**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff, physician, family and law enforcement interviews, the facility failed to supervise a severely cognitively impaired resident from exiting the facility without supervision. On 08/05/25 at approximately 8:30 pm Resident #1 followed Dietary Aide #1 out of the employee exit door and exited the facility. Resident #1 did have a wanderguard bracelet (component of a wander management system) on his left ankle; however, the door Resident #1 exited did not have a transmitter sensor and the magnetic lock was released when Dietary Aide #1 entered a code on the door keypad. Dietary Aide #1 believed Resident #1 to be a visitor (because he was wearing street clothes, had a hat on, and was walking unassisted) and had directed him to exit through the front door and did not realize Resident #1 had followed him out the door until he saw him walking outside the building toward the front as he was driving away. On 08/05/25 Resident #1 was located by local law enforcement at 10:37 pm (approximately 1.0 mile away from the facility.) He was found lying in the road on a five-lane main street where the I-40 interstate east and west on and off ramps are located at the intersection of [NAME] Road and [NAME] Street. When law enforcement arrived, a bystander was trying to help Resident #1 get out of the street. It appeared to law enforcement that Resident #1 had fallen over the median and was lying face down on the pavement in the middle of the busy road. It was raining and he was shaking, cold, and wet. He was returned to the facility by the Director of Nursing and Medication Aide #1 in Medication Aide #1's private vehicle. Emergency Medical Services (EMS) personnel assessed Resident #1 at 11:41 pm on 08/05/25 at the facility. Resident #1's mental status was oriented to person only and EMS presumed Resident #1 had fallen. EMS left the resident with his family to transport him to the hospital at the family's request. The family took him directly to a regional hospital where he was diagnosed with a left 1 cm (centimeter) subdural hematoma (brain bleed), a right 7 mm (millimeter) subdural hematoma (brain bleed), a 3 mm midline shift of the ventricle (when the brain moves past it's center line) due to the subdural hematoma (brain bleed), a right maxillary sinus fracture (beside the nose/beneath the eye), a right orbit fracture (bone around the eye), and a right zygomatic arch fracture (cheek). He was transferred to a higher-level trauma hospital for treatment. The Trauma Medical Center Physician stated Resident #1 had been transferred to their trauma unit from an affiliated regional medical center because the size of his brain bleed was too large for the other hospital to manage in accordance with their hospital protocol and the injuries Resident #1 presented with were life threatening. This was for 1 of 3 residents reviewed for accidents (Resident #1). Findings included:A history and physical assessment completed by Physician #1 on 05/28/25 for Resident #1 (when Resident #1 was previously admitted to the facility for a 5-day respite stay) was reviewed. Resident #1 was assessed to have severe chronic dementia. He required assistance with bathing and was continent of bowel and bladder. He was without untoward behaviors or overt agitation. He had a subtle anxious affect, with a tendency toward wandering.Resident #1 was admitted to the facility on [DATE] for respite care (temporary institutional care of a sick, elderly, or disabled person, providing relief for their usual caregiver). He entered the facility from home. Diagnoses included Alzheimer's disease, low back pain, chronic kidney disease stage 1, Type 2 Diabetes Mellitus, major depressive disorder, hypothyroidism, and essential hypertension.A Nursing Admission/Re-entry Evaluation assessment completed by Nurse #2 on 08/04/25 was reviewed. Resident #1 needed setup or clean-up assistance with dressing and personal hygiene. He needed moderate assistance with showering. He was independent with eating. He was independent with mobility, transferring, and ambulation. He did not use any assistive devices for mobility. He could communicate with some difficulty. He wore glasses. He had no falls within the past 30 days of admission. He had a serious intellectual mental health diagnosis. His admission to the facility was for short-term placement.A Wandering Risk Evaluation completed by Nurse #2 on 08/04/25 was reviewed. Nurse #2 documented Resident #1 had no known history of attempts to leave home or facility or wander. His mood and behavior was complacent. He was ambulatory and/or self-mobile. He had a diagnosis of Alzheimer's dementia or severe cognitive impairment. He never or rarely made decisions. He rarely/never understood or was understood when communicating. He made verbal statements of a desire or intent to leave the facility. Resident #1 scored 13 on the assessment (a resident who scores greater than 5 is at risk for wandering.) A progress note written on 08/04/25 at 4:25 pm documented Resident #1 arrived at the facility on 08/04/25 at 12:00 noon from PACE (a program of all-inclusive care for the elderly) for Respite Care accompanied by family. He had a wanderguard on his left leg. Resident #1 was a participant in the PACE of the Triad program under the primary care of the PACE physician. In an interview with the Pace Program Physician on 08/11/25 at 9:49 am she stated Resident #1 had been a participant in the Pace program since 05/01/25. She explained he wandered and was often agitated. She stated he