**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THE ON-SITE INVESTIGATION Based on medical record review, staff interview, resident representative interview, law enforcement interview, review of facility self-reported incidents (SRIs), review of police reports, review of police body camera footage, review of emergency medical services (EMS) run reports, review of hospital records, review of the Facility Assessment, and review of facility policies, the facility failed to ensure Resident #1 was free from physical abuse from Resident #2. This resulted in Immediate Jeopardy and serious life-threatening harm on 03/12/24 at approximately 5:00 A.M. when Resident #1 was found on the floor in a prone position (face down on the stomach) in his room with blood coming out of the left side of his head and face. The resident was transported to the emergency room. Upon further investigation by hospital staff and law enforcement, it was determined Resident #1 was physically assaulted by Resident #2, who had a documented history of violent behaviors and was Resident #1's roommate. Resident #1 sustained numerous blows to the head and abdomen and injuries including scattered abrasions about the head, significant swelling to the left side of the face mostly over the left eyelid with a laceration present in the area, bleeding on the brain, and a fractured sacrum. This affected one resident (#1) reviewed for physical abuse and had the potential to affect 42 additional residents (#3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #37, #38, #39, #40, #41, #42, #43, #44, #45 and #46) who resided on the secure dementia unit were Resident #2 resided. The facility census was 143. On 04/11/24 at 5:05 P.M., the Administrator and Corporate Registered Nurse (CRN) #116 were notified Immediate Jeopardy began on 03/12/24 at approximately 5:00 P.M. when Resident #1 was found on the floor in the prone position in his room with blood coming out of the left side of his head and face. The injuries were determined to be a result of an incident of physical abuse/assault by Resident #2. The facility did not begin corrective action until 03/18/24 when law enforcement arrived at the facility and informed facility staff Resident #1 alleged the assault by Resident #2, leaving the 43 additional residents residing on the unit at risk for physical abuse from Resident #2 between 03/12/24 and 03/18/24. The Immediate Jeopardy was removed and corrected on 03/21/24 when the facility implemented the following corrective actions: • On 03/12/24 Resident #1 was transferred to the hospital and did not return to the facility. On 03/18/24, Resident #2 was placed on one-to-one supervision until discharged to the hospital. • On 03/18/24, the Director of Nursing (DON) notified Resident #2's guardian and physician and orders were received to send the resident to a hospital for a psychological evaluation. Resident #2 was hospitalized from [DATE] to 03/21/24. • On 03/18/24, the Administrator initiated a facility Self-Reported Incident (SRI) and an investigation for resident-to-resident physical abuse involving Resident #1 and Resident #2 that occurred on 03/12/24. • On 03/18/24, the DON/Designee completed interviews with all interviewable residents who could potentially be affected regarding abuse and neglect. There were no negative findings from the resident interviews. • On 03/18/24, Assistant Director of Nursing (ADON) #249, Licensed Practical Nurse (LPN) Unit Manager #298, and Registered Nurse (RN) #288 completed skin assessments on all non-interviewable residents to identify any signs or symptoms of abuse. There were no negative findings from the skin assessments. • On 03/19/24, the interdisciplinary team (IDT) consisting of the Administrator, ADON #249, Social Service Designee (SSD) #220, RN #257, Regional Director of Clinical Services (RDCS) #350, and LPN Unit Manager #298 reviewed residents with like behaviors, including review of care plans and interventions, and review of all residents and their roommates for compatibility. As a result of the meeting, it was determined Resident #2 was moved to a private room upon readmission to the facility on [DATE]. There were no concerns found with the other residents during the review. • On 03/18/24, the Administrator/Designee began education with all staff on abuse, neglect, aggressive behaviors, and violent behaviors. The education was completed face-to-face for facility staff working in the facility and via telephone for staff members not present in the facility. Newly hired staff/agency staff were to be educated upon hire and upon assignment to the facility. All education of current staff members was completed on 03/19/24. • On 03/18/24, the DON/designee began audits to include interviews with five staff members three (3) times weekly for four (4) weeks and then monthly for two (2) months to monitor and assess residents for any signs and symptoms of abuse. