**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff and resident interviews, police interview, review of the facility's quality assurance investigation, review of the facility ' s Self-Reported Incident (SRI), and review of facility policies, the facility failed to provide adequate supervision to prevent the elopement of two residents (#35 and #49), without staff knowledge, who were cognitively impaired. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on [DATE] when Residents #35 and #49 eloped from the facility. Resident #49 was found by staff, a 45-minute waking distance from the facility near a four-lane city street the following day on [DATE]. Resident #35 was not located until the evening of [DATE] where she was found deceased in a heavy wooded area about a 25-minute walking distance from the facility. This affected two residents (#35 and #49) of four residents reviewed for risk of elopement. The facility identified a total of 11 residents as being at risk for elopement. The facility census was 76. On [DATE] at 12:30 P.M., the Administrator, and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 9:55 P.M., when Resident #35 and Resident #49 had eloped from the facility and were missing. Resident #49 was assessed as being at risk for wandering and elopement and had diagnoses of cerebral infarction and encephalopathy. Resident #35 had a diagnosis of dementia. On [DATE] after the 9:30 P.M. resident smoke break, facility staff were unable to locate Residents #35 and #49. Resident #49 was found at a gas station located approximately a 45-minute walking distance from the facility and was returned to the facility on [DATE] at approximately 9:00 A.M. by a facility staff member. At the time of the Immediate Jeopardy notification, Resident #35 remained missing. Resident #35 was subsequently located the evening of [DATE] deceased in a heavy wooded area about a 25-minute walking distance from the facility. The facility failed to provide adequate supervision to prevent the residents from eloping. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 9:55 P.M., Registered Nurse (RN) #67, who was working on the 300 unit where Resident #35 and #49 resided informed the DON she could not locate Residents #35 and #49. State Tested Nurse Aide (STNA) #36 had reported to RN #67, the residents were not seen after the 9:30 P.M. resident smoke break in the courtyard. · On [DATE] at 9:55 P.M., the DON initiated an internal facility search to locate Residents #35 and #49. · On [DATE] at 10:00 P.M., the DON checked the sign-out book, and began a head count, as no sign-out documentation was noted by Residents #35 and #49. · On [DATE] at 10:00 P.M., the DON and the staff started the search of the facility grounds. · On [DATE] at 11:00 P.M., the DON contacted and informed the Administrator. · On [DATE] at 11:03 P.M., the DON and facility staff searched neighboring areas and local stores. · On [DATE] at 12:00 A.M., the DON and Administrator contacted law enforcement, the Medical Director, and Resident #35 and #49 ' s family representatives. The family representatives did not respond to the facility notification. · On [DATE] at 1:00 A.M., a [NAME] police officer arrived at the facility and took report from the DON. · On [DATE] at 2:00 A.M., the DON began gathering written statements from staff regarding Resident #35 and #49. · On [DATE] at 7:00 A.M., all staff resumed searching for Residents #35 and #49. · On [DATE] at 8:30 A.M., the police reported no new information on the location of Residents #35 and #49. · On [DATE] at 9:00 A.M., Resident #49 was found and returned to the facility by STNA #36. Resident #49 was found at a gas station which was located a 45-minute walking distance from the facility. Resident #49 ' s skin assessment was completed by the DON and no injuries were noted. · On [DATE] at 9:20 A.M., the facility management team conducted a Quality Assurance and Performance Improvement (QAPI) meeting. The management team included the Administrator, DON, Business Office Manager (BOM) #09, Regional Nurse #120, Minimum Data Set (MDS) Nurse #52, Social Service Designee (SSD) #107, Housekeeping and Laundry Director #93, Maintenance Director #18, Admissions Marketing Director #06, Assistant DON ' s #54 and #55, Staff Scheduler #51, Dietary Manager #48, Activities Director #101, Medical Records Staff #47, and Director of Rehabilitation #108. · On [DATE] at 9:25 A.M., the DON started staff education on abuse and neglect, elopement, and changes in resident smoking schedules. · On [DATE] at 9:45 A.M., all residents were audited by the DON, Unit Manager (ID ##)This should be the ADON #54 who also was Unit Manager, and Regional Director of Clinical Operations (RDCO) (ID ##120) for risk of elopement. Any residents not assessed had an elopement assessment completed. · All residents were audited to ensure they had a Brief Interview for Mental Status (BIMs) test (a 15-point cognitive