was not okay to be outside by himself. She noted PACE staff often calmed Resident #1 down by singing hymns to him. She reported that he acted out in non-violent ways and was resistant to care.Review of a skin assessment dated [DATE] at 6:07 pm by the Treatment Nurse was reviewed. Resident #1 had no abrasions or cuts on his body on admission.A progress note written on 08/04/25 Nurse #1 at 11:35 pm documented, in part, that on admission Resident #1's skin was dry and warm to touch with no lesions noted, that he was ambulatory, wandered around and needed frequent redirection.Review of the care plan for Resident #1 initiated on 08/04/25 revealed the following focus areas: Wandering and or at risk for unsupervised exits from facility related to cognitive impairment and at risk for falls characterized by a history of falls/actual falls, injury and multiple risk factors. The goals were: 1) The whereabouts will be known to staff as demonstrated by no events of leaving the facility unsupervised, 2) Will have no episodes of unsupervised exits from the facility, and 3) The resident will remain free of injury as evidenced by no falls or accidents through the next review. Interventions included to place familiar objects in resident surroundings, Wanderguard alarm bracelet to the resident's left ankle, have commonly used articles within easy reach, and keep the call light within reach and answer timely.The following physician orders were reviewed: WANDERGUARD-Verify location and expiration every day and night shift for Safety (start date 08/05/25); and Check Wander Device Transmitter to ensure proper functioning every day and night shift for Safety/Monitoring (start date 08/05/25).A telephone interview was conducted with Nurse Aide #1on 08/12/25 at 10:29 pm. She stated she had cared for Resident #1 on 08/04/25 and 08/05/25 on day shift. She recalled on 08/04/25 he had been looking for his mama and asked her where she was. She told him that his mama wasn't there. She remembered she had seen him walking up and down the hall several times but had not seen him pushing on any exit doors.An interview was conducted with Medication Aide #2 on 08/12/25 at 10:16 am. She started her shift at 5:00 pm on 08/05/25. She recalled Resident #1 was sitting in a chair on the 400 hall and did not appear to be upset and he was calm. He was still sitting in the chair when the dinner carts came to the hall at approximately 5:30 pm. She stated at approximately 6:30 pm she saw Resident #1 walking up and down the 300 and 400 halls. Medication Aide #2 recalled when she was providing care to another resident, Resident #1 approached her and asked her where the door was to get out. She stated she told him, No, and directed him to his room, but he replied, I already paid my money and I'm going to see my mother and father and he walked away.In a telephone interview with Nurse Aide #1 on 08/12/25 at 10:29 pm she stated on 08/05/25 Resident #1 ate his meals in the hallway because he did not want to be in his room. She noted that he had refused to allow her to take him to the bathroom during her shift.A telephone interview was conducted with Nurse Aide #3 on 08/12/25 at 11:25 am. She stated she worked at the facility through an agency. She reported that she had arrived at work around 3:00 pm on 08/05/25. She observed Resident #1 walking around the facility and wandering in and out of rooms. She recalled he would swing his arms at staff who approached him. He was difficult to redirect and continued wandering in and out of rooms and hallways during the shift. Around 6:30 pm she helped pass out meal trays on the hall. At that time Resident #1 was wandering in the hallway. She had attempted to redirect him to his room for his meal, but he refused. She recalled she had taken a break at 7:30 pm. She reported that during her break she had been sitting in her car that was parked in the front of the building, and she did not see any resident leave the building while she was on break.An interview was conducted with the Dietary Aide on 08/12/25 at 9:42 am by telephone. He stated that on the night Resident #1 exited the building without staff knowledge on 08/05/25 he had worked the evening shift in the kitchen. He stated he clocked out at approximately 8:17 pm. He reported that when he approached the first set of double doors that lead to the employee exit door, he noticed a man (Resident #1) behind him. He stated Resident #1 was dressed in street clothes, had a hat on, and was walking unassisted and looked like a visitor, so he told him that visitors exited the building in the front and directed Resident #1 to go to the front and sign out. He noted the man kept saying, I paid my money. My parents are coming to pick me up. He thought Resident #1 had walked away. He stated his ride arrived; he punched in the code for the employee exit door and left the building. He recalled he was almost to the car when he noticed the employee exit door was open and alarming, so he went back to the building and secured the door. He stated he did not see Resident #1 exit the building; however, when he was leaving the parking lot, he had seen Resident #1 outside of the building walking toward the front. He explained he believed Resident #1 to be a visitor who was going to the front of the building to catch a ride, so he did not intervene.An interview was conducted with Medication Aide #1 on 08/12/25 at 9:50 pm by telephone. She stated when she went to give Resident #1 his evening medications on 08/05/25, he was not in his room. She reported it was 8:17 pm when