**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of a facility self-report incident, facility investigation review, police report review, policy review and interviews, the facility failed to provide adequate supervision and/or intervention to prevent resident elopement. This resulted in Immediate Jeopardy and the potential for actual harm beginning on 05/24/25 when Resident #13, who was assessed as an elopement risk, had exit seeking behaviors and was deemed incompetent by the court system, was permitted by staff to leave the facility unattended and without guardian consent. The resident's whereabouts were unknown until the resident was returned to the facility via police escort on this same date. The Immediate Jeopardy and potential for actual harm continued on 08/16/25 when staff allowed Resident #61, a moderately cognitively impaired resident to leave the facility unattended. The resident's whereabouts were unknown until the resident was found by police, on 08/17/25 a half mile from the facility sleeping on the ground behind a gas station. The resident was transported to the hospital for evaluation. In addition to the two incidents of elopement, the facility failed to have adequate systems in place to identify risks associated with its current practice of determining if residents could safely leave the facility unsupervised/unattended. In addition, concerns that did not rise to Immediate Jeopardy were identified when the facility failed to adequately supervise Resident #11, #37, #40 and #68 related to smoking and possession of smoking materials for safety/accidents. The facility also failed to ensure fall interventions were individualized and comprehensive to prevent falls for Residents #5. This affected two residents (#13 and #61) of three residents reviewed for wandering/elopement, four residents (#11, #37, #40 and #68) of 15 residents reviewed for smoking and one resident (#5) of three residents reviewed for falls. The facility identified three additional residents with guardianship in place (Resident #10, #51 and #55) and 21 additional residents with cognitive impairment (Resident #4, #8, #9, #11, #19, #22, #25, #31, #33, #34, #43, #44, #47, #51, #53, #61, #62, #63, #64, #66 and #72). The facility census was 72. On 08/28/25 at 2:04 P.M. the Administrator, Director of Nursing (DON) and Regional Registered Nurse (RN) #869 were notified Immediate Jeopardy began on 05/24/25 when the facility failed to have effective systems in place to prevent resident elopement (Resident #13 and #61) and to ensure residents' leaving the facility or with a desire to leave the facility were safe to be in the community independently and unsupervised. In addition, the facility failed to ensure adequate systems were in place to timely identify when residents were missing to ensure proper action was immediately taken. No changes in the facility's practice for determining if residents were able to leave the facility unattended was completed by the facility between 05/24/25 and 08/28/25. The Immediate Jeopardy was removed on 08/28/25 when the facility implemented the following corrective actions. On 08/17/25 the Administrator provided all staff education related to the facility elopement policy and procedures. On 08/18/25 Assistant Director of Nursing (ADON) #805 completed wandering assessments for all residents. On 08/18/25 the Administrator conducted a facility elopement drill. On 08/28/25 at 3:40 P.M. ADON #805 spoke with Resident #13's guardian, related to the resident's ability to leave the facility with supervision. On 08/28/25 by 6:00 P.M. the DON, Unit Manager #844 and ADON #805 re-assessed all residents for elopement risk. The results of the assessments revealed Resident #11, #13, #31, and #61 were identified as elopement risk. On 08/28/25 at 10:30 A.M., the door codes were changed by the door company. On 08/28/25 by 6:00 P.M., all residents were reviewed to determine if they were able to go on LOA supervised or unsupervised and orders were written to reflect the findings. On 08/28/25 the DON, ADON #805 and Unit Manager #844 consulted with resident families/guardians and physicians to determine resident LOA status. On 08/28/25 the DON/designee placed a list of residents (#4, #8, #9, #10, #11, #13, #22, #25, #31, #33, #34, #36, #43, #51, #53, #55, #61, and #66) who were not permitted to go on leave of absence (LOA) unsupervised at both nurses' stations and at the front receptionist area. On 08/28/25 Regional RN #869 reviewed and updated the elopement binders on all units. On 08/28/25, all staff were educated by Regional RN #869, LPN #865, Mobile Business Office Manager #890, Administrator, DON, ADON #805, Regional Director of Environmental Services #891, Dietary Manager #876, and Regional Dietary Manager #892 regarding all residents being required to have a physician order for LOA and if the LOA was required to be supervised or could be unsupervised. All staff were educated that nobody was to assist any resident out of