**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of the medical record for Resident #32 revealed an admission date of [DATE]. Diagnoses included dementia, type two diabetes, conversion disorder, and personal history of malignant neoplasm of breast. Review of the quarterly MDS assessment dated [DATE] revealed Resident #32 had severe cognitive impairment. The resident required two-person extensive assistance with transfers, dressing, toilet use, one-person extensive assistance with eating, and one-person total dependence with bathing. Observation on [DATE] at 9:53 A.M. of State Tested Nurse Aide (STNA) #369 brought a mechanical lift out of Resident #32's room after transferring her into the wheelchair from the bed after providing a bed bath. Observation revealed STNA #369 was the only staff in the room. Interview on [DATE] at 9:58 A.M., with STNA #369 verified Resident #32 required a mechanical lift to transfer, and she completed the transfer on her own without another staff member. STNA #369 verified mechanical lift transfers should be completed by two staff members. Review of the facility policy titled Mechanical Lifts and Transfers, revealed lifts were utilized to provide a safe and ergonomic method to assist residents to transfer, stand, or toilet without physically/manually lifting them. Use two employees to assist and for support in the safe use of a total lift transfer. This deficiency represents noncompliance discovered in Complaint Number OH00142016. Based on medical record review, observations, staff interview, review of witness statements, review of the police report, review of information from Google Maps, review of a weather report, review of the facility investigative files, review of in-service education, and policy review, the facility failed to complete thorough investigations following resident elopements to prevent additional elopements from occurring. Additionally, the facility failed to update residents' elopement assessments and care plans following elopements. Lastly, the facility failed to identify like-residents at risk for elopement to ensure appropriate interventions were in place to potentially prevent the same actions, situations, and/or practices from occurring in the future. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] at an unknown time when Resident #306, who resided on the west hall, exited the facility's secured unit on the south hall through a thirty second egress alarmed door, which lead to an exterior door to exit the building. Resident #306 was found at 2:40 A.M. approximately three-fourths of a mile away from the facility, which was approximately a 14-minute walk. The Immediate Jeopardy continued when Resident #306 exited the secured unit through the same alarmed door on [DATE] at approximately 8:15 A.M. when Maintenance Supervisor (MS) #370 saw Resident #306 walk by the maintenance window and started running down the driveway. Furthermore, the Immediate Jeopardy continued when Resident #86 exited the secured unit through a thirty second egress door on [DATE] without floor staff's awareness. Moreover, the Immediate Jeopardy continued when Resident #86 exited through a thirty second egress door on [DATE], without staff's awareness, and was found one tenth of a mile from the facility by Receptionist #380. Additionally, the facility failed to follow their elopement policy and did not review and update Resident #86's elopement risk assessment and care plan. This affected two (#86 and #306) of seven residents reviewed for elopement. Lastly, the facility failed to ensure residents who required the use of a mechanical lift were transferred safely with the assessed amount of staff. This affected one (#32) of 13 residents reviewed for transfers. The facility census was 101. Findings include: On [DATE] at 3:46 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Operations (RDCO) #427 were notified Immediate Jeopardy began on [DATE] at an unknown time when Resident #306 eloped from the facility and was found approximately 14 minutes later around 2:40 A.M. Resident #306 was found by Licensed Practical Nurse (LPN) #341 walking down the side of a two-lane busy road with no sidewalks or streetlights approximately three fourths of a mile away from the facility. Resident #306 was wearing black pants, a red t-shirt, and shoes. The temperature in the area was approximately 55 degrees Fahrenheit (F). Resident #306 refused to go back to the facility with staff, and police were called for assistance. Upon Resident #306's return to the facility, the facility had not updated his elopement care plan to prevent recurrence. Additionally, the facility had not identified like-residents to ensure appropriate interventions were in place to potentially prevent future elopements. The Immediate Jeopardy continued when Resident #306 exited the facility without floor staff awareness on [DATE] and was found by MS #370 running down the driveway. Upon Resident #306's return into the facility, the facility had not updated his wandering observation tool to prevent recurrence. Additionally, the facility had not identified like-residents to ensure appropriate interventions were in place to potentially prevent future elopements. The Immediate Jeopardy continued when Resident #86 exited the secured unit through a thirty second egressed door on [DATE] without floor staff's awareness. The Immediate Jeopardy continued when Resident #86 exited through a thirty second egress door on [DATE] without staff's awareness and was found one tenth of a mile from the facility by Receptionist #380. The facility failed to follow their elopement policy and did not review and update Resident #86's elopement risk assessment and care plan. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE], the DON/Unit Manager (UM)/Designee ensured all residents were accounted for and began to obtain statements from all staff on duty. • On [DATE], the DON/UM/Designee completed education with all staff on elopement and acknowledgment of door alarms. Wandering assessments were updated for all residents, the elopement binders were reviewed, updated, and elopement drills were held. • On [DATE], the DON/UM/Designee ensured all residents were accounted for and began to obtain statements from all staff on duty. • On [DATE], the DON/UM/Designee completed education with all staff on elopement and acknowledgment of door alarms. Elopement binders were reviewed, updated, and elopement drills were held. • On [DATE], the DON/UM/Designee ensured that all residents were accounted for and began to obtain statements from all staff on duty. • On [DATE], the DON/UM/Designee completed education with all staff on elopement and acknowledgment of door alarms. Elopement binders were reviewed, updated, and elopement drills were held. • On [DATE], the DON/UM/Designee ensured that all residents were accounted for and began to obtain statements from all staff on duty. • On [DATE], MS #370 assessed all doors and alarms for functionality without noted deficiency. • On [DATE], the DON/UM/Designee completed staff education on elopement and completed an elopement drill. Wandering assessments were updated for all residents with no new elopement risks noted. Elopement binders were reviewed. discharged residents were removed from the elopement binders and any new admissions not previously added, were added to the elopement binders. The medical director was notified of each elopement and agreed with intervention to monitor one-to-one. • On [DATE], the elopement binders were reviewed for accuracy. Resident #100 was added to the binder due to an elopement in February 2023. • On [DATE], all wandering resident assessments were updated with no changes needed. All care plans were validated and updated with no changes needed. All elopement binders were validated with no changes needed. Wandering assessments are completed upon admission, quarterly, with change in condition, and upon any elopement event. Staff have been educated on elopement. Nurses have been educated on accurately completing wandering assessments, care planning, and timely completion of care plans. • On [DATE], RDCO #427 provided education with the DON, the UM, and the Administrator on completing a thorough investigation including staff interviews/witness statements with all staff working the dates of the elopements. • On [DATE], education was provided by the DON/Designee with all staff regarding elopement risk and facility policy. All newly hired staff will be educated. • On [DATE], education was provided by RDCO #427/Designee with the licensed nurse to ensure wander observation tools are completed accurately. • On [DATE], education was provided by RDCO #427 with the DON, UM #304, #310, and #314 and the Minimum Data Set (MDS) staff #375 on ensuring care plans are in place regarding those identified at risk. • On [DATE], education was provided by RDCO #427 with the DON, UM #304, #310, and #314, the Administrator, Activity Director #322, Activity Staff #319, #329, #336, #337, and #338, Admissions Coordinator #385, and the Electronic Health Records Clerk #387 to ensure elopement binders are up to date with residents at risk for elopement. • On [DATE], LPN #350, State Tested Nursing Assistant (STNA) #369, Receptionist #380 and Maintenance Supervisor #370 stated they had been educated about elopements and responding immediately or as soon as it was safe to do so when alarms sounded. • The Administrator/Designee will conduct elopement drills twice weekly on each shift for four weeks, then once a week on each shift for four weeks, then once a week on each shift every two weeks, then monthly for two months. • The DON/Designee will audit the elopement binders on each unit to ensure that all residents in the facility are included twice a week for four weeks, then weekly for four weeks, then every other week for four weeks then random observation thereafter. • The RDCO #427 will review the completeness of all elopement investigations to ensure that all staff were educated on elopements, elopement binders are updated, and wandering observation tools were completed and accurate. RDCO #427 will review all staff statements to ensure all staff on duty at the time of elopement have provided thorough statements. This audit will occur for all elopements for three months. • All variances will be corrected upon discovery, and additional training/follow-up will be provided as deemed necessary. The DON/Designee will bring the results of the audits to the monthly Quality Assurance Performance Improvement (QAPI) meeting. The results of the audit will be reported, reviewed, and trended for a minimum of six months, then randomly thereafter for further recommendations. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the medical record for Resident #306 revealed an admission date of [DATE] with diagnoses including dementia, schizophrenia, and Parkinson's disease. Review of the MDS assessment dated [DATE] revealed Resident #306 was severely cognitively impaired and required supervision with mobility. Review of the most recent wandering observation tool dated [DATE] revealed Resident #306 was not at risk for elopement. Further review of the medical record revealed the facility had not completed a wandering observation tool after the elopement on [DATE]. Review of the elopement care plan for Resident #306 updated on [DATE] revealed the resident was an elopement risk related to wandering behavior, diagnoses of Parkinson's, dementia, schizophrenia, and a history of elopement. Interventions included one-to-one supervision until further notice; care conference with the family to discuss a possible transfer ([DATE]), assess hunger, thirst, ambulation, and toileting needs ([DATE]), complete wandering evaluation upon admission/re-admission, quarterly, and as needed ([DATE]), evaluate for need of secured unit and notify medical provider as needed ([DATE]), notify medical provider and resident representative of behavior changes ([DATE]), provide diversionary activities as needed and redirect when appropriate ([DATE]), and provide structured activities at times of increased elopement risk, diversional tasks, redirection of ambulation pattern, and utilization of safe wandering areas ([DATE]). Review of the nurse progress note dated [DATE] at 3:58 A.M. revealed LPN #415 was alerted by State Tested Nurse's Aide (STNA) #349 the door alarm on the south hall was triggered. LPN #415 and STNA #349 went through the alarming door and visualized the main exit door was ajar. LPN #415 and STNA #347 got into their vehicles and drove down the street. Resident #306 was found walking down Springdale Road towards [NAME] Road on the left side approximately a half a mile down the road. The police stopped and helped. Resident #306 was non-cooperative and resisted returning to the facility. Resident #306 was returned by the police. A head-to-toe assessment, neurological checks, vital signs, and nurse's notes were completed. The Director of Nursing (DON) and the family were notified. Review of LPN #341's statement (undated) revealed approximately an hour prior to the incident, Resident #306 was seen on the south hall using the phone. LPN #341 was on lunch when the incident occurred. LPN #341 was heading back from lunch when she saw Resident #306 walking on Springdale Road and called the facility to notify staff and to call the police. Review of STNA #347's statement dated [DATE] revealed at approximately 2:40 A.M., LPN #415 and STNA #420 from west hall came to the south hall to look for Resident #306. STNA #347 began to search for Resident #306. STNA #347 got into his car and drove around the facility looking for Resident #306 but had not found him. STNA #347 drove onto Springdale Road where LPN #341 and STNA #347 found him. STNA #347 did not know how Resident #306 exited the facility because STNA #347 was busy doing rounds and changing other residents. Resident #306 was resistive with staff when trying to bring him back to the facility and made STNA #347 bleed beneath his chin. Review of agency STNA #420's statement dated [DATE] revealed she was alerted by LPN #415 that STNA #349 stated the alarm was going off on the south unit. STNA #349 looked in Resident #306's room, but he was not there. All staff started looking in rooms and hallways and then moved outside of the facility. Resident #306 was found walking down the road. Review of agency staff STNA #425's statement (undated) revealed Resident #306 was walking up and down south hall towards nurse's station, and STNA #425 tried redirecting him to west hall, where he resided, but he refused. STNA #425 asked other staff to help redirect him. STNA #425 went to check on another resident on west hall and noticed Resident #306 was not in his room. STNA #425 asked other staff if they had seen him, and the other staff said no. STNA #425 reported that was when staff started looking for him. Review of Registered Nurse (RN) #318's statement dated [DATE] revealed at 2:40 A.M. she was at north hall nurse's station when the phone