she noticed he was not in his room. She explained she instructed two Nurse Aides to look up and down the 300 and 400 hallways because he did wander. The Nurse Aides could not find him, so the 100 and 200 halls were searched. Medication Aide #1 stated she could not find the resident in the facility. The search exhausted all areas he might have been and when she realized the resident might have exited the building, she notified Nurse #1. She could not remember what time she told Nurse #1 that the resident was missing. She stated Nurse #1 called a Code Orange (missing person) as soon as she told her. Medication Aide #1 concluded she had locked her medication cart and participated in the search but did not find the resident.An interview was conducted with Nurse #1 on 08/12/25 at 1:55 pm by facetime. Stated she was told that Resident #1 could not be located at 8:45 pm by Medication Aide #1 on 08/05/25. She explained she immediately called a code orange (missing person). She stated she had kept notes and written down times regarding the three searches she conducted. She recorded the following times: the first search was at 8:50 pm; the Director of Nursing (DON) was called at 8:55 pm, the second search was at 9:13 pm, and the third search was at 9:20 pm. All searches included inside and outside the facility. She stated at 9:25 pm she got in her personal car to search the surrounding area. She stated she went to the left when she turned out of the parking lot because she thought he would have gone that way because there were more lights, but she couldn't find him. She noted she continued to search for him until the police arrived at the facility. She stated that when the resident returned to the facility she helped the family change his clothes and provided first aide to a laceration on his face and abrasions on both his legs above his knees. She noted that EMS came to the facility and were able to assess the resident. She stated she was never able to perform a head-to-toe assessment on the resident because the family wanted to take him home. She concluded that the last time she interacted with the resident he had been sitting in a chair with his family in the front lobby. During the interview she provided a copy of the notations she had made regarding the times mentioned above along with a screen shot of the phone record that indicated the time she reported to the DON that Resident #1 was missing.In an interview conducted with Medication Aide #2 on 08/12/25 at 10:16 am she recalled sometime around 9:00 pm on 08/05/25 an Agency Nurse Aide approached her and asked if she had seen Resident #1 and stated staff could not find him. She stated she began to look for him and had searched the salon, bathroom, and laundry room but was unable to find him. As she was looking for him another Nurse Aide told her she had seen him on the 300 hall pulling at the exit door, but she did not know the Nurse Aide's name. She explained she went to the 300 hall to search for him. She checked all the doors on the 300 hall, and they were all locked. She stated she had not heard any door alarms sound during her shift. The following written statement made by Nurse Aide #4 on 08/06/25 was reviewed. She had documented, in part, that she witnessed Resident #1 push the exit door handle on the 300 hall at approximately 8:00 pm on 08/05/25. She also documented that she had seen the resident around 8:45 pm. She had told him that the door was locked, and he walked back up the 300 hall towards the nursing station. She wrote that he stated he was looking for his mom and dad. An interview was conducted with Nurse Aide #4 on 8/12/25 at 3:11 pm. She stated that her written statement was not correct. She reported she thought her first interaction with the resident was at 8:00 pm on 08/05/25 but she had heard some other staff member say 8:45 so that's what she documented. She denied she had seen him push the door handle and had only heard him say he wanted to get out to see him mom and dad.In a telephone interview conducted with Nurse Aide #3 on 08/12/25 at 11:25 am she remembered that when she returned to the building after her break on 08/05/25 she was told that Resident #1 was missing. She stated she really wasn't sure what time she returned to the building. She noted she joined in the search for the resident and recalled some staff members used their personal cars to search in surroundings neighborhoods. She stated when she punched out around 11:05 pm the resident had not been found.The law enforcement Incident/Investigation Report was reviewed. The date and time of the report was 08/05/25 at10:37 pm. The location of the incident was 2501 [NAME] Road and [NAME] Street. The victim was Resident #1. A second police officer assisted the responding officer on the scene. The responding law enforcement officer documented: On 08/05/2025 at 2237 (10:37 pm) hours, I responded to [NAME] Rd. and [NAME] St. in reference to a suspicious activity. The investigation is ongoing at this time.A return telephone call from the responding Law Enforcement Officer was received on 08/12/25 at 10:20 pm. He explained he had responded to a call at the location of [NAME] Road and [NAME] Street on 08/05/25 for an incident of simple physical assault. He stated when he arrived a bystander was standing over the resident trying to get him up and out of the street. Two young ladies had pulled over after exiting the I-40 ramp and were yelling aggressively at the bystander who was trying to help Resident #1. He stated when he interviewed the 2 young ladies they