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. All audits through 04/01/24 revealed no concerns. • On 03/18/24, the DON/Designee began audits to include interview with 10 residents who were interviewable and skin assessments on non-interviewable residents 3 times weekly for 4 weeks and then monthly for two months to assess for signs and symptoms of abuse. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. All audits through 04/01/24 revealed no concerns. • On 03/18/24, the DON/Designee began audits to review all residents with aggressive and violent behaviors to ensure appropriate interventions are implemented and/or updated to reflect current resident status. All residents will be audited weekly for 4 weeks and then monthly for 2 months to ensure compliance. All audits through 04/01/24 revealed no concerns. • On 03/19/24, the DON/Designee began audits of new admissions and readmissions to the facility to monitor for aggressive and violent behaviors to ensure appropriate interventions are implemented upon admissions. Review of the audits through 04/01/24 revealed no concerns. • On 03/21/24 Resident #2 was readmitted to the facility and placed in a private room as an intervention to decrease the risk for resident-to-resident abuse by Resident #2. • Review of SRIs on 04/09/24, revealed the facility had submitted no additional allegations of resident-to-resident physical abuse since 03/18/24. • Interview with State Tested Nurse Aide (STNA) #215, STNA #302, LPN #257, and LPN #298, on 04/15/24 between 8:35 A.M. and 8:55 A.M. revealed all staff members interviewed had been educated regarding abuse, neglect, aggressive behaviors, and violent behaviors. All staff members interviewed confirmed they retained knowledge regarding the content of the education provided. Findings Include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included seizures, depression, and post-traumatic stress disorder. Resident #1 shared a room with Resident #2 on admission and remained roommates until Resident #1 was discharged to a local hospital on [DATE] and did not return to the facility. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was assessed as cognitively intact and required limited assistance from one staff person for completing his activities of daily living. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, paranoid personality disorder, anxiety disorder, and violent behavior. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #2 was assessed as cognitively intact, had active delusions, and required the assistance of one staff person for completing his activities of daily living. Review of Resident #2's admission paperwork prior to arriving at the facility on 02/18/20 revealed Resident #2 was placed in a psychiatric hospital for physically assaulting another resident and staff person at another nursing facility, causing broken arms in both the staff person and the other resident. Review of the care plan for Resident #2, initiated on 02/18/20 and revised on 05/24/23, revealed a care plan focus that indicated Resident #2 had a mood problem related to paranoid schizophrenia. Resident #2 had the potential to express himself using verbal or physical violence when he was experiencing elevated feelings. Goals for the care plan focus were for Resident #2 to have improved mood through the next review date. Interventions included administering medications as ordered, monitoring/documenting for side effects and effectiveness, assessing/monitoring/recording/reporting to the medical doctor (MD) as needed for risk for harming others, assessing/recording/reporting to the MD as needed acute episodes or significant changes in mood, assessing/record/reporting to the MD as needed mood patterns signs and symptoms of depression, anxiety, mood as per facility behavior monitoring protocols, behavioral health consults/psychiatric consult as needed or per orders, encouraging the resident to express feelings, allowing them time to talk as needed, allowing for Resident #2 to express himself using active listening, maintaining eye contact, speaking in a calm manner, not challenging him while he was in an elevated emotional state, acknowledging and rephrasing what was frustrating Resident #2 so he was aware that he has been heard, and observing for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity. The care plan included no other interventions to specifically address Resident #2's specific behaviors, triggers, or other concerns to prevent violent and aggressive behaviors. Review of the Ohio Department of Health's Enhanced Information Dissemination Collection (EIDC) system revealed Resident #2 was involved in 16 separate incidents resulting in facility