the facility for any reason without consulting with the charge nurse who was assigned to that resident. Once a staff member confirmed with the nurse that a resident was permitted to go LOA, the staff member must enter the code without the resident seeing the code. At no time was it appropriate to give the code to a resident or family. Education included the facility door codes would be changed weekly. Education included not permitting residents to smoke in front of the facility and only permitting smoking in the designated courtyard. Beginning on 08/29/25 the DON/designee were assigned to review the LOA list daily in clinical meetings Monday through Friday and updates were to be completed if needed. A new list would be placed at both nursing stations and front desk on an ongoing basis. Beginning on 08/29/25 a process was initiated for the DON/designee to review new admissions in clinical meeting for LOA status on an ongoing basis. Beginning on 08/29/25 Human Resources (HR) #851/designee was assigned the duty to ensure all new hires were educated on the LOA process on an ongoing basis. Beginning on 08/29/25 the facility implemented a plan to conduct elopement drills by the DON/designee on a weekly basis each shift for four weeks then on an as needed basis. The drills were scheduled to begin the week of 09/01/25. Beginning on 08/29/25 the DON/designee was scheduled to interview five staff members on the LOA process weekly for four weeks then on an as needed basis. The interviews were scheduled to begin the week of 09/01/25. The results of all audits were to be reported, reviewed and trended for compliance through the facility Quality Assurance Committee for a minimum of six months then randomly thereafter for further recommendation. Beginning on 08/29/25 the Administrator/designee was to observe five smokers weekly for four weeks then on an as needed basis to ensure they were smoking in the appropriate areas. The results of all audits were to be reported, reviewed and trended for compliance through the facility Quality Assurance Committee for a minimum of six months then randomly thereafter for further recommendation. Although the Immediate Jeopardy was removed on 08/28/25, the deficiency remained 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 Resident #13's medical record revealed an admission date of 05/23/25. Resident #13 had a letter of guardianship for person only for an indefinite time dated 04/30/25. Resident #13 had diagnoses including delusional disorders, anti-social personality disorder, anxiety disorder, apraxia (a neurological condition characterized by loss of the ability to perform activities that a person is physically able and willing to do), difficulty walking, and insomnia. Resident #13 had no physician orders regarding LOA. A nursing note by RN #847 dated 05/24/25 at 12:19 A.M. indicated Resident #13 arrived at the facility at 8:16 P.M., transported from the hospital. Resident #13 ambulated into the facility independently while carrying his personal belongings. Upon arrival, Resident #13 immediately expressed his intention to sign out and return home. Resident #13 was provided with education regarding his care plan and the importance of staying at the facility, but he remained insistent on leaving. Unit Manager #844 was made aware of the situation and advised that Resident #13 be re-educated, especially since he reportedly had no alternative place to go. Unit Manager #844 also sent the contact information of Resident #13's legal guardian to notify her of the situation. Resident #13's guardian was contacted, informed of Resident #13's desire to leave and advised that Resident #13 should remain at the facility as he has no safe discharge destination. Resident #13's guardian instructed staff to calm him and, if necessary, use the pink slip (involuntary psychiatric hold) process should he become aggressive. Resident #13 was encouraged to stay and agreed to watch television (TV) for a few minutes before making a final decision. Resident #13 was escorted to the TV lounge and made comfortable. After spending some time there, Resident #13 approached staff and requested to be taken to his room, stating he would remain at the facility for the night and reconsider leaving the following day. A nursing admission assessment dated [DATE] indicated Resident #13 was admitted with a cognitive disorder. Resident #13 was alert and oriented to person, place and time. It was unknown if Resident #13 had a history of exit seeking or wandering. The elopement part of the assessment indicated Resident #13 did not have a history of wandering and/or a pattern tied to Resident #13's past. Resident #13 was not accepting the new admission situation and Resident #13 had expressed anxiety/apprehension to leave the facility. Resident #13 was determined to be at risk for elopement or unsafe wandering. A baseline care plan indicated Resident #13 was at risk for elopement. Interventions included assessing for hunger, thirst, ambulation, and