told him they thought the bystander was assaulting the resident but had never seen him or anyone hit the resident. The bystander explained to him that he had been walking by with his girlfriend, saw the resident lying in the middle of the road and was trying to help him. The responding Law Enforcement Officer stated the traffic on [NAME] was heavy that night on the 5-lane road. He reiterated that no one was seen beating up the resident. He commented that it was a very busy area and if someone was getting beat up there would have been more than one call to 911. He concluded it appeared that Resident #1 had fallen over the median and was lying face down on the pavement in the middle of the busy road and the bystander was trying to help him get out of the road. The responding Law Enforcement Officer concluded that the investigation was ongoing.Weather conditions reported by customweather.com for the Greensboro area on 08/05/25 documented the outside temperature to be between 66 degrees Fahrenheit at 7:54 pm and 63 degrees Fahrenheit at 10:54 pm. The conditions were mostly cloudy with light rain and fog.A telephone interview was conducted with Nurse Aide #2 on 08/12/25 at 4:39 pm. She stated it was about 10:40 pm on 08/05/25 when she and the DON went in her personal car to pick up Resident #1 from where he had been found by the police. She recalled Resident #1 was shaking because he was cold and wet. She stated that it had been raining that night. When they arrived, she noticed Resident #1 had some blood on his face. She stated she checked to see if his wanderguard bracelet was on and she found it on his left foot. She recalled she talked to Resident #1 while they waited for EMS to arrive, and it calmed him. They were at the intersection of [NAME] Road and [NAME] Street. The resident was rambling on about his mom and dad. He told her, They fought me, but they didn't win. She stated when EMS arrived the resident would not let them assess him. Resident #1 eventually allowed EMS to take his blood pressure and oxygen saturation percentage because she held his arm for them. She stated EMS would not transport the resident because they could only take him to the hospital and the family wanted him returned to the facility, so she and the DON took Resident #1 back to the facility in her personal car.An interview was conducted with the DON on 08/11/25 at 1:26 pm. The Administrator was also present. The DON stated Nurse #1 had called her and reported that staff could not find Resident #1 on 08/05/25. She was told that Resident #1 had been seen 15 to 20 minutes earlier on the top of 400 hall. She stated that she told Nurse #1 to stop everything and look for the resident. She asked Nurse #1 if any doors were alarming, if there were any visitors in the building, and did anyone let anyone out of the front door. She noted she got the first call at 8:55 pm. She explained she then called the Administrator to let him know Resident #1 could not be found. She recalled the Administrator came to the building about 9:15 pm. She started another search high and low. She left the building in her personal car and went up and down the road in her car but did see anything. She recalled the Administrator came and started searching outside about 9:45 pm. Maintenance was called to the building to check the doors. She went back outside and searched the surrounding area to the left of the facility, then the Administrator called her back to the building. She recalled the Administrator had called the police and the family to explain the resident was missing. She stated when the police arrived at the facility, they spoke to her and the Administrator and searched the facility. She heard the police officer get a call that the resident had been found. The DON explained they wanted to be sure the person the police found was Resident #1, so she and Nurse Aide #2 went in Nurse Aide #2's personal car to the corner of [NAME] and [NAME] Street at 10:52 pm. Two officers were present, 2 bystanders were there, along with Resident #1. She put Resident #1 in the back of Nurse Aide #2's car and called the Administrator. She recalled Resident #1 was confused and the police lights were agitating him. The police officers had called EMS before she got there. Resident #1 would not go to the EMS truck, and he wouldn't allow EMS to assess him. She notified the Administrator and explained the resident would not go with EMS. The family had arrived at the facility and requested she come back to the facility with the resident. The family met them at the front door when they returned. The resident was asking for momma and daddy and was confused. The DON recalled he had dirt on his pants and was wet, but it was not raining at the time she picked him up, although it had been raining earlier in the evening. Nurse #1 took Resident #1 to his room, and she suggested to the family that EMS be called, and they agreed. EMS and the provider were called. She noted EMS did arrive and went to the resident's room where Nurse #1 was assessing the resident and providing first aid aide. The Administrator interjected that the family and EMS came to him and reported that the resident did not want to leave with EMS and the family member told the resident that he did not have to be at the facility and that they would take him home. The Administrator explained that the family left the facility with the resident. He noted that the resident had appeared to have fallen because he had dirt on his clothing. Resident #1 was wearing his glasses that did not appear to be