observed to be unlocked from the inside, with a wanderguard alarm system device noted to the left side of the door mounted onto the wall with a keycode. NA #1 explained that anyone could get out of the exit door from the inside unless they had a wanderguard bracelet on, then the door would alarm, otherwise the door would not alarm. She stated from the outside the door required a badge to get inside of the building. NA #1 and the Surveyor exited the unlocked door, no alarm sounded. Once outside of the door there was a straight sidewalk approximately 50 feet from the door to the main road entrance of the facility. The sidewalk made an L shape back to the left and lead directly to the road leading out of the facility past the guard gate. NA #1 stated the road leading from the door was the main entrance to the facility parking lot. Resident #1 was found 870 feet from the facility on the sidewalk of Park South Drive. On 09/10/25 at 3:18 PM an observation of the conference room exit door and interview were conducted with the Director of Nursing and Facility Maintenance Director. A total of 3 wanderguard bracelets (one new out of the pack) were tested with the alarm system and none of the three devices triggered the system to alarm. The Facility Maintenance Director stated the wanderguard alarm system was malfunctioning and needed to be repaired for a second time. He stated his expectation was for the door to alarm if the wanderguard device entered the conference room. The functionality of the front entrance door was also checked and alarmed accordingly with the wanderguard device. The interview revealed the door systems were monitored at least on a weekly basis prior to the incident, however, since the incident they were monitored on a daily basis.EMS records dated 09/06/25 revealed medics arrived at the intersection at 2:17 PM to observe Resident #1 sitting down on the curb. He was located a short distance from the facility and had been walking around as if lost prompting a bystander to call 911 emergency services. Resident #1 had abrasions to his right cheek, left hand, and right knee. The resident could answer some questions such as his name but would/could not answer most other questions. Resident #1 was placed in a c-collar (medical device that supports the neck) due to possible head injury and age. He was transported to the hospital by EMS services at 2:33 PM.On 09/10/25 at 2:53 PM attempts to speak the EMS medic were unsuccessful.Hospital records dated 09/06/25 at 7:14 PM revealed Resident #1 had experienced an unwitnessed fall after being found 0.25 miles from the facility in which he resided with lacerations to his right check, left hand and right knee. The hospital note revealed a staff member was with Resident #1 who stated the resident had a monitor on that triggered the alarm systems when he attempted to leave the facility but unfortunately it was a system failure and Resident #1 managed to leave the facility. He was found by a bystander outside near the facility after an apparent fall. Resident #1 was noted to be acting at his baseline and did not appear in pain. The residents' vital signs were the following: blood pressure 193/106 (normal range 120/80), pulse 97 (normal range 60-100), oxygen saturation level 99% (normal range greater than 92%), temperature 97.9 (normal range 97-99). A computed tomography (CT) scan was completed of Resident #1's head resulting in no intracranial bleed or skull fracture. The after-visit summary diagnoses included contusion of the face, skin tear of the right hand, abrasion to right knee, fall from ground level and severe dementia without behavioral disturbance. Resident #1 was discharged from the hospital in stable condition.Resident #1 returned to the facility on [DATE] at 8:00 PM and was placed on the locked memory care unit.On 09/10/25 at 1:14 PM an interview was conducted with the facility security guard. During the interview he stated he was working on 09/06/25 but did not see Resident #1 walk by the security guard stand or through the gate. He explained that community members often walk on the sidewalk, and he would not have recognized Resident #1, or that the resident would have stood out. He explained the police arrived at the facility with a picture of the resident and asked if he resided on the campus. The interview revealed it was confirmed he was a resident at the facility, and the officer and Emergency Medical Services was directed to the facility for further assistance.On 09/11/25 at 10:10 AM an observation and interview were conducted with Resident #1. Resident #1 was observed on the facility's locked memory care unit sitting in a recliner chair. During the interview he stated he did recall leaving the facility and having a fall but could not recall the details of the incident. Resident #1 was observed to nod his head yes in response to questions with a delay in communication answering questions in a low tone whisper. Resident #1 pointed to his right check when asked if he had a fall but was difficult to understand. He was observed following direction from staff and standing/ambulating with his walker.On 09/10/25 at 3:01 PM an interview was conducted with Family Member #1 and Family Member #2. During the interview they stated the facility had contacted them regarding the incident on 09/06/25. The interview revealed that the facility had discussed issues with Resident #1 attempting to elope from the facility with them since admission on [DATE] and they hired a private sitter to sit with him originally on 07/22/25 during the night and day. Family Member #1 stated on 09/01/25 the family gradually started to reduce the time frame to 4 hours a day. Family Member #1 stated the facility wanted to move Resident #1 to the locked memory care unit on 07/22/25 and she strongly protested it because she wanted him near his spouse who was also located on the unit. Resident #1 was very strong-willed and was confused as to why he could not leave the facility as he typically did prior to admission to the facility. The Family Members explained they did not have contact information for the private sitter and stated they would attempt to gain the information and let the surveyor know. The interview revealed Resident #1 had previously lived on campus in an independent living setting, however the resident was becoming more forgetful such as leaving his coffee pot on during the day. Family Member #1 stated she did not feel comfortable with him living alone so the family decided to place him in a more assisted environment. On 09/10/25 at 11:41 AM an interview was conducted with the Assistant Director of Nursing (ADON). During the interview she stated on 09/06/25 Nurse #1 notified her Resident #1 had gone out of the conference room door and they were notified by the Police Department that he was on the main road outside of the facility campus. She stated Resident #1 was alert, he had an abrasion to his right cheek and hand and was sent to the hospital for an evaluation. The DON accompanied him to the hospital while she went to the facility to assist staff members. The ADON explained typically on weekends the double doors leading to the conference room were locked, however the Dietary Manager had come in that morning and unlocked the doors. The Dietary Manager was in the kitchen at the time of the incident and did not see the resident walk by and go out of the door. The interview revealed Resident #1 had several attempts to exit the facility prior to 09/06/25 and he was placed on every 2-hour monitoring, and the facility had discussed the incident at length with the Family members.On 09/10/25 at 9:45 AM an interview was conducted with the Director of Nursing (DON). The DON stated Resident #1 was previously in the independent living housing on the campus however due to a decline in cognition, he was moved into the skilled nursing home for increased supervision. The DON shared for exam