SRIs across four different nursing facilities being reported to the State agency since 2014. Notable SRIs which occurred in Resident #2's current facility in the reported SRIs investigations included, on 10/23/23, Resident #2 placed Resident #15 in a choke hold during a physical altercation which resulted in Resident #15 biting Resident #2's finger. Review of an SRI on 12/13/23 revealed Resident #2 and Resident #17 were roommates and Resident #17 was noted with swelling and redness to the right cheek. When a nurse attempted to assess Resident #17, the resident indicated he wanted to be left alone. Resident #2 was interviewed about the incident and stated, I punched him (Resident #17) for no reason. Review of an additional SRI on 02/07/24 revealed Resident #2 struck Resident #449, who at the time were roommates, in the lip causing Resident #449 to have a swollen lip. Review of psychiatrist progress notes from the facility noted the facility's psychiatrist was unwilling to reduce Resident #2's psychiatric medications due to ongoing behaviors. Resident #2 had been most recently seen by facility's psychiatrist for a medication review on 01/17/24 at which time Resident #2 was noted with impaired judgement and incoherent thought process. Resident #2 was documented with medical history of schizophrenia, paranoid personality, violent behavior, anxiety, and schizoaffective disorder. Further review revealed adjustments made since the last visit included an increase in Resident #2's antipsychotic medication Haldol to 300 milligrams every three weeks. Resident #2 was noted to not be a candidate for a dose reduction because of continuing target symptoms and a high risk of relapse if medication was lowered. Review of a nursing progress note dated 03/12/24 at 8:09 A.M. revealed Resident #1 was discovered on the floor of his room at 5:00 A.M. Resident #1 was laying in the prone position with his head turned to the right and blood coming from the left side of his head. Further review of the progress note revealed staff documented prior to a fall Resident #1 was walking around looking for his wheelchair. The progress note indicated Resident #1 was alert and oriented and able to maintain a conversation with the nurse. Resident #1 was transferred to the hospital for evaluation. Review of an EMS run report dated 03/12/24 revealed EMS personnel arrived at the facility at 5:07 A.M. Resident #1 was found lying on the ground in his bedroom with a laceration to the back of the head and his left eye was swollen shut. Nursing staff reported to EMS personnel that they did not know what happened, but assumed Resident #1 fell, but confirmed it was unwitnessed incident. Further review of the EMS run report revealed multiple pools of blood were noted on the doorway of Resident #1's room. As EMS transported Resident #1 to the facility's elevator, Resident #1 told the EMS personnel he did not just fall but was kicked in the face (multiple times) by another resident (#2) who lived in the facility. Review of hospital documentation dated 03/12/24 revealed Resident #1 admitted to the emergency room (ER) with a primary diagnosis of trauma and a left eyelid laceration and intracranial hemorrhage. Resident #1 was brought to the ER as a limited trauma after nursing staff found the resident on the ground, but Resident #1 reported to EMS he was assaulted and kicked multiple times in the head and body. Resident #1 reported to EMS personnel while enroute to the ER that he was assaulted by his roommate and named Resident #2. Resident #1 was alert and oriented to person, place, and time and reported pain throughout his body. Resident #1 was assessed with dried blood on his scalp with scattered abrasions without lacerations identified on his head. Resident #1 had significant swelling to the left side of the face mostly over the left eyelid with an approximate five millimeters long laceration present in the area. The laceration was treated and repaired with sutures. Assessment of Resident #1's abdomen produced some guarding. Review of Resident #1's history revealed the resident had a previous subdural craniotomy (a temporary flap surgically created to the skull) and a flap on the right side of his head where there was no skull. Review of a computed tomography (CT) image of Resident #1's pelvis revealed a nondisplaced acute fracture involving the caudal sacrum. Review of the police body camera footage during an interview with Resident #1 on 03/12/24 at 8:56 A.M., from the ER that Resident #1 was transferred to after the incident, revealed Resident #1 was lying flat on his back with a cervical collar on. Resident #1's face was covered in scratches and bruises with a significant amount of dried blood noted across his face. Photos taken during the interview by the police officer on the body