damaged. The Administrator stated that the resident was fully dressed when he returned to the facility wearing black sweatpants, dark gray shoes, a black t-shirt, a dark blue zip up jacket and a black hat.An incident report by EMS dated 08/05/25 at 11:05 pm was reviewed. The report documented that the nursing home staff would not let EMS fully assess the patient at the scene of [NAME] Road and [NAME] Street because they wanted him to be taken back to the facility at the family's request.An EMS Incident report dated 08/05/25 at 11:41 pm documented that EMS was called back to the facility to assess the resident. EMS personnel assessed Resident #1 at 11:41 pm on 08/05/25 at the facility. The EMS report documented Resident #1 had a blood pressure of 136/100 millimeters of mercury, a heart rate of 100 beats per minute, a respiratory rate of 18, and an oxygen saturation reading of 96% on room air. He had a right facial cheek laceration approximately 2.5 inches long with controlled bleeding. He had band aids on his knees placed by Nurse #1 during first aid care. Resident #1's mental status was oriented to person only. EMS presumed Resident #1 had fallen and they informed the family of the risks of an intracranial hemorrhage after a fall and the risks of transporting the resident themselves. EMS left the resident with his family to transport him to the hospital at their request and advised the family to call 911 for any changes.In an interview with a family member on 08/11/25 at 4:08 pm she stated the family took Resident #1 straight to the regional hospital after removing him from the facility. The regional hospital then sent him to the trauma center in [NAME]-Salem for treatment of a brain bleed. She stated Resident #1 was doing better but that the hospital was keeping him for a couple extra days in a regular room to keep an eye on the brain bleed to make sure there were no further complications.An interview was conducted with the Maintenance Director on 08/13/25 at 12:30 pm. He stated on the night of 08/05/24 he was called back to the facility to check the doors after Resident #1 had exited the building without staff supervision. He explained that only the front exit was alarmed for the wanderguard system, and all other doors had a keypad. Each door that had a keypad had its own unique key sequence to unlock the door. He stated all doors at the facility including keypads and the front entrance were checked daily and logged in the maintenance electronic computer system.An observation of the employee exit door was made on 08/12/25 at 10:10 am. The door was equipped with a keypad to enter a specifically assigned code for that door. When left ajar, the door did sound a faint alarm. The door was not equipped with a wanderguard alarm.An observation of the routes Resident #1 may have taken was conducted by the survey team by driving both routes on 08/12/25 beginning at 8:15 pm. Whether the resident turned left or right when leaving the facility driveway, the location where he was found by police was measured by driving the routes as 1.0 miles either way. The road where the resident was found (the intersection of [NAME] Road and [NAME] Street) had 5 lanes and was the hub for the on and off ramps for Interstate 40. Traffic was steady during the observation. There were streetlights that came on if the resident had turned right (Creek Ridge) but to the left the street was a dark industrial side road ([NAME] Street). Both routes were observed to be heavily wooded. A 35 mile per hour speed limit sign was observed on [NAME] road where Resident #1 was found.Hospital records dated 08/06/25 at 1:01 am were reviewed. Resident #1 was diagnosed with a left 1 cm (centimeter) subdural hematoma (brain bleed), a right 7 mm (millimeter) subdural hematoma (brain bleed), a 3 mm midline shift of the ventricle (when the brain moves past it's center line) due to the subdural hematoma (brain bleed), a right maxillary sinus fracture (beside the nose/beneath the eye),a right orbit fracture (bone around the eye), and a right zygomatic arch fracture (cheek). He was transferred to a higher level trauma medical center for treatment. A telephone interview with the Hospital physician was conducted on 08/15/25 at 4:09 pm. He stated Resident #1 was not able to tell him what had happened due to his advanced dementia but that the injuries he had to his face were caused from blunt force trauma and could have been the result of a fall. He reported that he thought the subdural hematomas he currently had could be a mix of an old subarachnoid brain bleed from January 2025 but that two of the subdural hematomas were acute meaning they had occurred within the last 24 hours. He explained he did not have anything else to offer, that Resident #1 had been transferred to a trauma hospital and the family was happy with the care Resident #1 had received at the Regional Medical Center.A telephone interview was conducted with the Trauma Medical Center Physician on 08/21/25 at 10:30 am. He stated Resident #1 had been transferred to their trauma unit from an affiliated regional medical center because the size of his brain bleed on 08/06/25 was too large for the other hospital to manage in accordance with their hospital protocol. He stated the injuries Resident #1 presented with were life threatening and very reasonably were caused from a fall. He stated he examined the brain scan results and noted both the subdural hematomas were new and had occurred within the previous 12 hours. The Trauma Center physician explained that Resident #1 had a