toileting needs. Wandering evaluations were to be completed upon admission/re-admission, quarterly and as necessary. Resident #13 was to be evaluated for need of a secure unit and the medical provider notified as needed. Interventions included providing diversionary activities as needed and redirecting Resident #13 when appropriate. A telehealth physician note by Physician #888 on 05/24/25 at 3:31 A.M. indicated Resident #13 was admitted after a psychiatric hospitalization. According to discharge papers, it appeared he had new onset delusions. A nursing note by LPN #861 dated 05/24/25 at 7:11 P.M. indicated Resident #13 signed out LOA around 3:45 P.M. stating he was going to the store. Resident #13 had not returned at that time. The note included all parties were aware. Review of a LOA sign out sheet dated 05/24/25 revealed Resident #13 signed out at 4:09 (did not indicate if A.M. or P.M. or include an anticipated return time) to go downtown. Sign in was at 8:24 or 8:29 (last number not completely legible) the same day. A nursing note by RN #846 dated 05/24/25 at 10:46 P.M. indicated Resident #13 was returned to the facility with police escorts at 8:10 P.M. No complaints were made. Record review revealed there was no evidence of further interventions or change in LOA process at this time for Resident #13. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was able to make himself understood and was able to understand others. A Brief Interview for Mental Status (BIMS) assessment indicated Resident #13 was cognitively intact with a score of 13 (out of 15 possible points). No signs of psychosis were noted. Wandering occurred daily. Wandering placed Resident #13 at significant risk of getting to a potentially dangerous place. Resident #13 was assessed as independent with walking 150 feet, once he was standing, in a corridor or similar space with no mobility devices. A nursing note by RN #805 dated 07/10/25 at 10:57 A.M. indicated Resident #13 began to exit seek. Resident #13 did not have clear directive as to where or why. A wanderguard device (a bracelet that alerts staff if a resident tries to leave a safe area) was applied. A voicemail was left for Resident #13's guardian. The resident's care plan was updated on 07/14/25 related to the wanderguard use and orders. A Nurse Practitioner (NP) note by NP #889 dated 07/31/25 indicated Resident #13 was hospitalized on [DATE] due to psychotic and cognitive disorders. Resident #13 was involuntarily probated by his sister for delusions involving Satan stealing his cigarettes and believing his sister was possessed by demons. Resident #13 exhibited poor hygiene, flight of ideas, paranoia and delusions. Review of the facility undated Resident Leave of Absence policy revealed a resident who was cognitively intact with independent decision making with a physician's order may sign themselves out for LOA. The procedure indicated a physician's order was to be obtained for the resident to leave the facility with or without supervision. The physician was to be alerted if the resident was at risk for elopement. Provide the resident or family/responsible party with the facility phone number as needed and instructions to contact the facility if return was delayed more than one hour from the anticipated return time. Contact the resident or family/responsible party if they had not returned within one hour of the anticipated return time. Notify the Executive Director if unable to contact the resident or responsible party, or if they refuse to return. On 08/27/25 at 8:15 A.M., the DON was interviewed regarding the facility LOA process. The DON indicated if a resident wanted to sign out LOA, nurses or herself checked a resident's BIMS score and expected it to be over 12 for a resident to leave unattended. Each resident had a LOA form in a notebook at their respective nursing station. Upon review of Resident #13's LOA form, the DON verified Resident #13 had not designated a planned return time when leaving in May 2025. The DON was asked about the rationale for Resident #13 being able to sign LOA when he had been assessed as an elopement risk and stated she would have to research it. On 08/27/25 at 10:58 A.M., the DON revealed Resident #13 was able to leave the facility on LOA by stating Resident #13 had been assessed as cognitively intact. The DON stated when the guardian was contacted the night of admission when Resident #13 wanted to leave, she had only indicated Resident #13 could not leave the facility to go home as he had no home or other alternate placement. The DON stated the guardian did not specifically state Resident #13 could not go out on LOA. During an interview on 08/27/25 at 10:13 A.M., LPN #859 stated if a resident wanted to go out LOA, they had to sign out on the LOA paper and nurses were to document it in the computer (recently started alert charting) that was accessible to the nurses and probably management, but she was not sure. The LPN revealed there was a