camera footage also noted numerous bruises on Resident #1's abdomen. Resident #1 was noted stating to the officer that he was beat up by his roommate (Resident #2). The body camera footage also noted Resident #1's hospital nurse explained to the officer that Resident #1 suffered bleeding on his brain, a broken sacrum, and was going to be transferred to the hospital trauma intensive care unit (ICU) for further medical care. Review of the police body camera footage dated 03/18/24 at 12:39 P.M. revealed Resident #2 was interviewed regarding the incident by Detective #300 at the nursing facility. Resident #2 stated Resident #1 was reaching for a religious picture that belonged to Resident #2, and he then stuck his foot out to block Resident #1 from touching the religious picture. Resident #2 stated Resident #1 bumped into his foot, Resident #2 took offense to Resident #1 bumping his foot and proceeded to strike Resident #1 with a closed fist. Review of the police body camera footage dated 03/18/24 at 1:23 P.M. in the ICU of the hospital revealed Resident #1 was interviewed by Detective #300. Resident #1 revealed he was thrown out of his wheelchair during the incident and was stomped multiple times on the ground by Resident #2. As a result of being thrown to the ground, Resident #1 suffered a broken tailbone. Resident #1 was informed that based on Detective #300's investigation, Resident #1 was the victim of felonious assault (defined as causing or attempting to cause serious physical harm to another person, or to their unborn child, with a deadly weapon or dangerous ordnance). Detective #300 further explained that after consultation with the county's prosecutor, the county would like to proceed with criminal charges. Resident #1 stated he would like to press charges for the incident with Resident #2. Detective #300 educated Resident #1 that the case would be brought to the county's grand jury to secure formal indictments against Resident #2. Review of a facility self-reported incident (SRI) dated 03/18/24 revealed Resident #1 was discovered on the floor in his room (on 03/12/24) at 5:00 A.M. Resident #1 was laying on the floor of his room in the prone position with his head turned to the right and bleeding from the left side of his head. The SRI included that while being assessed for injuries, Resident #1 informed his nurses that he fell looking for his wheelchair. After assessment, Resident #1 was transported to a local hospital for evaluation. While being evaluated in the hospital, Resident #1 informed hospital staff that he was assaulted by Resident #2. The facility was contacted related to the situation and then began an investigation into the incident. Interview on 04/09/24 at 2:47 P.M. with Resident #1's guardian revealed Resident #1 was nothing like he used to be before the incident on 03/12/24 and has periods of impaired cognition. Interview on 04/09/24 at 5:30 P.M. with the Administrator and DON verified Resident #2's history of physically aggressive behaviors toward other residents, and confirmed the facility did not develop individualized interventions to prevent Resident #2 from physically abusing other residents, including Resident #1. Interview with Detective #300 on 04/11/24 at 9:33 A.M. verified local law enforcement were moving ahead with charges of felonious assault against Resident #2 related to the incident with Resident #1 on 03/12/24. Detective #300 also commented the facility was visited often by law enforcement for incidents of resident-to-resident abuse and other similar incidents. Interview with STNA #215 on 04/15/24 at 8:44 A.M. revealed he was the staff person who found Resident #1 after the incident on 03/12/24. STNA #215 revealed Resident #1 was sitting on his knees on the floor with a large amount of blood coming from the left side of his head. STNA #215 noted Resident #2 was in the room lying awake in his bed and did not speak to STNA #215. Interview with STNA #302 on 04/15/24 at 8:50 A.M. revealed Resident #2 had numerous instances of violent behavior toward staff and others. STNA #302 further noted Resident #2's behaviors were often exacerbated when he had a roommate. Interview with LPN #257 on 04/15/24 at 8:55 A.M. revealed Resident #2's behaviors were often more extreme during the evening and late-night hours. Interview with Psychologist #900 on 04/15/24 at 2:35 P.M. revealed Resident #2 was very territorial in his behaviors, and if Resident #2's personal space and routine were changed/violated, he would very likely retaliate against others. Interview with Resident #2's guardian on 04/15/24 at 1:05 P.M. revealed Resident #2 had a long history of violent behaviors at numerous nursing homes and estimated Resident #2 was placed at over a half dozen nursing homes in the state over the last seven to ten years. Review