previous brain bleed in January 2025 which he reviewed and noted that the previous brain bleed was a very different type of bleed than the current subdural hematomas. The comparison showed the January 2025 brain bleed was from a different area of the brain and only had trace bleeding-unlike the current subdural hematomas that had a large amount of bleeding. He also noted that the January 2025 test results showed no facial fractures. He stated all of the facial fractures were also from this episode. He stated that Resident #1 was fortunate to be in stable condition. He noted it was a shame this had happened when the family had only placed Resident #1 for respite care to free up their time to hold a birthday party for Resident #1's wife. At the end of the interview the Trauma Center Physician reported that the resident had returned home with his family.The Administrator was notified of Immediate Jeopardy on 08/12/25 at 5:35 pm.The facility provided the following corrective action plan:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 is alert but not oriented, with a Brief Interview for Mental Status (BIMS) of 3. Diagnoses included Alzheimer's dementia and major depressive disorder. He was admitted to the facility on [DATE] for respite care. On August 5, 2025, at approximately 8:15 pm, Dietary Employee #1 observed an unknown gentleman (Resident #1), presumed to be a visitor, walking down the service hallway of the facility. The employee redirected the individual toward the front entrance, assuming he was unfamiliar with the building layout and attempting to exit. Upon the dietary employee exiting the facility via the service hall door, the gentleman followed behind him and proceeded to walk around to the front of the building. The dietary employee ensured the service hall door was secured and then proceeded to leave the facility with his transportation, believing the gentleman who came out behind him was walking around the front to meet his own ride.At approximately 8:30 pm, Medication Aide #1 attempted to administer Resident #1's, evening medications but was unable to locate him. Medication Aide #1 notified Nurse #1 that Resident #1 could not be located. A facility-wide search was immediately initiated, and a code orange (code used to notify all staff of a missing resident) was announced by Nurse #1. The Director of Nursing (DON) and Administrator were notified that resident #1 could not be located. Staff continued to search for resident #1 inside the facility and in the surrounding areas in their vehicles. At approximately 9:49 pm, the Administrator notified law enforcement that Resident #1 could not be located. At approximately 10:00 pm, local law enforcement arrived onsite to begin searching for Resident #1. At approximately 10:36 pm, the Administrator notified the Resident Representative (resident's daughter) that resident #1 could not be located. At approximately 10:45 pm, the police department notified the Administrator that the resident was located 0.9 miles away from the facility. The Director of Nursing and a Nursing Assistant #1 went to the location of the resident. The resident was uncooperative with EMS, so the family was contacted by the DON and made the decision for the resident to be brought back to the facility. Resident #1 was brought back to the facility via the staff's private vehicle, where the family was onsite at arrival. The Director of Nursing discussed with the resident's family the need for the resident to be sent to the emergency room (ER). The family agreed, and EMS was notified. An assessment was completed by the assigned hall nurse and revealed a laceration approximately one inch to the right cheek and a 3/4 inch abrasion above both knees. Treatment was provided to the areas along with resident care. EMS arrived to evaluate the resident and found the resident to be stable. The family decided to discharge the resident Against Medical Advice (AMA) and take the resident to the ER via their private vehicle. At approximately 11:32 pm, the physician services were notified by the DON of the incident and the family's decision to discharge the resident AMA. At approximately 12:00 pm, the resident left AMA with family.On 8/6/25, the Administrator completed a root cause analysis for Resident #1's unsupervised exit. The investigation identified the root cause to be that Resident #1 walked out behind a dietary aide, and the dietary aide did not intervene to prevent an unsupervised exit, thinking he was a visitor. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On 8/5/25, t[TRUNCATE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to lock the brakes on a resident's wheelchair before leaving her unattended on the facility's front patio. Nurse Aide (NA) #5 positioned Resident #102 on the front patio and then walked away from the resident without securing the wheelchair brakes. Due to the brakes not being locked, and the resident's inability to stop the wheelchair when it began to roll due to weakness in all of her extremities, Resident #102 rolled approximately 10 feet across a circle drive and then struck her head on a brick wall which resulted in two lacerations to Resident #102's forehead that required sutures to repair. In addition, the facility also failed to provide care in a safe manner when Resident #310 rolled off the bed while NA #6 was providing a bed bath. This deficient practice occurred for 2 of 10 residents reviewed for accidents (Resident #102 and Resident #310). The findings included:1. Resident #102 was admitted to the facility on [DATE] with