screening measure that evaluates memory and orientation) by Social Service Designee #107 on [DATE]. Assessments were completed by [DATE] for any resident without one at that time. · All residents were audited to ensure that behavioral monitoring was completed on [DATE] by RDCO #120, ADON #54, and MDS #52. · The facility implemented a plan for any resident assessed at risk for elopement to be care planned for their specific risk factors with interventions to prevent elopement on [DATE] by the DON, ADON #54, MDS #52, and RDCO #120. This would also be completed upon admission, annually, quarterly and when a resident exhibited any new exit seeking behaviors by the DON/Designee. · On [DATE] at 10:00 A.M., an elopement drill was completed with all staff by Maintenance Director #18 with no concerns identified. · On [DATE] at 11:15 A.M., Resident #49 ' s family representative visited the resident and attempted to retrace his events in an effort to locate Resident #35. Resident #35 was not located at this time. · On [DATE] at 12:00 P.M., Maintenance Director #18 installed additional lighting in the resident supervised smoking area courtyard. Maintenance Director #18 also changed the key code to the exit doors at this time. · On [DATE] at 1:30 P.M., Activities Aides #100, #102, and #103 were educated on the new smoking schedule and processes by the Administrator. · On [DATE] at approximately 2:00 P.M., three detectives from [NAME] Police Department arrived to talk to the Administrator, DON, and Resident #49. · On [DATE] at approximately 2:30 P.M., Resident #49 was escorted by the three detectives from the [NAME] Police Department to retrace Resident #49 ' s steps of [DATE] to locate Resident #35. Resident #35 was not located. · On [DATE] at 6:00 P.M., the staff re-searched the surrounding neighborhood and last seen location of Resident #35 and #49. · On [DATE] at approximately 7:00 P.M., the family representative, who cared for Resident #35 prior to admission, stated Resident #35 had a history of leaving and accepting rides from strangers. · On [DATE] at 8:30 P.M., staff were advised by the Administrator to abort the search for Resident #35 until 7:00 A.M. on [DATE]. · On [DATE], all staff were educated by the Administrator and the DON on Abuse and Neglect. · On [DATE], all staff were educated by the DON, ADON #54 and ADON #55 on ensuring that wander guards were tested weekly by licensed nurses and staff were informed not to yell out the code, to cover the keypad with hand when punching in the code and do not share code with family members. All staff were also educated on ensuring that doors are secure. · On [DATE], RDCO #120 educated Maintenance Director #18 on ensuring door checks are logged as they are checked to ensure door lock functionality. · All newly admitted residents and residents re-admitted to the facility must have elopement risk assessments upon admission. Any new resident that exhibits new wandering or exit seeking behaviors must have a new elopement risk assessment completed by the nurse. · The facility implemented a plan for any staff who witnessed any resident with wandering or exit seeking behaviors to report to the nurse so a new elopement risk assessment could be completed. · All newly admitted residents must have a BIMS test completed upon admission and any resident that exhibits new wandering or exit seeking behavior must have a new BIMS completed by SSD #107. · The DON or designee would audit all new admissions to ensure that elopement risk assessment is completed, daily for four weeks and then on going as needed. · The DON or designee would audit any resident that has new wandering or exit seeking behaviors to ensure that a new elopement risk assessment is completed, daily for four weeks then ongoing as needed. · The Administrator or designee would audit all new admissions to ensure that they have completed BIMS upon admission, daily for four weeks then ongoing as needed. · The Administrator or designee would audit for residents that exhibit new wandering or exit seeking behavior to ensure they have a new BIMS completed, daily for four weeks then ongoing as needed. · The DON or designee would audit Section E of the MDS which codes for the presence or absence of wandering behavior, five times a week for four weeks then ongoing. · The DON or designee would audit supervised smoke breaks to ensure residents have returned from the designated smoking area, daily for four weeks and then ongoing. · The DON or designee would audit to ensure doors are secure, code remains private, and resident safety is maintained, three days a week and ongoing. · All findings will be reviewed in weekly QAPI meeting for four weeks then ongoing. · Staff interviews were conducted on [DATE] at 6:55 A.M. with STNA #43, at 6:57 A.M. with STNA #46, at 7:20 A.M. with STNA #91 and Housekeeping Aide #91, and at 9:10 A.M. with Licensed Practical Nurse (LPN) #72 and on [DATE] at 1:30 P.M. with