of the Facility assessment dated [DATE], under the subsection of Mental health and behavior, revealed the facility would manage the medical conditions and medication-related issues causing psychiatric symptoms and behaviors, and identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/post-traumatic stress disorder, and other psychiatric diagnoses. Review of the policy titled, Secured Resident Unit Policy, dated 05/12/22, revealed the facility's secured unit was meant to improve quality of life via enhanced safety and maintenance or improvements in the level of functioning. Review of the policy titled, Abuse, Neglect, and Exploitation, dated 08/30/23 revealed the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Further review of the police revealed, in order to prevent and identify abuse, the facility will assessment, care plan, and monitors residents with needs and behaviors which might lead to conflict or neglect. This deficiency is based on incidental findings discovered during the course of the complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility Elopement/Unauthorized Absence policy and procedure and interviews, the facility failed to provide adequate supervision and individualized and comprehensive interventions to prevent Resident #101 from eloping from the facility. This resulted in Immediate Jeopardy and the likelihood of actual harm on 08/29/23 at approximately 9:48 A.M. when Resident #101, who was cognitively impaired and assessed to be at high risk for elopement, exited the facility grounds without staff knowledge, during a supervised smoke break. Staff failed to identify Resident #101 was missing until approximately 12:15 P.M. when the resident was not available for lunch. On 08/29/23 at 5:14 P.M. Resident #101 was found by police, approximately 2.8 miles away from the facility on a street corner. The resident was transported to the hospital for evaluation. This affected one resident (#101) of three sampled residents reviewed for accidents. This facility identified 14 residents (#3, #24, #27, #45, #46, #76, #86, #90, #98, #101, #124, #130, and #131) who were smokers and elopement risks. The facility census was 138. On 08/30/23 at 5:11 P.M. the Administrator, Regional Nurse Consultant, Director of Nursing and Administrator in Training were notified Immediate Jeopardy began on 08/29/23 when Resident #101, who was cognitively impaired, exited the facility grounds without staff knowledge during a supervised smoke break. Resident #101 was found on a street corner approximately 2.8 miles from the facility by police and was transferred to the local hospital for evaluation. The Immediate Jeopardy was removed on 08/31/23 when the facility implemented the following correction actions: • On 08/29/23 at 12:15 P.M. Resident #101 was identified as having eloped from the facility when he was not present in the dining room for lunch. Licensed Practical Nurse (LPN) #558 informed Licensed Social Worker (LSW) #403, immediately had the receptionist call Code [NAME] 512W. LSW #403 immediately notified the Administrator and Director of Nursing (DON). The administrator notified the Regional [NAME] President of Operations (RVPO) #559 and the Regional Director of Clinical Services #560. • Upon hearing the Code Green, facility staff conducted a head count on all floors and a facility sweep as well as the immediate area outside the facility. Several other staff members used their vehicles to begin searching for the residents in the surrounding neighborhoods, checking bars, convenient stores, and other areas of interest. All residents were accounted for by 12:30 P.M. except for Resident #101. • On 08/29/23 at 12:30 P.M. the DON notified the physician of Resident #101 leaving the facility. Attempts were made to notify the family of Resident #101; however, the attempts were not successful until 08/30/2023 at 2:00 P.M. • On 08/29/23 at approximately 12:30 P.M. all local hospitals and satellite emergency rooms were notified by clinical leadership. The receptionist contacted Cleveland Police Department (CPD) third district and Regional Transit Authority (RTA) police. LSW #403 called University Circle police and Case Western police. The Cleveland Police Department contacted all other local affiliate police departments and emergency medical services (EMS). • On 08/29/23 at 12:30 P.M. Administrator and Human Resource Director (HR) #495 reviewed camera footage. Resident #101 was last observed outside smoking in a supervised smoking group that was being conducted by State Tested Nursing Assistant (STNA) #526. Resident #101 was last seen on camera at 9:48 A.M. smoking with other residents. Resident #101 was not observed entering the facility when smoke break was over. • On 08/29/23 at 12:45 P.M. LSW #403 and the Administrator provided CPD a description