list of residents who could not sign out LOA at the nursing station and front desk. LPN #859 was unable to identify who made the determination Resident #13 was able to be signed out LOA on 05/24/25. During an interview on 08/27/25 at 10:28 A.M., Resident #13 stated he continued to want to leave the facility and had spoken to everybody at the facility about wanting to leave. Resident #13 did not wish to speak about his LOA when police escorted him back to the facility. During an interview on 08/27/25 at 11:27 A.M., Resident #13's guardian stated Resident #13 had a long psychiatric stay prior to his admission to the facility. She stated when she was contacted by the facility the night Resident #13 was admitted , she did tell the facility Resident #13 was homeless and had nowhere to go and if he was unstable the facility should send him back to the psychiatric hospital. Resident #13's guardian stated she presumed staff would know with his history and wanting to leave the facility he should not be allowed to sign out LOA unless he was accompanied by family or someone from the facility. The guardian stated had staff consulted with her, Resident #13's guardian would have told them there were to be restrictions on Resident #13 signing himself out LOA. Resident #13's guardian stated she believed it was poor judgement on the facility's part if they let him sign himself out LOA. Resident #13's guardian stated she was not notified of Resident #13 leaving LOA and subsequently returning with police intervention. Resident #13's guardian stated Resident #13 had a son in Florida but was homeless for much of his life. Resident #13 was admitted to the psychiatric hospital after he became psychotic and tried to kill his sister who he was staying with. During an interview on 08/27/25 at 10:14 A.M., Certified Nursing Assistant (CNA) #835 stated nursing assistants could let residents sign out LOA if they were not on a list at the nursing station as not being permitted to go LOA. During an interview on 08/27/25 at 11:45 A.M., Regional RN #869 stated she did not know Resident #13 well enough to know if he should have been permitted to sign out LOA or if he should have been assessed as an elopement risk based on not wanting to be at the facility. RN #869 stated staff did not always have a resident's history when first admitted . Based on that, the facility probably should have waited until they were more familiar with Resident #13 to determine if he could safely leave the facility independently. RN #869 stated Resident #13 was assessed as cognitively intact on admission and was used to being homeless. During an interview on 08/27/25 at 5:10 P.M., the Administrator stated the facility had not notified the police when Resident #13 had not returned from LOA on 05/24/25, stating Resident #13 was known by the police in the community from past interactions. The Administrator revealed police had seen Resident #13 and stopped to inquire about what he was doing at an undisclosed location, and Resident #13 was able to inform them he was a resident of the facility. During an interview on 08/28/25 at 8:10 A.M., RN #846 stated she was unable to recall if the police indicated why they had picked up Resident #13 and returned him to the facility on [DATE]. RN #846 stated if a resident wished to sign out LOA they had to be independent and cognitively clear. Nurses have them sign a form saying when they expect to return and document. If a resident had a guardian, they were permitted to leave with the guardian. However, the RN revealed the facility allowed residents who met the criteria of cognitive abilities and independence to sign out for LOA without guardian input. During an interview on 08/28/25 at 8:18 A.M., LPN #861 stated the parties referred to in her progress note on 05/24/25 at 7:11 P.M. was the on-call unit manager (later identified as Unit Manager #844). LPN #861 stated for a resident to be able to sign out LOA she referred to a list or asked the DON or unit manager. During an interview on 08/28/25 at 8:23 A.M., the Administrator stated she had never been informed of Resident #13 leaving the facility on LOA until it was brought to her attention after questioning by the survey team. During an interview on 08/28/25 at 9:56 A.M., Unit Manager #844 stated when residents wanted to go out on LOA it was based largely on the cognitive scores on the BIMS interview. However, the facility tried not to let residents sign out on LOA for the first 24 hours after admission. A resident was permitted to leave the facility LOA if they had a guardian unless the guardian had provided specific instruction for them not to do so. Unit Manager #844 stated she was not aware of Resident #13 signing out LOA on 05/24/25 until staff called to report he had been returned to the facility by police. Unit Manager #844 stated it was her understanding Resident #13 wanted to go to the hospital to get personal items he believed were still there. Unit Manager #844 stated police were