STNA #36 and they verified that they had been educated on elopements and had an elopement drill on [DATE]. · Observation on [DATE] at 2:20 P.M. revealed Residents #38, #33, #32, #40, #34, #44, #50, #43, #36, #49 and #59 had wander guards in place as these residents remain at risk for elopement. · Review of door audits revealed all facility doors were audited on [DATE] by the DON. · Interviews on [DATE] from 8:45 A.M. through 10:22 A.M. with STNAs #25, #46, #13, Housekeeping Aides #85 and 74 and LPN # 71 revealed staff had been in serviced on keeping door codes secure from residents and checking wander guard devices for functionality. STNA #25, #46 and #13 verified a residents accountability form was initiated on [DATE] to ensure residents are returned to their unit after smoke breaks. · Interview on [DATE] at 9:15 A.M. the DON stated the dining room door security system was repaired and was functioning at 4:30 P.M. on [DATE]. Although the Immediate Jeopardy was removed on [DATE], the deficiency remains at a Severity Level 2 (no actual harm with the 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 for on-going compliance. Findings include: Medical record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease, anxiety disorder, dementia, falls, atherosclerosis, malnutrition, nicotine dependence and Alzheimer ' s disease. Review of Resident #35 ' s care plans dated [DATE] revealed Resident #35 was at risk for falls related to decreased mobility, impaired cognition and incontinence, and risk for potential complications related to Diabetes Mellitus which included interventions to administer medications and blood sugar checks per physician ' s orders. Review of Resident #35 ' s care plan dated [DATE] revealed Resident #35 had risk for acute confused state characterized by changes in consciousness, disorientation, environmental awareness, and behaviors related to noncompliance with Diabetes Mellitus which included an intervention to monitor blood sugar levels. Review of Resident #35 ' s care plan dated [DATE] revealed Resident #35 had an activities of daily living deficit related to Diabetes Mellitus, syncope and collapse, difficulty walking, and muscle weakness and included interventions for extensive assist of one to two people for transfers and ambulation, and limited assistance for locomotion. Review of Resident #35 ' s smoking care plan dated [DATE] revealed the resident was at risk for injury due to smoking with intervention to provide supervision at all times for smoking. Review of Resident #35's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to have mild cognitive impairment and Resident #35 required extensive assistance with bed mobility, transfers, dressing, and toileting. The resident required limited assistance with locomotion and personal hygiene. Resident #35 also required supervision with eating. Review of Resident #35's elopement risk assessment dated [DATE] revealed the resident was cognitively impaired with poor decision-making skills and was physically capable of leaving the facility independently with a wheelchair. The resident had shown no signs of elopement and had voiced no desire to leave the facility. Review of Resident #35's smoking assessment dated [DATE] revealed the resident had cognitive deficits, smokes two to five times a day and required supervision for smoking. Review of Resident #35's physician orders dated [DATE] through [DATE] revealed Resident #35 was to have received a Cipro 500 milligrams antibiotic for a urinary tract infection. The resident's orders included NovoLog insulin 3 units prior to each meal, measure, and record blood sugar fingerstick prior to each meal and Lantus insulin 6 units at bedtime. Review of Resident #35's progress note dated [DATE] revealed Resident #35 was observed by nurse laying on floor on her left side in the bathroom of her room. Resident #35 reported she did not know what happened, she had gotten dizzy. New order from physician, to continue to monitor and notify of any changes. Review of Resident #35's fall risk screen assessment dated [DATE] revealed she had a history of multiple falls over the last six months, is confined to a chair and disoriented, and unable to independently come to a standing position. Review of Resident #35's blood sugar values log on [DATE] revealed a blood sugar value of 487 milligrams per deciliter (mg/dl) at 8:00 A.M., 423 mg/dl at 12:00 P.M. and 447 mg/dl at 4:00 P.M. Review of Resident #35's progress note dated [DATE] at 12:30 A.M. revealed the DON documented the resident was unable to be located after the 9:30 P.M. smoke break on [DATE]. The resident was reportedly at the designated smoke break; however, when attempts were made to administer the resident her routine evening medications, the resident could not be located. A resident head count and internal search was initiated immediately. The resident was not located. The Administrator, police and Medical Director were notified. A call was placed to the family with no answer and a message was left. Review of Resident #35's elopement care plan dated [DATE] revealed Resident #35 was at risk for elopement due to Alzheimer's Disease, and dementia. Interventions included monitoring resident location on the unit frequently each shift, offering diversional activities, assess if attempt to elope are related to unmet needs, and redirect distract resident from elevator and stairwells. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including encephalopathy, cerebral infarction, opioid abuse, cocaine abuse, nicotine dependence, anxiety disorder and altered mental status. Review of Resident #49's elopement risk assessment dated [DATE] revealed the resident was cognitively intact with poor decision-making skills and newly admitted and not accepting the facility admission. Review of Resident #49's smoking care plan dated [DATE] revealed the resident was at risk for injury due to smoking with intervention to provide supervision at all times for smoking. Review of Resident #49's care plan dated [DATE] revealed that Resident #49 had alteration in cognition and awareness related to diagnosis of cerebral vascular accident. Review of Resident #49's physician orders dated [DATE] revealed Resident #49 received an order for a wander guard monitoring device to left ankle due to the resident may attempt to leave the facility without being accompanied by staff. The order included checking placement every shift. Review of Resident #49's elopement care plan dated [DATE] revealed Resident #49 was at risk for elopement due to confusion. Interventions included wander guard monitoring device to left ankle, offer diversional activity, exit door alarms on, know whereabouts, observe for wandering, safety checks as needed, and resident to activities. Review of Resident #49's smoking assessment dated [DATE] revealed Resident #49 had cognitive loss, smoked two to five times a day, and required supervision with smoking. Review of Resident #49's admission MDS assessment dated [DATE] revealed the resident to have mild cognitive impairment and Resident #49 required supervision with bed mobility, transfers, dressing, eating and toileting. Review of Resident #49's progress note dated [DATE] at 9:30 P.M. revealed RN #67 documented Resident #49 left the facility without signing out. Other residents overheard Resident #49 needed to go to the store. Resident #49 was seen at the last smoke break. RN #67 notified the DON, police, and the Medical Director. A resident head count, internal search and external search was implemented. An attempt was made to contact the daughter. Review of a facility self-reported incident (SRI) dated [DATE] at 1:52 A.M., completed by the Administrator revealed the facility reported missing residents, Residents #35 and #49 to the State agency. The SRI noted an investigation was in progress. Interview and review of the Quality Assurance investigation, dated [DATE] at 9:00 A.M. with the Administrator, DON and Regional Clinical Nurse #120 on [DATE] at 3:35 P.M. revealed Residents #35 and #49 eloped from the facility on [DATE] and were missing after the 9:30 P.M. smoke break, which was monitored by STNA #36 and #34. RN #67's statement revealed Residents #35 and #49 did not return from the 9:30 P.M. smoke break and were missing from the 300 unit when she went to provide medication at 9:55 P.M. Review of the statement from STNA #34 revealed she last saw the residents at the 8:00 P.M. smoke break, returned to the inside of the facility and could not recall if the residents were at the 9:30 P.M. smoke break. Review of the statement of STNA #36 revealed he, along with STNA #34, provided the 9:00 P.M. smoke break, both residents (#35 and #49) attended and STNA #36 did not see the residents after the smoke break. Observation on [DATE] at 2:00 P.M with the Administrator revealed an internal key coded door to the courtyard. The courtyard paved patio measured approximately 50 feet by 20 feet. There was a brick wall approximately four feet high surrounding the courtyard with no gate closure. There was an enclosed clear walled smoking structure at the further point of the patio. There was a paved walkway exit, behind the enclosed walled structure, leading through the brick wall opening. The walkway led down a gradual grade to the parking lot behind the facility. The paved walkway was lined with thick bushes and a very steep grade to the street below. The paved walkway exit was not visible from the facility door. The patio was surrounded by lighting mounted to the side of the facility. Observation on [DATE] at 1:55 P.M. of Resident #49 revealed he was on the 300-unit hallway ambulating without difficulty. A wander guard monitor device was visible on his left ankle. Interview on [DATE] at 1:55 P.M. with Resident #49 revealed on [DATE] there were two staff at the resident smoke break, but he did not tell the staff