of Resident #101, full body picture of Resident #101 and Resident #101's face sheet for pertinent contact information. • On 08/29/23 at 5:14 P.M. CPD located Resident #101 at 5:14 P.M. at Forty Fifth Street and Cedar Avenue, approximately 2.8 Miles from the facility, and took Resident #101 to the hospital for evaluation. LPN #515 and Assistant Director of Nursing (ADON) #492 met the resident at the emergency room (ER). ADON #492 stayed at the ER until 11:15 P.M. when informed by personnel at the ER that they would watch the resident until his transportation arrived back to the facility at approximately 3:00 A.M. or 4:00 A.M. on 8/30/2023. • On 08/29/23 at 1:00 P.M. until 2:00 P.M, RDCS #560 reviewed progress notes for the last 72 hours for any resident changes in condition with no negative findings. • On 08/29/23 from 2:00 P.M. to 10:00 P.M. the DON and/or Designee completed new elopement assessments for all current residents. Residents who were identified as high risk for elopement had their care plan and [NAME] information updated. The facility ensured appropriate interventions were put in place if needed. • On 8/29/2023 at 3:20 P.M. the Administrator and RDCS #560 updated the process of outdoor group activities for residents with supervised leave of absences (LOAs) to reflect two staff must accompany residents for outdoor activities, no more than 15 residents at a time, and residents must be signed out and signed in when returning inside. This process went into effect on 8/31/2023. There was no outdoor supervised smoking after the event on 8/29/2023 and 8/30/2023. All residents were assisted smoking inside. • On 08/29/23 and 08/30/23 education was provided to all staff on the facility's elopement policy, outdoor smoking policy for residents with supervised leave of absences (LOA), and the new process on expectations of signing residents in and out when they are participating in an outdoor supervised group as well as clarifying the expectations of staff members who are taking responsibility for the security and safety of an outside group. Training was completed in person, telephone, email, and via text message system. • On 08/29/23 at 11:45 P.M., Licensed Practical Nurse (LPN) Supervisor # 431 completed an elopement drill. LPN Supervisor #431 noted staff response was very good. Staff searched and followed the policy properly. • On 08/29/23 at 5:00 P.M. a Quality Assurance Performance Improvement (QAPI) was held via telephone with the Administrator, DON, Regional [NAME] President of Operations (RVPO) #559, Regional Director of Clinical Services (RDCS) #560 and Medical Director (MD) #556. The QAPI minutes and findings were reviewed with the facility interdisciplinary team (IDT) and Medical Director during clinical morning meeting on 8/30/2023 at 9:45 A.M. • Beginning 08/29/23 the administrator/or designee would conduct elopement drills, one on each shift weekly for four weeks and then monthly for two months. Elopement drills will be evaluated, and education would be completed as needed. • Beginning 08/29/23 the Director of Nursing (DON) /or designee would complete audits of five residents who were at high risk for elopement or have had a change of condition three times per week for four weeks then monthly for two months. The Director of Nursing (DON) /or designee would review assessments, care plans and [NAME] information to ensure that orders were accurate, and revisions made as needed. • Beginning 08/29/23 the Administrator/or Designee would conduct audits three times weekly for four weeks and then monthly for two months for new admissions and re-admissions to ensure elopement risks were completed appropriately. Residents who were identified at risk would have their face sheet and picture placed in the elopement binders located on each unit and reception desk. • On 08/30/23 at 5:45 A.M. Resident #101 returned to facility. Resident #101 was assessed with no signs of pain or discomfort. For safety the resident was kept on his secured unit and smoking opportunities were provided on the unit. The facility arranged for an interpreter to interview the resident regarding the incident and during the interview the resident voiced suicidal ideations. The nurse practitioner was notified, and an order was received to send the resident to the hospital for psychological evaluation. One to one (1:1) was provided for safety to resident until he was transferred at 2:00 P.M. on 8/30/2023. • Beginning 08/30/23 the Administrator/or designee would complete an audit five times per week for four weeks and then monthly for two months for all residents taken out to smoke are signed out/in by staff and are accounted for upon returning to the unit. The results of all audits would be forwarded to the facility QAPI committee for review and correction actions would