rang. The call was from LPN #341 who reported Resident #306 from west hall was walking down Springdale Road, and she needed help to get him back to the facility. RN #318 reported LPN #303 went to help LPN #341 while she called emergency services to meet them on Springdale Road for assistance. RN #318 notified the DON and completed a head count on residents. Review of LPN #303's statement dated [DATE] revealed he received a call from LPN #341 that she found Resident #306 on the road on her way to lunch. LPN #303 went to the road to help bring Resident #306 back to the facility. While trying to bring Resident #306 back to the facility, the police stopped and brought Resident #306 back to the facility. Review of STNA #349's statement dated [DATE] revealed the door alarm on south hall was going off and STNA #349 went to turn off the alarm. STNA #349 went through the alarm door and noticed the door leading outside was open. STNA #349 looked around and had not seen any residents. STNA #349 saw Resident #306 on south hall before the alarm went off, and Resident #306 was nowhere to be found. STNA #349 alerted LPN #415 that Resident #306 got out of the facility. STNA #349 and LPN #415 went back through the door that was alarming and checked the maintenance room and parking lot. LPN #415 got into her car as well as STNA #347 to check the road. STNA #349 stated Resident #306 was found and brought back to the facility. Review of agency LPN #430's statement dated [DATE] revealed she heard door alarms sounding on south hall while she was unclogging a feeding tube in a resident's room. LPN #430 reported as she finished up with resident care, she witnessed LPN #415 and STNA #349 looking for Resident #306. LPN #430 had staff check all rooms and closets. LPN #430 went outside to check the grounds. LPN #415 and STNA #347 got into their cars to search for Resident #306. About twenty-five minutes later, the police and three staff members returned to the facility with Resident #306 in a police car. Review of the police report dated [DATE] revealed a call was placed at 2:43 A.M. for the well-being of Resident #306. On [DATE] at 2:45 A.M. police arrived on scene where Resident #306 was standing in the middle of the road. Staff were unable to get him back to the facility. Police assistance was needed, and Resident #306 was placed into a squad car. On [DATE] at 2:59 A.M. Resident #306 was escorted back to the facility. Review of the in-service provided to staff dated [DATE] revealed staff must immediately react to sounding door alarms. Staff must always investigate to ensure all residents were accounted for and safe. Door alarms may not be deactivated without ensuring all residents had been accounted for. Observations throughout the annual survey revealed the facility's secured door where Resident #306 resided was in working order and alarmed appropriately. Telephone interview on [DATE] at 9:39 A.M., with RN #318 revealed the other nurses went out and looked for Resident #306. RN #318 reported she completed a head count on her unit and notified the DON. RN #318 stated LPN #341 called into the facility and reported Resident #306 was on the road. Telephone interview on [DATE] at 10:09 A.M. with LPN #303 revealed he received a call from LPN #341, who was at lunch, that she saw Resident #306 walking down Springdale Road. LPN #303 reported he turned right out of the facility and met LPN #341 at the gas station. LPN #303 explained he tried to get Resident #306 in his car, but he refused. LPN #303 stated the police were notified and assisted with the return of Resident #306 back to the facility. Telephone interview on [DATE] at 3:31 P.M. with agency STNA #420 revealed she was working west hall where Resident #306 resided. STNA #420 reported Resident #306 got out of the south hall door. STNA #349 came and told LPN #415 that Resident #306 had gotten out of the facility. STNA #420 explained all staff started looking for Resident #306 on south unit, then checked the other units, and checked outside the facility. STNA #420 reported someone called the facility and said Resident #306 was walking down Springdale Road. Telephone interview on [DATE] at 3:36 P.M. with agency LPN #415 revealed Resident #306 was ambulatory on his own and typically walked from unit to unit at night. LPN #415 reported Resident #306 would walk to the south hall and would usually come back after 10 minutes. LPN #415 was working west hall on [DATE], where Resident #306 resided. LPN #415 heard the alarm going off on the south hall but could not recall how long the alarm sounded. STNA #349 notified LPN #415 that Resident #306 got out of the building. LPN #415 and STNA #347 got into their cars and drove in opposite directions down the road looking for Resident #306. LPN #415 reported the streets were very dark at that time. LPN #415 went the opposite direction of where they found Resident #306. Telephone interview on [DATE] at 8:14 A.M. with STNA #349 revealed she saw Resident #306 prior to entering a resident's