diagnoses including quadriparesis (weakness in all four limbs) and chronic dislocation of right shoulder. Resident #102 was discharged from the facility on 4/24/25.Resident #102's most recent quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #102 was cognitively intact, used a manual wheelchair, and was dependent on staff for all activities of daily living.The care plan last reviewed on 3/18/25 showed Resident #102 was care planned for falls and required assistance with activities of daily living due to chronic health conditions and weakness in extremities. The interventions included the use of a manual wheelchair for mobility. Review of physician orders showed Resident #102 was not on any blood thinners.An incident report dated 3/28/25 at 3:30 PM completed by the Director of Nursing (DON) revealed NA #5 transported Resident #102 out to the front patio of the facility. The report read that Resident #102 had lost control of her wheelchair and had rolled into the wall. The report further read that staff assisted immediately to complete a head-to-toe assessment, including vital signs, and applied pressure to stop bleeding. The emergency contact and the Nurse Practitioner were notified. Resident #102 was sent to the hospital for evaluation and treatment. During an interview with NA #5 on 7/1/25 at 2:17 PM, she stated she had pushed Resident #102 outside to the front patio in the afternoon of 3/28/25. NA #5 stated Resident #102 liked to sit in the sun, so she had pushed to her usual spot which was all the way across the patio and beside the circular drive. NA #5 also reported Resident #102 naturally leaned slightly forward in her wheelchair and did not have the strength to propel or stop herself in a wheelchair. NA #5 indicated she always locked the brakes on the wheelchair and couldn't explain why she didn't that day other than she just forgot. NA #5 stated she had just walked back into the building when she turned and saw Resident #102 slowly rolling across the circular drive. NA #5 reported she didn't reach her fast enough and Resident #102 struck her forehead on the brick retaining wall. NA#5 stated Resident #102 did not fall out of her chair and she didn't lose consciousness. NA #5 further stated that Resident #102 told her she was trying to get into the sun more and couldn't stop the wheelchair from rolling. NA #5 stated she didn't remember calling for any assistance, but other staff members then appeared to assist with getting Resident #102 back into the building to assess her and address her wound on her head that was bleeding.During an interview with the DON on 7/1/25 at 3:34 PM, she stated that she was up front on 3/28/25 when the incident with Resident #102 occurred. The DON stated she heard a staff member (unable to recall whom) say a resident just had an accident outside. The DON stated she responded immediately and performed an assessment on Resident #102. The DON reported Resident #102 did not fall out of her wheelchair, did not lose consciousness, and was complaining of minimal to moderate pain around the wound on her forehead. The DON stated Resident #102 told her she was trying to move further into the sun and couldn't stop the chair from rolling. The DON stated she contacted the emergency contact and NP #1 who provided the order to send Resident #102 to the hospital to assess her wound. The DON stated her vital signs were normal and Resident #102 was verbally responding in her normal manner.Review of the Emergency Medical Service note showed they arrived on 3/28/25 at 3:31 PM to the facility and found Resident #102 sitting upright in her wheelchair in the lobby. The note further read Resident had free rolled several feet across the drive into a brick wall. The resident had two small lacerations on her forehead. Bleeding was controlled, the area was cleaned and bandaged by staff .Resident is not on blood thinners and did not lose consciousness. Resident requested transport to a specific hospital for treatment. Alert and oriented, vital signs normal. No complaints of dizziness, only some pain around laceration. Resident is a non-emergency transport today.Review of the emergency department note dated 3/28/25 at 4:09 PM showed Resident #102 sustained two lacerations- a 4.2-centimeter laceration over the middle of the forehead and a 1.0 centimeter laceration to the right of the other. There was a small amount of bleeding with no visible bone. Both wounds were closed with a total of 6 non-absorbable simple sutures. All lab work and diagnostic scans, including computed tomography of Resident #102's cervical spine and head were negative, and Resident #102 was transported back to the facility on 3/28/25.An observation of the facility main entrance front patio on 7/1/25 at 3:15 PM showed an approximate 10 foot by 20-foot concrete slab directly adjacent to a circular drive that was approximately 10 feet wide. The drive adjacent to the patio appeared slightly sloped away from the front patio and sloped down toward the wall on the opposite side of the drive. There was an approximately 4-foot-high brick retaining wall on the other side of the circular drive.During a follow-up interview with the DON on 7/2/25 at 9:24 AM, she stated after investigating the incident, they found that NA #5 inadvertently forgot to lock the wheelchair brakes on Resident #102's chair and they had addressed that with NA #5. Resident #102 stated she attempted to move herself further into the sun, began slowly rolling and was unable to stop due to the limited amount of strength in her extremities. The