be made. • On 08/30/23 at 10:00 A.M., Registered Nurse (RN) #501 completed an elopement drill and noted staff did an excellent job. A suggestion was made to add color code to the back of name tags. • On 08/30/23 at 12:00 P.M. the facility elopement binder was updated and placed on each floor and at the receptionist desk. • On 08/30/23 at 3:30 P.M., Registered Nurse (RN) #501 completed an elopement drill. RN #501 noted staff searched appropriately inside and outside. • On 08/30/23 at 11:45 P.M. Licensed Practical Nurse (LPN) Supervisor #431 completed an elopement drill. Licensed Practical Nurse (LPN) Supervisor #431 noted staff overall did a good job. A list of common codes was to be given to staff to place with name tags. • On 08/31/23 at 9:30 A.M. Registered Nurse (RN) #540 completed an elopement drill. Registered Nurse (RN) #540 noted staff were very responsive and went through all rooms and areas. Staff given copies of policy. • Interviews on 08/31/23 from 8:00 A.M. through 11:30 A.M. with State Tested Nursing Assistant (STNA) #507, Licensed Practical Nurse (LPN) #491, STNA #480, Housekeeper #443, STNA #550, LPN #517, Physical Therapist Aide (PTA) #561 and LPN #504 confirmed they were educated and knowledgeable of the elopement and smoking policies and procedures. Although the Immediate Jeopardy was removed on 08/31/23, the facility remained out of compliance at 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: Review of the medical record for Resident #101 revealed an admission date of 04/17/23 with diagnoses including dementia without behavioral disturbance, alcohol dependence, epilepsy, and human immunodeficiency virus (HIV) disease. Review of the elopement assessment dated [DATE] at 4:32 P.M. revealed Resident #101 was at high risk for elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/23/23 revealed Resident #101 had severely impaired cognition and was independent for mobility, transfers, and ambulation. Review of Resident #101's comprehensive care plan revealed no evidence goals and/or interventions were identified to address the resident's high risk of elopement or exit seeking behaviors. Review of the physician's orders for August 2023 revealed an order indicating Resident #101 may go on leave of absence (LOA) with supervision. Review of the smoking assessment dated [DATE] at 9:44 A.M. revealed Resident #101 required supervision by staff, volunteer, or family member always when smoking. Review of the nurse's note dated 05/06/23 at 4:03 P.M. revealed Resident #101 had previous exit seeking behavior after being moved from the facility fifth floor to the fourth floor. Resident #101 stated I want to leave and go home during the shift, and was standing near the elevator, got on the elevator as the doors opened and went to the main floor lobby. The resident was encouraged by staff to return to the assigned unit, he finally agreed, and was seen flicking a lighter. The resident agreed to hand it (the lighter) to this nurse. The family of the resident came in for a visit and voiced concerns about the resident's current room and requested he be transferred back to the fifth floor. The resident agreed to the move, and a supervisor and Director of Nursing (DON) were made aware. Resident #101 moved then moved back to the fifth floor. Review of the nurse's note dated 08/29/23 at 12:36 P.M. revealed Resident #101 was not in the dining area and not in his room. An overhead page was sent, and staff surveyed the facility. Resident #101 was noted to be out of the building. The physician was notified and attempted to notify the family but there wasn't a working number. Review of the nurse's note dated 08/29/23 at 7:32 P.M. revealed during lunch tray pass at/or around 12:45 P.M. Resident #101 was unable to be located on the unit. The DON and Administrator were made aware, and complete search of facility and surrounding grounds was completed by staff. Local police departments were notified and given description of resident, surrounding hospitals called, staff out in vehicles searching area. On 08/29/23 at approximately 5:15 P.M. CPD notified facility that Resident #101 was located and taken to hospital for medical evaluation. Review of the care plan dated 08/30/23 revealed Resident #101 was at risk of elopement because he believed he was in Philadelphia instead of Cleveland. Interventions included but were not limited to complete elopement assessments upon admission, quarterly and as needed, resident information in elopement binder, and staff to follow procedures for elopements, if applicable to ensure safe return. Review of the facility investigation dated 08/30/23 at 10:53 A.M. revealed Resident #101 exited the facility grounds while out on 08/29/23 during the 9:18 A.M. supervised smoke break without staff knowledge and was found by