he was leaving. The resident stated, after the smoke break, he went to the store to get snacks because he didn't like the snacks at the facility. He stated he took Resident #35 with him because she had money and knew the store location. He stated he took Resident #35 down the sidewalk in the back and made a right turn. Resident #49 stated Resident #35 fell out of the wheelchair, and he tried to find someone to help. He stated he went to [NAME], came back, and went to the facility. The facility was locked so he walked the rest of the night until the staff found him. Interview on [DATE] at 3:10 P.M with STNA #34 revealed at the 8:00 P.M. smoke break, STNA #36 assisted STNA #34 with opening the door and passing cigarettes. STNA #34 verified Resident #35 stayed inside the facility, as the resident did not have any cigarettes. Resident #49 went outside to the courtyard, attended the smoke break and returned inside the facility. STNA #34 revealed at the 9:00 P.M. smoke break, she did not observe Resident #35 or Resident #49. STNA #34 stated STNA #36 was in attendance to assist with the 9:00 P.M. smoke break. STNA #34 stated the smoke break was very chaotic with multiple residents going in and out of the facility doors. There were more than ten residents in the smoke break area. It was well lit and there was no precipitation. STNA #34 verified the courtyard is surrounded with a wall without a secured gate. Interview on [DATE] at 1:30 P.M. STNA #36 revealed on [DATE] he observed Resident #49 on the first-floor units and was unsure if Resident #49 attended the 9:00 P.M. smoke break. He stated he observed Resident #35 at 8:00 P.M. near the smoke break area. He was unsure if Resident #35 attended the smoke break as there were multiple residents at the smoke time. He verified Resident #35 did not have cigarettes. STNA #36 revealed it was difficult to keep track of residents coming in and out of the smoke door into the facility. STNA #36 verified the back area of the smoke patio was not visible to the facility smoke door. STNA #36 stated he thought Residents #35 and #49 exited the smoke area on the pathway through the ungated brick wall. Interview on [DATE] at 2:38 P.M. with the Administrator revealed local detectives reported a store, visited by Residents #35 and #49 on [DATE], had a video camera. The video camera showed the residents were in the store, and purchased items on [DATE] at 9:26 P.M. Interview on [DATE] at 3:53 P.M. with the DON revealed she entered the facility on [DATE] at approximately 9:00 P.M. She was approached by RN #67 regarding Residents #35 and #49 missing at about 9:55 P.M. The DON stated internal and external searches began immediately and the external searches lasted through 2:00 A.M. on [DATE] and began again on [DATE] from 7:00 A.M through 8:30 P.M. The DON stated she obtained statements from STNAs #34 and #36, who were witness to the missing residents, and RN #67. The DON verified the statements had inconclusive information regarding how the residents exited the facility. The DON stated when STNA #36 returned Resident #49 to the facility on [DATE] at 9:00 A.M., the resident still had a wander guard monitoring device on the left ankle, and the wander guard functioned correctly at the front door, by sounding the alarm. The DON indicated staff must respond to the front door and all other doors to silence the alarm. The DON stated no door alarms were sounding when she arrived at the facility at 9:00 P.M. The DON then clarified she could not determine how Residents #35 and #49 exited the facility, whether during the smoke break through the courtyard, after smoke break and/or which doors were used to exit the facility. The facility had no exterior cameras. Observation and interview on [DATE] at 8:40 A.M. revealed Resident #49 was finishing up his breakfast and he had a wander guard on the left ankle. Resident #49 stated he gets his cigarettes donated. Resident #49 did walk with the surveyor and MDS Nurse #52 to the front door and the alarm went off and staff had to reset the alarm. The door does not lock, it only sets off an alarm. Resident #49 stated the alarm goes off because he had his bracelet on, and staff come to turn off the alarm. He stated he goes to the front desk area once a week to check out a book. The surveyor then asked Resident #49 to show surveyor where he goes to smoke. Resident #49 was confused as to which hall to go down but did find the way after two tries. Resident #49 stated he used to go out the door until they changed the code. He stated he knew the code before but did not know the code now. He denied going out any other doors by himself except the door to the smoke area and stated staff lets the residents out into the smoke area at smoke time. Observation and interview on [DATE] at 9:20 A.M. revealed Maintenance Director #18 was actively working on the dining room door (that was in same vicinity as door that leads to smoke area), the