familiar with Resident #13 and simply gave him a ride to the facility, stating no police report had been filed. On 08/28/25, the local police department verified there was no police report involving Resident #13 on 05/24/25. During an interview on 08/28/25 at 12:47 P.M., RN #847 stated she assessed Resident #13 as an elopement risk on admission because he was very aggressive regarding his desire to want to leave and go home because there was nobody at his home to take care of it. RN #847 stated Resident #13 hovered at the front entrance for a long time, making attempts to leave but could not because he did not have the code to open the door. RN #847 stated Resident #13 was so upset he could not leave he made threatening moves toward her and only stopped when other residents placed themselves between her and Resident #13. On 08/28/25 at 4:25 P.M., ADON #805 spoke with Resident #13's guardian who indicated Resident #13 was to only go on supervised LOA with the guardian only. If anyone other than the guardian wanted to leave the facility with the resident, the guardian must be notified and give permission. During an interview on 09/02/25 at 11:21 A.M., LPN #858 stated she was not aware Resident #13 was unable to leave the facility on 05/24/25. Police had phoned the facility after her shift started (night shift) and told her Resident #13 was unsupervised downtown, maybe at the bus stop or the hospital, and they knew he should not be wandering around unaccompanied. Police offered to return Resident #13 to the facility. Once he arrived, Resident #13 was upset, and she explained to him he could not leave when he had a guardian. Resident #13 appeared to be confused and stated he did not know he had a guardian. During an interview on 09/02/25 at 4:18 P.M., the Medical Director stated he did review facility policies and provide input. However, regardless of how good a policy was, it was only effective upon staff implementing it. The Medical Director stated he had not been asked to provide input for LOA orders in the past three months. The facility had their own criteria for addressing LOA and would not necessarily involve guardian notification. Per the medical director, Resident #13's going LOA on 05/24/25 was not appropriate as Resident #13 had not been at the facility long enough to be assessed for health risks associated with him going LOA. 2. Record review revealed Resident #61 was admitted [DATE] with diagnoses of unspecified dementia, severe, with behavioral disturbance, unspecified mood disorder, alcohol dependence in remission, and cognitive communication deficit. Review of the Wandering Observation Tool dated 06/13/25 and 07/14/25 revealed Resident #61 was not at risk for wandering or eloping. Review of the quarterly MDS assessment dated [DATE] revealed Resident #61 was moderately cognitively impaired based on a score of eight out of 15 on the BIMS scale. The MDS revealed the resident was independent with all activities of daily living. Review of the progress note dated 08/17/25 at 2:57 A.M. by Curricular Practical Training (CPT) Intern RN #846 revealed Resident #61 was last seen (on 08/16/25) between 8:00 P.M. and 8:30 P.M. during medication administration. At regular night rounds, CPT Intern RN #846 noticed Resident #61 was not in his room. A facility and ground search was conducted, and Resident #61 was not found. The Nurse Supervisor LPN #858 was notified at 2:00 A.M. The Nurse Manager #844 contacted Resident #61's mother, the hospital, and various police stations, all of which were unaware of Resident #61's location. Review of the progress note dated 08/17/25 at 9:23 A.M. by Charge Nurse #842 revealed a call was received from the Local Police Department that Resident #61 was being transported to the hospital for an unknown reason. Review of the progress note dated 08/17/25 at 4:01 P.M. by RN Unit Manager #844 revealed Resident #61 was placed on 1:1 supervision upon return to the facility. Review of the physician orders revealed Resident #61 was placed on 1:1 supervision effective 08/17/25. Review of the progress note dated 08/17/25 at 4:04 P.M. by Charge Nurse #842 revealed Resident #61 returned to the facility (on 08/17/25) at 3:45 P.M. by ambulance with two staff and was alert and oriented to self. Resident #61 refused to have a wanderguard placed on his body. Review of a police report from the Local Police Department dated 08/17/25 revealed the facility reported a missing person incident on 08/17/25 at 2:53 A.M. The responding officer arrived at the facility at 4:15 A.M and spoke with healthcare worker CPT Intern RN #846 upon arrival. It was reported that Resident #61 had wandered away from the facility sometime after 8:30 P.M. on 08/16/25. CPT Intern RN #846 advised Resident #61suffered from depression, mood disorders, and alcoholism which caused him confusion at times. CPT Intern RN #846 advised she last gave the resident his medications on 08/16/25 at 8:30 P.M. at which time she watched him take a phone