DON also stated the resident should not have been left alone with the brakes unlocked, was not safe to be left unsupervised with the wheelchair brakes unlocked, and that the facility continued doing neurological checks after Resident #102 returned for an additional 3 days.During an interview with the NP #1 on 7/3/25 at 2:08 PM, she stated she saw Resident #102 after she returned from the hospital and removed her stitches from her forehead. NP #1 stated the two wounds healed well, Resident #102 voiced no complaints of pain to her, and she had no other injuries related to the incident.2. Resident #310 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, and weakness.Review of physician orders showed Resident #310 was not on any blood thinners.Resident #310's admission MDS dated [DATE] showed Resident #310 was cognitively intact and was dependent on staff for all activities of daily living including bed mobility. The MDS showed Resident #310 weighed 275 pounds.The care plan last reviewed on 5/2/25 showed Resident #310 was care planned as totally dependent on staff for activities of daily living due to chronic health conditions and weakness.The care guide dated 5/2/25 being used by nurse aides to determine how much care Resident #310 needed with her activities of daily living showed the resident was totally dependent on staff for bed mobility and bathing.Review of the incident report by Nurse #6 dated 6/17/25 stated during morning care with NA #6, Resident #310 became weak and had a witnessed fall. Resident verbalized no pain. While still lying on the floor, during the nursing assessment, Resident #310 had a syncopal (fainting) episode and became unresponsive. Oxygen was immediately applied by Nurse #6, and 911 was called. Resident #310 never stopped breathing, regained consciousness in less than a minute, and left the facility with oxygen level of 93%.During an interview with NA #6 on 7/1/25 at 10:36 AM, she stated she was giving Resident #310 a bed bath sometime after breakfast on 6/17/25 and had raised the bed up to her waist height. NA#6 stated she was aware Resident #310's care guide showed she required two staff members, but she stated everyone was usually busy helping other residents so sometimes she just did it herself. NA#6 reported Resident #310 was on her left side facing away from NA #6, NA #6 was on the right side of the bed, and the NA was talking with the resident while she was washing the resident's back when Resident #310 stopped responding to her and slowly rolled away from her off the left side of the bed onto the floor, landing on her right side facing the bed. NA #6 stated she called for help and Nurse #6 responded quickly. NA#6 reported Resident #310 was alert at that time, rolled over to her back and asked how she got on the floor.During an interview with Nurse #6 on 7/1/25 at 2:20 PM, she stated she responded to Resident #310's room when NA#6 called for her (unsure of time) on 6/17/25 and found Resident #310 lying on her back beside her bed. Nurse #6 reported NA #6 told her she was giving Resident #310 a bath and NA#6 had the resident on her side washing her back when Resident #310 talking to her and then rolled forward off the bed onto the floor. Nurse #6 stated Resident #310 was alert but confused about how she ended up on the floor and was not complaining of any pain. Nurse #6 stated Resident #310's blood pressure was slightly low for her at 114/52 but was still within normal range. Nurse #6 reported Resident #310 was responding appropriately to questions and then became unresponsive. Nurse #6 stated another staff member (unable to recall whom) called 911, brought in oxygen, and it was applied. Nurse #6 reported Resident #310 regained consciousness quickly and was able to say her name and responded appropriately to questions. EMS arrived and transported the resident to the emergency room for evaluation. Nurse #6 reported that cardiopulmonary resuscitation was not needed nor provided, and Resident #310 never stopped breathing.Review of the Emergency Medical Service note showed they arrived on 6/17/25 at 10:55 AM to the facility and found Resident #310 lying on the floor. The report further stated Resident fell presumably due to weakness and possibly hit her head. No blood thinners taken. Resident is hypotensive (low blood pressure) but responsive to stimulation. Intravenous fluids started . Resident became more responsive to verbal stimuli and spoke her name clearly upon leaving the facility . Resident transported to the hospital for evaluation.Review of the emergency department note dated 6/17/25 at 11:25 AM showed Resident #310 was alert and oriented upon arrival and had no complaints of pain. Lab work and diagnostic tests showed possible pneumonia and a high creatinine indicating the need for possible dialysis. Resident #310 was admitted for further testing and did not return to the facility.During an interview with the DON on 7/2/25 at 10:49 AM, she stated she was made aware of the incident on 6/17/25 when Resident #310 rolled off the bed during a bed bath. The DON stated the facility did in-service training regarding bed mobility and the importance of following the care guide for each resident which is what NA#6 should have done which would have prevented Resident #310 from rolling off the bed. The DON also stated Resident #310 was diagnosed with pneumonia at the hospital and was found to be in need of dialysis based on her labs compared to her previous labs done prior to admission to the facility which likely contributed to her fainting episode.