room to provide care. STNA #349 reported when she came out of the resident's room, the door alarm had been sounding. STNA #349 turned off the alarm and went through the alarming door to see the door to the outside was ajar. STNA #349 looked around and in Resident #306's room but had not seen him. STNA #349 alerted LPN #415 that Resident #306 was missing. STNA #349 and staff looked for Resident #306. LPN #415 and STNA #347 got into their cars and headed down the road. Telephone interview on [DATE] at 8:23 A.M. with agency STNA #425 revealed Resident #306 exited the building when she was providing resident care. STNA #425 reported LPN #341 called into the facility and said Resident #306 was on the street. STNA #425 could not recall any other pertinent information about the incident. Telephone interview on [DATE] at 5:55 P.M. with LPN #341 revealed she had seen Resident #306 prior to the incident wearing different clothes. LPN #341 reported she went to lunch at approximately 2:00 A.M. LPN #341 stated she was on her lunch break when she saw Resident #306 walking down Springdale Road. LPN #341 noticed a man walking down the side of the road with black pants, a red t-shirt, and shoes on. LPN #341 slowed down because she was surprised to see someone walking in a short-sleeved shirt because it was chilly. LPN #341 slowed down and realized it was Resident #306. LPN #341 put on her hazards and yelled his name, but she said he didn ' t slow down or look her way. LPN #341 called into the facility and notified staff that Resident #306 was walking down Springdale Road and to call the police. LPN #341 reported when other staff arrived on scene, she left because she had a passenger in her car. LPN #341 explained the Assistant Director of Nursing (ADON) called her on [DATE] to obtain her statement regarding the incident on [DATE] because the facility misplaced her original statement. Review of the nurse progress note dated [DATE] at 8:32 A.M. revealed Resident #306 exited through the south hall door. RN #314 was notified Resident #306 possibly got out of the facility. RN #314 immediately went out to the parking lot where Resident #306 was with the Maintenance Supervisor (MS) #370. Resident #306 was assisted back to his room. Resident #306 was assessed from head-to-toe without injury noted. The daughter was notified, and Resident #306 was placed on one-to-one supervision. Review of the in-service provided to staff dated [DATE] revealed staff were trained regarding elopement prevention and elopement management. Review of the former Business Office Manager (BOM) #431's statement dated [DATE] revealed she was walking into work around 8:20 A.M. when she saw Resident #306 running out of the maintenance door on the side of the building. As former BOM #431 started towards him, MS #370 immediately followed Resident #306 trying to redirect him. Resident #306 continued to run. Former BOM #431 continued to move towards him to prevent him from going further away from the facility. MS #370 was able to reach him, and Resident #306 stopped running. RN #314 came out to the parking lot and escorted Resident #306 back into the facility. Review of MS #370's statement dated [DATE] revealed at approximately 8:20 A.M., he heard the alarm go off next to the maintenance door. MS #370 saw Resident #306 walking down the sidewalk toward Springdale Road. MS #370 caught up to Resident #306 and was able to redirect him toward the entrance of the facility. Interview on [DATE] at 3:18 P.M. with MS #370 revealed he had not recalled the door alarm going off, but he looked out the window and saw Resident #306 by the south door outside of the facility. MS #370 reported that by the time he got up from the desk and over to the door, Resident #306 was running down the hill on the driveway. Resident #306 was fully clothed but had no shoes, only socks on. MS #370 was shocked Resident #306 did not fall. MS #370 revealed Resident #306 made it approximately 40 to 50 yards from the facility. MS #370 stated the former Executive Director #440 and former BOM #431 met him out in the parking lot for assistance with Resident #306. MS #370 could not recall if any floor staff assisted. Interview on [DATE] at 1:39 P.M. with RDCO #427 verified Resident #306's wandering observation tool was not updated after the elopement on [DATE]. Review of an online map per google maps revealed the gas station near where Resident #306 was found on [DATE] was approximately 0.7 miles from the facility and approximately a 14-minute walk. Review of the online weather resource https://www.accuweather.com/en/us/[NAME]/45243/september-weather/2214995?year=2022 revealed the air temperature was 55 degrees F for the morning of [DATE] for the city in which the facility was located. 