police, approximately 2.8 miles away, on the corner of Forty Fifth Street and Cedar Avenue on 08/29/23 at 5:14 P.M. Interview on 08/30/23 at 7:15 A.M. with State Tested Nursing Assistant (STNA) #526 revealed on 08/29/23 she took Resident #101 outside to smoke and get fresh air. She stated she did not realize Resident #101 was not with the group when they re-entered the building. STNA #526 revealed she regularly took Resident #101 outside for smoke breaks without difficulty. Observation on 08/30/23 at 7:20 A.M. confirmed Resident #101 returned to the facility. Resident #101 was observed walking the halls with a towel around his waist. Security Officer #545 observed Resident #101 and got an aide to assist him back to his room for a shower. Interview on 08/30/23 at 8:56 A.M. with LSW #403 confirmed Resident #101 eloped from the facility after not receiving adequate supervision during a smoke break. LSW #403 revealed he was notified at approximately 12:30 P.M. Resident #101 got away from the smoking group at approximately because he was not available for meal pass. LSW #403 called surrounding police departments, gave description of the resident, and reported Resident #101 missing. Human Resources (HR) #495 reviewed camera footage and Resident #101 was last seen at 9:48 A.M. on 08/29/23. The facility staff searched the facility and grounds as well as started driving around. Police came to the facility and were given Resident #101's medical record face sheet. The Police Department called the facility on 08/29/23 at 5:14 P.M. and stated Resident #101 was found approximately 2.8 miles away, on the corner of Forty Fifth Street and Cedar Avenue on 08/29/23 at 5:14 P.M. A nurse went to the hospital and brought the resident back. Interview on 08/30/23 at 11:21 A.M. with the Assistant Director of Nursing (ADON) revealed when he received notification Resident #101 was at the hospital the ADON retrieved fresh clothes and went to the hospital. The hospital wanted the ADON him to stay with Resident #101. The ADON stated he waited until 11:00 P.M. and that transportation would not be there for a couple more hours, but the hospital stated the ADON could leave. The ADON indicated Resident #101 had no bruises, and all tests completed came back negative. Interview on 08/31/23 at 8:54 A.M. with Receptionist #527 revealed smokers who required a supervised leave of absence (LOA) must be accompanied by staff. The list gets updated weekly and Resident #101 was on the list. Receptionist #527 stated she assisted in calling places looking for Resident #101 after the resident was noted to be missing. Review of Resident #101's progress notes revealed on 08/30/23 at 11:06 A.M. Resident #101 was interviewed by LSW #403, LPN #515 and a phone interpreter (OPI) to understand Resident #101's thoughts on why he left the facility unsupervised on 08/29/23. Resident #101 could state his basic needs but when dialogue was more complex, he understood better with his native language. According to LSW #403, Resident #101 stated he was unsatisfied with the facility, and they were not providing for him the amenities he felt that he should have (cigarettes). Resident #101 was unfamiliar with his diagnoses but did identify he was forgetful and that his memory fails him often. Resident #101 stated he left the facility because he wanted more cigarettes because he was not given any more by the facility. Resident #101 was not oriented to place or time during the conversation and insisted he was in Philadelphia. The resident insisted he was in a prison during the interview. Resident #101 did make homicidal and suicidal statements during the interview. LPN #515 notified the resident's physician, and the resident was sent for a psychological evaluation and admitted . Review of the sign out sheet dated 08/29/23 revealed STNA #526 signed out Resident #63, #75, #86, #88, #98, #124 and a resident that was not residing in the facility. The sign out sheet had no time out or time in documented. Resident #101 was not included on the sign out sheet. On 09/07/23 at 9:50 A.M. observation of the smoking area for residents revealed there were chairs and a bench located on the side of the building. Human Resources Director # 495 was outside and stated they believed Resident #101 went around the building and exited on the driveway that connected the facility and condominiums next door. Review of facility policy dated 09/2008 with a revision date of 03/18/22 titled, Elopement/Unauthorized Absence Policy, revealed the facility would identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility would implement its policies and procedures promptly to locate the resident in a timely manner. This deficiency is an example of noncompliance investigated under Master Complaint Number OH00145983 and Complaint Number OH00145980.