latches were removed and there was a key code box next to the door. Maintenance Director #18 stated he started employment at this facility about three weeks ago. He stated he was not requested to change to a new doorknob until two days ago by the Administrator. He stated this door previously functioned as a closed door and locked from the outside and was not asked to secure the door by key code. He stated before, the dining room door could be exited but not able to re-enter from the courtyard. He stated that the keypad has not been attached. He stated he was now adding a lock so the door can be entered from the courtyard with a key by staff only and would check to see if he can get the key code alarm added to the door. He stated he never saw anyone go out except the dietary staff to take the trash out but never had to pay attention to the door function since only staff used it and he verified he knew the door did not have a key code alarm functioning. He verified residents could get out this dining room door without an alarm sounding because it was not hooked up. He stated he checks the functions of the doors, alarm, and ensures it is working properly. He stated he has not documented the door checks since he was hired. He stated that he has no form to document door monitoring. Interview on [DATE] at 10:15 A.M. with Resident #49 revealed he got the smoke area door code from watching the staff put in the code. He stated the night he went to go to the store ([DATE]), after the staff had residents in from the 9:00 P.M. smoke break, he used the code and went out the door to the courtyard. He stated Resident #35 was in the courtyard and they took the paved walkway to the street, then to the store. He stated Resident #35 had the money and he knew the area because he used to work in the area and that Resident #35 knew of the store. He stated that he was not seen by staff because staff was gone from taking residents in from smoking. He denied ever trying or using any other door because they were alarmed with the wander guard system. A phone interview was conducted on [DATE] at 2:35 P.M. with Police Sergeant #150 who stated the detectives were unable to discuss the investigation due to clearance and they were still working on the reports. Police Sergeant #150 did verify they found Resident #35 at the corner of two avenues in a heavily wooded area and the cause of death was yet to be determined via autopsy; however, did appear to have been a fall and they did not suspect foul play. Observation on [DATE] from 9:15 A.M. through 9:25 A.M. revealed the dining room door was repaired and the door security was functioning. The door code leading to the smoke area was reset and functional. Observation on [DATE] at 10:32 A.M. revealed STNA #25 using a check form for residents returning to the 300 unit from smoke break. Observation on [DATE] at 10:34 A.M. of Resident #49 revealed he had a wander guard device on the left ankle. Resident #49 was unable to enter door codes to the smoke area and the dining room door. At the front door, Resident #49's wander guard device activated the security alarm and staff responded and had to reset the alarm at the alarm box. Interview on [DATE] at 10:34 A.M. with Resident #49 revealed the door codes had been changed last week and he had not tried to leave the facility since [DATE]. He stated the staff now watch to see if he returns to his second-floor unit after he completes each smoke break. Interviews on [DATE] from 11:55 A.M. through 12:08 P.M. with STNAs #25, #46, and #13, Housekeeping Aides #85 and 74 and LPN # 71 revealed no other residents had eloped since [DATE]. Additionally, the DON verified no other residents had eloped since [DATE]. Interview on [DATE] at 1:45 P.M. with Regional Maintenance Director #160 revealed that on [DATE] by 4:30 P.M., maintenance had repaired the dining room door to make it functional and the security company came in and repaired it to make it secure with a door code. Review of the facility's wandering and elopement policy dated [DATE] revealed staff would identify residents at risk of unsafe wandering and include in the plan of care interventions to maintain the resident's safety and prevent harm. Review of the facility undated policy titled, Resident Smoking revealed all residents require monitoring of their smoking cigarette use and shall receive direct supervision in the designated smoking area. Review of facility policy titled, Abuse, Neglect Exploitation or Misappropriation, dated [DATE] revealed all reports of neglect were immediately reported to the state licensing agency within two hours of allegation of suspected abuse and neglect that results in serious bodily injury. The reported incident will be thoroughly investigated by facility management. This deficiency represents noncompliance investigated under Master Complaint Number OH00143020 and Complaint Numbers OH00142899, OH00142929, OH00142926, and OH00142925.