2) Resident #86 was admitted on [DATE] with diagnoses including dementia, hereditary neuropathy, hypertension, disorientation, and insomnia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #86 had severe cognitive deficits and required supervision with locomotion. Review of the wandering observation tool dated [DATE] revealed Resident #86 was not a risk for elopement. Review of the next wandering observation tool dated [DATE] revealed the resident was an elopement risk. Review of the wandering observation tool dated [DATE] revealed the resident was an elopement risk. Review of the wandering observation tool dated [DATE] revealed it was completed with incorrect information revealing the resident was not an elopement risk. Review of a nursing note dated [DATE] at 3:51 P.M. revealed RN #343 was notified by staff Resident #86 was out in the parking lot walking. Resident #86 was seen by the receptionist at that time and was assisted back to the unit by staff and assessed with no injuries. Notifications were made and one-to-one supervision was initiated. Review of the investigation related to the elopement on [DATE] revealed there was no timeline to determine the root cause of how Resident #86 eloped. Resident #86 had no updated plan of care with interventions to prevent elopement. Review of STNA #329's witness statement dated [DATE] revealed two Residents (#16 and #103) were at the south ambulance entrance door touching the door which set off the alarm at the time. Resident #91 informed STNA #329 that Resident #86 was outside. Everyone began looking for Resident #86. Review of a physician order dated [DATE] revealed Resident #86 was placed on increased supervision one-to-one until [DATE] every shift for resident safety. Review of RN #389's witness statement dated [DATE] revealed Resident #91 informed her and another staff member that Resident #86 was outside. RN #389 immediately addressed the situation, running outside to get him. Resident #86 was standing by the cars in the parking lot. No alarms were going off when first notified of the incident. Resident #86 was redirected back to the facility without difficulty. Review of STNA #320's witness statement dated [DATE] revealed she had seen Resident #86 at the south door trying to leave the unit, STNA #320 redirected Resident #86 away from the door and he walked towards the west unit. Review of the former Licensed Social Worker (LSW) #428's witness statement dated [DATE] revealed following the incident, the south ambulance door was alarming with no staff around. LSW #428 and maintenance disarmed the door and ensured the door was locked. Review of STNA #363's witness statement dated [DATE] revealed she saw Resident #86 on the north unit trying to open the door and she redirected him back to his unit. Review of LPN #429's witness statement dated [DATE] revealed Resident #86 kept pushing on the door trying to open it and she asked him to stop pushing on the door. Review of Receptionist #380's witness statement dated [DATE] revealed she was walking past her desk and saw Resident #86 outside and got help. A follow-up interview on [DATE] at 11:57 A.M. with RDCO #427 verified there was no wandering observation tool completed related to the elopement on [DATE] until [DATE]. Review of the nursing note dated [DATE] at 7:40 P.M. revealed Resident #86 was found in the parking lot by Receptionist #380 with a coat, hat, and shoes on. Resident #86 was alert, verbal, and redirected back into the building with no behaviors. Resident #86 was placed on increased one-to-one supervision. Review of the investigation related to the elopement dated [DATE] revealed the incident was not thoroughly investigated and there was no timeline of events to determine a root cause. Review of Receptionist #380's witness statement dated [DATE] revealed she was taking her trash out and walked around the front of the facility and spotted Resident #86 walking towards the end of the driveway. Review of STNA #348's witness statement (undated) revealed she was providing care to Resident #54 and heard the back door alarm. After STNA #348 finished providing care she checked outside, reset the alarm, and informed the nurse. Review of Nurse Practitioner (NP) #430's note dated [DATE] revealed Resident #86 was seen for follow-up due to dementia with wandering behaviors/elopement. Resident #86 was an [AGE] year-old male with dementia and eloped from the facility over the weekend. Resident #86 was found in the parking lot and redirected back to the facility without difficulty. The plan was to continue one-to-one supervision and follow-up with the psychiatrist as needed for behaviors. Observation and interview on [DATE] at approximately 9:00 A.M., the door on the south unit was alarming continuously and when the surveyor questioned what the noise was, RN #399 stated it was the door alarm and it alarmed all the time because it was broken, and the facility can ' t seem to get it fixed. Observation on [DATE] at 12:15 P.M. with MS #370 revealed the door beyond the keypad 30 second egress door on the south unit, was opened, leading to an open outdoor area. The door was opened and immediately sounded a loud alarm, which sounded for 30 seconds. After 30 seconds, the alarm silenced automatically. No staff