call and walk outside for a cigarette. She further stated that he had wandered from the facility before but not for this length of time. On 08/17/25 time unspecified, Youngstown Police Department received a message from Austintown Police Department stating Resident #61 was located by their officers and was being transported to the local emergency room. The facility was notified, and Resident #61 was removed from Law Enforcement Automated Data System (LEADS). Review of the Wandering Observation Tool dated 08/17/25 revealed Resident #61 was identified as a high risk for elopement or unsafe wandering. Review of the progress note dated 08/17/25 at 5:58 P.M. by LPN #858 revealed vital signs were obtained and a skin assessment was completed. There were no known injuries noted. There were no new orders from the emergency department, and Resident #61 continued to refuse a wanderguard. Review of the investigation of self-reported incident (SRI) tracking number 264129 revealed the following sequence of events: · On 08/16/25 at 7:30 P.M. Certified Nursing Assistant (CNA) #817 observed Resident #61 in his room and was told “a few hours later” Resident #61 was gone. · On 08/16/25 around 9:30 P.M. CNA #828 reported Resident #61 was seen by the front door attempting to put in door code to go outside and smoke. To not cause the door alarm to go off, CNA #828 entered the code and let Resident #61 out the front door to go smoke. CNA #828 observed Resident #61 walking towards the left side of the facility to sit at the table and chairs. CNA #828 revealed the resident did not have on a wanderguard and therefore, was not an elopement risk prior to letting him outside. · On 08/16/25 at 9:30 P.M. CNA #809 reported seeing Resident #61 at the bus stop when she went to a store across the street on her break, but the resident “was gone” when she came back. Around 2:00 A.M. she noticed he was not in his room and notified the nurse at which time they began to look for him. · On 08/16/25 at an unspecified time LPN #858 was notified by CNA #809 that Resident #61 was not in his room and unable to be found. LPN #858 initiated the facility's elopement action plan, and staff searched inside and outside the facility, but Resident #61was not accounted for. Management was notified during the search. · On 08/17/25 at 2:35 A.M. LPN #858 contacted Resident #61's mom and determined Resident #61was not there. · On 08/17/25 between 2:40 A.M. and 3:35 A.M. the police and hospital were contacted, but Resident #61 was still not located. A voice message was left with Resident #61's friend who was also listed as a contact. LPN #858 made multiple attempts to reach Resident #61 on his cell phone but was unsuccessful. As of 4:15 A.M. when LPN #858 left, Resident #61 had not been located. · On 08/17/25 at 2:00 A.M. CNA #833 reported another aide approached her to say that Resident #61was missing and that she saw him at the bus stop (on 08/16/25) about 9:00 P.M. They then started looking for him. · Review of the Police Dispatch Log revealed on 08/17/25 at 8:07 A.M. Resident #61 was found at a gas station which was one-half mile from facility and a 15-minute walk. Between 8:07 A.M. and 8:10 A.M. a male in the store notified police a man was sleeping behind the store. The responding officer noted Resident #61 was awake and breathing but was unable to focus or understand questions, had possible altered mental status, was very confused, and not aware of what happened last night. · Review of the Ambulance Prehospital Care Report Summary dated 08/17/25 revealed Resident #61 was transported to a local emergency department. Resident #61 walked with assistance to stretcher. No drug use was suspected, he was psychologically impaired, with the chief complaint being altered mental status. Resident #61 was found asleep behind a gas station and had no idea how he got there, where he lived, or what happened prior to his arrival at the scene. On 08/27/25 the administrator provided a list of residents with wanderguards and required 1:1 supervision. The list identified Resident #13 and #31 with wanderguards and #61 with 1:1 supervision. Observation on 08/27/25 at 8:03 A.M. revealed Resident #61 in his room sleeping with an aide standing outside his door. Several attempts from 08/27/25 to 08/28/25 to interview CNA #828, who initially let Resident #61 out of the building were unsuccessful. Interview on 08/27/25 at 10:58 A.M. with the DON revealed one CNA was assigned to always supervise Resident #61 on all shifts. That CNA did not provide any care to any other residents, was not included in the count for the floor aides and was to keep eyes on Resident #61 at all times. Observation at the time of the interview revealed CNA #822 was assigned to Resident #61 and was seated in a chair on the left side of the doorway to his room. Resident #61's assigned 1:1 CNA was not included in the count for the floor aides. Interview on 08/27/25 at 2:07 P.M. with LPN #858 revealed she was not schedul